NR565/NR 565 Midterm Exam Study Guide (Latest 2024 /2025) Advanced Pharmacology Fundamentals - Chamb

NR565 / NR 565 Midterm Exam (Latest 2024 / 2025): Advanced Pharmacology Fundamentals Chamberlain During what trimester is a pregnant woman most at risk for adverse drug reactions with potential long term consequences? ANSWER: 1st trimester (fetus most at risk d/t rapid growth) What is BEERS criteria? ANSWER: Recommendations of medications inappropriate for elderly (65 and older), prescriber ultimately decides What is the CYP450 (cytochrome P450) ANSWER: liver enzyme system where medications are metabolized, can either be inducers or inhibitors and create drug-drug interactions CYP450 inducers ANSWER: Speed up metabolism of drugs (drug is cleared faster), drug has lesser effect (decrease blood levels of drug), elevate CYP450 enzymes CYP450 inducers pneumonic ANSWER: "Bullshit Crap GPS INDUCES rage" CYP450 inducer drug names ANSWER: Barbituates, St John wort, Carbamazepine, rifampin, alcohol, phenytoin, griseofulvin, phenobarbital, sulfonylureas CYP450 inhibitors ANSWER: inhibit metabolism, increase blood levels of medications CYP450 pneumonic ANSWER: "VISA credit card debt INHIBITS spending on designers like CK to look GQ" CYP450 inhibitors drug names ANSWER: Valproate, isoniazid, sulfonamides, amiodarone, chloramphenicol, ketoconazole, grapefruit juice, quinidine Physiological changes during pregnancy that impact pharmacodynamics and pharmacokinetic properties of drugs? ANSWER: increase glomerular filtration rate leads to increase durg excretion increase hepatic metabolism decrease tone and motility of bowel increase drug absorption Examples of medications that can be teratogenic ANSWER: Antiepileptic drugs, antimicrobials such as tetracyclines and fluoroquinolones, vitamin A in large doses, some anticoagulants, and hormonal medications such as diethylstilbestrol (DES).

How is absorption of intramuscular medications different in neonates? ANSWER: slow and erratic due to low blood flow in muscles first few days of life Why is absorption of medication in the stomach increased in infancy? ANSWER: delayed gastric emptying Some medications that should be avoided in the pediatric patient? ANSWER: glucocorticoids, discoloration of developing teeth with tetracyclines, and kernicterus with sulfonamides, levofloxacin (antibiotics) aspirin (Severe intoxication from acute overdose) what should be included in medication administration patient education? ANSWER: dosage size and timing route and technique of administration duration of treatment drug storage nature and time course of desired responses nature and time course of adverse responses finish taking antibiotic What are some things that put the elderly patient at higher risk for adverse drug reactions? ANSWER: reduced renal function polypharmacy (the use of five or more medications daily) greater severity of illness presence of comorbidities use of drugs that have a low therapeutic index (e.g., digoxin) increased individual variation secondary to altered pharmacokinetics inadequate supervision of long-term therapy poor patient adherence How can healthcare providers decrease likelihood of an elderly patient experiencing an adverse drug reaction? ANSWER: obtaining a thorough drug history that includes over-the-counter medications considering pharmacokinetic and pharmacodynamics changes due to age monitoring the patient's clinical response and plasma drug levels using the simplest regimen possible monitoring for drug-drug interactions and iatrogenic illness periodically reviewing the need for continued drug therapy encouraging the patient to dispose of old medications taking steps to promote adherence and to avoid drugs on the Beers list How can we promote medication adherence with elderly patients? ANSWER: simplifying drug regimens providing clear and concise verbal and written instructions using an appropriate dosage form clearly labeling and dispensing easy-to-open containers developing daily reminders

monitoring frequently affordability of drugs support systems Why do nitrates need to be taken no later than 4 PM? ANSWER: Need nitrate free interval so tolerance doesn't develop Nine factors that impact outcome of medication? ANSWER: Gender and race Genetics and pharmacogenomics Variability in absorption placebo effect Tolerance patho age bodyweight Do you need informed consent for genetic testing? ANSWER: yes What is the purpose of the Genetic Information Non-Discriminatory Act? ANSWER: Protects patients from discrimination by employers and insurance providers based on genetic information Difference between practice authority and prescriptive authority? ANSWER: Practice authority refers to the nurse practitioner's ability to practice without physician oversight, whereas prescriptive authority refers to the nurse practitioner's authority to prescribe medications independently and without limitations.

Who regulates prescriptive authority? ANSWER: the jurisdiction of a health professional board. This may be the State Board of Nursing, the State Board of Medicine, or the State Board of Pharmacy, as determined by each state.

What is scope of practice determined by? ANSWER: is determined by state practice and licensure laws.

