NAPLEX Review

Prepared by a 2006 graduate. A must study document. I have done light editing to add som e new
drugs and correct a few misspellings.

AIDS:
Initial treatm ent: NNRTI + 2 NRTIs or PI + 2 NRTIs

NRTIs:
a. MOA: interfere with HIV viral RNA-dependent DNA polym erase, resulting in chain termination
& inhibition of viral replication
b. Class toxicities:
i. Lactic acidosis, severe hepatom egaly with steatosis
ii. Most require renal dosing (except abacavir)
c. Do not use lam ivudine & emtricitabine together (chemically sim ilar)
d. Do not use zidovudine with stavudine together (both require thym idine for activation)
e. Do not use didanosine with stavudine during pregnancy (increased risk of lactic acidosis & liver
dam age)
f. The “D” drugs cause pancreatitis & peripheral neuropathy & lactic acidosis
i. ddI (didanosine), d4T (stavudine), ddC (zalcitabine)
g. Low pill burden
h. All are prodrugs requiring 2-3 phosphorylations for activation
i. Zidovudine (Retrovir):
i. AZT, ZDV
ii. SE: bone marrow suppression, GI intolerance
iii. Dosage forms available: IV, 200 m g (10 m g/m L); syrup 50 m g/5 m L in 240 m L; capsule,
100 m g & tablet 300 m g
j. Lam ivudine (Epivir):
i. 3TC
ii. Minim al toxicity
k. Abacavir (Ziagen):
i. ABC
ii. SE: hypersensitivity reaction that can be fatal with rechallenge
l. Didanosine (Videx, Videx EC):
i. ddI
ii. Take ½ hour before or 2 hours after m eals (em pty stom ach)
iii. SE: pancreatitis, peripheral neuropathy
m. Stavudine (Zerit):
i. D4T
ii. SE: pancreatitis, peripheral neuropathy
n. Zalcitabine (Hivid):
i. ddC
ii. SE: pancreatitis, peripheral neuropathy
o. Tenofovir (Viread):
i. TDF
ii. SE: renal insufficiency, Fanconi syndrom e
p. Em tricitabine (Em triva):
i. FTC
ii. Minim al toxicity
q. Com bination products:
i. Zidovudine 300 m g + lam ivudine 150 m g (Com bivir)
ii. Zidovudine 300 m g + lam ivudine 150 m g + abacavir 300 m g (Trizivir)
iii. Tenofovir 300 mg + emtricitabine 200 mg (Truvada)
iv. Lam ivudine 300 m g + abacavir 600 m g (Epzicom )

2. NNRTIs:
a. MOA: bind to reverse transcriptase at a different site than the NRTIs, resulting in inhibition of
HIV replication
b. Class toxicities: rash & hepatoxicity
 c. All should be dosed for hepatic im pairm ent
d. Most are affected by food (except efavirenz)
e. Efavirenz is CI in pregnancy
f. Efavirenz (Sustiva):
i. EFV
ii. Take on an empty stomach
iii. SE: CNS side effect; false + cannabinoid test
g. Nevirapine (Viram une):
i. NVP
ii. Autoinducer
iii. SE: rash, sym ptom atic hepatitis, including fatal hepatic necrosis
h. Delavirdine (Rescriptor):
i. DLV
ii. SE: rash, increased LFTs

3. PIs:
a. MOA: inhibit protease, which then prevents the cleavage of HIV polyproteins & subsequently
induces the formation of im m ature noninfectious viral particles
b. All should be dosed for hepatic im pairm ent
c. Most should be taken with food (except am prenavir & indinavir)
d. Amprenavir & fosam prenavir are chemically sim ilar- avoid com bination
e. Atazanavir & indinavir require norm al acid levels in stomach for absorption
f. Ritonavir is the most potent
g. Lopinavir/ritonavir, ritonavir, & saquinavir gel caps require refrigeration
h. Class toxicities: lipodystrophy, hyperglycem ia, hyperlipidem ia, hypertriglyceridem ia, bleeding
in hem ophiliace, osteonecrosis & avascular neocrosis of the hips, osteopenia & osteoporosis
i. All are CYP3A4 inhibitors
j. Lopinavir + ritonavir (Kaletra):
i. SE: GI intolerance
ii. Refrigerate caps stable until date on label; stable for 2 m onths at room temperature
iii. Can cause hyperglycem ia
k. Atazanavir (Reyataz):
i. ATV
ii. SE: increased indirect hyperbilirubinemia, prolonged PR interval
l. Fosam prenavir (Lexiva):
i. f-APV
ii. SE: rash
iii. Sulfonam ide
iv. Oral solution contains propylene glycol
m . Am prenavir (Agenerase):
i. APV
ii. SE: rash
iii. Sulfonam ide
iv. Avoid high fat meal
n. Saquinavir:
i. SQV-hard gel cap (HGC)- (Invirase):
(1) SE: GI intolerance
(2) Room temperature
ii. SQV- soft gel cap (SGC)- (Fortovase):
(1) SE: GI intolerance
(2) Refrigerated caps stable until date on label; stable for 3 m onths at room temperature
iii. HGC & SGC are not bioequivalent & should not be interchanged
o. Nelfinavir (Viracept):
i. NFV
ii. SE: diarrhea
iii. Needs 500 kCal of food for absorption; take after eating
p. Ritonavir (Norvir)
i. RTV
ii. SE: GI intolerance
 iii. Refrigerated caps stable for 1 m onth at room tem p
q. Indinavir (Crixivan):
i. IDV
ii. SE: nephrolithiases- drink at least 48 oz. daily to prevent
iii. Take on an empty stomach

4. Fusion inhibitors:
a. MOA: binds to gp41 on HIV surface, which inhibits HIV binding to CD4 cell
b. Enfuvirtide (Fuzeon)
i. T20
ii. Salvage regim ens
iii. Reconstituted form should be stored in the refrigerator- stable for 24 hours

5. Those available as suspensions: Nevirapine

6. Those available as a syrup or oral solution: Epivir, Ziagen, Videx, Kaletra, Agenerase, Viracept,
Norvir

7. Post-exposure Prophylaxis (PEP):

a. Start therapy within 1-2 hours of exposure
b. Length of therapy is 4 weeks
c. Treatment options:
i. AZT 200 mg po Q8h or 300 m g po Q12h AND 3TC(lam ivudine) 150 mg po Q12h
ii. AZT 200 mg po Q8h or 300 m g po Q12 + 3TC 150 m g po Q12h + Indinavir 800 mg Q8h
(1) OR Nelfinvir 750 mg po Q8h or 1250 mg Q12h

8. PCP treatm ent:

a. A protozoan, but may be more closely related to fungi
b. Treat when CD4+ cells fall below 200
c. DOC: trim ethoprim -sulfam ethoxazole (Bactrim DS) DS po QD
d. Alternatives:
i. TMP + dapsone
ii. Atovaquone (Mepron)
iii. Pentamidine (NebuPent; Pentam-300)
(1) Comes as injection & powder for nebulization
iv. Clindam ycin + prim aquine
v. Trim etrexate (NeuTrexin) + folinic acid
e. Treatm ent for PCP also covers prophylaxis for: toxoplasm osis

9. Macobacterium avium com plex (MAC):

a. Treat when CD4+ cells fall below 50/m m 3
b. DOC is azithromycin 1200 mg po Q week

10. CMV: Cytom egalovirus

a. Ganciclovir (Cytovene, Vitrasert):
i. Use: treatment of CMV retinitis in im m unocom prom ised individuals, including patients
with AIDS
ii. CI: ANC <500/m m 3 or PLT <25,000/m m 3
iii. Dosage forms:
(1) Capsule (Cytovene)
(2) Im plant, intravitreal (Vitrasert)- 4.5 m g released gradually over 5-8 m onths
(3) Injection, powder for reconstitution
(a) Should be prepared in a vertical flow hood
(b) Reconstitute powder with sterile water NOT bacteriostatic water because parabens
m ay cause precipitation

Alzheim er’s Disease:

1. Donepezil (Aricept):
a. Cholinesterase inhibitor
 b. M OA: reversibly & noncom petitively inhibits centrally active acetylcholinesterase, the enzyme
responsible for hydrolysis of acetylcholine
c. Available dosage form s: tablets, ODT
d. Max dose: 10 mg QD

2. Galantam ine (Razadyne, Razadyne ER, Rem inyl-old nam e):

a. Acetylcholinesterase inhibitor
b. Max dose:
i. IR tablet or solution: 24 mg/day (in 2 divided doses)
ii. ER capsule: 24 mg/day

3. Mem antine (Nam enda):

a. Low affinity, non-competitive, voltage dependent NMDA receptor antagonist
b. Neuroprotective
c. Less cognitive decline & im proves cognition in im paired patients
d. After depolarization, Nam enda leaves the site & allows sodium & calcium entry into the cell
e. Behaves like magnesium
f. Approved for moderate to severe Alzheim er’s Disease

4. Rivastigm ine (Exelon):

a. Acetylcholinesterase inhibitor (central)
b. M OA: increases acetylcholine in the CNS through reversible inhibition of its hydrolysis by
cholinesterase
c. SE: GI upset (titrate slowly to avoid)
d. Dosage forms: capsules & solution

Anem ia:
Folic acid deficiency would also be called: m acrocytic anem ia or increased m ean corpuscular volume
5. Macrocytic (large cell):
a. Megaloblastic:
i. Vitam in B 1 2 deficiency
(1) Lack of intrinsic factor results in pernicious anem ia
ii. Folic acid deficiency dec Hct, Hgb, RBC, inc MCH; Norm ochrom ic, norm ocytic
b. Aplastic anem ia
c. Anem ia of chronic disease

6. Hypochrom ic (low hem oglobin content), m icrocytic (sm all cell):

a. Iron deficiency
i. Inc TIBC, dec MCV, MCH, MCHC, Hgb
b. Genetic anom alies: Sickle cell anem ia, thalassem ia

7. Treatment:
a. Darbepoetin Alpha (Aranesp):
i. Recom binant hum an erythropoietin
ii. Caution in patients with HTN or with a hx of seizures
(1) Can cause hypo- or hypertension
iii. Available as an injection
b. Epoetin Alpha (Epogen, Procrit):
i. Colony stim ulating factor
ii. Onset of action: several days
iii. Peak effect: 2-3 weeks
iv. SQ 1-3X per week
v. SE: HTN

Antidotes:
1. Acetaminophen overdose:
a. Antidote: Acetylcysteine (Mucom yst, Acetadote):
i. MOA: thought to reverse APAP toxicity by providing substrate for conjugation with the toxic
m etabolites
 ii. Dose: oral- 140 mg/Kg followed by 17 doses of 70 m g/Kg Q4h; repeat dose if em esis occurs
within 1 hour of adm inistration

2. Albuterol overdose:
a. Antidote: propranolol or beta blocker

3. Anticholinergic overdose:
a. Antidote: Physostigm ine (Antilirium ):
i. Do not use if solution is cloudy or dark brown

4. Arsenic overdose:
a. Antidote: Succim er (Chem et) or dim ercaprol (British anti-lewisite, BAL in oil)

5. Benzodiazepine overdose:
a. Antidote: flumazenil (Rom azicon)
b. â-blocker overdose: beta-stim ulant (Isoproterenol) and glucagon (GlucaGen)

6. CCB overdose:
a. Antidote: calcium chloride 10% or glucagon (GlucaGen)

7. Carbam ates overdose:

a. Antidote: atropine

8. Coumadin overdose:
a. Antidote: Vitam in K 1 or phytonadione (M ephyton, AquaM EPHYTON); fresh frozen plasma
b. Dosage forms available for phytonadione: injection & tablet

9. Digoxin overdose:
a. Antidote: digoxin im m une antibody fragment (Digibind, DigiFab)

10. Ethylene glycol (Antifreeze) overdose:

a. Antidote: ethyl alcohol; fomepizole (Antizol); pyridoxine (Am inoxin-OTC); sodium bicarbonate

11. Heparin overdose:

a. Antidote: protam ine sulfate

12. Iron overdose:

a. Antidote: deferoxam ine (Desferal)
b. Antidote: Polyethylene glycol (high m olecular weight)
c. Lethal dose of iron is 180-300 m g/Kg

13. Isoniazid overdose:

a. Antidote: pyridoxine (Vitam in B 6 )

14. Lead overdose:

a. Antidotes:
i. Succim er (Chem et)
ii. Dim ercaprol; also called British anti-lewisite (only for lead encephalopathy)
iii. Calcium disodium EDTA (calcium disodium versenate)

15. Leucovorin:
a. Antidote for folic acid antagonists (m ethotrexate, trim ethoprim, pyrim etham ine)
b. W ater soluble vitam in

16. Magnesium overdose:

a. Death due to muscle relaxation (includes heart failure)
b. Antidote: calcium

17. Methanol or Ethylene glycol overdose:

 a. Antidote: Ethanol 10%
b. Antidote: Fom epizole (Antizol)
i. AKA: 4-methylpyrazole or 4-MP
ii. MOA: com petitively inhibits alcohol dehydrogenase, an enzym e which catalyzes the
m etabolism of ethanol, ethylene glycol, & m ethanol to their toxic metabolites
iii. ?Decreases m etabolism of m ethanol (prevents m etabolism )

18. Methem oglobinem ia overdose:

a. Antidote: methylene blue

19. Opioid overdose:

a. Antidote: Naloxone (Narcan)
i. MOA: opioid antagonist that com petes at all three CNS opioid receptors (m u, kappa, delta)
b. Antidote: Nalm efene (Revex)

20. Organophosphates overdose:

a. Antidote: atropine or pralidoxim e (Protopam )

21. Salicylate overdose:

a. Antidote: sodium bicarbonate

22. TCAs overdose:

a. Antidote: sodium bicarbonate

23. Type Ia antiarrhythm ics overdose:

a. Antidote: sodium bicarbonate

24. Vecuronium overdose: and other nondepolarizing neurom uscular blockers

a. Antidote: edrophonium (Enlon, Reversol)

Asthm a:
1. Drugs available for nebulization:
a. Budesonide 0.25 & 0.5 mg (Pulmicort Respules®)
i. Shake well before using
ii. Use with jet nebulizer connected to an air com pressor
iii. Adm inister with a m outhpiece or facem ask
iv. Do not use with an ultrasonic nebulizer
v. Do not mix with other medications
vi. Rinse mouth after use
b. Cromolyn (Intal®)
i. Mast cell stabilizer
ii. Use: adjunct in the prophylaxis of allergic disorders, including asthm a; prevention of
exercise-induced bronchospasm
(1) Nasal: for prevention & treatm ent of seasonal & perennial allergic rhinitis
c. Albuterol
d. Ipratropium
e. Ipratropium & Albuterol

2. Drugs available as M DI:

a. Beclom ethasone HFA 40 mcg/puff & 80 m cg/puff (QVAR®)
b. Flunisolide 250 mcg/puff (Aerobid®)
c. Fluticasone 44, 110, 220 mcg/puff (Flovent®)
d. Cromolyn (Intal®)
e. Nedocrom il (Tilade®)
f. Albuterol (Proventil®, Ventolin®)
g. Pirbuterol (Maxair Autohaler®)
h. Ipratropium (Atrovent®)
i. Ipratropium & Albuterol (Com bivent®)
3. Drugs available as turbuhaler:
a. Budesonide 200 mcg/inhalation (Pulm icort® Respules)
i. Inhaler should be shaken well im m ediately prior to use

4. Drugs available for dry powder inhalation (DPI):

a. Fluticasone (Flovent Rotadisk®)
b. Fluticasone-salm eterol (Advair Diskus®)
c. Form oterol (Foradil Aerolizer®)
d. Salm eterol (Servent Diskus®)
i. Stable for 6 weeks after removing foil
ii. 1 inhalation BID

5. Drugs available as M DI/spacer:

a. Triam cinolone 100 mcg/puff (Azm acort®)

6. Class of drugs to use to prevent a child allergic to pollen from having an asthm a attack- could use
antihistam ines, cromolyn or inhaled corticosteroids

7. A patient would m onitor their asthma from hom e with a peak flow m eter which measures the FEV 1
a. Goal: 80% of personal best
b. Green zone (80-100% ), yellow zone (50-79% ), & red zone (<50% )

8. Montelukast (Singulair):
a. MOA: selective leukotriene receptor antagonist that inhibits the cysteinyl leukotriene receptor
b. Use: asthm a & allergies
i. NOT for COPD
c. Dosing;
i. 6-23 m onths: 4 m g oral granules
ii. 2-5 years: 4 m g chewable tablet or oral granules
iii. 6-14 years: 5 mg chewable tablet
iv. >15 years: 10 mg tablet
v. Take in evening
d. Granules must be used within 15 m inutes of opening

9. Zafirlukast (Accolate):
a. MOA: selectively & com petitive leukotriene-receptor antagonist of leukotriene D4 & E4
b. Use: prophylaxis & chronic treatm ent of asthm a in adults & children >5 years old
c. Dose: 20 mg BID
d. Administer 1 hour before or 2 hours after m eals
e. Monitor: LFTs
f. Extensively hepatically metabolized via CYP2C9
g. Tablets only

