NR565 / NR 565 Midterm Exam (Latest 2024 / 2025): Advanced Pharmacology Fundamentals – Chamberlain
NR-565 Advanced Pharmacology Fundamentals
Midterm Exam
US Drug Enforcement Administration description of the scheduled drugs
Correct Answer:
The DEA enacted the Controlled Substances Act (CSA) in 1970 to regulate
drugs and other substances based on their potential for abuse and
dependency. Five schedules of controlled substances were created that are
updated annually. Classes of scheduled substances include narcotics,
depressants, stimulants, hallucinogens, and anabolic steroids. The DEA
issues eligible providers with a registration number to write prescriptions for
controlled substances.
Schedule I
Correct Answer:
high potential for abuse and no current accepted medical use
example of schedule I
Correct Answer:
Heroin, Lysergic Acid Diethylamide (LSD), Marijuana (cannabis), 3,4-
Methylenedioxymethamphetamine (ecstasy), Methaqualone, and Peyote
Schedule II
Correct Answer:
substances, or chemicals are defined as drugs with a high potential for
abuse, with use potentially leading to severe psychological or physical
dependence
Examples of schedule II
Correct Answer:
Combination products with less than 15 milligrams of Hydrocodone per
dosage unit (Vicodin), Cocaine, Methamphetamine, Methadone,
Hydromorphone (Dilaudid), Meperidine (Demerol), Oxycodone (OxyContin),
Fentanyl, Dexedrine, Adderall, and Ritalin
Schedule III
Correct Answer:
substances, or chemicals are defined as drugs with a moderate to low
potential for physical and psychological dependence. Abuse potential is less
than schedule I and II drugs, but more than schedule IV
examples of schedule III
Correct Answer:
Products containing less than 90 milligrams of Codeine per dosage unit
(Tylenol with codeine), Ketamine, Anabolic steroids, Testosterone
Schedule IV
Correct Answer:
substances, or chemicals are defined as drugs with a low potential for abuse
and low risk of dependence
example schedule IV
Correct Answer:
Xanax, Soma, Darvon, Valium, Ativan, Talwin, Ambien, Tramadol
Schedule V
Correct Answer:
substances or chemicals are defined as drugs with lower potential for abuse
than schedule IV and consist of preparations containing limited quantities of
certain narcotics. Are generally used for antidiarrheal, antitussive, and
analgesic purposes
example schedule V drugs
Correct Answer:
Cough preparations with less than 200 milligrams of Codeine or per 100
milliliters (Robitussin AC), Lomotil, Motofen, Lyrica, Parepectolin
What type of analgesic for mild to moderate pain?
Correct Answer:
tylenol, NSAID (Advil/motrin), COX2 inhibitors (like NSAIDS)
What type of analgesic for moderate to severe pain?
Correct Answer:
opioids
When to start using short acting opioids?
Correct Answer:
Should be used exclusively for acute pain in opioid naïve (never had before)
patients as opposed to opioid tolerant patients
Adverse effects of opioids
Correct Answer:
constipation
urinary retention
orthostatic hypotension
emesis
neurotoxicity (delirium, agitation)
tolerance and physical dependence
respiratory depression
What are strong opioids analgesics usually reserved for?
Correct Answer:
moderate to severe pain, postoperative pain, labor and delivery, cancer,
chronic pain, hospice/palliative care, end of life, acute traumatic events,
burns
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Which schedule drugs can APRNs prescribe?
Schedule 2-5 drugs; collaborative
Who determines and regulates prescriptive authority?
o State law determines the prescriptive authority
o Health professional board (Board of Nursing) regulates the prescriptive authority
How does limited prescriptive authority impact patients within the healthcare system?
o This creates numerous barriers to quality, affordable, and accessible patient care
o Requirement to obtain physician cosign on prescriptions may increase patient
waits ):
o Restrictions on the distance of APRNs from physicians may prevent outreach to areas
of most need
What are the key responsibilities of prescribing?
-The ability to prescribe medications is both a privilege and a burden. Have a documented provider-patient relationship, do not prescribe medications to family or friends or yourself, exercise Safe and competent practice
-Document a thorough history and physical examination, including any discussions you have with the patient about risk factors, side effects, or therapy options, have documented plan regarding drug monitoring or titration if you consult additional providers not that you did so. Use the references provided in the following boxes to assist in safely and rationally choosing one medication over another.