What is full practice authority? ANSWER: Nurse practitioners have the autonomy to evaluate patients, diagnose, order and interpret tests, initiate and manage treatments and prescribe medications, including controlled substances without physician oversight.

What is reduced practice authority? ANSWER: Nurse practitioners are limited in at least one element of practice. The state requires a formal collaborative agreement with an outside health discipline for the nurse practitioner to provide patient care. ex/ physician involvement for 5 yrs than independent

What is restricted practice authority? ANSWER: Nurse practitioners are limited in at least one element of practice by requiring supervision, delegation, or team management by an outside health discipline for the nurse practitioner to provide patient care.- typically doctor on site What are components of Rx? ANSWER: Prescriber Contact info Prescribers name NPI DEA Patient name DOB Date Allergies Medication name Strength Quantity Indication for use Direction for use Refills Signature What are some potential problems that arise with written prescriptions? ANSWER: Must contain all elements May have pre-populated information Write legibly Avoid error prone abbreviations Tamper resistant scripts are often required Reasons for monitoring drug therapy ANSWER: determining therapeutic dosage evaluating medication adequacy identifying adverse effects serious or life-threatening risks.

Which schedules of drugs can APRNs prescribe? ANSWER: depends on state - most II-V How does limited prescriptive authority impact patients within the healthcare system? ANSWER: longer wait times to sign a prescription limits practitioners that are needed in rural areas unequal relationships between providers. Ex. one has more power high need for providers due to lack of providers and high amounts of patients.

Independent practitioners= more patients being seen= lessens the patient/provider load Provider key responsibilities when prescribing? ANSWER: safe and competent practice

understanding of the drugs, reactions, and pharmacology Be aware of the age group you are prescribing to Ex. Children vs older adults What should be used to make prescribing decisions? ANSWER: documented provider-patient relationship, not prescribing for family or friends, documenting a thorough H&P, including discussions with the patient, drug monitoring/titrating. cost, guidelines, availability, interactions, side effects, allergies, hepatic and renal function, need for monitoring, and special populations What happens when someone has a poor metabolism phenotype? ANSWER: medications metabolized slower, medication might not work or put them at risk for sideeffects What does the US food and drug administration regulate when it comes to medications? ANSWER: Whether the drug is safe, effective, and benefits of a drug outweigh the risks reasons for medication non-adherence ANSWER: patients never filling/refilling prescriptions (resulting in therapeutic failure) multiple chronic disorders multiple prescription medications multiple doses per day for each medication drug packaging that is difficult to open multiple prescribers changes in the regimen (adding meds, changes in dose or timing) cognitive or physical impairment (reduction in memory, hearing, visual, color, or manual dexterity) living alone recent discharge from hospital low literacy inability to pay for meds personal conviction that a drug is unnecessary or the dosage is too high presence of side effects Which statements are possible reasons for medication non-adherence? ANSWER: "I tried to take for weeks and it just wasn't working" "It was so expensive I only took it once a day instead of twice" "I dropped the whole medication bottle on the floor" "I was traveling and busy" "I lost the medication level" "I ran out" "I couldn't remember if I took it this morning and sometimes I just forget" What are black box warnings? ANSWER: Is the strongest safety warning a drug can carry and still remain on the market. Usually presented on the label with a heavy black border.

Why are black box warnings issued? ANSWER: Issued by the FDA due to having serious or life-threatening risks What is neonate and infant drug dosing based on? ANSWER: weight or body surface area (BSA) After age one what happens to pharmacokinetic parameters, including drug sensitivity? ANSWER: mirror adult parameters Children under two have fast metabolism ANSWER: true How is absorption of transdermal medications different in neonates? ANSWER: more rapid and complete in infants than in older children and adults. the skin is very thin and blood flow is great in infants How is absorption of oral medications different in neonates? ANSWER: absorption may be enhanced or impeded depending on the properties of the drug. gastric emptying is irregular, drugs absrobed in the intestine are absorbed slower.

Common fears with genetic testing ANSWER: Lack of education - many health care providers do not possess the knowledge or comfort to interpret the tesgin financial cost - many insurance plans do not cover this. cost can be from $100-2000. discrimination from employers, insurance companies or providers 12 CDC guidelines for prescribing opioids ANSWER: 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 migrate risk Review PDMP data Use urine drug testing Avoid concurrent opioid and benzo prescribing Offer treatment for opioid use disorder Pure opioid agonist ANSWER: activate opioid receptors in brain resulting in opioid effect examples of pure opioid agonist ANSWER: morphine, methadone, fentanyl, heroin, oxycodone, hydrocodone, opium

