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Pharm Exam Review CHAPTER 28- PHARMACOTHERAPY OF DM Insulin (For Type 1) Onset (How quickly it starts working)

Timing of Injection (When it should be given)

Peak (When it is most effective)

Duration (How long it works)

blank 10–15 minutes

blank 1–2 hours

blank 3–5 hours

blank Given with one or more meals per day. To be given 0–15 minutes before or after meals.

30 minutes

2–3 hours

6.5 hours

Given with one or more meals per day. Should be injected 30–45 minutes before the start of the meal.

Basal insulins Intermediate-acting Humulin N/NPH

blank 1–3 hours

blank 5–8 hours

blank Up to 18 hours

Long-acting analogues Glargine (Lantus) Detemir (Levemir)

90 minutes

Not applicable

Lantus: Up to 24 hours Levemir: 16– 24 hours

blank Often started once daily at bedtime. May be given once or twice daily. Not given at any time specific to meals. Often started once daily at bedtime. Levemir may be given once or twice daily. Not given at any time specific to meals.

Type Bolus insulins Rapid-acting analogues aspart (Novorapid), glulisine (Apidra), lispro (Humalog) Short-acting Humulin R/Novolin ge Toronto

Short-Acing Insulin Mechanism of action Reduces blood glucose by stimulating cells to take in, use and store glucose. Replaces missing endogenous insulin Therapeutic effects and uses Insulin replacement therapy for type I DM patients Adverse effects Hypoglycemia – occurs when too much insulin is given to patient, or if given during at wrong time, symptoms include tachycardia, confusion, sweating, drowsiness → convulsions, coma, death if not treated, treated with glucagon or glucose source Irritation at injection site Hypokalemia Somogyi or Dawn Phenomenon effect Nursing Interventions Blood glucose levels, Weight and complications i.e. neuropathy, hypoglycemia Lab values - serum potassium levels, urine for ketones if blood glucose above 14 mmol/L Rotate injection sites and monitor for signs of irritation or infection at site of injection Referral to dietician or diabetic nurse specialist Treat hypoglycemia if it occurs Patient Teaching Insulin, potential adverse effects, technique for self-administering insulin

Encourage - diet and lifestyle modifications to support treatment Provide education S/S of hypoglycemia due to too much insulin Examples Humulin, Novolin ge Toronto Type 2 Diabetes Drug

Action(s)

Nursing Considerations

Alpha-glucosidase inhibitors

Interferes with carbohydrate breakdown and absorption; acts locally in GI tract with little systemic absorption

Biguanides i.e. metformin/ Glycophage

Decreases production and release of glucose from the liver; increases cellular uptake of glucose; lowers lipid levels; promotes weight loss Slows the breakdown of insulin, keeping it circulating in the blood longer; slows the rate of digestion, which increases satiety Stimulates insulin release

Common GI effects; hypoglycemia can occur if combined with another oral drug; if this occurs, treat with glucose, not sucrose; take with meals Common GI adverse effects; risk for lactic acidosis (rare); avoid alcohol; low risk for hypoglycemia

Incretin enhancers

Meglitinides

Sulfonylureas i.e. glyburide/ DiaBeta

Stimulates insulin release; decreases insulin resistance

Thiazolidinediones

Decreases production and release of glucose from the liver; increases insulin sensitivity in fat and muscle tissue

Metformin Therapeutic effect and uses Decreases blood glucose levels Mechanism of Action Decreases the hepatic production of glucose (gluconeogenesis) Reduces insulin resistance Lowers lipid levels Promotes weight loss Does not cause hypoglycemia Adverse Effects Minor, GI-related i.e. N & V

CHAPTER 29- PHARMACOTHERAPY OF THYROID DISORDERS Drugs for Hypothyroidism

Well tolerated; minor nausea, vomiting, and diarrhea; some weight loss is likely; low risk for hypoglycemia Can cause hypoglycemia, GI effects; well tolerated; administer shortly before meals Can cause hypoglycemia, GI disturbances, rash; cross sensitivity with sulfa drugs and thiazide diuretics; possible disulfiram response with alcohol Can cause fluid retention and worsening of heart failure; therapeutic effects take several weeks to develop