10. Theophylline:
a. 0.80 Aminophylline x 0.8 = Theophylline
b. SE:
i. 15-25 mcg/m L: GI upset, N/V/D, nervousness, headache, insom nia, agitation, dizziness,
m uscle cram p, trem or
ii. 25-35 mcg/mL: tachycardia, occasional PVC
iii. > 35 mcg/m L: ventricular tachycardia, frequent PVC, seizure
c. Theophylline + erythromycinà increased levels of theophylline
d. DI with cim etidine

11. A patient who has had too much albuterol could be given a cardioselective beta blocker

Bioterrism :
1. Ebola: virus; no cure
2. Anthrax: bacteria (aerobic, gram + bacillus); ciprofloxacin or doxycycline for 60 days
Benign Prostatic Hypertrophy (BPH):
1. Tamulosin (Flom ax) & Alfuzosin (Uroxatrac):
a. Greater affinity to alpha-1 in prostate
b. Less SE
c. W ork quickly for instant relief

2. Finasteride (Proscar/Propecia) & Dutasteride (Avodart):

a. Great for a large prostate
b. Take longer to work
c. Proscar M OA: a com petitive inhibitor or both tissue & hepatic 5-alpha reductace; this results
in the inhibition of the conversion of testosterone to dihydrotestosterone & markedly suppresses
serum dihydrotestosterone levels

3. Doxazosin (Cardura) & terazosin (Hytrin) also used for BPH

4. Saw palm etto – advertised but has failed in good clinical trials

Cancer:
1. Chem o drugs that should be refrigerated: cyclophospham ide (after reconstitution)

2. Antim etabolites:
a. Pyrim idine analogs: interfere with the synthesis of pyrim idine bases & thus DNA synthesis
i. Can cause mucositis
ii. Capecitabine (Xeloda)
iii. Fluorouracil; 5-FU (Adrucil)
iv. Cytarabine (Cytosar)
v. Gem citabine (Gem zar)
vi. AE: m ucositis
b. Folic acid analog: interferes with synthesis of pyrim idine bases & thus DNA synthesis
i. Methotrexate
(1) After reconstitution with preservative: may refrigerate
(2) AE: m yleosuppression, N/V, m ucositis
c. Purine analogs: interfere with synthesis of purine bases & thus DNA synthesis
i. Mercaptopurine (Purinethol)
(1) DI with allopurinol
ii. Thioguanine (Tabloid)
iii. Fludarabine (Fludara)
iv. Cladribine (Leustatin)
v. Pentostatin (Nipent)

3. Plant alkaloids:
a. Vinca alkaloids: bind to tubulin to prevent form ation of m icrotubules during m itosis
i. Fatal if administered intrathecally
ii. Vincristine (Oncovin):
(1) Neurotoxic
(2) Can cause a decrease in sensation reflexes
iii. Vinblastine (Velban)
iv. Vinorelbine (Navelbine)
v. AE: neuropathy
b. Podophyllotoxins: bind to tubulin, inhibiting topoisom erase II to cause DNA strand breaks
i. Etoposide; VP-16 (VePesid)
ii. Teniposide (Vumon)
iii. AE: myelosuppression, neuropathy
c. Taxanes: bind to tubulin, prom otes synthesis of nonfunctional m icrotubules
i. Paclitaxel (Taxol)
(1) Use a in-line filter; non-PVC
ii. Docetaxel (Taxotere)
iii. AE: m yelosuppression, alopecia
 d. Cam ptothecins: inhibits topoisom erase I, stabilizing single-strand breaks in DNA
i. Irinotecan (Cam ptosar)- *Diarrhea*
ii. Topotecan (Hycam tin)
iii. AE: m yelosuppression, alopecia

4. Alkylating Agents: cross-link between DNA bases or between DNA strands to inhibit DNA replication
a. Nitrogen Mustard Derivative:
i. Mechloretham ine (Mustargen)
ii. Melphalan (Alkeran)
iii. Chloram bucil (Leukeran)
iv. Cyclophospham ide (Cytoxan)
v. Ifosfam ide (Ifex)
vi. AE: myelosuppression
vii. Mesna is given with cyclophospham ide & ifosfam ide to prevent hem orrhagic cystitis
b. Other:
i. Carm ustine (BiCNU)
ii. Lom ustine (CeeNU)
iii. Stretozocin (Zanosar)
iv. Thiotepa (Thiopex)
v. Busulfan (Myleran)
vi. Dacarbazine (DTIC)

5. Antitum or antibiotics:
a. Anthracycline:
i. Cardiotoxic: 450-550 mg/m 2 cum ulative lifetim e dose
ii. Doxorubicin (Adriam ycin):
(1) MOA: appears to directly bind to DNA & inhibit DNA repair (via topoisom erase II
inhibition) resulting in the blockade of DNA & RNA synthesis & fragm entation of DNA
(2) Turns urine & all other body fluids red
(3) SE: myelosupression, cardiotoxicity, extravasation
(4) Decrease dose in renal im pairm ent
iii. Daunorubicin (Cerubidine)
iv. Idarubicin (Idam ycin)
v. Mitoxantrone (Novantrone)
vi. AE: myelosuppression
b. Other:
i. Mitom ycin C (Mutam ycin)
ii. Bleomycin (Blenoxane)

6. Heavy M etals:
a. Cisplatin (Platinol)
b. Carboplatin (Paraplatin)
c. Oxaliplatin (Eloxatin)
d. AE: m yelosuppression, neuropathy

7. Antiandrogens: inhibit uptake & binding of testosterone & dihydrotestosterone in prostatic tissue
a. Flutam ide (Eulexin)
b. Bicalutam ide (Casodex)
c. Nilutam ide (Nilandron)
d. AE: diarrhea

8. Progestins: suppress release of LH & increase estrogen m etabolism (decrease available estrogen for
estrogen-dependent tum ors)
a. Megestrol (Megase): also used to stim ulate appetite
b. Medroxyprogesterone (Provera)

9. Estrogens: estram ustine is com bination of estrogen plus nitrogen m ustard; estrogen facilitates
uptake, nitrogen mustard released to alkylate cancer cells
a. Estram ustine (Em cyt)
10. Antiestrogens: bind to estrogen receptor in breast tissue, preventing binding by estrogen & thereby
reducing estrogen-stim ulated tum or growth
a. Tam oxifen (Nolvadex): can cause bone pain
b. Torem ifine (Fareston)

11. Gonadotropin-releasing horm one analogs: turn off negative-feedback release of FSH & LH, reducing
testosterone & estrogen production in testes & ovaries
a. Leuprolide (Lupron (breast/prostate); Eligard (prostate); Viadur (prostate))
i. MOA: potent inhibitor of gonadotropin secretion; continuous daily adm inistration results
in suppression of ovarian & testicular steroidogenesis due to decreased levels of FSH & LH
with subsequent decreases in testosterone & estrogen levels
b. Goserelin (Zoladex)

12. Aromatase inhibitors: blocks enzym e responsible for conversion of circulating androgens to
estrogens
a. Anastrazole (Arim idex):
i. For breast cancer
ii. Can increase LDL
iii. Cannot use with Tam oxifen
iv. AE: vasodilation, headache, pain, depression, hot flashes, HTN, osteoporosis
b. Letrozole (Femara)
c. AE: diarrhea

13. Other m iscellaneous agents for cancer:

a. Asparaginase (Elspar)
b. Hydroxyurea (Hydrea)
c. Tyrosine kinase inhibitors:
i. Imatinib m esylate (Gleevec)
ii. Erlotinib (Tarceva)
iii. Gefitinib (Iressa)
d. 26S Proteasom e inhibitor:
i. Bortezomib (Velcade)
e. Biological Response Modifiers
i. Imm une therapies:
(1) Aldesleukin (Proleukin)
(2) Interferon-alpha 2b (Intron A)
(3) Levam isole (Ergam isol)
f. Monoclonal antibodies:
i. Rituxim ab (Rituxan)
ii. Trastuzum ab (Herceptin): works at HER-2 receptor
iii. Gemtuzum ab (Mylotarg)
iv. Alem tuzumab (Cam path)
v. Bevacizumab (Avastin)
vi. Cetuxim ab (Erbitux)
vii. Denileukin diftitox (Ontak)
viii. Ibritumom ab tiuxetan (Zevalin)
ix. Tositum omab (Bexxar)

14. Colony Stim ulating Factors:

a. Filgastrim (Neupogen):
i. MOA: granulocyte colony stim ulating factor (G-CSF); stimulation of granulocyte production
in patients with malignancies
ii. Increases production of neutrophils
iii. Does not cause agraulocytosis— used to treat it
iv. SE: bone pain
v. Store in refrigerator
vi. Injection
 b. Pegfilgrastim (Neulasta):
i. MOA: stim ulates the production, m aturation, & activation of neutrophils; activates
neutrophils to increase both their migration & cytotoxicity
ii. Prolonged duration of effect relative to filgastrim & reduced renal clearance
iii. Store in refrigerator
iv. SE: bone pain
v. Injection

15. Octreotide (Sandostatin):

a. Som atostatin analog
b. Use: antidarrheal agent for diarrhea secondary to cancer
c. MOA: mim ics natural som atostatin by inhibiting serotonin release, & the secretion of gastrin,
VIP, insulin, glucagons, secretin, m otilin & pancreatic polypeptide
d. Dosage form s available: injection only

16. High emetic potential:

a. Cisplatin, cyclophospham ide, cytarabine, dacarbazine, ifosfam ide, m elphalan, m itomycin,
m echloretham ine

17. Prevention of Acute Chem otherapy-Induced N/V:

a. 5-HT 3 receptor antagonist:
i. Dolasetron (Anzem et)
ii. Granisetron (Kytril)
iii. Ondansetron (Zofran)
iv. Palonosetron (Aloxi)
b. Phenothiazines:
i. Prochlorperazine (Compazine)
ii. Chlorprom azine (Thorazine)
iii. Prom ethazine (Phenergan)
c. Butyrophenones:
i. Droperidol (Inapsine)
ii. Haloperidol (Haldol)
d. Corticosteroids:
i. Dexam ethasone (Decadron)
e. Cannabinoids:
i. Dronabinol (Marinol)
f. Benzodiazepines:
i. Lorazepam (Ativan)
g. Benzam ides:
i. Metoclopram ide (Reglan)
h. Neurokinin-1 Antagonist:
i. Aprepitant (Em end):
(1) Substance P/neurokinin 1 receptor antagonist
(2) Uses: prevention of acute & delayed N/V associated w ith highly-emetogenic
chem otherapy in com bination with a corticosteroid (i.e. dexam ethasone) & 5-HT 3
(ondansetron) receptor antagonist
(3) Avoid with grapefruit juice (CYP3A4)
(4) MOA: prevents acute & delayed vom iting by selectively inhibiting the substance
P/neurokinin 1 (NK 1 ) receptor
(5) Dose: oral: 125 mg on day 1, followed by 80 m g on days 2 & 3
(a) 1 st dose should be given 1 hour prior to chemotherapy
Cardiology:
1. Angiotensin Converting Enzym e Inhibitors (ACEIs):
a. Benazepril (Lotensin)
b. Captopril (Capoten):
i. Used to decrease the progression of CHF
ii. SE: rash, hyperkalemia, angioedema, cough
iii. Strengths:
(1) Tablets: 12.5, 25, 50, & 100 m g
 iv. Dosed BID-TID
c. Enalapril (Vasotec):
i. Enalaprilat (Vasotec): only ACEI available as IV
(1) 1.25 m g/dose given over 5 m inutes Q6 hours
ii. 40 mg/day m ax dose
d. Fosinopril (Monopril)
e. Lisinopril (Prinvil, Zestril)
f. Moexipril (Univasc)
g. Perindopril (Aceon)
h. Quinapril (Accupril)
i. Ram ipril (Altace)
j. Trandolapril (Mavik)
k. Proven to decrease mortality in CHF
l. Ineffective as monotherapy in African Americans
m. MOA: inhibit the conversion of angiotensin I to angiotensin II (a potent vasoconstrictor)
n. SE: increased SCr, cough, angioedem a, sexual dysfunction, hyperkalemia, rash
o. CI: bilateral renal artery stenosis; pregnancy
p. DI: aspirin (high doses); rifam pin; antacids (m ore likely with captopril- separate adm inistration
by 1-2 hours); NSAIDS; probenecid (captopril); lithium ; allopurinol

2. Alpha agonists:
a. MOA: causes decreased sym pathetic outflow to the cardiovascular system by agonistic activity
on central á-2 receptors
b. Clonidine (Catapres)
i. More withdrawal
ii. Unlabeled use: heroin or nicotine withdrawal
c. Guanabenz (W ytensin)
d. Guanfacine (Tenex)
i. Less withdrawal
e. Methyldopa (Aldom et)
f. SE: sedation, dry m outh, bradycardia, withdrawal HTN, orthostatic hypotension, depression,
im potence, sleep disturbances

3. Alpha blockers:
a. MOA: blocks peripheral á-1 postsynaptic receptors, which causes vasodilation of both arteries
& veins (indirect vasodilators)
b. Causes less reflex tachycardia than direct vasodilators (hydralazine/m inoxidil)
c. Dosazosin (Cardura)
d. Prazosin (Minipress)
e. Terazosin (Hytrin)
f. Counseling: take 1 st dose at bedtim e, m ay cause dizziness
g. SE: weight gain, peripheral edem a, dry m outh, urinary urgency, constipation, priapism,
postural hypotension
i. No effects on glucose or cholesterol

4. Anti-arrhythm ic Drugs:
a. Arrhythm ias:
i. A. Fib or flutter: DOC- digitalis glycoside; alternative- verapam il or propranolol
ii. Supraventricular tachycardia: DOC- verapam il or adenosine; alternative- diltiazam or
procainam ide
iii. Ventricular prem ature complexes: DOC- beta blocker; alternative- beta blocker
iv. Ventricular tachycardia: DOC- beta blocker; alternative- am iodarone
v. Ventricular fibrillation: DOC- am iodarone; alternative- beta blocker
vi. Digoxin-induced tachyarrhythm ia: DOC- lidocaine; alternative- phenytoin
vii. Torsades de pointes: DOC- m agnesium ; alternative- beta blocker
viii. Class IA: inhibit fast Na channels
(1) Quinidine
(a) SE: Cinchonism
(2) Procainam ide (Pronestyl)
 (a) SE: lupus-like syndrom e
(3) Disopyram ide (Norpace)
ix. Class IB: inhibit fast Na channels
(1) Lidocaine (Xylocaine):
(2) Phenytoin (Dilantin)
(a) SE: nystagm us
(3) Tocainide (Tonocard)
(4) Mexiletine (Mexitil)
x. Class IC: inhibit fast Na channels
(1) Moricizine (Ethm ozine)
(2) Flecainide (Tam bocor)
(3) Propafenone (Rhythm ol)
xi. Class II: beta-adrenergic agents
(1) Propranolol (Inderal)
(2) Esm olol (Brevibloc)
(3) Acebutolol (Sectral)
xii. Class III: prim arily block K channels
(1) Bretylium (Bretylol)
(2) Am iodarone (Cordarone®):
(a) SE:
(i) IV: phlebitis
(ii) General: corneal microdeposits, photophobia, 8LFTs, photosensitivity, blue-
gray skin discoloration, pulm onary fibrosis (reduced at low doses- 300 m g/d;
increases as dose increases), hyper- or hypothyroidism , polyneuropathy
(b) W atch for iodine allergy
(c) Avoid grapefruit juice
(d) Prior to use: check thyroid levels, eye exam
(3) Ibutilide (Corvert)
(4) Sotalol (Betapace)
(5) Dofetilide (Tikosyn)
(a) SE: torsades de pointes
xiii. Class IV: calcium channel antagonists
(1) Verapam il (Isoptin, Calan)