pure opioids produce what effects? ANSWER: analgesia, euphoria, sedation, respiratory depression, physical dependence, constipation prototype for strong opioid agonist ANSWER: morphine moderate to strong opioid agonist prototype ANSWER: codeine A person who is depend on a pure opioid agonist should NEVER receive an opioid agonist antagonist ANSWER: true opioid agonist-antagonist ANSWER: used to treat opioid dependence and pain. They work by reducing the affects of withdrawal symptoms and affecting pain sensors. examples of opioid agonist-antagonist ANSWER: Buprenorphine, Pentazocine, Butorphanol, Nalbuphine pure opioid antagonist ANSWER: reverse and blocks opioid effects example opioid antagonist ANSWER: naloxone When to refer a patient to a pain specialist? ANSWER: required for patients who take 120 mme per day of morphine milligram equivalents What is used to calculate pt's overdose risk? ANSWER: total morphine milligram equivalent (MME) per day to help assess the patient's overdose risk. If it is high (≥50 MME/day and especially ≥90 MME/day) Calculate total daily dose: 1. daily amount of each opioid that patient takes 2. convert to MME, multiply dose for each opioid by conversion factor 3. add them together What is MME and when to use? ANSWER: morphine milligram equivalent, represents the potency of an opioid in comparison to morphine, used to identify opioid prescription burden of a person What is the prescription drug monitoring program? ANSWER: electronic databases enable providers to access information regarding a patient's prescription history of controlled substances. Nearly all states have implemented PDMPs, and some states require providers to check the PDMP before prescribing controlled substances.

When should PDMP be used? ANSWER: anytime a controlled substance is prescribed, refilled, or filled

Why is PDMP important? ANSWER: identify those at risk for overdose Assess someone for possible drug diversion? ANSWER: Urine test at least yearly PDMP routinely How does renal and hepatic function impact medication levels in body? ANSWER: Patients with renal or hepatic insufficiency can experience greater peak effect and longer duration of action for medications, thereby reducing the dose at which respiratory depression and overdose may occur. Similarly, for patients ages 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 do elderly metabolize differently than younger people? ANSWER: Older adults metabolize opioids slowly and therefore require lower doses than younger adults.

When should naloxone be prescribed? ANSWER: with every opioid prescription What is the typical dose of naloxone and how is it administered? ANSWER: 4 mg, nasal spray- one spray to one nostril If no response, additional doses can be given every 2 to 3 minutes until emergency services arrive In regards to dosage, why do we need to be cautious when giving naloxone? ANSWER: Dosage must be titrated carefully bc if too much is given the patient will swing from a state of intoxication to withdrawal What is the half-life of naloxone? ANSWER: Short- naloxone must be administered every few hours until opioid concentrations have dropped to nontoxic levels US Drug Enforcement Administration description of the scheduled drugs 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 ANSWER: high potential for abuse and no current accepted medical use example of schedule I ANSWER: Heroin, Lysergic Acid Diethylamide (LSD), Marijuana (cannabis), 3,4Methylenedioxymethamphetamine (ecstasy), Methaqualone, and Peyote

Schedule II 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 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 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 ANSWER: Products containing less than 90 milligrams of Codeine per dosage unit (Tylenol with codeine), Ketamine, Anabolic steroids, Testosterone Schedule IV ANSWER: substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence example schedule IV ANSWER: Xanax, Soma, Darvon, Valium, Ativan, Talwin, Ambien, Tramadol Schedule V 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 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? ANSWER: tylenol, NSAID (Advil/motrin), COX2 inhibitors (like NSAIDS) What type of analgesic for moderate to severe pain? ANSWER: opioids When to start using short acting opioids? 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 ANSWER: constipation urinary retention

orthostatic hypotension emesis neurotoxicity (delirium, agitation) tolerance and physical dependence respiratory depression What are strong opioids analgesics usually reserved for? ANSWER: moderate to severe pain, postoperative pain, labor and delivery, cancer, chronic pain, hospice/palliative care, end of life, acute traumatic events, burns Use of opioids and these other medications should be avoided and why? ANSWER: respiratory depression with other drugs with CNS depressant action CNS depressants barbiturates benzo alcohol general aesthetics anti-histamines phenothiazine anticholinergic drugs atropine tricyclic antidepressants (constipation and urinary retention) what is the classic triad of symptoms for an opioid overdose? ANSWER: MAOI (hyperpyrexia coma) coma, resp depression, pinpoint pupuls How does strength of fentanyl compare to morphine ANSWER: high milligram potency (about 100 times that of morphine) through what system is fentanyl metabolized? ANSWER: CYP34A (isoenzyme of CYP450), levels of fentanyl can be increased by CYP34A inhibitors What is methadone used to treat? ANSWER: relieve pain and treat opioid addiction For what level of pain is codeine prescribed? ANSWER: mild to moderate What does 10% of codeine convert to/black box warning ANSWER: 10% of each dose of codeine undergoes conversion to morphine, the active form of codeine (led to death in children and toxicity in infants through breast milk) Black box warning for hydrocodone ANSWER: products that contain Tylenol are associated with hepatotoxicity