-Be sensible, accept responsibility, do not fear it, know constraints and limitations, always learn and update, keep Rx pads in a safe place, confirm allergies, verify medication list with the patient, do not let insurance dictate the quantity of Rx, Charting is key (particularly with off label use), Provide use and rationale.
What should be used to make prescribing decisions?
-The best way to keep your patients (and yourself) safe is to be prudent and deliberate in your decision-making process.
-Follow CPG
o Cost
o Guidelines
o Availability
o Interactions
o Side effects
o Allergies
o Hepatic and renal function
o Need for monitoring
o Special populations
-Cost, availability, current practice guidelines, medication interactions including interactions with food, side effects, need for monitoring, how the drug is metabolized (hepatic or renal), special populations (pregnancy, nursing, older adults)
Be familiar with pharmacokinetic and pharmacodynamic changes of older adults and how that would translate to baseline information needed to prescribe.
o Pharmacokinetic changes: Decreased absorption d/t increased gastric pH,
decreased absorptive surface area decreased splanchnic blood flow, decreased GI motility, delayed gastric emptying
Decreased Distribution of drugs d/t increased body fat, decreased lean body mass, decreased serum albumin, decreased cardiac output
Decreased metabolism of drugs d/t decreased hepatic blood flow, decreased hepatic mass, decreased activity of hepatic enzymes
Decreased excretion of drugs d/t decreased renal blood flow, glomular filtration rate, decreased tubular secretion, and decreased the number of nephrons.
o Beta-adrenergic blocking agents (primarily used for cardiac disorders) are less effective in older adults than in younger adults. Possible reduction in the number of beta receptors and a reduction in the affinity of beta receptors for beta receptor blocking agents.
o Other drugs such as warfarin and central nervous system depressants produce effects that are more intense in older adults.
Beer’s Criteria
What is it?
This is a list created recently updated by the American geriatrics society designed to reduce older adults’ drug-related problems including, but not limited to exposure to potentially inappropriate medications, drug-disease interactions, and medications that warrant extra caution in the older adult population.
Beer’s Criteria
Why is it important?
It’s important because older adults experience the highest prevalence of adverse drug events and many of these events are avoidable.
Impacts/outcomes of polypharmacy
nonadherence, inability to pay for medications,
failure to comprehend the regimen increased Drug-drug interactions.
Polypharmacy greatly increases the risk of interactions. Drug interactions with mild side effects to life-threatening consequences. The Elderly is at a higher risk of polypharmacy due to taking five or more medications daily.
CYP450 inhibitors mnemonic
SICKFACES.COM
S- Sodiumvalporate
I-Isoniziad
C- Cimetdine
K- Ketocanozole
F-Fluconazole
A- Alcohol – binge
C-Chloramphenicol
E-Erythromycin
S-Sulfonamides
C-Ciprofloxacin
O-Omerprazole
M- Metronidazole
G- Grapefruit Juice
CYP450 inhibitors examples
Liver enzymes. It’s not just a single molecular entity but rather a group of 12 closely related enzyme families.
VISACKGQ Valproate, Isoniazid, Sulfonamides, amiodarone,
Chloramphenicol, ketoconazole, grapefruit juice, Quinidine
CYP450 inhibitors
What do they do?
inhibit metabolic activity of one or more CYP450 enzymes They are xenobiotics that inhibit one of the enzymes in the
CYP450 family. This slows the enzymes activities and thereby can increase the
level of the drug by decreasing metabolism of certain drugs affected by those
enzymes.
CYP450 inhibitors
What do they cause if not used correctly? (What would the patient experience?)
Toxicity. drug build up
Examples of CYP450 inducers
CRAPGPS- Carbamazepine, rifampin, alcohol, phenytoin,
griseofulvin, phenobarbital, sulfonylureas
barbiturates, St Johns wart
CYP450 inducers
What do they do?
Elevates CYP450 enzyme activity by increasing enzyme synthesis elevates the activity of the CYP450 enzymes by increasing enzyme synthesis. The increased number of sites increases the metabolism of the medications. This can cause the medication to metabolize quicker and lose
effectiveness
CYP450 inducers
What do they cause if not used correctly? (What would the patient experience?)
Decreases serum concentration of other drugs that use same enzyme
What happens when someone has a poor metabolism phenotype?