5. Anticoagulation:
a. Direct thrombin inhibitors:
i. Argatroban:
(1) A synthetic molecule that reversibly binds to throm bin
(2) Elim inated by the liver
(3) Use if renal im pairm ent
ii. Lepirudin (Refludan):
(1) Recom binant DNA-derived polypeptide nearly identical to hirudin
(2) Produces an anticoagulant effect by binding directly to throm bin & does not require
AT to produce it effect
(3) Does not bind to other proteins as heparin does
(4) Elim inated by the kidneys
(5) Use if liver im pairm ent
b. Enoxaparin (Lovenox):
i. Low molecular weight heparin
ii. MOA: inhibits factor Xa greater than IIa
iii. Dosing:
(1) DVT prophylaxis: 40 m g QD or 30 m g BID
(2) DVT treatm ent: 1 mg/Kg/dose Q12 hours or 1.5 m g/Kg/dose QD
iv. Monitor: anti-Xa, platelets
c. Heparin:
i. MOA: potentiates the action of antithrom bin III & prevents the conversion of fibrinogen to
fibrin
ii. Dosing:
(1) DVT prophylaxis: 5000 units SQ Q8-12 hours
 (2)IV infusion: 10-30 units/Kg/hr
(3)Line flushing: 10 units/m L for infants (<10 Kg); 100 units/m L for older infants,
children & adults
iii. Monitor: PTT (1.5-2X the upper lim it of control; 50-70 sec), platelets

d. W arfarin (Coumadin, Jantoven)

i. MOA: inhibits reduction of vitam in K to its active form ; leads to depletion of vitamin K-
dependent clotting factors II, Vii, IX, X & protein C & S
ii. Requires 4-5 days before full anticoagulation effect is achieved
iii. Recom m ended starting dose: 5 m g po QD
iv. Strengths/Dosage forms:
(1) Injection: 5 m g
(2) Tablets: 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 m g
v. Most indications want an INR in the 2.0-3.0 range
(1) Mechanical valves require a higher level of anticoagulation (INR 2.5-3.5)
vi. Minor bleeding or elevated INR: hold warfarin dose or decrease dose until INR returns to
appropriate range
vii. Purple Toe Syndrom e may occur due to cholesterol m icroembolization
e. Acetam inophen is usually a good antipyretic & analgesic choice for patients taking oral
anticoagulants
f. Risk factors for DVTs: >40 years old; prolonged im m obility; m ajor surgery involving the
abdom en, pelvis, & lower extremities; traum a, especially fractures of the hips, pelvis, & lower
extremities; malignancy; pregnancy; previous venous throm boem bolism; CHF or
cardiomyopathy; stroke. Acute MI; indwelling central venous catheter; hypercoagulability;
estrogen therapy; varicose veins; obesity; IBD; nephrotic syndrom e; m yeloproliferative disease;
sm oking

6. Antiplatelet Drugs:
a. Thienopyridines:
i. MOA: block adenosine diphosphate (ADP)-m ediated activation of platelets by selectively &
irreversibly blocking ADP activation of the glycoprotein IIb/IIIa complex
ii. Clopidogrel (Plavix):
(1) Use: reduce atherosclerotic events (MI, stroke, vascular deaths)
(2) MOA: irreversibly blocks the ADP receptors, which prevents fibrinogen binding at that
site & thereby reducing the possibility of platelet adhesion & aggregation
(3) AE: chest pain, headache, dizziness, abdominal pain, vom iting, diarrhea, arthralgia,
back pain, upper respiratory infections
iii. Ticlopidine (Ticlid):
(1) Maintenance dose: 250 m g BID
(2) DC if the ANC drops to <1200 or platelet count drops to <80,000
(3) AE: rash, nausea, dyspepsia, diarrhea, neutropenia, throm botic throm bocytopenic
purpura
(4) Dosage form: 250 m g tablet
iv. CI: active bleed, severe liver disease, ticlopidine: neutropenia, throm bocytopenia
b. Glycoprotein IIb/IIIa inhibitors:
i. Abcixim ab (Reopro)
(1) No renal dosing adjustment required
ii. Eptifibatide (Integrillin)
iii. Tirofiban (Aggrastat)
(1) Storage: room tem perature, protect from light

7. Angiotensin Receptor Blockers (ARBs):

a. Candesartan (Atacand)
b. Eprosartan (Tevetan)
c. Irbesartan (Avapro)
d. Losartan (Cozaar)
e. Olm esartan (Benicar)
f. Telm isartan (Micardis)
g. Valsartan (Diovan)
8. Beta Blockers:
a. Nonselective:
i. Nadolol (Corgard)
ii. Penbutolol (Levatol)
(1) Has ISA
iii. Pindolol (Visken)
(1) Has ISA
iv. Propranolol (Inderal):
(1) Nonselective beta blocker
(2) Can increase cholesterol
(3) Strengths available:
(a) ER capsule (InnoPran XL): 80, 120 m g
(b) SR capsule (Inderal LA): 60, 80, 120, 160 m g
(c) Injection (Inderal): 1 m g/m L
(d) Solution: 4 m g/m L; 8 m g/m L
(e) Tablet (Inderal): 10, 20, 40, 60, 80 m g
v. Tim olol (Blockadren)
b. Cardioselective:
i. Acebutolol (Sectral)
(1) Has intrinsic sympathomim etic activity (ISA)
ii. Betaxolol (Kerlone)
iii. Bisoprolol (Zebeta)
iv. Metoprolol (Lopressor, Toprol XL)
(1) Strength/dosage forms:
(a) Lopressor:
(i) Injection: 1 m g/m L
(ii) Tablet: 25, 50, or 100 m g
(iii) ER tablets: 50 & 100 m g
(b) Toprol XL:
(i) Tablets: 25, 50, 100, 200 mg
c. Mixed:
i. Labetalol (Trandate):
(1) Beta blocker (heart rate drop) with alpha-blocking (vasodilation & BP drop) activity
ii. Carvedilol (Coreg):
(1) MOA: blocks â-1, â-2, & á-1 receptors
(2) Has had proven effects on patient survival in large clinical trials for HF
(3) Take with food
(4) Antioxidant effects
(5) Preferred in HF patients who BP is poorly controlled due to its greater hypertensive
effect
(6) Increases stroke volum e
d. MOA: com petitively blocks response to beta-adrenergic stim ulation:
i. Blocked secretion of renin; decrease cardiac contractility, thereby decreasing CO; decreased
central sym pathetic output; decreased HR, thereby decreasing CO
e. Mask signs of hypoglycem ia
f. Can increase lipids

9. Calcium Channel Blockers (CCBs):

a. MOA: inhibit the influx of Ca ions through slow channels in vascular sm ooth m uscle & cause
relaxation of both coronary & peripheral arteries
i. SA & AV nodal depression & decrease in m yocardial contractility (nondihydropyridines)
b. Nondihydropyridines:
c. SE: conduction defects, worsening of systolic dysfunction, gingival hyperplasia
i. Diltiazem (Cardizem, LA & CD, Dilacor XR, Tiaziac)
(1) SE: nausea, headache
(2) Cardizem : 30, 60, 90, 120 m g tablets
(3) Cardizem LA: 120, 180, 240, 300, 360, 420 m g
(4) Cardizem CD: 120, 180, 240, 300, 360 m g capsules
 ii. Verapam il:
(1) IR: (Calan, Isoptin)
(2) LA: (Calan SR, Isoptin SR)
(3) Coer: (Covera HS, Verlan PM)
(4) SE: constipation
d. Dihydropyridines:
i. SE: edem a of the ankle, flushing, headache, gingival hyperplasia
ii. Am lodipine (Norvasc)
iii. Felodipine (Plendil)
iv. Isradipine (DynaCirc & CR)
v. Nicardipine (Cardene SR)
vi. Nifedipine (Procardia XL, Adalat CC)
vii. Nisoldipine (Sular)

10. Combination products:

a. Amlodipine & benazepril (Lotrel)
b. Bisoprolol & HCTZ (Ziac)
c. Losartan & HCTZ (Hyzaar)

11. Direct vasodilators:

a. SE: headaches, fluid retention, tachycardia, peripheral neuropathy, postural hypotension
b. Hydralazine (Apresoline)
c. Minoxidil (Loniten)
i. Hirsutism

12. Diuretics:
a. Monitor: urine output, edem a, weight
b. Can increase lipids
c. Loops:
i. MOA: reduction of total fluid volume through the inhibition of Na & Cl reabsorption in the
ascending loop of Henle, which causes increased excretion of water, Na, Cl, Mg, & Ca
ii. Are more effective that thiazides in patients with renal failure (SCr >2 m g/dL or GFR < 30
m L/m in)
iii. AE: ototoxicity at high doses; photosensitity; m ay increase blood glucose in diabetics;
orthostatic hypotension; hypokalem ia; gout
iv. DI: am inoglycosides (increase risk of ototoxicity), NSAIDs (blunt diuretic response), Class
Ia or III antiarrhythm ics (m ay cause torsades de pointes with diuretic induced
hypokalem ic); probenecid (blocks loop effects by interfering with excretion into the urine)
v. Bum etanide (Bum ex)
vi. Furosem ide (Lasix)
(1) Available dosage forms: injection, solution, tablet
vii. Torsem ide (Dem adex)
d. Thiazides:
i. MOA: direct arteriole dilation; reduction of total fluid volume through the inhibition of Na
reabsorption in the distal tubules, which causes increased excretion of Na, water, K, &
hydrogen; increase the effectiveness of other antihypertensive agents by preventing re-
expansion of plasm a volum e
ii. Significant decrease in efficacy in renal failure (SCr > 2 m g/dL or GFR < 30 m L/min)
iii. DI: steroids (cause salt retention & antagonize thiazide action), NSAIDs (blunt thiazide
response), Class Ia or III antiarrhythm ics (m ay cause torsades de pointes with diuretic
induced hypokalem ic); probenecid & lithium (blocks thiazide effects by interfering with
excretion into the urine), lithium (thiazides decrease lithium renal clearance & increase risk
of lithium toxicity)
iv. AE: increased cholesterol & glucose (short term ); decreased: K, Na, Mg; increased: uric
acid & Ca; photosensitivity; pancreatitis; im potence; sulfonam ide-type reactions
v. Bendroflumethiazide (Naturetin)
vi. Benzthiazide (Aquatag, Exna)
vii. Chlorothiazide (Diuril)
viii. Chlorthalidone (Hygroton, Hylidone)
 ix. Hydrochlorothiazide (HydroDIURIL, Microzide)
x. Hydroglumethiazide (Saluron, Diucardin)
xi. Meethyclothiazide
xii. Polythiazide (Renese)
xiii. Trichlorm ethiazide (Metahydrin, Naqua)
e. Thiazide-like:
i. Less or no hypercholesterolem ia com pared to other thiazides; decreased microalbuminuria
in DM
ii. Metolazone (Mykrox, Zaroxolyn)
iii. Indapam ide (Lozol)
f. Potassium -sparing:
i. MOA: interferes with K/Na exchange in the distal tubule; decreases Ca excretion, increases
Mg loss
ii. AE: hyperkalemia
iii. Am iloride (Midam or)
iv. Triam terene (Dyrenium )
(1) Avoid with history of kidney stones or hepatic disease
g. Aldosterone Blocker:
i. Eplerenone (Inspra):
(1) Selective
(2) CI: DM type II; K > 5.5; ClCr < 30 m L/m inPO- tablet 25 & 50 mgK
sparingSpironolactone (Aldactone)

13. Epinephrine (Adrenalin):

a. MOA: stim ulates á-, â-1, & â-2 adrenergic receptors resulting in relaxation of sm ooth muscle
of the bronchial tree, cardiac stim ulation, & dilation of skeletal m uscle vasculature
b. Sensitive to light & air- protection is recomm ended
i. Oxidation turns drug pink, then a brown color
ii. Solutions should not be used if they are discolored or contain a precipitate
iii. Adm ixture is stable at room temperature for 24 hours

14. Heart failure:

a. Drugs that can worsen or precipitate:
i. Antiarrhythm ics: disopyram ide, flecainide, propafenone
ii. Beta blockers
iii. CCB: verapam il & diltiazem
iv. Oral antifugals: itraconazole & terbinafine
v. Cardiotoxic drugs: doxorubicin, daunorubicin, cyclophospham ide, alcohol
vi. Na & water retention: NSAIDs, glucocorticoids, rosiglitazone, pioglitazone
b. Metoprolol, bisoprolol, & carvedilol (Starting dose: 3.125 m g BID for 2 weeks) have all shown
to be effective in HF
c. Digoxin (Lanoxin):
i. Does not improve m ortality, but does produce sym ptom atic benefits
ii. MOA: inhibits Na-K-ATPase pum p, which results in an increase in intracellular Ca, which
causes a + inotropic effect
(1) Reduces sym pathetic outflow from the CNS
iii. AE: arrhythm ias, bradycardia, heart block, anorexia, abdominal pain, N/V, visual
disturbances, confusion, fatigue
(1) Toxicity is more comm only associated with serum concentrations > 2 ng/m L, but may
occur at lower levels if patients have hypokalem ia, hypom agnesem ia, & in the elderly
iv. Serum levels: 0.5-1.0 ng/mL
v. 60-80% is elim inated renally- dosage requirement for renal insufficiency
d. ACEI & beta blockers improve m ortality
e. Aldosterone antagonist reduce the risk of death & hospitalization
f. Diuretics- sym ptomatic relief

15. Inotropes:
a. Dobutam ine (Dobutrex):
 i. MOA: stim ulates â-1 receptors causing increased contractility & heart rate, with little effect
on â-2 or alpha receptors
(1) â-1 > â-2 > á
(2) Increases CO & vasodilates
ii. Use: inotropic support for patients with shock & hypotension
iii. Dosage: start at 3 mcg/Kg/m in & titrate to 20 m cg/Kg/m in
b. Dopam ine (Intropin):
i. MOA: depends on the given dose
(1) 1-5 mcg/Kg/min: renal dose; increases urine output
(a) Stim ulates dopam ine receptors
(2) 5-15 mcg/Kg/m in: increases contractility, HR
(a) Stim ulates â-1 & â-2 receptors
(3) >15 mcg/Kg/min: increases BP
(a) Stim ulates á-1 receptors
ii. Extravasation: give phentolam ine
c. Milrinone (Prim acor):
i. MOA: inhibits phosphodiesterase III, increases cAMP, resulting in positive inotropic &
vasodilating effects
ii. Use: short-term IV therapy of CHF; calcium antagonist intoxication Dosage: 50 mcg/kg
LD over 10 min; followed by 0.375 m g/Kg/m in
iii. Preferred over inam rinone because of decreased risk of throm bocytopenia

16. MONA-B for M I:

a. Morphine, oxygen, NTG, Aspirin, beta blockers

17. Norepinephrine (Levophed):

a. MOA: stim ulates â-1 adrenergic receptors & á-adrenergic receptors causing increased
contractility & HR as well as vasoconstriction thereby increasing systemic BP & coronary blood
flow
i. Alpha effects > beta effects
b. Readily oxidized, protect from light
c. Do not use if brown coloration
d. Adm ixture stable at room temperature for 24 hours

18. Postganglionic adrenergic neuron blockers:

a. Guanadrel (Hylorel)
b. Guanethidine (Ism elin)
c. Reserpine (Serpasil)
i. Can cause depression

19. Torsades de pointes:

a. Com m on drugs that can cause it:
i. quinidine, dofetilide (Tikosyn), sotalol (Betapace), thioridazine, ziprasidone (Geodon)

20. Throm bolytics:

a. Use:
i. ST-elevation > 1 m m in 2 or m ore contiguous leads or left bundle branch block
ii. Presentation within 12 hours or less of sym ptom s onset
iii. In patients >75 years old m ay be useful & appropriate
iv. Can be used in STEMI when tim e to therapy is 12-24 hours if chest pain is ongoing
v. Should NOT be used if the tim e to therapy is >24 hours, & the pain is resolved
vi. CI in a patient with NSTEMI
b. Drugs:
i. Streptokinase (SK, Streptase)
ii. Tissue plasm inogen activator (tPA, Alteplase)
iii. Tenecteplase (TNK, TNKase)
iv. AE: hemorrhage (cerebral)

21. Vasodilators:
 a. Nitroprusside (Nitropress):
i. Vasodilator
ii. Use: hypertensive crises; CHF
iii. W atch for cyanide toxicity (especially with hepatic dysfunction)
iv. W atch for thiocyanate toxicity (especially with renal dysfunction or prolonged infusions)
v. Highly sensitive to light
(1) Normally a brownish color
(2) A blue color indicates alm ost com plete degradation & breakdown to cyanide
b. Nesirtide (Natrecor):
i. B-type natriuretic peptide that increases diuresis & is an arterial & venous dilator
c. Nitroglycerin (NitroBid, Nitrostat):
i. Venous dilator but also an arterial dilator at higher doses
ii. MOA: Nitroglycerin, an organic nitrate, is a vasodilating agent that relieves tension on
vascular sm ooth muscle & dilates peripheral veins & arteries
(1) It increases guanosine 3'5' m onophosphate (cyclic GMP) in sm ooth m uscle & other
tissues by stim ulating guanylate cyclase through form ation of free radical nitric oxide
(2) This activity results in dephosphorylation of the light chain of m yosin, which improves
the contractile state in sm ooth muscle , and subsequent vasodilation
iii. Dosage form s available:
(1) Spray (do not inhale), ER cap, infusion, injection, ointm ent (Nitro-Bid), buccal tab
(Nitrogard), SL tab (NitroQuick, Nitrostat, Nitro-tab), patch (Minitran, Nitrek, Nitro-Dur)
iv. Isosorbide mononitrate (Im dur (ER), Ism o, M onoket):
(1) Long acting m etabolite of the vasodilator isosorbide dinitrate used for the prophylactic
treatm ent of angina
(2) Should be given at 8 AM & 3 PM (any com bination that doses them within 7-8 hours
of each other to allow for the nitrate-free period in the PM)
v. Isosorbide dinitrate (Dilatrate-SR, Isochron, Isordil)