Black box warning opioids, fentanyl, oxycodone, hydromorphone, oxymorphone ANSWER: respiratory depression black box warning for methadone ANSWER: prolong QT interval, fatal dysrhythmias Do opioid agonist-antagonist have high or low potential for abuse? ANSWER: low - when compared with opioid agonists If you switch a patient from oxycodone to buprenorphine quickly what may we expect to see? ANSWER: If given to a patient who is physically dependent on a pure agonist, there drugs can precipitate withdrawal What level of pain is tramadol approved for ANSWER: moderate to moderately severe What schedule is tramadol classified as? ANSWER: schedule IV What population should tramadol be AVOIDED in? ANSWER: pt's with epilepsy, neurologic disorders, elderly What drugs should be avoided for patients taking tramadol? ANSWER: CNS depressants (benzo, alcohol), MAOI, SSRI, serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, triptans What government branch declared the opioid crisis a public health emergency? ANSWER: Health and Human Services (HHS) what are the top 5 priorities of HHS? ANSWER: Improving access to treatment and recovery services Promoting use of overdose-reversing drugs Strengthening our understanding of the epidemic through better public health surveillance Providing support for cutting edge research on pain and addiction Advancing better practices for pain management What were provisions made to the guidelines for prescribing opioids to non-cancer patients? ANSWER: Using opioids only after non-opioid analgesics or more conservative methods have failed Discussing the benefits and risks for long term opioids with patient When possible, one prescriber, one pharmacy Ensuring comprehensive follow up to assess efficacy and side effects of treatment and monitor for signs of opioid abuse Stopping opioids after an attempt at opioid rotation had produced inadequate benefits Fully documenting the entire process When prescribing opioids should patient be initially started on IR or ER? ANSWER: IR- lowest dose for shortest amount of time

How are patients initially exposed to opioids? ANSWER: either recreationally (illicitly) or in context of pain management in medical setting Which group of professionals are at greater risk for abusing? ANSWER: health care providers, nurses, pharmacists What are some effects of opioid use that DON'T change with long term use and tolerance? ANSWER: constipation and miosis (pupil constriction) tolerance does develop? ANSWER: euphoria, respiratory depression, and nausea Is opioid withdrawal life threatening? ANSWER: unpleasant but rarely dangerous Methadone can be used for which two therapies? ANSWER: maintenance- transferring addict from abuse opioid to oral methadone suppressive- prevent the reinforcing effects of opioid induced euphoria Methadone half life? ANSWER: long, prescribed only by providers with special training in pain management Does methadone or buprenorphine have a ceiling (drugs that impact on body plateus) to respiratory depression? ANSWER: buprenorphine - makes it safer What are the therapeutic uses for morphine? ANSWER: pain management, sedation, euphoria, respiratory depression, cough suppression, reduces anxiety, a sense of well-being, suppress GI motility (help with severe diarrhea) Therapeutic uses of fentanyl? ANSWER: Chronic or acute severe pain, cancer pain Risk factors for opioid use disorder ANSWER: chronic pain, family history, other substance abuse, prescribed for long term use Drugs not safe to take with opioids ANSWER: opioids, benzos, alcohol, CNS depressants, anti-histamines, general anesthetics Buprenorzhine and Naloxone ANSWER: agonist-antagonist Buprenorzhine and Naloxone benefit of combination ANSWER: Naloxone is added to buprenorphine to decrease the likelihood of diversion and misuse of the combination drug product

Treatment of chronic pain- Example: How should something like osteoarthritis be treated? ANSWER: Non Opioid medications - NSAIDs, cox-2 inhibitors Nonpharmacologic tx - heat/cold, yoga, physical therapy, exercise, healthy weight When prescribing medication we must understand that liver function declines with age due to what cause? a. enlarged liver b. decreased blood flow to liver c. increased activity of the hepatic enzymes ANSWER: decreased blood flow to liver a. decreased liver mass c. decrease in enzyme activity What is the most important cause of adverse drug reactions? (older age) a. high drug dosages b. lack of monitoring medications c. decreased renal excretion d. overprescribing/polypharmacy ANSWER: decreased renal excretion Distribution of medication can be affected in the elderly in what ways? SATA 1. decreased hormones 2. increased body fat 3. decreased lean mass 4. decreased albumin ANSWER: 2, 3, 4 changes in body composition associated with age due to an increase in body fat percentage and decrease in lean muscle mass. There is also a decrease in total body water. Distribution can also be impacted by decreased total body water and decreased cardiac output. Absorption can be impacted by increase gastric pH, decreased absorption surface area decreased G.I. motility and decrease gastric emptying. Metabolism can be impacted by de Cristo paddock blood flow, paddock mask, and activity of hepatic enzymes.

Excretion can be impacted by decreased renal blood flow, decrease GFR, decrees to both secretion, and decrease number of nephrons An 82 year old male visits the clinic complaining that his pain medications "take forever" to work after he takes his pill. What are possible reasons you can explain to him?