Mechanism of action T4 replacement therapy for hypothyroidism, mimics action of T 4 Increases metabolic rate, thereby increasing oxygen consumption, respiration, and heart rate Increases rate of fat, protein, and carbohydrate metabolism Promotes growth and maturation Adverse effects Overexpression of T3 / T4 effects CNS excitability: Tremors, headache, nervousness, insomnia Allergic skin reactions Diarrhea, vomiting Serious effects: Tachycardia, angina, cardiac arrest Interventions Vital signs for changes in temperature, pulse, blood pressure (indicators of increasing T 3 / T4 levels) Weight loss (indicator of increasing T3 / T4 levels) Hyperthyroidism Lab values serum levels of T3 / T4, TSH, blood glucose Evaluation Decreasing symptoms of hypothyroidism Examples Levothyroxine (Eltroxin, Synthroid) Drugs for Hyperthyroidism Propylthiouracil (PTU) Therapeutic effects and uses Hyperthyroidism caused by the overproduction of thyroid hormone Establishes normal thyroid state prior to surgery or radioactive iodine treatment Palliative control of toxic nodular goiter Mechanism of action Inhibits synthesis of thyroid hormone Suppresses peripheral conversion of T4 to T3 Adverse effects Leukopenia Rash, urticaria Arthralgia, joint swelling Glomerulonephritis Headache, vertigo, neuritis, paresthesia Nausea Serious adverse effects: Aplastic anemia, liver impairment CHAPTER 38- PHARMACOTHERAPY OF ATHMA, COMMON COLD, AND OTHER PULMONARY DISORDERS Beta 2- adrenergic agonists (Bronchodilators) Beta2-adrenergic agonists: (short-acting/ intermediate acting is most effective for acute episodes) Promote bronchodilation by relaxing smooth muscle Commonly referred to as “bronchodilators” Most frequently prescribed drugs for treatment of bronchoconstriction Available in PO, inhaled and parenteral formulations Salbutamol (Ventolin) is commonly prescribed Salmeterol (Ventolin) Therapeutic uses and effects

Long-acting beta2 agonist indicated for prevention of asthma episodes in patients with severe persistent asthma (not effective for acute asthma attack, as is long-acting) Chronic bronchitis Mechanism of action Stimulates beta2 receptors in smooth muscles of bronchioles promoting bronchodilation and improved airflow and ventilation Adverse effects Throat irritation Headache Restlessness, insomnia, nervousness Dry mouth Serious adverse effects Tachycardia, chest pain Paradoxical bronchospasm Allergic response Tremor Nursing Considerations Should not be used if client has history of dysrhythmia or MI Use limited in children younger than 6 years Not recommended for women who are breast-feeding Methylxanthines (ex. aminophylline) long-term management of asthma when beta agonists, anticholinergics do not work Chemically similar to caffeine Nausea, vomiting, CNS stimulation are common adverse effects Inhaled anticholinergics (ex. Atrovent) Therapeutic effects and uses Relieving and preventing bronchospasm of asthma and chronic bronchitis Mechanism of action Blocks muscarinic Ach receptors in bronchial smooth muscle (blocks the PNS) Intranasal administration blocks parasympathetic receptors, reducing nasal hyper-secretion. Promote bronchodilation by blocking muscarinic acetylcholine receptors (blocks the PNS) alternative to short-acting beta2 agonists. Can be combined with beta2 agonists. Adverse effects Dry mouth Nausea, GI distress Irritation of upper respiratory tract Bitter taste Serious adverse effects: paradoxical bronchospasm, tachycardia Nursing Considerations Assess for history of narrow-angle glaucoma, benign prostatic hyperplasia, renal disorders, urinary bladder neck obstruction Contraindicated in clients with history of these and in elderly Not recommended for women who are breast-feeding