-Medication is broken down very slowly It is possible to have side effects even with a very low drug dose because the enzyme is very slow to break down the drug.
-Rapid or Ultrarapid Metabolizers. These enzymes are very active, often breaking
down drugs, before they can have any effect.
What does the U.S. Food and Drug Administration regulate when it comes to medications?
Safety and effectiveness of drugs in the US- the government agency responsible for reviewing, approving, and regulating medical products, including pharmaceutical drugs and medical devices
Reasons for medication non-adherence
(1) forgetfulness, (2) lack of
planning, (3) cost, (4) dissatisfaction, and (5) altered dosing.
Statements:
-medication wasn’t working
-It’s expensive so I cut the dose
-I was busy or travelling
-I ran out
-I forgot to take it
Black Box Warnings
o What are they?
o Why are they issued?
o What are they?
Highest safety-related warning for high-risk medications. Concise summaries of adverse effects of concern in a box surrounded by a thick black line.
o Why are they issued?
-To make healthcare professionals aware and put careful consideration before prescribing
-Neonate and infant drug absorption
-Purpose is to alert the provider to potentially severe side effects and ways to prevent or reduce harm. Provides a concise summary of the adverse effects of concerns. The FDA requires a boxed warning on drugs with serious or life-threatening risks.
Neonate and infant drug absorption
o Be familiar with general development and when absorption would reach adult levels
Adult values by 6-8 months
Increased absorption in stomach
Decreased absorption in intestines
Neonates metabolize faster than adults then declines after 2 years until puberty
Common fears with genetic testing
Fear of discrimination from employers, insurance companies, or providers
WEEK 2
…
Guiding principles for prescribers
…
Examples of pure opioid agonists
-Morphine (strong or moderate-strong)
-Codeine (moderate-strong)
-Fentanyl
-Heroin
-Methadone
-oxycodone
These are active U and K receptors. By doing so the pure agonists can produce analgesia, euphoria, sedation, respiratory depression, physical dependence, constipation, and other effects. They can be divided into two groups: strong opioid agonists and moderate to strong opioid agonists. Morphine is strong. Codeine is
moderate to strong.
What is used to calculate a patient’s overdose risk? (An actual calculation won’t be done on the exam)
NIDA-Modified ASSIST; Morphine milligram equivalents
How would you know when to refer someone to a pain specialist for pain management?
If they are taking >120 mg/per day morphine equivalent
Prescription Drug Monitoring Program (PDMP)
o What is it?
o Why is it important?
o When to use it?
o What is it?
Prescription Drug Monitoring Program -> track controlled substance prescriptions by state for a patient
o Why is it important?
Can provide important patient information that assists with patient care and improve opioid prescribing
o When to use it?
Checked before prescribing any opioids, should be checked periodically or every 3 months during treatment.
How renal and hepatic function impact medication levels in the body
-Patients with renal or hepatic insufficiency can experience greater peak effects and longer duration of action for medications, thereby reducing the dose at which respiratory depression and overdose may occur.
-Similarly, for patients aged 65 years and older, reduced renal function and medication clearance due to age can result in a smaller therapeutic window between safe dosages and dosages associated with respiratory depression and overdose
How to assess someone for possible drug diversion
Multiple prescribers given prescription drugs, refill requested early
-Patient history of multi providers or abuse
-Watch patterns
-Urine Tox
Statements or stories:
-I dropped my meds on the floor.
-I lost the med bottle
When should naloxone be prescribed for a patient?
o When patients are prescribed opioids and are at high risk of opioid overdose
Those using CNS depressants
You may want to consider prescribing naloxone for the following patients at risk:
-Patients taking benzodiazepines concurrently with opioids
Patients receiving high opioid dosages (≥ 50 MME per day)
Patients diagnosed or suspected of having OUD
Patients with a history of nonfatal overdoses
Patients who have concurrent alcohol or substance use
Naloxone can cause acute withdrawal symptoms with adverse effects in patients physically dependent on opioids. -Caution must be exercised with a review of needs, benefits, and risks.