1.Perhaps we need to increase your dosage.

2.Sometimes as you get older, absorption may be slower resulting in a delayed response.

3.As we get older the gastric acid decreases and may slow absorption. ANSWER: 2&3 Order of HTN medications typically prescribed ANSWER: Thiazide diuretics Ace Inhibitors ARBS CCB BB

Which is best HTN medication for someone with diabetes ANSWER: ACE inhibitor and ARB Which medication to avoid in a patient who is pregnant or breastfeeding? ANSWER: Avoid ACE and ARBs in patients who are pregnant or may become pregnant. Especially ARBs in the second and third trimester.

Medications best for HTN for patient who is pregnant? ANSWER: labetalol, methyldopa, nifedipine For general population which HTN class is appropriate? ANSWER: thiazide diuretics For African Americans which class of HTN medications is appropriate? ANSWER: thiazide, CCB, BB For a chronic kidney disease, what is the best HTN medication class? ANSWER: ACE Inhibitors or ARBS What class of medications to avoid in African Americans? ANSWER: ACE inhibitors and ARBS Thiazide diuretics MOA ANSWER: blockade of sodium and chloride reabsorption increases renal excretion of sodium, chloride, potassium, and water (hyponatremia, hypochloremia, hypokalemia) ACE inhibitors MOA ANSWER: Angiotensin Converting Enzyme Inhibitors (ACE-I) prevent the conversion of angiotensin I to angiotensin II, which disrupts the renin-angiotensin-aldosterone system (RAAS).

1. reduce levels of angiotensin II (through inhibition of ACE) 2. increasing levels of bradykinin (through inhibition of kinase 11) End in -pril ARBS MOA ANSWER: Block angiotensin II receptors on blood vessels in heart and adrenals. Increases renal excretion of sodium and water. Cause dilation of arterioles and veins.

End in -sartan CCB MOA ANSWER: They work by preventing calcium from entering the cells of the heart and arteries. Calcium causes the heart and arteries to squeeze (contract) more strongly. By blocking calcium, calcium channel blockers allow blood vessels to relax and open.

blockade of peripheral arterioles cause dilation and reduces arterial pressure, arterioles of the heart increases coronary perfusion, blockade of the SA node reduces heart rate, decreases AV node conduction, myocardium decreases force of contraction Prescribing considerations when carbamazepine is prescribed with warfarin ANSWER: Carbamazepine lowers the effectiveness of Warfarin. This is because of the induction of drug-metabolizing enzymes. There needs to be close monitoring for the Warfarin dose by checking the prothrombin and INR. The dose may need to be adjusted to counterbalance the effect of adding or removing the inducing agent A patient with HF develops fibrotic changes, what should the provider do next? ANSWER: ensure that a patient is on an ARB (valsartan) as this inhibits fibrosis (aldosterone antagonist) Adverse effects of lasix (flurosemide) ANSWER: ototoxicity What medication causes ototoxicity as well and should not be prescribed with lasix? ANSWER: aminoglycoside antibiotics, end in -cin What medication might we consider prescribing with a loop diuretic to prevent an electrolyte imbalance?

ANSWER: potassium sparing diuretic (spironolactone) black box warning for spironolactone ANSWER: endocrine effects - gynecomastia, menstrual irregularities, hirsutism, deepening of voice HYPERKALEMIA What is the action of aldosterone? ANSWER: acts on distal tubules of the kidney to cause retention of sodium and excretion of potassium and hydrogen. Retention of Na causes water to be retained as well. Aldosterone increases blood volume which increases blood pressure How to migrate adverse effects of aldosterone? ANSWER: Aldosterone antagonist (ex/ spironolactone, eplerenone) common side effects of ACE inhibitors ANSWER: angioedema, dry non-productive cough, hyperkalemia, first-dose hypotension Name of only direct-renin inhibitor? ANSWER: Aliskiren (Tekturna, rasilez) What is the DRI only approved for? ANSWER: hypertension What should be avoided with the administration of a DRI? ANSWER: high fat meals

MOA eplerenone ANSWER: retention of potassium and increased excretion of sodium and water Inhibitors of what can lead to toxic levels of eplerenone? ANSWER: Inhibitors of CYP3A4, increase levels of medication, risk for toxicity MOST concerning adverse effects of eplerenone ANSWER: hyperkalemia adverse effects of CCBs in elderly patients ANSWER: gingival hyperplasia (overgrowth of gum tissue) and chronic eczematous rash verapamil increases the plasma level of what medication by 60%? ANSWER: digoxin What should patients avoid taking with CCBs? ANSWER: grapefruit juice (INHIBITOR) Can nifedipine be used to treat dysrhythmias? ANSWER: No Reflex tachycardia can occur with which CCB? ANSWER: Nifedipine What patient education should we provide when prescribing vasodilators? ANSWER: increased risks for falls, symptoms of hypotension (orthostatic) and advised to sit if these occurs common vasodilators medications ANSWER: ACE inhibitors such as benazepril (Lotensin®) or lisinopril (Prinivil®, Zestril®).