Corticosteroids Main actions

Decrease inflammation, suppress immune response Side effects Increased appetite, fluid retention, immunosuppression, metallic taste (IV admin.), mood swings, osteoporosis (long term use) Nursing interventions Monitor labs (CBC), vitals, I&O, for signs and symptoms of infections, efficacy Patient teaching Report signs and symptoms of infection, side effects and when to notify MD Examples Prednisone, cortisone acetate, aldosterone, dexamethasone (Decadron), Beclomethasone Beclomethasone Therapeutic effects and uses Asthma Allergic rhinitis Mechanism of action Corticosteroid that suppresses airway inflammation and immune response, thus decreasing frequency of asthma episodes Adverse effects Dry mouth, hoarseness Masks infections Serious adverse effects: corticosteroid toxicity (signs of Cushing’s syndrome) when taking for long periods Risk of infection: oropharyngeal candidiasis Must teach patient to rinse mouth following administration, S/S of infection Not recommended during pregnancy/ breast-feeding Not used to terminate acute bronchospasm Antitussives (Opioid [codeine] & Non-opioid [dextromethorphan, benzonatate]) Main action Suppress or inhibit coughing Side effects N/V, drowsiness, dizziness; rare Nursing interventions Monitor airway, cough, efficacy Patient teaching Avoid using for productive coughs or chronic coughs associated with pulmonary issues Examples Dextromethorphan, codeine, benzonatate Dextromethorphan Trade names Koffex DM, Robitussin DM Therapeutic effects and uses Treating non-productive cough Mechanism of action Raises the cough threshold in the CNS Adverse effects At moderate dose, dizziness, sedation

Serious adverse effects: Abuse can cause CNS toxicity, depression, ataxia, slurred speech, stupor, seizure, coma, respiratory depression Expectorants Main action Liquefies mucous secretions (tenacious secretions) allowing them to be coughed up or expectorated Side effects N/V/D, headache; rare Nursing interventions Monitor for signs of congestion, efficacy Patient teaching Do not take more than recommended dose Avaliable OTC Examples Guaifenesin (Robitussin, Mucinex) Mucolytics (ex. acetylcysteine) Mucomyst Breaks down thick mucous Not available OTC CHAPTER 52- DIURETIC THERAPY AND THE PHARMACOTHERAPY OF RENAL FAILURE Loop (High-Ceiling Diuretics) Reduces Na+, K+, Cl- reabsorption at loop of Henle by blocking transport protein Filtrate becomes hypertonic drawing more water into nephron Available in oral or parenteral formulations Indications Edema Hypertension Adverse effects Hypotension, hypokalemia Thiazide and Thiazide-Like Diuretics Block Na+ reabsorption at distal tubule, reducing reabsorption of water Available only by PO except for chlorothiazide Indications Hypertension Edema Adverse effects similar to loop diuretics, but thiazides do not promote ototoxicity Chlorothiazide (Diuril) Therapeutic effects and uses Hypertension, heart failure Fluid retention secondary to heart failure, liver disease, corticosteroid and estrogen therapy Mechanism of action Blocks Na+ / Cl- transporter, reducing reabsorption of Na+ and ClExcess Na+ in filtrate drives Na+ / K+ antiport increasing K+ in the filtrate Less water is reabsorbed Adverse effects