Com patibility:
Drugs that must be mixed with sterile water:
a. Amphotericin B: no electrolytes, m ix in D5W , & reconstitute with sterile water

Conversions:
1 lb = 454 gm 1 in = 2.54 cm
1 grain = 64.8 mg 1 avoirdupois pound = 454 gm
1 fluid ounce = 29.57 mL 1 gallon = 128 fluid oz, 3785 m L, 4 quarts, 8 pints
1 pint = 473 mL (round to 480 mL)

COPD:
1 st line therapy: beta-2 agonist or ipatropium

Counseling Points:
1. Calcitonin (Miacalcin):
a. For injection:
i. Keep vials in refrigerator
ii. Stable for 2 weeks at room temperature
iii. Give injection in upper arm , thigh or buttock
b. Nasal spray:
i. Store unopened bottle in refrigerator
ii. Once pum p has been activated, store at room temperature
(1) Good for 30 days
iii. Must prim e prior to first use or if it has been greater than 5 days
c. Adequate vitam in D & calcium intake is essential for osteoporosis
d. May cause increased warm th & flushing (should last only about 1 hour after adm inistration)
i. Take in evening to minim ize discomfort

2. Sulfa eye drops: burns

3. Nicotine gum : chew until peppery taste appears, then park

Cystic Fibrosis:
1. Autosomal recessive disease of exocrine gland function resulting in abnorm al m ucus production
2. Genetic m utation on the long arm of chrom osom e 7
a. The protein encoded by this gene, the cystic fibrosis transmembrane regulator (CFTR), is a
channel involved in the transport of water & electrolytes
b. Most com m on genetic mutation involves a 3-base-pair deletion at position ÄF508

3. Antibiotics for Cystic Fibrosis:

a. Cover for Staphylococcus aureus, H. flu, & pseudom onas
i. Double coverage of antibiotics when pseudom onas (m ost comm on) is suspected
(1) Antipseudom onal PCN: piperacillin (Pipracil), m ezlocillin (Mezlin), piperacillin-
tazobactam (Zosyn), ticarcillin-clavulanate (Tim entin), ticarcillin (Ticar), aztreonam
(Azactam ), meropenem (Merrem ), or im ipenem (Prim axin)
(2) Or a cephalosporin: ceftazidime (Fortaz, Tazidime, Tazicef)
(3) AND an am inoglycoside: tobram ycin
ii. Vancom ycin for MRSA
iii. Burkholderia & Stenotrophom onas species are com m only resistant
(1) Trim ethoprim -sulfam ethoxazole (Bactrim ), chloram phenicol (Chloromycetin),
ceftazidim e, doxycycline, piperacillin
b. Fluoroquinolones are the ONLY oral antibiotics with good coverage against pseudomonas

4. Pulm ozym e (dornase alfa):

a. Recom binant hum an deoxyribonuclease
b. Use: for m anagem ent of CF patient to reduce the frequency of respiratory infections that require
parenteral antibiotics, & to im prove pulm onary function
c. MOA: reduces mucous viscosity resulting in airflow im provem ent
d. Used with a nebulizer (jet nebulizer)
e. Must be stored in the refrigerator & should be protected from light
i. Should not be exposed to room temp for a total of 24 hours
ii. Should not be mixed with or diluted with other drugs in the nebulizer

Devices:
1. Swan Ganz catheter:
a. Inserted into right side of heart into the pulm onary circulation
b. Measures pulm onary capillary wedge pressure
c. Takes accurate measurem ent of BP

2. You must measure the scrotum to fit a swim m er’s athletic support

3. Crutches:
a. Armpits should be 2 inches above top of crutches

4. PICC line:
a. Peripherally inserted central catheter

Diabetes:
1. Insulin:
a. Rapid-acting:
i. Lispro (Hum alog)
ii. Aspart (NovoLog)
iii. Glulisine (Apidra)
iv. Onset: <15 min
v. Peak: 30-90 min
vi. Duration: 3-5 hours
b. Short-acting:
i. Regular- hum an (Hum ulin R, Novolin, Velosulin BR)
 ii. Regular- purified (Regular Ilentin II-pork)
iii. Onset: 30-60 min
iv. Peak: 2-3 hours
v. Duration: 3-6 hours
c. Interm ediate-acting:
i. NPH- isophane insulin suspension (NPH Iletin II- pork)
ii. Human (Humulin N, Novolin N)
iii. Lente- insulin zinc suspension (Lente Iletin II- pork)
iv. Human (Humulin L, Novolin L)
v. Onset: 2-4 hours
vi. Peak: 6-12 hours
vii. Duration: 10-18 hours
d. Long-acting:
i. Ultralente- extended insulin zinc suspension; hum an (Hum ulin U, Ultralente)
(1) Onset: 6-10 hours
(2) Peak: 10-16 hours
(3) Duration: 18-20 hours
ii. Insulin glargine (Lantus)
(1) Onset: 5 hours
(2) Peak: none
(3) Duration; 20-24 hours
(4) Cannot mix with any other insulin
e. Prem ixed products:
i. 50/50: 50% regular with 50% NPH
(1) Rapid acting for pre-m eal & interm ediate acting to control later hyperglycemia
ii. 70/30: 30% regular with 70% NPH
iii. 70/30 analogue: 30% aspart with 70% neutral protamine aspart insulin analogue
iv. 75/25: 25% lispro with 75% neutral protamine lispro insulin analogue
f. MOA: decreases blood glucose & assists with glucose control by:
i. Increasing glucose uptake & utilization by peripheral tissues (prim arily in m uscle)
ii. Increasing glycogenesis (glucose à glycogen; prim arily in liver)
iii. Decreasing glycogenolysis (glycogen à glucose)
iv. Decreasing gluconeogenesis (am ino acids à glucose)
v. Decreasing lipolysis & ketogenesis (fats à ketone bodies)
vi. Converting am ino acids to increase protein
vii. Converting triglycerides & fatty acids to increase adipose tissue
g. Appearance:
i. Clear (solution): aspart, lispro, glulisine, glargine, regular
ii. Cloudy (suspension): NPH, lente, ultralente, all prem ixed insulin products
h. Sites of injection: abdom en > arm > hip > thigh > buttock
i. In order of greater & more rapid absorption to lesser & slower absorption
i. There’s 1000 units in a 10 mL bottle

2. Insulin secretagogues:
a. MOA: stim ulates pancreatic â cells to secrete insulin
b. 1 st generation sulfonylureas: can cause a disulfiram -like rxn
i. Acetohexam ide (Dym elor)
ii. Chlorpropam ide (Diabinese)
iii. Tolazam ide (Tolinase)
iv. Tolbutam ide (Orinase)
c. 2 n d generation sulfonylureas
i. Glim epiride (Am aryl)
(1) Max dose: 8 mg/day
ii. Glipizide (Glucotrol, Glucotrol XL)- use in renal im pairm ent
iii. Glyburide (Diabeta, Micronase)- safe in pregnancy
iv. Glyburide m icronized (Glynase)
d. Regular meal tim es are necessary- m ust not skip
e. SE: hypoglycem ia & weight gain
3. Alpha-glucosidase Inhibitors:
a. Acarbose (Precose)
b. Miglitol (Glyset)
i. Least likely to cause hypoglycem ia even when fasting
c. Should be taken with the first bite of a m eal
d. MOA: delays carbohydrate m etabolism & absorption (due to competitive & reversible inhibition
of intestinal alpha-glucoside hydrolase & pancreatic alpha-am ylase)
e. SE: GI intolerance
f. To treat a hypoglycem ic attack: treat with oral glucose
i. Sucrose or fructose would not work

4. Biguanide:
a. Metform in (Glucophage, Fortamet, Riom et):
i. MOA: 9 insulin resistance
(1) 1° in liver; 2° in periphery
ii. Dosage: start with 500 mg po BID or 875 m g po QD
(1) Max: ~2500 mg QD (850 m g TID)
iii. W hen to hold: in patients undergoing diagnostic radiology procedures that use an
iodinated contrast media; hold for 48 hours after the radiology drug is adm inistered
(1) i.e. angiogram
iv. SE: GI, megaloblastic anem ia, & lactic acidosis (Scr men >1,5, wom en >1.4- don’t use)

5. Thiazoladinediones (glitazones or TZDs):

a. Pioglitazone (Actos)
b. Rosiglitazone (Avandia): need AST prior to starting
i. W ait 3 months before deciding on therapeutic failure
c. MOA: 9 insulin resistance
i. 1° in periphery; 2° in liver
d. SE: edem a, anem ia, weight gain, exacerbation of CHF, URIs, resum ption of ovulation

6. Meglitinides (nonsulfonylurea secretagogues):

a. Repaglinide (Prandin)
i. Max daily dose: 16 mg/day
b. Nateglinide (Starlix)
c. MOA: stim ulates pancreatic â cells to secrete insulin
d. SE: hypoglycem ia, weight gain, GI

7. Combination drugs:
a. Glyburide + Metformin (Glucovance)
b. Glipizide + Metform in (Metaglip)
c. Rosiglitazone + Metform in (Avandam et)

8. Example of question: Diabeta is most like Prandin

9. Glyset will not cause hypoglycem ia

a. Only sulfonylureas & insulin will lower blood sugar in non-diabetics
10. Glucagon (GlucaGen):
a. Use: m anagem ent of hypoglycemia
i. Unlabeled use: beta blocker & CCB overdose
b. MOA: stim ulates adenylate cyclase to produce increased cAMP, which prom otes hepatic
glycogenolysis & gluconeogenesis, causing a rise in blood glucose levels
c. 1 unit = 1 m g
11. Diabetic nephropathy:
a. Microalbum inuria (30-300 mg album in/24 hours) used to diagnosis
b. Annual screening for DM type II m easures m icroalbum in-creatinine ratio (norm al <30)
12. Diabetic neuropathy:
a. Treat with TCA’s
b. Neurontin, carbazepine
c. ACEI treat the decreased renal function, NOT the neuropathy itself
13. DKA:
a. A potentially fatal com plication that occurs in up to 5% of patients with Type I annually
b. Seen less frequently in Type II
c. Precipitating factors: interruption of insulin therapy, sepsis, traum a, MI, pregnancy
d. Clinical features: N/V, vaguely localized abdom inal pain; dehydration, respiratory distress,
shock & com a can occur
e. Lab evulation: anion gap metabolic acidosis & positive serum ketones; plasm a glucose is
usually elevated
i. Hyponatrem ia, hyperkalem ia, azotem ia, & hyperosm olality
f. Treatm ent:
i. Supportive measures
ii. Fluids
iii. Insulin therapy
iv. Dextrose (5% )- once plasm a glucose decreases to 250 mg/dL & the insulin infusion rate
decreased to 0.05 U/Kg/hr
v. Potassium
vi. Bicarbonate therapy
vii. Phosphate & magnesium

Drug-Drug Interactions:
Sertraline (Zoloft) & diltiazem (Cardizem; Cartia XT; Dilacor XR; Diltia XT; Taztia XT; Tiazac)
Hydroxyzine pam oate (Vistaril) & meperidine (Dem erol) – Both are CNS depressants

Epilepsy:
Pharmacotherapy:
a. Carbam azepine (Tegretol):
i. Na channel blocker
ii. An autoinducer
iii. Tegretol XL: ghost tablets in stool
iv. SE: rash (rarely causing DC), folate deficiency, hepatotoxicity, aplastic anem ia
v. Teratogenic
vi. Cannot be given for status epilepticus
b. Felbam ate (Felbatol):
viii. Rarely used
ix. MOA: blocks glycine on N-Methyl-D-Aspartate receptor (NMDA)
x. SE: hepatotoxicity, aplastic anem ia
xi. 50% renal elim ination
g. Gabapentin (Neurontin):
i. MOA: unknown; structurally related to GABA but does not interact with GABA receptors
ii. Also used for peripheral neuropathies
iii. 100% renal elim ination- no DI that effect drug m etabolism
iv. Al or Mg containing antacids m ay decrease absorption
h. Lamotrigine (Lam ictal):
i. MOA: decrease glutamate & aspartate release, delays repetitive firing of neurons, blocks
Na channels
ii. SE: life-threatening skin rash
(1) Titrate slowly to avoid
i. Levetiracetam (Keppra):
i. MOA: m ay prevent hypersynchronization of epileptiform burst firing & propagation of
seizure activity
ii. Adjust in renal dysfunction
j. Oxycarbazepine (Trileptal):
i. MOA: Na channel blocker
ii. PKS: active metabolite- 10-m onohydroxycarbazepine (MHD)
iii. SE: hyponaturem ia; blood dysrasias
k. Phenobarbital (Barbital, Lum inal, Solfoton):
i. MOA: increases GABA-m ediated Cl- influx
ii. SE: drowsiness, dizziness, hyperactivity, folate deficiency, hepatic failure, SJS
iii. Teratogenic
 iv. Decreases effectiveness of BC pills
l. Phenytoin (Dilantin):
i. MOA: Na channel blocker
ii. Can only prepare in NS @ 50 m g/m L
iii. Highly protein bound
iv. SE: peripheral neuropathy, hydantoin faces, acne, hirsutism, gingival hyperplasia,
osteom alacia, vitam in K- deficient hem orrhagic disease, folate deficiency (m egaloblastic
anem ia), hepatic failure, SJS
(1) Dose-related SE: nystagm us, ataxia, drowsiness, cognitive im pairm ent
v. PKS: exhibits capacity-limited or saturable (Michaelis-Menton) PKS
vi. Teratogenic
vii. DC tube feedings 2 hours before & after a dose of phenytoin
viii. Available dosage forms: suspension, chewable tablet, prom pt-release capsule, ER capsule,
injection
ix. Need album in level to calculate phenytoin level
m . Prim idone (Mysoline):
i. MOA: increase GABA-m ediated Cl- influx
ii. Metabolized to Phenobarbital & phenylethylm alonamide (PEM A)
iii. Primidone, Phenobarbital, & PEMA all have anti-epileptic activity
n. Tiagabine (Gabitril):
i. MOA: blocks GABA reuptake in presynaptic neuron
o. Topiram ate (Topam ax):
i. MOA: blocks Na channels, enhances GABA activity, antagonizes AMPA/kainite activity
(1) Also a weak carbonic anhydrase inhibitor
ii. Elim ination: prim arily renal
iii. SE: drowsiness, dizziness, kidney stones, oligohidrosis (m ay not sweat)
iv. Sprinkle capsules can be opened & sprinkled onto a sm all am ount of cool, soft food (i.e.
applesauce or yogurt)
v. Drink plenty of fluids
vi. Dosage form s available: sprinkle capsules & tablets
p. Valproic acid:
i. MOA: blocks T-type Ca currents, blocks Na channels, increases GABA production
ii. SE: weight gain, alopecia, throm bocytopenia, increased LFTs, heptotoxicity (fatal),
hem orrhagic pancreatitis (fatal), folic acid deficiency
iii. Available dosage forms:
(1) Sodium valproate (Depacon): injection
(2) Divalproex sodium :
(a) Depakene: syrup & gel capsule
(b) Depakote Sprinkles: capsules
(c) Depakote: delayed-release tablets
(d) Depakote ER: ER tablet
q. Zonisam ide (Zonegran):
i. MOA: Na channel blocker, blocks T-type Ca channels (currents)
(1) W eak carbonic anhydrase inhibitor
ii. SE: kidney stones, weight loss, oligiohidrosis
iii. Sulfa drug
14. Nonpharmacologic therapy:
a. Ketogenic diet: devised in the 1920’s
i. High in fat & low in carbohydrates & protein
ii. Leads to acidosis & ketosis
iii. Most calories are provided in the form of cream & butter
iv. No sugar allowed
v. Fluids are also controlled
15. Status epilepticus: seizure lasting longer than 5 m inutes or $2 discrete seizures between which
there is incomplete recovery of consciousness
a. Treatm ent:
i. ABC’s: airway, breathing, circulation
ii. 1 st line: benzodiazepines
(1) Lorazepam (Ativan): rapid onset
 (2) Diazepam (Valium )
iii. IV phenytoin (Dilantin)
(1) provided patient was not on phenytoin at hom e
(2) Can only mix with NS
(3) 15-20 mg/Kg
(4) Contains propylene glycol- cardiotoxic therefore do not infuse faster than 50 mg/min
(5) Fosphenytoin (Cerebyx):
(a) Prodrug of phenytoin
(b) Im proves water solubility of phenytoin
(c) Can be adm ixed with any IV solution
(d) Dosed in PE (phenytoin equivalents): 1 m g of phenytoin = 1.5 m g of fosphenytoin
(e) Can be give at a rate of 150 m g/m in
iv. IV Phenobarbital (20 mg/Kg)or begin a continuous infusion of m idazolam
v. Begin a m edically-induced com a
(1) Must be on a vent