ARBs such as losartan (Cozaar®).

CCBs such as diltiazem (Cardizem®, Tiazac®).

Other direct vasodilators such as hydralazine (Apresoline®), minoxidil (Loniten®) or nitroglycerin (Nitrostat®).

What is minoxidil reserved for? ANSWER: severe hypertension what is the unique potential adverse effect of minoxidil? ANSWER: hypertrichosis (excessive growth of hair) Potential adverse effect of hydralazine ANSWER: acute rheumatoid syndrome resembles systemic lupus erythematosus (SLE)

Major cardiovascular risk factors of hypertension ANSWER: dyslipidemia, diabetes, advancing age, cigarette smoking, physical inactivity, family history, microalbuminuria What anti-hypertensives should be avoided in patients with HF? ANSWER: CCB What anti-hypertensives should be avoided or used with caution in patients with diabetes? ANSWER: thiazides, Lasix, BB(mask s/s hyperglycemia) Nearly all hypertensives interfere with what? ANSWER: sexual function Patient should be educated to hold medication if their heart rate is lower than what? ANSWER: heart rate less than 50 optimal digoxin plasma drug level range ANSWER: 0.5 to 0.8 ng/mL adverse effects of digoxin ANSWER: GI- anorexia, nausea, vomiting CNS- fatigue Visual disturbances **(appearance of halos around dark objects) dysrhythmias Black box warning for quinidine ANSWER: increase mortality in patients with a-flutter and a-fib black box warning for mexiletine ANSWER: increased risk for mortality when used to treat non-life threatening arrhythmias black box warning for amiodarone ANSWER: lung damage - resemble HF and pneumonia Amiodarone should NOT be taken with what? ANSWER: CYP3A4 inhibitors and grapefruit juice (levels can be increased) Are statins safe in pregnancy? ANSWER: No What can be used in pregnancy if needed? (related to statins and pregnancy) ANSWER: ezetimibe and fibrates At what time of day should statins be given and why? ANSWER: evening- cholesterol synthesis increases at night

adverse effects of statins ANSWER: rhabdomyolysis, hepatoxicity, new-onset diabetes What medications should be used cautiously with statins bc they can raise plasma levels? ANSWER: inhibitors of CYP3A4 (ex/ erythromycin, amiodarone, grapefruit) What are bile salts such as colesevlam used for? ANSWER: decrease LDL What is gemfibrozil used to treat ANSWER: decreases total glyiceride and raises HDL What is a major drug interaction with gemfibrozil (fibrate) ANSWER: warfarin (increases anti-coagulant effects) fibrates are contraindicated in what patients ANSWER: liver and gallbladder disease adverse effects of nitro ANSWER: headache, hypotension, and tachycardia (secondary to vasodilation) what medication is contraindicated when a patient is prescribed nitro? ANSWER: inhibitors of PDE-5 How can we prevent nitro tolerance? ANSWER: use lowest effective dosage and long term acting formulations (patches, sustained release) used on intermittent schedule allowing at least 8 drug free hours every day (usually at night) Warfarin MOA ANSWER: suppresses coagulation by decreasing production of four clotting factors, inhibits enzyme vit K from converting to active form INR target range for warfarin ANSWER: 2.5 to 3.5 patient education on warfarin ANSWER: bleeding - soft toothbrush, electric razor, avoid green leafy vegetables Beta-blockers use with nitroglycerin ANSWER: Beta Blockers suppress nitroglycerin induced tachycardia. They do so by preventing sympathetic activation of beta 1 adrenergic receptors on the heart.

Nitroglycerin lowers BP by reducing venous return and dilating arterioles. the lowered BP activates the baroreceptor reflex causing reflex tachycardia. Which will increase cardiac demand and negate the therapeutic effects of nitroglycerin. Txt with beta blocker can suppress the heart and slow the rate. no digoxin - increase contractility of heart

examples of beta blockers ANSWER: end in -lol/-olol Atenolol, bisoprolol, metoprolol, metoprolol succinate, Carvedilol, labetalol, nadolol, propranolol, and Sotalol (Betapace®) Risk of stopping beta blockers abruptly ANSWER: Stopping abruptly can increase the incidence and intensity of anginal attacks and may even precipitate MI What happens when beta blockers are given to someone with asthma? ANSWER: Beta blockers can increase airway reactivity and may interfere with the activity of betaagonists and can cause bronchospasms contraindications to thiazide diuretics ANSWER: Sulfa Allergy Pts w severe renal impairment and/or/cardiovascular issues History of gout diabetes hyperlipidemia Monitoring needs for diuretics ANSWER: weight vitals blood glucose BUN & creatinine/kidney function electrolytes - sodium, potassium, calcium, magnesium cardiac glycosides (Digoxin) ANSWER: increase the output force of the heart and increase its rate of contractions by acting on the cellular sodium-potassium ATPase pump Positive Inotropic action can increase myocardial contractile force.