Behaviors that predict controlled substance addiction
Schedule II drugs examples
Examples
Morphine
Hydrocodone (Vicodin)
Hydromorphone (Dilaudid)
Oxycodone (OxyContin, Percocet)
Meperidine (Demerol)
Fentanyl
Methadone
Methamphetamine
Adderall, Ritalin
Schedule II drugs
o Rules around prescribing
-Use PDMP prior to prescribing
-Establish a relationship with the patient
-Document clinical needs and progression
- Opioids are not first-line therapy
- Establish goals for pain and function
- Discuss risks and benefits
- Use immediate-release opioids when starting
- Use the lowest effective dose
- Prescribe short durations for acute pain
- Evaluate benefits and harms frequently
- Use strategies to mitigate risk
- Review PDMP data
- Use urine drug testing
- Avoid concurrent opioid and benzodiazepine prescribing; high risk for respiratory depression and deaths
- Offer treatment for the opioid disorder.
US Drug Enforcement Administration description of the scheduled drugs
…
Treatment of Chronic Pain
o Example: How should something like osteoarthritis be treated?
Salicylates: 3.6-5.4 g/day Use of pregabalin- can help relieve neuropathic pain. Acute pain (sharp, darting
pain) is especially responsive, although other forms of neuropathic pain
(cramping pain, aching pain, and burning pain) also respond.
-Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for
chronic pain. Clinicians should consider opioid therapy only if expected benefits for both
pain and function are anticipated to outweigh risks to the patient. If opioids are used, they
should be combined with nonpharmacologic therapy and nonopioid pharmacologic
therapy, as appropriate.
Risk factors for Opioid Use Disorder
history of overdose, history of substance use
disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use
Methadone
o Black Box Warning
QT prolongation and severe respiratory depression
Methadone
o Benefits of use in opioid use disorder
Maintenance and suppressive therapy
Creates tolerance -> patient less likely to seek out illicit drugs because no desirable effects
Buprenorphine and Naloxone
o Benefit of using this combination
Discourages IV use
Makes risk for withdrawal low
Treatment of chronic pain
o Use of pregabalin
For seizures and neuropathic pain
Regulated as a controlled substance
Effects similar to diazepam when given with other sedative-hypnotic drugs
Treatment of chronic pain
o Use of pregabalin Side effects
o Sedation, dizziness, and ataxia are more commonly linked to pregabalin. Gastrointestinal bleeding may be caused by COX-2 inhibitors and NSAIDs.
WEEK 3
…
How to treat hypertension
o Order HTN medications are typically prescribed in
ACEs, ARBs, thiazides, calcium channel blockers
How to treat hypertension
Which is best for someone with diabetes
ACE -> ARB -> calcium channel blocker -> diuretic
How to treat hypertension
Best approach or drug to use during pregnancy or someone wishing to become pregnant
Labetolol, nifedipine, and methyldopa (little mama)
How to treat hypertension
The therapeutic action of drug classifications used
How to treat hypertension
Ethnic groups impacted by certain drug classifications
African Americans- African americans do not
respond well to ACE-I or ARBs. First line would be thiazide diuretics and then
CCB’s.
Prescribing considerations when carbamazepine is prescribed with warfarin
Decreases effects of warfarin – consider increasing dosage
Beta-blockers
o Their use with nitroglycerin and tachycardia
May mask common signs of hypoglycemia
Can help suppress nitro-induced tachycardia
Beta-blockers
Know examples
Cardioselective examples include:
Atenolol (Tenormin®), bisoprolol
(Bystolic®), metoprolol (Lopressor®) and metoprolol succinate (Toprol-XL®)
Non-selective beta blockers-
Carvedilol (Coreg®), labetalol (Trandate®), nadolol
(Corgard®), propranolol (Inderal®) and Sotalol (Betapace®
Beta-blockers
Risk of stopping them abruptly
tachycardia
Beta-blockers
What happens when given to someone with asthma?
May cause dry cough from constriction of the bronchi
Diuretics action
decreases preload on the heart (what’s coming back to the heart) by diuresing fluid volume and vasodilation
-decrease blood volume, venous pressure, and preload
Blocks sodium-chloride channel in the kidney
Diuretics Contradictions to thiazide diuretics
Sensitivity to sulfa drugs
Sensitivity to thiazides
Hepatic coma
Diuretics Monitoring needs
Daily weights, edema
BP and HR
Signs of hypokalemia
Heart failure
o What to prescribe in response to fibrotic changes
ACEIs
Heart failure
Effects of cardiac glycosides (digoxin)
Positive inotropic effect on the heart -> increases cardiac output -Increase myocardial contractility
and CO by inhibiting Na+ K+
Heart failure
Quinidine and digoxin
o What happens when they are combined?