Equations:
§ BMI: body m ass index
o Men = 66 + (13.7 X W ) + (5 X H) – (6.8 X A)
o W om en = 665 + (9.6 X W ) + (1.8 X H) – (4.7 X A)
o W here W = adjusted body weight in Kg; H= height in centim eters; A= age in years
o 1 in = 2.54 cm
§ CrCl = (140- age) (IBW ) X 0.85 (if wom an)
(72) (SCr)
§ IBW m an = 50 + 2.3 (inches over 5’)
§ IBW w om an = 45.5 + 2.3 (inches over 5’)
§ ABW = IBW + 0.4 (Actual – ideal)
§ Henderson Hasselbach:
o pH= pka + log [base]/[acid]
o log values:
§ log 100 = 2
§ log 10 = 1
§ log 1 = 0
§ log 0.1 = -1
§ log 0.01 = -2
§ Loading dose (LD) = C ss X V D
§ Dose = C ss X Cl or C ss X V D X Cl
§ T 1 / 2 = 0.693 V D /Cl
Fanconi’s Syndrom e:
§ A congenital anem ia due to low production of RBC’s
§ Can also be induced by anything that causes failure of the proxim al renal tubules
§ Patients develop polyuria (cannot concentrate the urine), osteom alacia, & reduced growth size
§ At one tim e it was associated with the use of out-dated tetracycline but this is no longer a
problem since the product has been reform ulated
o The filler was the actual culprit
§ Tenofovir (Viread) can cause this

GERD:
§ H2RA:
o Cim etidine (Tagam et)
o Fam otidine (Pepcid)
o Nizatidine (Axid)
o Ranitidine (Zantac)
§ Available dosage forms:
· 150 & 300 m g capsules
· 50 mg infusion for IV
· 25 mg/m L injection
· 15 mg/mL syrup
· 75, 150, 300 m g tablet
 · 75 mg effervescent tablet
§ PPIs:
o MOA: suppresses gastric acid secretion by inhibiting the parietal cell H+/K+ ATP
pum p
o Rabeprazole (AcipHex):
§ Strength/dosage form: delayed-release EC 20 m g tablet
o Esom eprazole (Nexium ):
§ Strength/dosage form :
· Capsule: delayed release 20 & 40 m g
· Injection, powder for reconstitution: 20 & 40 m g
o Lansoprazole (Prevacid):
§ Strength/dosage form :
· Capsule: delayed release 15 & 30 m g
· Granules, for oral suspension: 15 & 30 m g/packet
· Injection, powder for reconstitution: 30 m g
· ODT: 15 & 30 m g
o Om eprazole (Prilosec):
§ Do not put in OJ- not stable in an acidic environm ent
§ Can be opened & sprinkled onto applesauce
§ Strength/dosage form :
· Capsule: delayed release 10 & 20 m g
· Oral suspension (Zegerid): 20 & 40 m g
· Tablet: delayed release 20 m g (OTC)
o Pantoprazole (Protonix):
§ Strength/dosage form :
· Injection, powder for reconstitution: 40 m g
· Tablet: delayed release 20 & 40 m g
o Take 15-30 m inutes before breakfast to m axim ize efficacy
§ GERD can exacerbate asthm a

Glaucoma:
§ Increased intraocular pressure, which causes pathologic changes in the optic nerve & typical
visual field defects
§ Open-angle glaucoma:
o Prim ary glaucom a
o The angle of the anterior cham ber rem ains open in an eye, but filtration of aqueous
hum or is gradually dim inished because of the tissues of the angle
o 80-90% of cases
§ Angle-closure (narrow angle) glaucoma:
o Prim ary glaucom a
o Shallow anterior cham ber & narrow angle; filtration of aqueous humor is
com prom ised as a result of the iris blocking the angle
§ Therapy:
â-adrenergic antagonists:
§ MOA: decrease in aqueous hum or form ation with slight increase in outflow
(beta selective)
§ Often DOC for open-angle glaucom a
§ AE: cardiac effects, worsening pulm onary effects, depression, dizziness
§ Nonselective:
· Tim olol (Tim optic)
· Carteolol (Ocupress)
· Levobunolol (Betagen)
· Metipranolol (OptiPranolol)
§ Selective:
· Betaxolol (Betoptic)
· Levobexaxolol (Betaxon)
o Carbonic anhydrase inhibitors:
§ MOA: decrease in aqueous hum or form ation
§ AE: lethargy, decreased appetite, GI upset, urinary frequency
 § Do not use with sulfa allergy
§ Acetazolam ide (Diam ox)
· Tablets, capsules
§ Dorzolam ide (Trusopt)
§ Brinzolam ide (Azopt)
§ Methazolam ide (Neptazane)
· Tablets
o Prostaglandin analogs:
§ MOA: increased uveoscleral outflow without effect on aqueous humor
formation
§ Also used as 1 st line agents or in combination with beta blockers
§ AE: iris pigm entation, eyelid darkening, m acular edem a
§ Latanoprost (Xalatan)
· Adm inister 1 drop at bedtim e
· Refrigerate
· Can change blue eyes to brown
§ Bim atoprost (Lum igan)
· Can cause darkening of eyelids & eye lashes
§ Travoprost (Travatan)
· Frequent ocular hyperem ia
§ Unoprostone (Rescula)
á-2 adrenergic agonists:
§ MOA: decrease in aqueous hum or form ation
§ AE: tachycardia, dry m outh, eyelid elevation, CNS effects in the old & young
§ Brim onidine (Alphagan)
· W ait at least 15 m inutes after using before placing soft contacts
o Other á-adrenergic agonists:
§ MOA: increase in aqueous hum or outflow
§ AE: tachycardia, increased BP, allergic responses
§ Dipivefrin (Propine)
· Prodrug of epinephrine
§ Pilocarpine (Pilocar)
· Once weekly dose form called Ocuserts
· Miotic agent
o Com bination:
§ Tim olol & dorzolam ide (Cosopt)
o Hydroxypropyl methylcellulose added to decrease burning

Gout:
§ Treatm ent of acute attack:
o Colchicine:
§ MOA: inhibits phagocytosis of urate crystals by leukocytes; anti-
inflam m atory agent without analgesic activity
· Decrease leukocyte mobility thereby decreasing inflam m ation
§ Dosed until resolution of sym ptom s, severe GI sym ptom s occur, or max of 8
mg
§ Available PO (0.6 mg) & IV (0.5 mg/mL)
o Indom ethacin
o Corticosteroids
§ Effective when given intra-articularly, IV, or PO
§ Used when there is failure to colchine and NSAIDS
§ Prophylaxis:
o Colchicine (low dose: 0.6-1.2 mg/d)
o Colchicine + probenecid (ColBenemid)
o Probenecid (Benem id):
§ MOA: uricosuric agent that prom otes the excretion of UA by blocking its
reuptake at the proxim al convoluted tubule
· Inhibits renal absorption of UA from the urine into the blood
§ Should drink at least 2 L of water/day to decrease the risk of UA stone
 formation
§ Available as a 500 m g tablet
§ Avoid use with aspirin
o Sulfinpyrazone (Anturane):
§ MOA: uricosuric agent that prom otes the excretion of U A by blocking its
reuptake at the proxim al convoluted tubule
§ Drink at least 2 L of water/day
§ Do not use with CrCl < 50 m L/m in
o Allopurinol (Zyloprim ):
§ MOA: allopurinol & its metabolite oxypurinol, inhibit xanthine oxides
form ation, which is the rate-lim iting step in UA synthesis; this facilitates the
clearance of the more water soluble precursors of UA, oxypurines
· Inhibits xanthine oxides which reduces UA form ation from the
m etabolism of purine bases of DNA & RNA
§ Take with food
§ W atch for rash- SJS can occur
§ DI: azathioprine, 6-m ercaptopurine, ACEI

Hem orrhoids:
§ Therapy:
o Soap suds enem a QD
o Sitz bath QD
o Fiber therapy
o Sitting on a doughnut
o Cleaning anal area with soap & water after each defecation
o Dibucaine (Nupercainal): OTC local anesthetic for fast tem porary relief of pain &
itching due to hemorrhoids
o Pram oxine (Anusol ointment, ProctoFoam NS, Tucks): OTC local anesthetic for fast
temporary relief of pain & itching due to hemorrhoids

Hepatic Encephalopathy:
§ Syndrom e of disordered consciousness & altered neurom uscular activity seen in patients
with acute or chronic hepatocellular failure or portosystem ic shunting
§ Precipitating factors: azotem ia; use of tranquilizer, opioid, or sedative-hypnotic m edication;
GI hem orrhage; hypokalem ia & alkalosis; constipation; infection; high-protein diet
§ Monitor: am m onia levels
§ Treatment:
o Fleet’s enem a
o Protein restriction; special diet (vegetable protein or branched-chain amino acid
enriched)
o Nonabsorbable disaccharides: lactulose (Cephulac, Constulose, Enulose, Generlac,
Kristalose), lactitol, & lactose
§ Lactulose syrup 30 m L of 50% solution QID; dim inish to BID when 3 or more
bowel movem ents a day occur daily
§ Lactulose dosage form s: powder for oral suspension, oral solution, oral syrup
o Neom ycin
o Metronidazole

Herbs:
§ Herbals that interfere with anticoagulation:
o Ginkgo, Ginseng, Fish Oil, Garlic, Feverfew, & Ginger
o “All begin with F or G”
§ Cham om ile:
o Uses: dyspepsia, oral m ucositis, derm atitis, ADHD
o Might have anti-inflam m atory effects; m ight bind to GABA receptors
o DI: benzodiazepines, tam oxifen, CNS depressants, warfarin, estrogens, CYP1A2 &
CYP3A4 substrates
o CROSS-ALLERGENICITY: Germ an cham om ile may cause an allergic reaction in
individuals sensitive to the Asteraceae/Com positae fam ily; mem bers of this fam ily include
 ragweed, chrysanthem um s, m arigolds, daisies, and many other herbs
§ Chasteberry:
o Uses: PMS, BPH, menstrual irregularities, fem ale infertility, insect repellant
o DI: antipsychotics, contraceptives, dopamine agonists, estrogens, m etoclopramide
§ Cholesterol: garlic
§ Depression:
o St. John’s W ort, SAM-e (& OA), DHEA, Kava-kava (anxiety, stress)
§ Dong quai:
o Used for PM S & m enopausal sym ptom s
o Interaction with warfarin- m ade up of several coum arin constitutes
§ Increase INR
§ Feverfew:
o Use: migraines, arthritis, allergies
o DI: anticoagulants, antiplatelets, CYP (1A2, 2C9, 2C19, 3A4)
§ Garlic:
o Active com pounds: alliin, allicin
o Uses: hyperlipidem ia, HTN, prevention of atherosclerosis
o MOA: May act as an HMG-CoA reductase inhibitor; may vasodilate & relax smooth
m uscle, release NO; may also reduce oxidation of LDL & inhibit platelet form ation
o Generally safe with the exception of heartburn, N/V, body ordor, bad breath
o DI: CYP3A4, cyclosporine, saquinavir, OCs, anticoagulants
§ Ginkgo:
o Uses: m em ory, Raynaud’s, glaucoma, diabetic retinopathy, interm ittent claudication,
PMS, vertigo
o Can cause seizures at high doses
o DI: anticoagulants (warfarin), anticonvulsants, Buspar, CYP (1A2, 2C19, 2C9, 2D6,
3A4), ibuprofen, insulin, drugs that lower the seizure threshold (i.e. anesthetics (propofol,
others), antiarrhythmics (mexiletine), antibiotics (amphotericin, penicillin, cephalosporins,
im ipenem ), antidepressants (bupropion, others), antihistamines (cyproheptadine, others),
im m unosuppressants (cyclosporine), narcotics (fentanyl, others), stim ulants
(m ethylphenidate), theophylline)
§ Glucosam ine:
o Use: OA, TM J, glaucom a
o Glucosam ine is an am ino sugar, which is a constituent of cartilage proteoglycans. It
is derived from marine exoskeletons or produced synthetically
o DI: APAP, antidiabetic agents, warfarin
§ Hyperglycem ia may be caused by:
o Black tea, coffee, cola nut, green tea, guarana, m ate, N-acetyl glucosam ine, niacin,
oolong tea, shark cartilage
§ Kava Kava:
o Uses: insom nia, anxiety, stress, benzodiazepine withdrawal
o May adversely affect the liver- increase LFTs
o DI: xanax, CNS depressants CYP (1A2, 2C19, 2C9, 2D6, 2E1, 3A4), hepatotoxic
drugs, levodopa
§ Licorice:
o Uses: dyspepsia
o has antispasm odic, anti-inflam m atory, laxative, & soothing properties
o The constituents glycyrrhizin & glycyrrhetinic acid inhibit 11-beta-hydroxysteroid
dehydrogenase, an enzyme located in the aldosterone receptor cells of the cortical
collecting duct
o Glycyrrhizin m ay contribute to licorice-associated m ineralocorticoid SE, including
HTN & hypokalemia, by both binding directly to mineralocorticoid receptors & by
decreasing the conversion of active cortisol to inactive cortisone
o DI: antihypertensives, corticosteroids, CYP3A4, digoxin
§ Milk thistle:
o Used for liver disorders; dyspepsia
o Interactions with CYP2C9 (warfarin, elavil, diazepam ), CYP3A4 substrates, estrogens
o Avoid with hormone sensitive cancers
§ Hot flashes & menopausal sym ptom s: black cohosh
 § Passion Flower:
o Used for anxiety, GAD, opioid withdrawal
o Interactions with CNS depressants
§ Podophyllin:
o Uses: applied locally for wart rem oval;
o Can increase LFTs
§ SAM-e:
o Uses: depression & OA
o S-adenosylm ethionine (SAMe) is a naturally occurring m olecule that is distributed
throughout virtually all body tissues and fluids; concentrations are highest in childhood
& decrease with age
o Plays an essential role in >100 biochemical rxn involving enzym atic transmethylation
o It contributes to the synthesis, activation &/or m etabolism of hormones,
neurotransm itters, nucleic acids, proteins, phospholipids, & some drugs
o DI: antidepressants, dextrom ethorphan, levodopa, m eperidine
§ St. John’s W ort:
o Uses: depression, anxiety
o Two constituents that play a significant role are hypericin & hyperforin
o MOA: believed to act as a serotonergic 5-HT 3 and 5-HT 4 receptor antagonist, & down-
regulate beta-adrenergic, & serotonergic 5-HT 1 & 5-HT 2 receptors when used chronically
in anim als
o DI: triptans, xanax, elavil, antidepressants, barbiturates, plavix, OCs, cyclosporine,
dextrom ethorphan, CYP (1A2, 2C9, 3A4), warfarin
§ Valerian:
o Used for anxiety, stress, insom nia
o A sedative; sim ilar effects to Ambien
o Avoid with: etoh, benzadiazepines, CNS depressants, CYP3A4 substrates
§ Som e herbs that affect platelet aggregation: angelica, clove, danshen, dong quai, garlic,
ginger, ginkgo, feverfew, Panax ginseng, horse chestnut, red clover, turm eric

Hyperkalemia:
§ Sodium polystyrene disulfonate (Kayexalate): cation exchange resin- prom otes the exchange
of Na for K in GIT
o Can be adm inistered as a retention enem a or orally
§ IV insulin
o Causes K to shift into the cells & temporarily lowers the plasma K
§ Calcium gluconate
o Decreases m em brane excitability
o Adm inister 1 st with hyperkalemia & EKG changes
§ Other: IV NaHCO 3 (shifts K into cells); â-2 adrenergic agonists (prom ote the cellular uptake
of K); Loop & thiazide diuretics (enhance K excretion if renal function is adequate); dialysis
§ If the patient also has EKG changes the usual treatment (in order) is:
o IV calcium first
o Then IV bolus of 10-20 units of regular insulin with 25 gm of glucose (prevents
hypoglycem ia)
o 150 mEq of sodium bicarbonate is one liter of D5W forces K into cells
o Beta-2 agonists (i.e. Albuterol) nebulized or SQ
o Com bination of loop & thiazide (i.e. Lasix + Diuril) if the renal function is adequate
o Kayexalate (slow to work)
o Hem odialysis is best overall, if the tim e is available & K is severe
o Peritoneal dialysis is less effective