Increase cardiac output.

Positive impact on neurohormonal systems.

Quinidine and digoxin - what happens when they are combined ANSWER: Quinidine can cause plasma levels of digoxin to rise by 1) displacing digoxin from tissue binding sites and 2) reducing renal excretion of digoxin. By elevating free levels of digoxin, quinidine can promote digoxin toxicity. The combo should be avoided Atherosclerotic Cardiovascular Disease (ASCVD) Risk Score What is it? ANSWER: ASCVD risk assessment is directed at determining the patient's absolute risk of developing clinical coronary disease over the next 10 years. Defines high risk as 7.5% or greater. a calculation of your 10-year risk of having a cardiovascular problem, such as a heart attack or stroke.

When is it used - ASCVD Risk Score ANSWER: In children a screening should be done between ages 9 and 11 and then again at ages 19 and

21. For adults every 5 years after the age of 20. Some people are at greater risk like those with diabetes and a risk score greater than 7.5% and should be screened more often ezetimibe- when can it be used? ANSWER: pregnancy/breastfeeding can be use in monotherapy or as adjunct therapy with a statin or a fibrate What is ezetimibe? ANSWER: Cholesterol Absorption Inhibitor- lowers cholesterol levels by decreasing the amount of cholesterol that is absorbed from the small intestine, so that there is less intestinal cholesterol delivered to the liver. Does not affect triglycerides lifestyle changes for high cholesterol ANSWER: Lifestyle changes are non drug measures used to lower LDL. Four main issues are diet, exercise, weight control, and smoking cessation If a patient wanted to minimize side effects, which drug classification is a good choice? ANSWER: Non-statins- fibrates, Ezetimibe, Bile acid sequestrants. Statins are generally well tolerated and side effects are uncommon. Some patients develop headache, flatulence, constipation, or GI disturbances, but these effects are usually mild and transient Therapeutic action of organic nitrates (nitroglycerin) ANSWER: direct relaxant effect on vascular smooth muscles, and the dilation of coronary vessels improves oxygen supply to the myocardium. The dilation of peripheral veins, and in higher doses peripheral arteries, reduces preload and afterload, and thereby lowers myocardial oxygen consumption. promote vasodilation Contraindications for ranolazine ANSWER: Agents that inhibit CYP3A4 can increase the levels of ranolazine and thereby increase the risk of torsades de pointes. These things include: grapefruit juice, HIV protease inhibitors, macrolide antibiotics, azole antifungal drugs, and some CCB. Most CCB but not amlodipine can increase levels of ranolazine. Drugs that prolong the QT interval can increase the risk of torsades de pointes. (quinidine, sotalol).

At what age can statins be prescribed? ANSWER: avoid statin use in children under the age of 10 CCB role with variant angina ANSWER: promote relaxation of coronary artery spasm, increasing cardiac oxygen supply what medication can be added for patients with worsening symptoms of HF? ANSWER: aldosterone antagonist- promotes myocardial remodeling and fibrosis, help with symptoms CCB stable angina ANSWER: promote relaxation of peripheral arterioles, decreasing afterload and reducing cardiac oxygen demand

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?

1. lets lower the dose and frequency of use 2. I will prescribe a BB to help with this 3. Next time this happens, lie down and practice deep breathing, this will bring your heart rate down ANSWER: 2- I will prescribe a BB to help with this What do CYP450 inhibitors and reducers do when not used correctly/what would patient experience? ANSWER: increased side effects, adverse reactions and toxicity A 55 year old male comes into the clinic with a gouty arthritis. He states that he has one flareup a year.

Your response is: 1. I will prescribe you glucocorticoids to help with inflammation 2. Lets start you on prophylactic therapy colchicine.

3. It will be helpful to take an NSAID to start with to help relive some inflammation. I'll prescribe naproxen. ANSWER: 3- in patients with infrequent flareups, being less than three per year, treatment of symptoms is all thats needed. NSAIDS are the first line agent for relieving pain of an acute gout attack.

A patient comes in stating that he tried NSAIDS to relieve a gouty attack but it hasnt helped. He asks, "what are my options?" He further states that he has attacks every few years but when he does NSAIDS do not help. Your response is: 1. I can prescribe a glucocorticoid (prednisone) and that will bring down the inflammation and pain.