Quinidine increases digoxin levels by decreasing excretion of digoxin, altering distribution of digoxin, or both
Atherosclerotic Cardiovascular Disease (ASCVD) Risk Score
o What is it?
Cholesterol guideline with 4 categories of patients who would benefit from statin treatment
ASCVD) Risk Score
When is it used?
Based on…
The presence or absence of ASCVD
Number of risk factors an individual has
10-year ASCVD score
Hyperlipidemia
o Statin Drugs
At what age can they be prescribed
Over 10 years old
Hyperlipidemia
o Ezetimibe (Zetia)
What is it?
Reduces plasma cholesterol, LDL,
Blocks cholesterol absorption in the small intestine
Can produce a small increase in HDL
Hyperlipidemia
o Ezetimibe (Zetia)
When would it be used?
Adjunct to diet modification
Approved for monotherapy and combined
use with statin
Hyperlipidemia
o Pharmacological option to minimize side effects
In other words, how would you treat high cholesterol if someone was concerned about or experiencing side effects from other medications?
Which drug classification would be a good choice?
Usually statins at lowest dose then bile acid sequestrants
Angina
o Therapeutic action of organic nitrates
Acts directly on vascular smooth muscle to promote vasodilation
Angina
o Contraindications for ranolazine
Pre-existing QT prolongation
Hepatic impairment
Taking drugs that inhibit CYP3A4 (most calcium channel blockers EXCEPT for amlodipine)
WEEK 4
…
Most appropriate treatment approach for OA
o Pharmacological
NSAIDS, corticosteroids, colchicine
Most appropriate treatment approach for OA
o Non-Pharmacological
Exercise
Gout
o Complications of untreated gout
EROSION, irreversible joint damage, renal calculi
Gout
o Treatment of acute flare with colchicine
Patient education
Adverse effects
Adverse effects: GI toxicity -> nausea and vomiting, diarrhea and
abdominal pain and bone marrow suppression Patient edu- If GI effects occur then colchicine must be d/c immediately.
Gout
o Long-term use of allopurinol
What condition can be developed?
Formation of cataracts with long-term use more than 3 years
Gout
o Drug interactions with allopurinol
Warfarin – inhibits hepatic drug-metabolizing enzymes, delays interaction
of this drug; dosage should be reduced
Mercaptopurine and azathioprine – accumulate to toxic levels, reduce dosage
Theophylline – should not be combined
Ampicillin – high incidence of rash
Gout
o What should be co-administered with febuxostat?
Prophylactic NSAIDs or colchicine for up to 6 months because of gout flare-up
NSAIDS
o Black Box Warning
thrombotic events, GI ulceration, bleeding
NSAIDS
o Drug interactions
Warfarin, heparin, and other anticoagulants – increases risk for bleeding
Glucocorticoids – promotes gastric ulceration
ACEI – increases risk for renal impairment
Other NSAIDs – can negate effects of ASA
Vaccines – may blunt immune response to vaccines
NSAIDS
o Therapeutic action
Provides rapid relief, anti-inflammatory
NSAIDS
o Mechanism of action
Non-selective inhibitor of cyclooxygenase
COX 1 – protection against MI and ischemic stroke
COX 2 – reduces inflammation, pain, and fever
DMARDs
o What baseline diagnostics are needed for all DMARDs
Liver enzymes
creatinine
LFTs, kidney function, and bone marrow function, WBC, and pregnancy test (Can be hard on
the liver and kidneys)
DMARDs
o Therapeutic response of methotrexate
Reduces joint destruction and SLOWS disease progression
Osteoporosis
o Alendronate
Patient education
Remain upright for 30 min.
Take on empty stomach
Take in AM
Osteoporosis
o Ibandronate
Which dietary supplement can interfere with absorption?
Antacids, calcium, vit D, or other vitamin supplements
Remain upright for 60 min.
Don’t eat/drink for 60 min.
Rheumatoid Arthritis
o Treatment during pregnancy
Biologic DMARDs:
-TNF antagonists are US Food and Drug Administration (FDA) Pregnancy Risk Category B.
-Rituximab and abatacept are Pregnancy Risk Category C.