Hyperlipidemia:
§ Bile Acid Sequestrants:
o Effects on cholesterol:
§ TC: 9
§ TG: 8 or <-->
§ LDL: 9
§ HDL: 8
 o Cholestyram ine Resin (Questran, Prevalite):
§ MOA: forms a nonabsorable complex with bile acids in the intestine,
releasing chloride ions in the process; inhibits enterohepatic reuptake of intestinal
bile salts & thereby increases the fecal loss of bile salt-bound low density
lipoprotein cholesterol
o Colesevelam (W elChol)
§ Strength/dosage forms: 625 m g tablet
o Colestipol (Colestid)
o Not absorbed; safest for pregnant wom en
§ Fibrates:
o Effects on cholesterol:
§ TC: 9
§ TG: 9
§ LDL: 8 or <-->
§ HDL: 8
o MOA: increase catabolism (breakdown) of triglycerides
o Can cause pancreatitis & liver problem s
o Fenofibrate (Tricor)
§ Changed from 160 m g (with m eals) to 145 m g
· Made it nanocrystals for better bioavailability
o Gemfibrozil (Lopid)
§ Take 30 m inutes before breakfast & dinner
o Clofibrate (Atrom id-S)
§ Statins:
o Effects on cholesterol:
§ TC: 9
§ TG: 9
§ LDL: 9
§ HDL: 8
o MOA: HMG-CoA reductase inhibitors
o Atorvastatin (Lipitor)
o Fluvastatin (Lescol, Lescol XL)
§ Shortest t 1 / 2
o Lovastatin (Mevacor, Altoprev- with niacin)
§ Strengths/Dosage form s:
· Tablet: 10, 20, 40 m g
· Mevacor: 20, 40 m g ER tablets
· Altoprev: 10, 20, 40, 60 m g tablets
§ No grapefruit
o Pravastatin (Pravachol)
§ Not m etabolized in the liver- therefore statin with the least am ount of DIs
§ M ax daily dose: 80 m g
o Rosuvastatin (Crestor)
o Sim vastatin (Zocor)
§ No grapefruit
§ Manufacturer recom m ends lim iting sim vastatin dose to 20 m g/day when
used with am iodarone or verapam il, & 10 m g/day when used with cyclosporine,
gem fibrozil, or fibric acid derivatives
o All except for Lipitor & Crestor should be adm inistered in the evening
o Pregnancy category: X
o Monitor: LFTs, CK
§ Cholesterol Absorption Inhibitor:
o Effects on cholesterol:
§ TC: 9
§ TG: 9
§ LDL: 9
§ HDL: 8 or <-->
o Ezetim ibe (Zetia):
§ Monitor for muscle pain & increased liver enzym es
 § Niacin (Niacor, Niaspan, Slo-Niacin: OTC):
o Synonym s: Nicotinic acid; vitam in B 3
o Effects on cholesterol:
§ TC: 9
§ TG: 9
§ LDL: 9
§ HDL: 8
o MOA: inhibits the synthesis of VLDL
o Target dose: 1.5-6 g/day in 3 divided doses with or after m eals
o SE: flushing (pretreat by taking aspirin 30 minutes prior), dizziness, lightheadedness
o Caution in DM & gout
§ Combination products:
o Niacin & lovastatin (Advicor)
o Ezetim ibe & sim vastatin (Vytorin)
o Aspirin & pravastatin (Pravigard PAC)- aspirin tablets & pravastatin tablets are
separate tablets within the PAC
§ Exercise will help to raise HDL

Hyperm agnesemia:
§ Treatment: 10% calcium gluconate (renal failure) or 0.9% saline with 2 g calcium gluconate
per liter (absence of severe renal failure)

Hyperthyroidism :
§ Thyrotoxicosis
§ Graves disease- most comm on cause
§ Thyroid storm is a life threatening, sudden exacerbation of all the sym ptom s of thyrotoxicosis
characterized by fever, tachycardia, delirium , & com a
§ Can be caused by drugs such as am iodarone & iodine
§ S/Sx: heat intolerance, weight loss, weakness, palpitation, anxiety, trem or, tachycardia,
eyelid sag, warm or moist skin
§ Diagnosis: 8T 4 or T 3 , 9 TSH
§ Three m odes of treatment:
o Surgery
o Radioactive iodine (RAI)
o Antithyroid (thionam ide) drugs:
§ Propylthiouracil (PTU):
· MOA: inhibit the synthesis of thyroid horm ones by preventing the
incorporation of iodine into iodotyrosines & by inhibiting the coupling of
m onoiodotyrosine & diiodotyrosine to form T 4 & T 3 ; also inhibits the
peripheral conversion of T 4 to T 3
· Dosage form : tablets
§ Methim azole (Tapazole):
· MOA: inhibit the synthesis of thyroid horm ones by preventing the
incorporation of iodine into iodotyrosines & by inhibiting the coupling of
m onoiodotyrosine & diiodotyrosine to form T 4 & T 3
§ SE: fever, headache, paresthesias, rash, arthralgia, urticaria, jaundice,
hepatitis, agranulocytosis, leucopenia, bleeding
o Iodide drugs:
§ Strong iodine solution (Lugol’s Solution):
· Dosage form : solution- 5% iodine & 10% K iodide; delivers 6.3 mg
iodine per drop
§ Saturated solution of potassium iodide (SSKI)
· Dosage form : solution- 1 g/m L; delivers 38 m g iodine per drop of
saturated solution
§ MOA: blocks horm one release, inhibits thyroid horm one synthesis

Hypokalemia:
§ Diarrhea is associated with liquid KCl
Hyponatremia:
§ Drugs can cause by 1 of 3 mechanisms:
o Stim ulation of vasopressin release (i.e. nicotine, carbam azepine, Lithium, TCA’s,
antipsychotic agents, antineoplastic drugs, narcotics)
o Potentiation of antidiuretic action of vasopressin (i.e. chlorpropam ide,
m ethylxanthines, NSAIDs)
o Vasopressin analogs (i.e. oxytocin, DDAVP)

Hypothyroidism :
§ Deficient thyroid hormone production
§ Hashim oto’s disease is the cause of 90% of prim ary hypothyroidism
o Autoim m une resulting from cell- & antibody-mediated thyroid injury
§ S/Sx: cold intolerance, fatigue, somnolence, constipation, m enorrhagia, myalgias,
hoarseness, thyroid gland enlargem ent or atrophy, bradycardia, edem a, dry skin, weight gain
o Body slows down
§ Thyroxine (T 4 ) is the m ajor horm one secreted by the thyroid, which is converted to the more
potent triiodothyronine (T 3 ) in tissues
o Thyroxine secretion is stim ulated by thyroid stim ulating horm one (TSH)
o Diagnosis: 8TSH, 9T 4
§ Drug therapy:
o Levothyroxine sodium , T 4 (Synthroid, Levothroid, Levoxyl, Unithroid, Thyro-Tabs):
§ Usually DOC
§ Typical dose is 100-125 m cg po QD; reduce dose to 50 mcg for elderly & 25
m cg in patients with CAD to reduce risk of precipitating angina
Dose changes are made within a 6-8 week interval
o Desiccated thyroid USP (Armour Thyroid, Nature-Throid, W esthroid)
o Liothyronine, T 3 (Cytom el, Triostat)
o Liotrix, T 4 & T 3 in a 4:1 ratio (Thyrolar)
o Take 30 m inutes before breakfast
o Don’t take antacids, calcium, or iron supplem ents within 4 hours of levothyroxine
o SE: tachycardia, arrhythm ia, angina, MI, trem or, headache, nervousness, insomnia,
diarrhea, vom iting, weight loss, excessive sweating, hair loss
§ Body speeds up

ID:
§ Am inoglycosides:
o MOA: bactericidal; interferes with bacterial protein synthesis by binding to 30S &
50S ribosom al subunits resulting in a defective bacterial cell m em brane
o For serious aerobic gram - infections
o Poorly absorbed for GIT
o Renally elim inated by glom erular filtration
o W atch for oto- & nephrotoxicity
o Target serum concentrations:
§ Am ikacin peak: 15-30 m cg/m L
§ Am ikacin trough: <5 m cg/m L
§ Gentam icin & tobram ycin peak: 4-10 m cg/m L
§ Gentam icin & tobram ycin trough: <2 m cg/m L
o Amikacin (Amikin)
§ Least susceptible to resistance
§ Rule of nines (see gentam icin)
o Gentam icin (Garam ycin):
§ Rule of eights to determ ine dosing interval
· SCr X 8
· i.e. 2 X 8 = 16- - dose Q16 hours
o Netilm icin (Netrom ycin)
o Tobram ycin:
§ Should be given after dialysis and be a routine loading dose
§ ANC: absolute neutrophil count
o Neutrophils = bands + segs
 § i.e. 5 + 65 = 70
§ This means that 70% of the W BCs are neutrophils
§ If W BC= 14000 cells per cubic m illim eter X 0.70 = 9800 neutrophil cells
§ Neutrophils are elevated with bacterial infections
§ Lym phocytes are elevated with viral infections
§ Not much elevation with fungal infections
o Granulocytes= bands + segs + basophils + eosinophils
§ Anti-fungal agents:
o Amphotericin B:
§ Am photericin B-conventional (Am phocin; Fungizone)
· Prem edicate 30-60 m inutes prior with NSAID or APAP with or without
diphenhydram ine
o Or hydrocortisone
· Reconstitute ONLY with sterile water without preservatives, not
bacteriostatic water
· Can add D5W
§ Am photericin B- lipid com plex (Abelcet)
· May also need to prem edicate
§ Am photericin B-liposom al (Am Bisom e)
· May also need to prem edicate
§ Am photericin B Cholesteryl Sulfate Com plex (Am photec)
§ May also need to prem edicate
o Itraconazole (Sporanox):
§ MOA: interferes with cytochrom e P450 activity, decreasing ergosterol
synthesis (principle sterol in fungal cell mem brane) & inhibiting cell membrane
function
§ CI: CHF
§ Dosing:
Onychom ycosis, Fingernail: ORAL, 200 mg BID X1 wk, off drug for 3
·
wk, repeat 200 mg BID X 1 wk
Onychom ycosis, Toenail: ORAL, 200 m g QD X 12 wk
·
Aspergillosis, Blastomycosis, Histoplasm osis: ORAL, 200 m g QD, MAX
·
200 mg BID
§ Dosage forms available: 100 m g capsule; injection; oral solution
§ Anti-influenza drugs:
o Am antadine (Sym m etrel)
§ Blocks influenza A; no activity against influenza B
§ Effective when initiated within 48 hours of initial sym ptom s & continued for
7-10 days
§ SE: GI disturbances & CNS dysfunction, including dizziness, nervousness,
confusion, slurred speech, blurred vision, & sleep disturbances
§ May lower seizure threshold- avoid with seizure history
o Rim antadine (Flum adine)
§ Blocks influenza A; no activity against influenza B
§ Effective when initiated within 48 hours of initial sym ptom s & continued for
7-10 days
§ SE: GI disturbances & CNS dysfunction, including dizziness, nervousness,
confusion, slurred speech, blurred vision, & sleep disturbances
· Fewer SE than with am antadine
o Zanam ivir (Relenza)
§ Blocks influenza A & B neuram inidases
§ Powder for inhalation (rotadisk with Diskhaler)
§ 1-2 day im provem ent in sym ptom s in patients w ho are sym ptom atic for no
longer than 48 hours
§ SE: headache, GI disturbances, dizziness, upper respiratory sym ptoms
o Oseltamivir (Tam iflu)
§ Block influenza A & B neuram inidases
 § 1-2 day im provem ent in sym ptom s in patients w ho are sym ptom atic for no
longer than 48 hours
§ Dosing:
· Prophylaxis: 75 mg po QD X at least 7 days; should begin within 2
days of contact with infected individual
· Treatm ent: 75 m g po BID initiated within 2 days of onset of
symptoms; duration of treatm ent is 5 days
§ SE: N/V/D
§ Oral capsules & suspension
§ Anti-viral agents:
o Acyclovir (Zovirax):
§ Counseling: avoid sexual intercourse when lesions are present; this is not a
cure for herpes; can take with food; maintain adequate hydration (2-3 L/day); may
cause lightheadedness or dizziness
o Fam ciclovir (Fam vir):
§ Uses: genital herpes, herpes zoster
§ Biotransform ed to the active m etabolite: penciclovir
§ Need dose adjustm ent for renal im pairm ent
§ Tablet only
o Valacyclovir (Valtrex):
§ Uses: treatm ent of herpes zoster (shingles), herpes labialis (cold sores) &
genital herpes
§ MOA: rapidly & nearly com pletely converted to acyclovir by intestinal &
hepatic m etabolism ; inhibits DNA synthesis & viral replication by com peting with
deoxyguanosine triphosphate for viral DNA polym erase & being incorporated into
viral DNA
§ Reduce dose with renal dysfunction
§ Aspergillus:
o Fungus
o Am photericin B (Am photec, Abelcet, Am Bisom e), itraconazole (Sporanox),
voriconazole (VFEND), caspofungin (Cancidas)
§ Spells out CAVI
§ NOT ketoconazole
§ Cephalosporins:
o 3 rd generation:
§ Cefpodoxim e (Vantin)
· Refrigerate
§ Chlam ydia:
o STD
o S/SX:
§ Males: urethritis, epdidym itis, proctitis, reiter syndrom e, testicular pain
§ Females: cervictis, urethral syndrome, endometritis, PID, urethral or cervical
discharge, pelvic pain
o If left untreated can lead to infertility
o Treatment: doxycycline, azithrom ycin, erythrom ycin (pregnant)
§ Tetracyclines & quinolones CI in children & pregnant wom en
§ Clostridium difficile:
o Gram +, anaerobic rod
o Treatment:
§ DOC: m etronidazole
§ Vancom ycin
§ Enterococcus faecalis: penicillin, am picillin, vancom ycin, linezolid, aminoglycosides
o Chloram phenicol, streptom ycin, bactrim
o Gram +
o Clindam ycin or cefazolin (cephalosporins) will not treat
§ Escherichia coli:
o DOC: cefazolin (Ancef), cephalixin (Keflex, Biocef), cefotaxim e (Claforan), gentamicin
(Gentak)
§ Fluoroquinolones:
 o MOA: bactericidal; inhibit bacterial DNA topoisom em rase & disrupt bacterial DNA
replication
o Can cause QT prolongation
o AE: crystalluria, tendon rupture
o Avoid PO in children under 18 years old- may cause cartilage growth suppression
o 2 n d generation:
§ Ciprofloxacin (Cipro):
· MOA: inhibits DNA-gyrase in suspectible organism s; inhibits
relaxation of supercoiled DNA & prom otes breakage of double-stranded
DNA
· Dosage form s: infusion, injection, m icrocapsules for oral suspension,
ophthalm ic ointment (Ciloxan) & solution (Ciloxan), tablet, ER tablet
· Cipro ear drops:
o Ciprofloxacin & dexam ethasone (Ciprodex):
§ Antibiotic/corticosteroid
§ Treatm ent of acute otitis m edia in peds with
tym panostom y tubes or acute otitis externa in children &
adults
o Ciprofloxacin & hydrocortisone (Cipro HC):
§ Antibiotic/corticosteroid
§ Treatment of acute otitis externa (swim m er’s ear)
§ Gonorrhea:
o Neisseria gonorrhoeae
o Gram –
o Cefixim e, ceftriaxone, ciprofloxacin, ofloxacin
§ Inhibit cell wall synthesis:
o Vancom ycin, PCNs, cephalosporins
§ Legionella pneum ophilia:
o DOC: azithrom ycin, clarithrom ycin, erythrom ycin
o Alternative: Rifam pin, ciprofloxacin, levofloxacin
§ Lincosam ides:
o Treat gram +, gram - & anaerobic infections
o Lincom ycin (Lincocin)
o Clindam ycin (Cleocin)
§ Lym e’s Disease:
o Lym e borrelliosis
o Caused by spirochete Borrelia burgdorferi
o Tick-borne illness
o Symptoms:
§ Stage 1 (early disease): erythemia m igrans- a slowly expanding m acular rash
> 5 cm in diam eter, often with a central clearing & m ild constitutional symptoms
§ Stage 2 (early disseminated): occurs within several weeks to months &
includes multiple erythema m igrans lesions, neurologic sym ptoms (7 th cranial
nerve palsy, m eningoencephalitis), cardiac sym ptom s (AV block, m yopericarditis),
& asym m etric olioarticular arthritis
§ Stage 3 (Late disease): occurs after m onths to years & includes chronic
derm atitis, neurologic disease, & asymm etric m onoarticular or oligoarticular
arthritis
o Treatm ent:
§ Doxycucline 100 m g BID
§ Am oxicillin 500 m g TID
§ Cefuroxim e axetil 500 mg BID for 14-21 days
§ Macrolides:
o Bacteriostatic
o Clarithrom ycin (Biaxin):
§ Should not be stored in the refrigerator
o Erythrom ycin:
§ Oral products:
· Erythromycin base (E-Mycin, Ery-Tab, PCE (polym er coated ery), Eryc)
 o Sensitive to acid
o Coating on m ost products
o Adm inister on an empty stom ach
· Erythrom ycin stearate (Erythrocin stearate, W yam ycin S)
o Properties sim ilar to ery base but better absorbed
· Erythrom ycin estolate (Ilosone)
o Most hepatotoxic
o Better absorbed than ery base
· Erythrom ycin ethylsuccinate (Eryped, EES)
o Best absorbed form from GIT
o Available in liquid formulation
o 400 m g of EES = 250 m g erythrom ycin base
§ Parenteral products:
· Erythrom ycin lactobionate
· Erythrom ycin gluceptate
§ Topical products:
· Erythrom ycin (Staticin, Em gel)- for acne (colorless)
· Erythrom ycin (Ilotycin)- ophthalm ic use
§ MOA: bacteriostatic macrolide antibiotic; may be bactericidal in high
concentrations or when used against highly susceptible organisms. It penetrates
the bacterial cell m em brane & reversibly binds to the 50 S subunit of bacterial
ribosom es
§ Reacts with theophylline by altering hepatic metabolism
· Also increases levels of carbam azepine, cyclosporine, triazolam,
lovastatin, sim vastatin, valproate
o Azithrom ycin (Zithromax):
§ More gram – activity than erythrom ycin or clarithrom ycin
§ Suspension & capsules: take on an empty stom ach
§ Tablet: with or without food
§ Not for children < 6 m onths old
§ Dosage form s available: injection, oral suspension, tablet, Tri-PAK (3, 500 mg
tabs), Z-PAK (6, 250 m g tabs)
§ Meningitis:
o Inflam m ation of the m eninges that is identified by an abnorm al num ber of W BC in
the CSF
o Causative organism s: many gram + & - species
§ Bacterial agents are associated with a large increase in W BCs, increased CSF
protein, & decreased CSF glucose
§ Fungal & viral agents exhibit smaller increases in CSF W BCs, smaller
increases in CSF protein, & lim ited decreases in CSF glucose
§ Mycoplasm a pneum oniae:
o Erythrom ycin, tetracycline, doxycycline, fluoroquinolones, azithromycin,
clarithrom ycin
§ Onychomycosis:
o Infection of the nail by fungi (derm atophytes, Candida, m olds)
o Treatment:
§ Fluconazole (Diflucan):
· 300 mg po weekly X 6 months (pulse therapy)
§ Itraconazole (Sporanox):
· 200 mg po BID X 1 week per m onth for 2 m onths for fingernails & 3-4
m onths for toenails (pulse therapy)
§ Terbinafine (Lam isil):
· 250 mg po QD X 3 months
§ Other:
o Daptom ycin (Cubicin):
§ Used for resistant gram + infections
§ MOA: binds to bacterial membrane causing rapid depolarization of m embrane
potential which leads to inhibition of protein, DNA & RNA synthesis, resulting in
bacterial cell death
 § Dosing: 4-6 mg/Kg QD
o Linezolid (Zyvox):
§ Available dosage forms: IV, powder for oral suspension, tablet
§ For resistant gram + skin infections, vancomycin-resistant E. faecium
§ Monitor for myelosuppression, throm bocytopenia, & HTN (especially if used
with tyram ine-containing foods)
§ Do not com bine with SSRIs because of potential for serotonin syndrome
§ Bacteriostatic/bactericidal agent
§ Adjustment with renal dysfunction
o Metronidazole (Flagyl):
§ Use: treatm ent of bacterial vaginosis & trichomonias
§ MOA: after diffusing into the organism, interacts with DNA to cause a loss
of helical DNA structure & strand breakage resulting in inhibition of protein
synthesis & cell death in susceptible organism s
§ Avoid with etoh
o Mupirocin (Bactroban):
§ Intranasal: eradication of nasal colonization with MRSA in adult patients &
healthcare workers
· BID
§ Topical treatm ent of im petigo due to Staphylococcus aureaus, beta hemolytic
Streptococcus, & S. pyogenes
· Apply 2-5 tim es/day for 5-14 days
o Nystatin:
§ Brand nam es: Bio-Statin; Mycostatin; Nystat; Nystop; Pedi-Dri
§ Antifungal agent for the treatment of susceptible cutaneous, mucocutaneous,
& oral cavity fungal infections caused by the Candida species
§ MOA: binds to sterols in fungal cell m em brane, changing the cell wall
perm eability allowing for leakage of cellular contents
§ System ic relief in 24-72 hours from candidiasis
§ Oral: poorly absorbed
§ Available dosage forms: cream , lozenge (DSC), ointment, powder for
compounding, suspension, tablet, vaginal tablet
§ Mycolog cream contains a corticosteroid (triam cinolone) as well as an
antifungal (nystatin)
· Could be used for a patient with an ileostomy pouch
· W ould also treat the inflam m ation that can occur from what are
basically “tape burns”
o Quinupristin/dalfopristin (Syncerid):
§ Indicated for vancom ycin-resistant Enterococcus faecium & serious bacterial
skin infections
§ MOA: inhibits bacterial protein synthesis by binding to different sites on the
50S bacterial ribosom al subunit thereby inhibiting protein synthesis
§ Strengths/dosage forms:
· Injection, powder for reconstitution:
o 500 m g: quinupristin 150 m g & dalfopristin 350 m g
o 600 m g: quinupristin 180 m g & dalfopristin 420 m g
o Vancom ycin (Vanocin, Vancole):
§ MOA: inhibits bacterial cell wall synthesis by blocking glycopeptide
polym erization through binding tightly to D-alanyl-D-alanine portion of cell wall
precursor
§ Alternative to other antim icrobials, including penicillins & cephalosporins for
serious gram + infections (resistant strains of strep, MRSA)
§ W atch for ototoxicity
§ Red m an’s syndrom e: rapid drop in BP accompanied by m aculopapular rash
in neck or chest area often associated with rapid IV infusion
· Should be infused slowly >60 m ins
§ Draw peak 1 hour after infusion has com pleted; draw trough just before next
dose
§ Therapeutic peak: 25-40 m cg/m L (>80 toxic)
 § Therapeutic trough: 5-12 m cg/m L
§ Otitis media:
o 1 st line drugs: am picillin, am oxicillin, bacam picillin
o Augmentin: (> 3 m onths & < 40 kg) 90 mg/Kg/day divided Q12 hours X 10 days
o 2 n d generation cephalosporin (cefaclor- Ceclor, cefuroxim e- Ceftin, cefprozil-Cefzil,
loracarbef-Lorabid)
o Zithrom ax (treat recurrent OM), Biaxin, Bactrim
o Most com m on causative organism s: Streptococcus pneum oniae (pneum ococcus), H.
flu, m oraxella catarrhalis, pseudom onas, klebsiella
o Rocephin can be used to treat: 50 m g/Kg in a single dose or for relapsing: 50 mg/Kg
QD X 3 days
§ P. acne:
o Clindamycin, erythromycin, & tetracycline are effective
o Erythrom ycin & benzoyl peroxide (Benzam ycin):
§ Apply BID
§ This product contains benzoyl peroxide which may bleach or stain clothing
§ Available as a topical gel or Benzam ycin Pak (supplied with diluent containing
alcohol
§ Penicillins:
o Resistance to PCN is caused by beta lactam ase enzym e production & alteration of
PCN-binding proteins
§ Pseudom em branous enterocolitis (PE): Clostridium difficile overgrowth
o Caused by clindam ycin & lincom ycin
o Treat PE with fluid & electrolyte replenishm ent, oral m etronidazole (IV if patient
cannot take po), &/or vancom ycin (oral only)
§ Pseudom onas:
o Aerobic, gram – bacillus
o Treatment:
§ Antipseudom onal PCN (m ezlocillin, piperacillin, carbenicillin, ticarcillin)
§ Ceftazidime (Fortaz, Tazidime, Tazicef), Cefepim e (Maxipime) + am inoglycoside
§ Quinolone + imipenem
§ Sulfonam ide derivates:
o SJS
o The only sodium sulfa salt suitable for ophthalm ic use is sulfacetamide sodium
(Sodium Sulam yd, Bleph-10)
o Metabolized via acetylation
o Elim inated renally- good for UTIs
o Can result in crystalluria- drink sufficient amounts of water to prevent (2-3 L/day)
o Sulfam ethoxazole & trim ethoprim (Bactrim , Septra):
§ MOA:
· Sulfam ethoxazole interferes with bacterial folic acid synthesis &
grow th via inhibition of dihydrogolic acid form ation form
paraam inobenzoic acid (PABA)
· Trimethoprim inhibits dihydrofolic acid reduction to tetrahydrofolate
resulting in sequential inhibition of enzymes of the folic acid pathway
§ Staphylococcus aureus:
o DOC: dicloxacillin, nafcillin, oxacillin,
o PCN allergy: erythromycin, clindam ycin, TCN, linezolid, synercid, vancomycin
§ System ic fungal infection:
o W ould NOT use nystatin
o Fluconazole (Diflucan)
§ TB:
o Initial therapy involves RIPE:
§ As therapy continues, therapy m ay go to RIP & then RI
§ May continue for 6-18 m onths
§ Rifam pin (Rifadin, Rim actane):
· Potent enzym e inducer
· Orange discoloration of all bodily fluids- stains contacts
· Also used for elim ination of m eningococci from the nasopharynx in
 asym ptomatic carriers
§ Isoniazid (Nydrazid):
· AKA: INH
· MOA: inhibits the bacterial cell wall of susceptible isolates & is
therefore active against actively dividing cells only
o Bacteriocidal or bacteriostatic depending on tissue
concentration of the agent
· May cause vitam in B 6 deficiency- give B 6 (pyridoxine) with use
· SE: peripheral neuropathy
§ Pyrazinam ide:
· MOA: Mycobacterium tuberculosis converts pyrazinamide to
pyrazinoic acid which possesses antitubercular activity
§ Etham butol (Myam butol)
o Monitor TB drugs with:
§ LFTs
§ AST
§ Or other transferases
§ Tetracyclines:
o Broad spectrum
o Doxycycline (Atridox, Doryx, Periostat, Vibra-Tabs, Vibram ycin):
§ MOA: bacteriostatic effects by blocking the synthesis of bacterial proteins
§ Long-acting (BID) TCN
§ Elim inated via non-renal routes- good choice for renal im pairm ent
§ DI with trivalent cations- Al (com patible with divalent cations)
§ Thrush:
o Norm ally found in the m outh
o It is a fungal infection of the m outh consisting of white spots
§ UTI- pyelonephritis:
o E. coli
o Bactrim , fluoroquinolones. Am picillin + gentam icin
o UTI & sulfa allergy- treat with a FQ
§ Do not give FQ to children