Hypotension, dehydration Electrolyte imbalances (hypokalemia, hypomagnesemia) Dizziness, headache Nausea, vomiting Serious adverse effects: Blood dyscrasias Potassium-Sparing Diuretics Loop diuretics and thiazide diuretics both promote hypokalemia Potassium-sparing diuretics increase urine output but promote retention of K + Mechanism of action Aldosterone antagonists – aldosterone promotes reabsorption of Na+ and secretion of K+; blocking aldosterone receptors prevents reabsorption of water by preventing reabsorption of Na+, retaining K+ Spironolactone (Aldactone) Therapeutic effects and uses Mild hypertension Mechanism of action Inhibits action of aldosterone in distal tubule and collecting ducts of nephron Sodium, chloride, and water excretion are increased; potassium is retained Adverse effects Muscle weakness, flaccid paralysis Paresthesia Fatigue Bradycardia Shock Decreased fertility Serious adverse effects: Cardiac dysrhythmias Nursing Considerations for Patients Receiving Diuretic Therapy Assessment Obtain a complete health history including allergies and drug history (alcohol and nicotine in particular), recent surgeries and trauma Obtain baseline vital signs Obtain blood and urine samples for laboratory analysis Planning Patient to exhibit normal fluid and electrolyte balance during therapy Provide education regarding drug action, precautions and possible adverse effects Patient to report adverse effects including symptoms of hypokalemia, hyperkalemia, and hypersensitivity Interventions Monitor electrolyte levels Monitor vital signs, especially blood pressure as diuretics reduce blood volume Assess for changes to LOC, dizziness, fatigue, postural hypotension Monitor fluid intake and output, body weight as measures of effective therapy Monitor potassium intake and potassium levels as diuretics alter ECF potassium Monitor for signs of hypersensitivity Monitor hearing as some diuretics are ototoxic Monitor vision as thiazide diuretics interact with digitalis, causing visual disturbances Monitor for signs of photosensitivity

WEEK 52 & 53- RENAL DIURETIC THERAPY & ELECTROLYTE REPLACEMENT THERAPY Diuretics Main action Increase urine volume and maximize excretion of water and solutes Side effects Frequent urination, rash, hypotension, fluid and electrolyte imbalances, dizziness Nursing interventions Monitor vitals (BP), I&O, electrolytes, rash, changes in mental status Patient teaching Monitor BP, report side effects to physician, teach importance of having bloodwork performed (electrolytes) Examples Furosemide (Lasix), hydrochlorothiazide, spironolactone (Aldactone), torsemide (Demadex), mannitol (Osmitrol) LASIX – furosemide Main Use Diuresis (fluid retention, CHF) Drug Classification Loop diuretic Mechanism of action Prevents reabsorption of sodium and chloride, primarily in the Loop of Henle to increase urine flow, reduce blood volume and cardiac workload Adverse effects Dehydration, fluid and electrolyte imbalance, hypotension, hypokalemia, dysrhythmias, hearing loss Assess Renal function; creatinine Vital signs, intake/output Monitor blood glucose and blood-urea nitrogen (BUN) Hydration status MONITOR POTASSIUM!!!! Client Teaching Monitor sodium and potassium intake through diet, report weight loss, fatigue and muscle cramps, change position slowly, maintain adequate hydration HYDROCHLOROTHIAZIDE – HCTZ Main Use HTN, diuresis (fluid retention) Drug Classification Thiazide diuretic Mechanism of action Decreases the kidneys’ ability to retain water Adverse effects Dehydration, fluid and electrolyte imbalance, hypotension, can initially reduce blood volume causing a decrease in cardiac output Assess Renal function; creatinine Electrolyte levels Vital signs Intake/output

Hydration status Client Teaching Monitor sodium intake, take as prescribed, keep appointments with doctor, monitor BP, rise slowly, maintain adequate hydration SPIRONOLACTONE - Aldactone Drug Classification Potassium-sparing diuretic Mechanism of action Weak diuretic, targets the distal nephron (collecting tubule), where only small amounts of sodium are reabsorbed, it is a steroid that blocks the effects of the hormone’s aldosterone and testosterone Primary use Diuresis (fluid retention, CHF); can be combined with other diuretics to increase efficacy Adverse effects Hyperkalemia Assess Renal function; creatinine Electrolyte levels Vital signs Intake/output Hydration status Client Teaching Monitor sodium intake, change position slowly, maintain adequate hydration, monitor intake of potassium through diet K-DUR - potassium chloride Drug Classification Electrolyte, mineral Mechanism of action Maintains acid-base balance, isotonicity, and electrophysiologic balance throughout body tissues Crucial to nerve impulse transmission and contraction of cardiac, skeletal, and smooth muscle. Also essential for normal renal function and carbohydrate metabolism Primary use Potassium electrolyte replacement Adverse effects Dehydration, hyperkalemia Assess Potassium levels Vital signs Intake/output EKG changes Client Teaching Monitor intake of potassium through diet, take with food and water to avoid GI upset, do not chew or crush