-Nonbiologic DMARDs: Azathioprine is teratogenic. Both leflunomide and methotrexate can cause fetal death and congenital abnormalities.
-Hydroxychloroquine may cause fetal ocular toxicity; however, in some conditions, such as maternal lupus or malaria, the drug decreases the fetal risk associated with the conditions it treats.
-Sulfasalazine is Pregnancy Risk Category B.
Rheumatoid Arthritis
Which drugs have highest risk vs which ones are the safest
NSAIDs and DMARDS are highest risk
Corticosteroids are safest option
Hydrocodone/Acetaminophen (Lortab)
- directions for use
- indication
- common doses
- Directions: take 2.5 mg po every 4-6 hours
- Indication: moderate-severe pain
- Dose: 2.5-10 mg po q4-6 prn
Lisinopril
- directions for use
- indication
- common doses
- Directions: take 10 mg po daily
Check HR and BP before taking medication
Monitor for symptoms -> dry, productive cough
First-dose hypotension - Indication: hypertension
- Dose: 10-40 mg po daily
Colchicine
- directions for use
- indication
- common doses
- Directions: take 1.2 mg po then 0.6 mg one hour after (acute)
Take 0.6 mg po 3x daily for 1.8 mg max dose - Indication: acute gout flare-up and prophylaxis
- Dose: 1.2 mg initial dose then 0.6 mg one hour after or 0.6 mg 3x, should not exceed 1.8 mg
Amlodipine (Norvasc)
- directions for use
- indication
- common doses
- Directions: take 5 mg po daily (2.5 mg if elderly) visit the provider to evaluate the dose adjustment in 1-2 weeks
Check HR and BP before taking medication - Indication: hypertension
- Dose: start at 5 mg po daily, adjust the dose in 1-2 weeks
Which medications are schedule II drugs, select all that apply:
- valium & Ativan
- Oxy
- Fentanyl
- Methadone
- Oxy
- Fentanyl
- Methadone
(also includes Adderall- requires monthly visit including drug and tox screening)
Which medications are schedule III drugs, select all that apply:
- Xanax
- Tramadol
- <90mg of codeine
- Anabolic steroids
- <90mg of codeine
- Anabolic steroids
What is the abuse potential with schedule III drugs?
Moderate to Low potential for abuse
Which medications are schedule IV drugs, select all that apply:
- Ativan
- Tramadol
- Methadone
- Adderall
- Ativan
- Tramadol
An 82-year-old male visits the clinic complaining that his pain meds “Take forever” to work after he takes his pill. What are possible reasons you can explain to him?
- Perhaps we need to increase your dose.
- Sometimes as you get older, absorption may be slower resulting in a delayed response.
- As we get older the gastric acid decreases making it harder to break up the med, causing a slower absorption.
-Sometimes as you get older, absorption may be slower resulting in a delayed response.
- As we get older the gastric acid decreases making it harder to break up the med, causing a slower absorption.
Distribution of medication can be affected in the elderly in what ways?
- Decrease hormones
- Increased body fat
- Decreased lean mass
- Decreased Albumen
- Increased body fat
- Decreased lean mass
- Decreased Albumen (less protein binding sites available- mostly seen in malnourished)
When prescribing medications, we must understand that liver function declines with age due to what cause?
- enlarged liver
- decreased blood flow to liver
- increased activity of the hepatic enzymes
- decreased blood flow to liver
(Liver usually shrinks, enzyme activity usually decreases)
What is the most important cause of adverse drug reactions?
- High drug dosages
- Lack of monitoring of meds
- Decreased renal excretion
- Overprescribing/Polypharmacy
- Overprescribing/Polypharmacy
How does poor metabolism affect a high or low therapeutic index?
results in low efficacy or toxicity
Example: Plavix
If Plavix is not converted to its active form what adverse effects can occur?
Clot formation leading to stroke
Black Box (BB) warning for opioids?
Resp depression
Black Box (BB) warning for Fentanyl?
Fatal resp depression (fent is 100x stronger than morphine)
Black Box (BB) warning for Methadone?
Prolonged QT- typically has an EKG ordered with it
Black Box (BB) warning for Codeine?
10% of the drug can be converted to morphine by the liver- concerns for breastfeeding mothers.
Black Box (BB) warning for Hydromorphone and Oxymorphone?