Inflam m atory Bowel Disease:

§ Ulcerative colitis: an idiopathic chronic inflamm atory disease of the colon & rectum
§ Crohn’s disease: can affect any part of the tubular GIT & is characterized by transmural
inflamm ation of the gut wall
§ Treat with:
o Sulfasalazine (Azulfidine, Sulfazine)
o Mesalam ine (Asacol, Canasa, Pentasa, Rowasa)
o Olsalazine (Dipentum)
o Glucocorticords
o Imm unosuppressive agents (6-mercaptopurine, azathioprine, m ethotrexate,
cyclosporine)
o Antibiotics (m etronidazole)
o Inflixim ab (Rem icade)
§ Sulfasalazine (Azulfidine®):
o Used in the treatm ent of inflam m atory bowel disease (ulcerative colitis) & RA
o W atch for sulfa allergy, salicylate allergy, & urinary discoloration
o Sulfasalazine à sulfapyridine + mesalamine (5-aminosalicyclic acid; 5-ASA)
§ 5-ASA is more active
§ If patient cannot tolerate sulfasalazine because of a sulfa hypersensitivity,
m esalam ine (Asacol, Pentasa, Rowasa) m ay be used
· Asacol
o Delayed released, EC coated tablet- do not crush or chew

Im munosuppressive Therapy:
§ Calcineurin inhibitors:
o Cyclosporine (Sandimm une, Neoral)
 o Tacrolim us (Prograf)
§ mTOR inhibitors:
o Sirolim us (Rapam une)
§ Antiproliferative agents:
o Azathioprine (Im uran)
o Mycophenolate mofetil (CellCept)
o Mycophenolate sodium (Myfortic)
o Leflunomide (Arava)
§ Monoclonal antibodies:
o Muromonab-CD3 (Orthoclone OKT 3)
o Basliximab (Sim ulect)
o Daclizum ab (Zenepax)
§ Polyclonal antibodies:
o Anti-thym ocyte globulin (Atgam ): equine
o Anti-thym ocyte globulin (Thym oglobulin): rabbit

Insom nia, Anxiety, or both:

§ Benzodiazepines:
o Most undergo oxidation to active metabolites in liver
o Lorazepam (Ativan), oxazepam (Serax), & temazepam (Restoril) undergo
glucuronidation to inactive m etabolites
§ Useful in elderly & those with liver disease
o Can experience seizures & delirium with sudden discontinuation
o Hypnotic agents:
§ Estazolam (ProSom )
§ Flurazepam (Dalm ane)
§ Quazepam (Doral)
§ Tem azepam (Restoril)
§ Triazolam (Halcion)
§ Trazodone (Desyrel):
o Antidepressant that is useful for severe anxiety or insom nia
o Highly sedating, causing postural hypotension & is associated with priapism
o Doses:
§ Sedation: 25-50 m g
§ Depression: 150 m g divided into 3 daily doses; m ax 600 mg/day
§ Zolpidem (Am bien):
o An im idazopyridine hypnotic agent
o MOA: has much or all of its actions explained by its effects on benzodiazepine
receptors, especially the omega-1 receptor
§ binds the benzodiazepine (BZ) receptor subunit of the GABA-A receptor
complex
o No withdrawal sym ptom s, rebound insom nia or tolerance
o Rapid onset good for initiating & m aintaining sleep
o SE: headache, daytime somnolence, GI upset
o Avoided in patients with obstructive sleep apnea
§ Zaleplon (Sonata)
o Nonbenzodiazepine hypnotic
o MOA: interacts with benzodiazepine GABA receptor complex
o T1/2 is ~1 hour & has no active metabolites
o SE: drowsiness, dizziness, & im paired coordination
o Caution in those with comprom ised respiratory function
§ Eszopiclone (Lunesta):
o MOA: may interact with GABA-receptor complexes
§ OTC sleep aids:
o Doxylam ine (Unisom )
o Diphenhydram ine (Nytol, Som inex)
o Diphenhydram ine + APAP (Tylenol PM, Unisom Pain Relief)
o Diphenhydramine + ASA (Bayer PM)
Lupus:
§ Autoim m une inflam m atory condition
§ System ic Lupus Erythem atosus (SLE)
§ Drugs that can contribute: procainam ide**, phenytoin, chlorprom azine, hydralazine*,
quinidine, m ethyldopa, & isoniazid
§ Therapy:
o Arthritis: NSAIDs or glucocorticoids
o Derm atologic com plications: hydroxychloroquine (Plaquenil)
o Throm bocytopenia: glucocorticoid therapy
o Refractory cases: cyclophospham ide

Metabolic acidosis:
§ Give sodium acetate- acetate ion converts to bicarbonate
§ Bicitra:
o Sodium citrate & citric acid
o Other brand nam es: Cytra-2 & Oracit
o AKA: Modified Shohl’s solution
o Use: treatm ent of m etabolic acidosis; alkalinizing agent in conditions where long-
term maintenance of an alkaline urine is desirable
§ Also solution antacid pre-op if patient has eaten just before emergency
surgery or delivery of child
o Dosing: oral- 10-30 mL with water after m eals (to avoid laxative effect) & at bedtime
o SE: N/V/D, hyperkalem ia, tetany