CHAPTER 56 DRUGS FOR COAGULATION DISORDERS Pharmacotherapy for Coagulation Disorders Anticoagulants: Drugs that prolong bleeding time in order to prevent blood clots from forming/ enlarging Antiplatelet Agents: Drugs that prevent platelet function (primarily aggregation) Thrombolytics: Drugs that lyse/dissolve existing clots in clients with MI/ CVA/ PE Anticoagulants MOA Inhibit specific clotting factors to treat thromboembolic disorders Diminish clotting action of platelets Therapeutic Use These drugs are often referred to as “blood thinners”- However, they do not change the viscosity of the blood but instead inhibit the clumping action of the platelets Given prophylactically to prevent clot formation in high risk patients: Ex. Post-operative patients, immobile patients, patients with decreased fluid intake Therapy can start IV or Sub-Q (heparin) and then progresses to PO (warfarin) Patient teaching Teach signs and symptoms of bleeding and bleeding precautions, avoid eating vitamin K containing foods (such as green, leafy vegetables) Examples Heparin (Hepalean) Prevents clotting within blood vessels Given SC or IV (only) Adverse effects: Abnormal bleeding, thrombocytopenia (deficient platelets causing bleeding into tissues, bruising, slow clotting) Antidote: Protamine sulfate Labs: aPTT Low molecular weight heparins (LMWH) Ex: Innohep, Lovenox, Fragmin Is a SC injection into the abdomen Lovenox is safer in pregnancy (cannot cross placenta) Mechanism is similar to heparin Same degree of anticoagulant activity as heparin but less likely to cause thrombocytopenia Duration of action of LMWH is 4 x longer with a more stable response therefore less follow-up lab work is required Adverse effects: Abnormal bleeding, thrombocytopenia Warfarin (Coumadin) Prevents clotting within blood vessels by inhibiting Vitamin K (needed for clotting cascade) Given orally Adverse effects: Abnormal bleeding, thrombocytopenia Not to be used during pregnancy as can cause hemorrhage or abnormalities in the fetus Antidote: Vitamin K (Teach patient to moderate consumption of foods high in vitamin K while on Coumadin therapy such as kale, spinach, broccoli, brussels sprouts, asparagus, etc..) Labs: PT/ INR Antiplatelet Agents: Clopidogrel (Plavix) Antiplatelet Agents: Drugs that prevent platelet function (primarily aggregation) Prototype drug: clopidogrel (Plavix) Common drug: acetylcitic acid/ ASA (Aspirin): Available OTC

Primary use: To prevent thrombi, stroke, or myocardial infarction (MI) and prevent post-op DVT Adverse effects: Headache, dizziness, rash, pruritus, cough ASA: Toxicity is manifested by tinnitus and should be reported to the physician ASA: Not given to children as shown to cause Reye’s syndrome Nursing considerations similar to anticoagulants Thrombolytics Thrombolytics: Drugs that lyse/dissolve existing clots in clients with MI/ CVA/ PE Ex. alteplase (Activase) (tpa) Mechanism of action: Converts plasminogen to plasmin Sometimes referred to as a “CLOT BUSTER” Usually administered under emergent circumstances (patient teaching limited) Most effective if given within 4 hours of clot formation Contraindications: Current internal bleeding, 3 (+) hours since the onset of stroke, severe hypertension, recent CVA (in past 2 months), older than 65 years These drugs are non-specific and will dissolve both normal and abnormal clots Nursing considerations: Rule out contraindications with complete health history, baseline VS/Lab values, monitor VS/LOC closely post-administration CHA...