Resp depression
-High abuse potential
Black Box (BB) warning for Oxycodone?
Resp depression
-High abuse potential
What are the therapeutic uses for morphine?
Pain control for palliative, cancer, labor, post-op patients.
What are the therapeutic uses for Fentanyl?
Anesthesia and breakthrough, sometimes used for opioid tolerant patients.
When should a patient be referred to a pain specialist?
Chronic pain patients who reach an MME of 120 or greater
What is MME and when to use it?
Morphine Milligram Equivalents
- It is a way to calculate how much pain meds someone is getting based on the type of med they are getting, helps safely prescribe.
-Typically used when there is a dosage change or when trying to establish a dosage.
At what MME would you prescribe naloxone?
At 50 MME
Risk factors for OUD?
-Family history of abuse
-History of depression
-History of anxiety
-History of S.I.
-Poor social history
Drugs not safe to take with opioids?
-Benzos
-Other opioids
-Antihistamines
- CNS depressants
What are the key responsibilities of prescribing opioids?
-Check the PDMP
-Assess for abuse
-Non pharm options used
-Assess when to d/c
-Med reconciliation
-Give lowest dose
-Provide education
-Never prescribe to family or friends
In what patient population are statins contraindicated?
-Pregnancy
In what patient population is Warfarin contraindicated?
-Pregnancy
(typically Heparin or lovenox is used)
What patient population needs a lower dose of Warfarin?
Pediatrics
What BP meds are okay to use during pregnancy?
-Labetalol
-Methaldopa
little mama
What are some examples of drug-drug interactions of Warfarin?
-Carbamazepine
-Aspirin
-Dig
-Amiodarone
-Vit K
-Phenobarbital
-birth control
-Phenytoin
Statins can have potentiating AE effects from which inhibitor?
-Grapefruit from CYP family
Furosemide can have a drug-drug interaction with what medications?
-Potassium sparing meds
-Digoxin
-gentamycin (auto toxic)
What are some medications for the treatment of Angina?
-Nifedipine
-Nitro
-beta blockers
-ranolazine
Contraindications for Ranolazine?
-QT prolongation and drugs that may cause QT prolongation
-Liver impairment
-Renal impairment
A 41 year old patient comes into the clinic complaining of increased heart rate after starting Nitro patches for stable angina. What would an appropriate response be?
- Lets lower the dose and frequency of use
- I will prescribe a beta blocker to help with this
- Next time this happens, lie down and practice deep breathing, this will bring your heart rate down.
- I will prescribe a beta blocker to help with this.
(Barrow receptor reflex- when the pressure senses that the blood pressure dropped, it tells the heart to raise the HR leading to reflex tachycardia)
HF and HTN
What is the role of aldosterone?
Increase sodium and water retention
angio 1 –> angio 2- constricts the blood vessels and promotes the stimulation of aldosterone
AE of aldosterone?
Increases heart fibrosis, remodeling of the heart, causing fibrotic changes.
A patient with HF develops fibrotic changes, what should the provider do next?
-Initiate:
-ACE inhibitor
-ARBS
-DRI
They decrease aldosterone production by acting on angio 2
How to mitigate adverse effects of aldosterone?
-implement ACE inhibitors
-ARBS
-anything that stops angio 2
For the general population what class of HTN medication is appropriate?
-Thiazides considering no comorbid issues
For a CKD patient, what class of HTN is appropriate?
-ACE inhibitors
help vasodilate the vassals in the kidneys
-If a cough develops or med not tolerated start ARBS
For the Africans American patient, what class of HTN medication is appropriate?
-Thiazide & CCB
-Avoid ACEI
What is contraindicated in ACEI?
-Pregnancy in the 2nd and 3rd trimesters
-Bilateral renal stenosis
-Hypotension, renal failure, hx of
ACEI-induced cough or angioedema
What is contraindicated in Ranolazine?
-QT prolongation history
What is contraindicated in Beta Blockers?
-Asthma**
-Diabetics (Can mask hypoglycemia)
-Bradycardia, persistent
hypotension, advanced heart block
Can promote constriction of vessels in the airway
Clinic tools used to treat hyperlipidemia?
-ASCVD (Risk assessment score based on LDL, Age, ethnicity, cholesterol levels what you are at risk for) helps decide intensity of the statin
When would you use the ASCVD?