2. Have your tried increasing your dosage of NSAIDS and drink plenty of water?

3. Lets start by making some changes in your diet, can you tell me what you eat regularly? ANSWER: 1 3- can also be correct but BEST answer Colchicine is considered for long term treatment if a person has how many gouty attacks per year? ANSWER: three or more Colchicine should not be taken with what medications? ANSWER: statins, CYP3A4 inhibitors adverse effects of colchicine ANSWER: nausea, vomiting, diarrhea, myelosuppression, myopathy, rhabdomyolysis what condition can develop with long term allopurinol ANSWER: SCAR (severe cutaneous adverse reaction - rash, fever, eosinophilia, liver and kidney function) What should be co-administered with febuxostat? ANSWER: NSAIDS or colchicine Complications of untreated gout ANSWER: Erosion and irreversible joint damage, renal damage, tophi (stone deposits in joints and tissues)

Alendronate patient education ANSWER: minimize risk of esophagitis by swallowing the pill whole with a full glass of water, then sit up for at least 30 min but 60 min preferred. intake of food prevents absorption, take this med 30 min prior to other intake Which dietary supplement interferes with Ibandronate absorption? ANSWER: calcium, magnesium, iron 1st line treatment of osteoporosis ANSWER: alendronate Is allopurinol safe to use in a patient with renal dysfunction? ANSWER: yes - drug of choice for patients with renal dysfunction or who over produce uric acid Baseline diagnostics for DMARDS ANSWER: CBC with WBC differential s/s of infection (TB and hepatitis) malignancies rule out pregnancy ALT, AST, serum creatinine comprehensive history and physical exam assess risk for immunocompetence and liver and renal status Baseline data for Methotrexate (DMARD) ANSWER: chest x-ray, emphasis on pulm and GI status which DMARD needs ophthalmologic and cardiac exam? ANSWER: hydroxychloroquine black box warning for Raloxifene ANSWER: risk for venous thromboembolic events (DVT, PE, stroke) Behaviors that should predict controlled substance addiction ANSWER: reinforcing properties of drugs - pleasurable (euphoria) or reduce unpleasant experience (reduce anxiety and stress physical dependence physiological dependence (well-being depends on drug) social factors (peer pressure) drug availability (Drugs in hospitals - reason for nurses or pharmacist abuse) vulnerability of individual impulsive low tolerance for frustration rebellious against social norms depressive, anxiety, and anti-social personality disorders abuse other drugs

Treatment of chronic pain with pregabalin ANSWER: adjuvant analgesic for neuropathic pain Effective in diabetic neuropathy, seizures, central neuropathy, postherpetic neuralgia, and fibromyalgia adverse effects of pregabalin ANSWER: Sedation/drowsy, dizziness, and ataxia, blurred vision, difficulty thinking GI bleeding is linked to ANSWER: COX-2 inhibitors and NSAID patient education with colchicine ANSWER: only when needed to relieve an attack: Start taking this medicine at the first sign of the attack for best results. Stop taking this medicine as soon as the pain is relieved or at the first sign of nausea, vomiting, stomach pain, or diarrhea. longer you wait to start with attack, less effective it might be Which drugs are high risk in pregnancy with RA? ANSWER: methotrexate leflunomide biologics: anti-TNF agents, rituximab and abatacept (end in -mab) Which drugs are safe for pregnancy with RA ? ANSWER: NSAIDs, corticosteroids, plus several DMARDs, including sulfasalazine and hydroxychloroquine NSAID black box warning ANSWER: NSAIDs may increase the risk for myocardial infarction, stroke, and other thromboembolic events. NSAIDs increase the risk for dangerous gastrointestinal adverse effects such as bleeding, ulceration, and perforation.

Drug interactions with Allopurinol ANSWER: Mercaptopurine and azathioprine (immunosuppressants) warfarin Theophylline Ampicillin therapeutic response for methotrexate ANSWER: If you are taking methotrexate to treat rheumatoid arthritis, it may take 3 to 6 weeks for your symptoms to begin to improve, and 12 weeks or longer for you to feel the full benefit of methotrexate.

Continue to take methotrexate even if you feel well. adverse effects for bisphosphonates ANSWER: osteonecrosis of the jaw and hip fracture, Esophagitis When are bisphosphonates contraindicated? ANSWER: esophageal disorders cr below 30 -35

therapeutic action of NSAIDS ANSWER: relieve pain/discomfort, reduce inflammation, and bring down a high temperature.

MOA NSAIDS ANSWER: inhibition of the enzyme cyclooxygenase (COX), decreased synthesis of prostaglandins Women who have hypertension and osteoporosis should be prescribed which antihypertensive? ANSWER: thiazide diuretic Drug interactions with NSAIDS ANSWER: other NSAIDS, alcohol, warfarin (blood thinners), ACE inhibitors and diuretics Rules for prescribing schedule II drugs ANSWER: written in ink, can write in emergency cases but must submit within 72 hour, no refills, can have multiple scripts by different MDs Depends on state