When risk factors are present (smoker)(sedentary)
A 55 year old male comes into the clinic with gouty arthritis. He states that he has one flareup a year. your response is?
- I will prescribe you glucocorticoids to help with inflammation
- Lets start you on a prophylactic therapy of colchicine.
- It will be helpful to take an NSAID to start with to help relieve some inflammation. Ill prescribe Naproxen
- It will be helpful to take an NSAID to start with to help relieve some inflammation. Ill prescribe Naproxen or indomethacin
(NSAIDS are first line)
A patient comes in stating that he tried NSAIDS to relieve a gouty attack but it just hasn’t helped. He asks, “what are my options” He further states that he has attacks every few years but when he does NSAIDS “never help”. Your response is?
- I can prescribe a glucocorticoid and that will bring down the inflammation/pain.
- Have you tried increasing your dosage of NSAIDS and drink plenty of water.
- Lets start by making some changes in your diet, can you tell me what you eat regularly.
- I can prescribe a glucocorticoid and that will bring down the inflammation/pain.
(but 1 & 3 are right)
(2nd line is a steroid)
(stay away from beer)
Colchicine is considered for long-term treatment if a person has _ or more gouty attacks per year.
3
Colchicine should not be taken with what meds?
Statins- because similar side effects
Side effects of Colchicine
Nausea, vomiting, diarrhea, myelosuppression and myopathy
Side effects of Allopurinol
SCAR can develop, generally well tolerated with minimal GI and neuro effects
Side effects of Probenecid
Take with food to minimize GI side effects and drink 2.5-3L of water to prevent uric acid crystal formation in the kydneys
True or False
Colchicine requires a renal and liver dose adjustment?
True
-We don’t start with allopurinol or colchicine because it can precipitate another attack
What should be Co-administered with febuxostat?
(lowers urate levels) (can cause flare ups)
NSAIDS or Colchicine for about six months
Lesinurad should be combined with what other gout medication?
Allopurinol or febuxostat
(helps excrete uric acid out, not a monotherapy) Can send patient into renal insufficiency
Allopurinol can cause what condition when taken long-term?
Cataracts (taking for greater than 3 years)
Initiation of allopurinol can elicit an acute gouty attack. What can be taken in conjunction to prevent that?
Colchicine or low dose NSAIDS
Adverse effects of Colchicine?
nausea, vomiting, abdominal pain, diarrhea, Myopathy
Complications of untreated gout?
-Renal injury, irreversible joint damage
Osteoporosis
Patient education of Alendronate?
-sit up for 30 mins after taking (can cause esophagitis)
-take with water
-Must be able to sit up
Denosumab adverse effects?
osteonecrosis of the jaw, decreased ability to fight infections, Hypocalcemia need dexa-scan
Ibandronate
Do not take with Calcium, magnesium, or iron.
Alendronate
1st line treatment of Osteoporosis
Raloxifene
DVT, PR and risk of stroke
DMARDS baseline data needed for all?
-CBC w/ Diff
-TB check
-Hepatitis
-pregnancy
-Check for malignancies on the skin
-Liver and renal function
-No live vaccines
-Up to date prior to treatment
LFTs, kidney function, and bone marrow function, WBC (Can be hard on
the liver and kidneys)
Baseline diagnostics for all DMARDS?
-Dexa
-Xray look for TB and pneumonitis
-Pregnancy test
-opthomological exam (retinal damage with hydrochloroquine)
-EKG (BBB caused by DMARDS)
DMARDS patient teaching?
-Do not get pregnant take oral contraceptives
-You are immunocompromised
-No active vaccines
-Avoid alcohol
-Don’t stop taking med
Methotrexate side effects
DMARDs I
bone marrow suppression
increased risk of infection
liver damage
GI ulceration
pulmonary fibrosis
pneumonitis
What is a typical dose of Alendronate?
5 mg
What is the most common CYP450 subtypes?
CYP3A4, CYP2C9
Schedule III drugs examples
-Products containing less than 90 milligrams of codeine per dosage unit (Tylenol with codeine)
-ketamine
-anabolic steroids
-testosterone
Schedule IV drugs examples
-Xanax
-Valium
-Ativan
-Ambien
-Tramadol
Soma, Darvon, Darvocet, Talwin
Quinidine can double the levels of what antidysrhythmic?
Digoxin