Migraines:
§ Triptans:
o Selective serotonin receptor agonists that activate 5-HT 1 B /5-HT 1 D & to a lesser extent
5-HT 1 A /5-HT 1 F
o Agents:
§ Alm otriptan (Axert): 6.25 & 12.5 m g tablets; CYP450 & MAO m etabolism
· NMT 2 doses in 24 hours
§ Sum atriptan (Im itrex): 25, 50, & 100 m g tablets, 5 & 20 m g nasal spray, 12
m g/m L injection; MAO m etabolism
· Can re-dose oral tablets & nasal spray if no response after 2 hours
· Can re-dose injection if no response after 1 hour
§ Eletriptam (Relpax): 20 & 40 m g tablets; CYP 3A4 m etabolism
· Can re-dose after 2 hours
· 80 mg/day m ax
§ Frovatriptan (Frova): 2.5 mg tablet; renal 50%
· Can re-dose after 2 hours
· 7.5 mg/day m ax
§ Rizatriptan (Maxalt): 5 & 10 m g tablet/wafer; MAO m etabolism
· Can re-dose after 2 hours
· 30 mg/day m ax
· 15 mg m ax if also taking propranolol
§ Zolm itriptan (Zom ig): 2.5 mg tablet/wafer, nasal spray 5 m g, ODT; CYP450
& MAO metabolism
· Can re-dose after 2 hours
· NMT 10 m g per 24 hours
§ Naratriptan (Am erge): 1 & 2.5 m g tablets; renal 70% & CYP450
· Dose may be repeated after 4 hours
· NMT 5 m g in 24 hours
o SQ sumatriptan has the fastest onset followed by sum atriptan nasal spray
o Rizatriptan may have a slightly faster onset of action than the others
o Migraine recurrence rates may be lower with long half-life triptans such as
naratriptan & frovatriptan
o SE: tingling & paresthesias; sensations of warm th in the head, neck, chest, & limbs;
dizziness; flushing; neck pain or stiffness
o Do not give sum atriptan to patients who have risk factors for CAD
 o CI: in patients with hx of ischemic heart disease, MI, uncontrolled HTN, or other
heart disease; pregnancy
o Should not be taken within 24 hours of other triptans, isom etheptene, or ergot
derivatives
§ Com bination:
o Midrin:
§ Oral Capsule: (Acetaminophen - Dichloralphenazone - Isometheptene Mucate)
325 MG-100 MG-65 MG
Isom etheptene: is an indirect-acting sym pathom im etic agent with
§
vasoconstricting activity
Dichloralphenazone: a m ild sedative & relaxant
§
Acetaminophen: may act predom inantly by inhibiting prostaglandin synthesis
§
in the CNS &, to a lesser extent, through a peripheral action by blocking pain-
im pulse generation
The peripheral action m ay also be due to inhibition of prostaglandin
·
synthesis or to inhibition of the synthesis or actions of other substances
that sensitize pain receptors to mechanical or chemical stim ulation
Butalbital 50 mg, aspirin 325 m g, & caffeine 40 m g (Fiorinal):
o
Capsules
§
Butalbital, acetam inophen, & caffeine (Anolor 300; Dolgic; Esgic; Fioricet; Medigesic;
o
Repan; Zebutal):
Butalbital 50 mg, APAP 325 m g & caffeine 40 m g (Fioricet)
§
Tablet
·
§ Ergot derivatives:
o CI: pregnancy, peripheral vascular disease, CAD, sepsis, hepatic or renal impairment
o Dihydroergotam ine (DHE 45, Migranal):
§ Migraines: with or without aura
§ MOA: ergot alkaloid alpha-adrenergic blocker directly stim ulates vascular
sm ooth m uscle to vasoconstrict peripheral & cerebral vessels; also has effects on
serotonin receptors
· 5-HT 1 D receptor agonist
§ Max: 6 mg/week
§ Patient takes too m uch: N/V/D, dizziness, paresthesia, peripheral ischemia,
peripheral vasoconstriction
§ Available dosage form s: injection (DHE 45) & intranasal spray (Migranal)
· Migranal: 1 spray in each nostril; can repeat in 15 m inutes; m ax is
4 sprays/day
o Discard open am pules after 8 hours
o Ergotam ine tartrate & caffeine (Cafergot):
§ Available dosage forms: tablets & suppositories
§ Max: 6 mg/day or 10 m g/week
o SE: nausea & vomiting (resulting from stim ulation of the CTZ)
o Ergotism : severe peripheral ischem ia
§ Sx: cold, num b, painful extremities, continuous paresthesias, diminished
peripheral pulses & claudication m ay result from the vasoconstrictor effects of the
ergot alkaloids
§ Gangrenous extremities, MI, hepatic necrosis, & bowel & brain ischemia are
rare, but have been reported
§ Propylactic therapy:
o DOC:
§ Propranolol (Inderal): use if patient also has HTN
· Lipid soluble
 § Am itriptyline (Elavil): concom itant depression
§ Valproate (Depakote): concomitant seizures
§ Cyproheptadine (Periactin): useful for m igraines in children
§ Feverfew: herbal with som e benefits shown
§ Ergonovine maleate: effective for m enstrual m igraines
§ Methysergide (Sansert):
· Dose: 2 m g BID up to 8 m g X 6 months
o Then stop for 1 m onth
o If you don’t stop- get SE of retroperitoneal fibrosis: organs in
abdom inal cavity becom e fibrotic & can die
o This can occur as the result of constant vasoconstriction-
which provides less blood flow to organs
o You m ust stop to allow blood flow to return

Miscellaneous Drugs:
§ Acetylcysteine (Mucom yst, Acetadote):
o MOA: exerts m ucolytic action through its free sulfhydryl group which opens up the
disulfide bonds in the m ucoproteins thus lowering m ucous viscosity; thought to reverse
APAP toxicity by providing substrate for conjugation with the toxic metabolites
o Also used for prevention of radiocontract-induced renal dysfunction
§ Adalim um ab (Hum ira):
o Tumor necrosis factor (TNF) blocking agent
o MOA: binds to hum an tum or necrosis factor alpha (TNF-alpha) receptor sites
§ Elevated TNF levels in the synovial fluid are involved in pathologic pain
o Use: treatment of active RA in patients with inadequate response to one or more
DMARDs; psoriasis
o Dose: 40 mg SQ EOW
o Before starting therapy: TB test, m easure rheumatoid factor, PT
§ Adefovir (Hepsera):
o Antiretroviral agent; reverse transcriptase inhibitor (nucleoside)
o MOA: acyclic nucleotide reverse transcriptase inhibitor (adenosine analog) which
interferes with HBV viral RNA dependent DNA polym erase resulting in inhibition of viral
replication
o Use: treatment of chronic hepatitis B
§ Aspirin & dipyridam ole (Aggrenox):
o Use: reduction in the risk of stroke in patients who have had transient ischemia of
the brain or com pleted ischem ic stroke due to throm bosis
o MOA:
§ Dipryidam ole: inhibits the uptake of adenosine into platelets, endothelial
cells & erythrocytes
§ Aspirin: inhibits platelet aggregation by irreversible inhibition of platelet
cyclooxygenase & thus inhibits the generation of throm boxane A2
o Dosing: 1 capsule BID
§ Atropine (AtroPen; Atropine-Care; Isopto; Sal-Tropine):
o AtroPen formulation is available for use prim arily by the departm ent of defense
o MOA: blocks the action of acetylcholine at parasym pathetic sites in sm ooth muscle,
secretory glands & the CNS; increases CO, dries secretions, antaonizes histamine &
serotonin
§ Bism uth subsalicylate, m etronidazole, tetracycline (Helidac):
o If patient has + urea breath test indicating H. pylori present
§ Chlorhexidine (Periogard):
o Antibacterial agent for oral rinse
o Bactericidal
o Uses: disinfectant; gingivitis; periodonitis; inhibits plaque form ation
§ Crom olyn (NasalCrom ):
o Dose: use 1 spray in each nostril 3-4 tim es per day
§ Cyclosporin (Gengraf, Neoral, Restasis, Sandim m une):
o Neoral & Sandim m une are NOT therapeutically equivalent
o Im m unosuppressant agent
 o MOA: inhibition of production & release of interleukin II & inhibits interleukin II-
induced activation or resting T-lym phocytes
§ Danazol (Danocrine):
o Use: treatm ent of endom etriosis, fibrocystic breast disease & hereditary angioedema
o Androgen
o MOA: suppresses pituitary output of FSH & LH that causes regression & atrophy of
norm al & ectopic endom etrial tissue; decreases rate of growth of abnorm al breast tissue
o CI: markedly im paired hepatic, renal, or cardiac function
§ Desm opressin (DDAVP, Stim ate):
o Vasopressin analog
o Uses: diabetes insipidus; control bleeding in hemophilia A & van W illebrand disease;
prim ary noctural enuresis
o Strengths/dosage forms:
§ Injection (IV): 4 m cg/m L
§ Solution, intranasal: 100 m cg/m L
§ Tablets
§ Desoxim etasone (Topicort):
o Intermediate to high potency topical corticosteriod
o Available as a cream & ointm ent
§ Dicyclom ine (Bentyl);
o MOA: anticholinergic agent
o Uses: treatm ent of functional disturbances of GI motility such as irritable bowel
syndrom e
o NOT used for GERD
§ Diphenhydram ine (Benadryl):
o Analgesic, antihistamine, antipruritic, sleep aid, antitussive, antiem etic
o Class: Ethanolam ine
o Dosing adjustm ents in renal im pairm ent
o MOA: Diphenhydramine hydrochloride acts as an antihistam ine by com peting with
histam ine for receptor sites on effector cells
o Precautions: bladder neck obstruction; concurrent MAOI therapy; concurrent use
of CNS depressants; decreases mental alertness & psychom otor perform ance; do not use
topical form on eyes or eye lids; elderly are m ore susceptible to the SE of
diphenhydram ine; history of bronchial asthm a, increased intraocular pressure,
hyperthyroidism , cardiovascular disease or HTN; may cause excitation in young children;
narrow angle glaucom a; pyloroduodenal obstruction; stenosing peptic ulcer; sym ptomatic
prostatic hypertrophy
§ Diphenoxylate & Atropine (Lom itol; Lonox):
o Antidiarrheal
o CI: severe liver disease; jaundice; narrow angle glaucom a; children < 2 years old
o MOA: diphenoxylate inhibits excessive GI motility & GI propulsion
o Comm ercial preparations contain a subtherapeutic amount of atropine to discourage
abuse
o Dosing: 15-20 m g/day of diphenoxylate in 3-4 divided doses
§ Maintenance: 5-15 m g/day in 2-3 divided doses
o May cause drowsiness
§ Etancercept (Enbrel):
o Disease modifying agent
o MOA: binds to TNF & blocks its interaction with cell surface receptors
§ TNF blocker
o Use: moderate-severe RA; chronic plaque psoriases
o Dose: 25 mg injection SQ twice weekly or 50 m g injection SQ once weekly
o Initial storage of drug: in refrigerator (not frozen)
o Stability of vials after reconstitution: 14 days in refrigerator
o Allow prefilled syringes 15-30 m inutes at room temperature prior to injection
o Some foaming is normal
o No DI with methotrexate
o Stop using when patient has a serious infection
§ Guaifensin:
 o MOA: expectorant which acts by irritating the gastric m ucosa & stim ulating
respiratory tract secretions, thereby increasing respiratory fluid volumes & decreasing
m ucus viscosity
§ Hyaluronate (Hyalgan, Biolon, Healon, Hylaform, Orthovisc, Provisc, Restylane, Supartz,
Synvisc, Vitax):
o MOA: sodium hyaluronate is a polysaccharide which is distributed widely in the
extracellular m atrix of connective tissue in m an. It form s a viscoelastic solution in water
(at physiological pH & ionic strength) which m akes it suitable for aqueous & vitreous
humor in ophthalm ic surgery & functions as a tissue &/or joint lubricant
o Use:
§ intra-articular injection (Synvisc)- treatm ent of pain in OA in knee in patients
who have failed nonpharm acologic treatment & sim ple analgesics
· No weight bearing exercise for 48 hours
§ Intraderm al- correction of m oderate to severe facial wrinkles
§ Ophthalm ic- surgical aid in cataract extraction, intraocular im plantation,
corneal transplant, glaucom a filtration, & retinal attachm ent surgery
§ Topical- management of skin ulcers & wounds
§ Hydroxyzine (Atarax, Vistaril):
o MOA: competes with histam ine for H 1 receptor sites on effector cells in the GIT, blood
vessels, & respiratory tract; possesses skeletal muscle relaxing, bronchodilator,
antihistam ine, antiem etic, & analgesic properties
o Use: treatm ent of anxiety; preoperative sedative; antipruritic; antiem etic
o Causes sedation
o Hydroxyzine pam oate (Vistaril)
o Hydroxyzine HCl (Atarax)
o Not to be confused with Hydralazine
§ Interferon beta 1b (Betseron):
o Use: treatment of MS
o Can cause hepatotoxicity- m onitor LFTs
§ Isotretinoin (Accutane, Am nesteem , Clarais, Sotret):
o Retinoic acid derivative
o MOA: reduces sebaceous gland size & reduces sebum production; regulates cell
proliferation & differentiation
o Use: treatm ent of sever recalcitrant nodular acne unresponsive to conventional
therapy
o RiskM AP, S.M .A.R.T., S.P.R.I.T., I.M .P.A.R.T. program s
§ Cannot be dispensed unless the rx is affixed w ith a yellow, self-adhesive
qualification sticker filled out by the prescriber
§ Telephone, fax, or com puter-generated rxs are no longer valid
§ Rx cannot be written for m ore than a 1-m onth supply, must be dispensed
with a patient education guide
§ Fem ales m ust have their rxs filled within 7 days of the qualification date-
considered expired if > 7days
o Pregnancy risk factor: X
§ Fem ales must have 2 m ethods of contraception; 1 m onth prior to starting
therapy & 1 month after discontinuation of therapy
§ Therapy is begun after 2 negative pregnancy tests
o SE: increased triglycerides, elevated blood glucose, photosensivitivity, seizure,
cataracts
o Avoid additional vitamin A supplem ents
o Dose: 0.5-2 m g/Kg/day in 2 divided doses
o Take with food; lim it exercise while on therapy; capsules can be swallowed, or chewed
& swallowed; capsule m ay be opened with a large needle & contents placed on applesauce
or ice cream
o Excerbation of acne may occur during the 1 st weeks of therapy
o Accutane, Am nesteem , & Sotret contains soybean oil (Claravis does not)
§ Lansoprazole (30 mg), am oxicillin (1 g), clarithrom ycin (500 m g) (Prevpac):
o For H. pylori
o Taken together BID for 10-14 days
§ Leflunom ide (Arava):
o Disease modifying agent
o MOA: inhibits pyrim idine synthesis, resulting in antiproliferative & anti-
inflam m atory effects
o Use: treatment of active RA; indicated to reduce signs & sym ptom s, & to retard
structural damage & im prove physical function
§ Luride: source of fluoride to prevent dental caries
o Supplied as sodium fluoride in chewable tablets that provide 0.25 m g, 0.5 mg, & 1
m g of fluoride ion per tab
o Prolonged ingestion with excessive doses may result in dental fluorosis (staining or
hypoplasia of the enam el of the teeth) & osseous changes
§ Malathion (Ovide):
o Class: organophosphate; pediculicide
o Uses: pediculosis capitis; lice
o MOA: acts via cholinesterase inhibition. It exerts both lousicidal & ovicidal actions
in vitro.
o Safety not established in children under 6 years old
o Lotion
§ Mannitol (Osm itrol, Resectisol):
o Osm otic diuretic
o MOA: increases osmotic pressure of glomerular filtrate, which inhibits tubular
reabsorption of water & electrolytes & increases urinary output
§ Mebendazole (Verm ox):
o Anthelm intic agent
o MOA: selectively & irreversibly blocks glucose uptake & other nutrients in
susceptible adult intestine-dwelling helm inthes
o Dosing:
§ Pinworm s: 100 m g po ASD; m ay need to repeat after 2 weeks; treatment
should include fam ily m em bers in close contact with patient
§ W hipworms, roundworm s, hookworm s: 1 tablet BID, m orning & evening on
3 consecutive days; if patient is not cured within 3-4 weeks, a 2 n d course of
treatment may be adm inistered
§ Capillariasis: 200 mg BID for 20 days
o Strengths/dosage forms:
§ Tablet, chewable: 100 m g
§ Methotrexate (Rheum atrex; Trexall):
o MOA: inhibits dihydrofolate reductase causing interference with DNA synthesis,
repair, & cellular replication
o Juvenile RA: oral, IM: 10 m g/m 2 once weekly
o Does cause alopecia
o Causes myelosuppression & throm bocytopenia
§ NOT throm bocytosis (increased PLT)
o BBW for hepatotoxicity
o Can cause megalobastic anem ia
§ Misoprostol (Cytotec):
o MOA: synthetic prostaglandin E1 analog that replaces the protective prostaglandins
consum ed with prostaglandin-inhibiting therapies (i.e. NSAIDs); has been shown to
induce uterine contractions
o Dosing:
§ Prevention of NSAID-induced ulcers: 200 mcg po QID with food (to decrease
diarrhea)
§ Labor induction or cervical ripening: intravaginal- 25 m cg (1/4 of a 100 m cg
tablet)
· Do not use in patients with previous cesarean delivery or prior major
uterine surgery
§ Fat absorption in CF (unlabeled use): 100 mcg QID (ages 8-16)
o Tablets only (no IV)
§ Nim odipine (Nim otop):
o MOA: calcium channel blocker
 o Use: spasm following subarachnoid hemorrhage from ruptured intracranial
aneurysm s
o Has a greater effect on cerebral arteries- m ay be due to the drug’s increased
lipophilicity
o Dosing: 60 mg po Q4h x 21 days; start 96 hours after subarachnoid hemorrhage
o If the capsules cannot be swallowed, the liquid m ay be rem oved by m aking a hole in
each end of the capsule with an 18-guage needle & extracting the contents via syringe
§ Oxybutynin (Ditropan):
o Urinary antispasm odic agent
o MOA: Non-selective muscarinic receptor antagonist with a higher affinity for M1 &
M3 receptors
§ Increases bladder capacity, decreases uninhibited contractions, & delays
desire to void
o Dosage form s available: syrup, tablet (IR, XR), patch (Oxytrol)
§ Palivilizum ab (Synagis):
o Use: m onoclonal antibody used for prevention of serious lower respiratory tract
disease caused by respiratory syncytial virus (RSV) in infants & children < 2 years
o MOA: exhibits neutralizing & fusion-inhibitory activity against RSV
§ Ribavirin (Copegus, Rebetol, Ribasphere, Virazole) also used to treat RSV
· Available as: capsule; powder for aerosol; oral solution; tablet
§ Pancuronium :
o Nondepolarizing neurom uscular blocking agent
o MOA: blocks neural transm ission at the m yoneural junction by binding with
cholinergic receptor sites
o Onset: 2-4 minutes
o Duration after single dose: 40-60 m inutes
o Use: adjunct to general anesthesia to facilitate endotracheal intubation & to relax
skeletal muscles during surgery; does not relieve pain or produce sedation
o DOC for neurom uscular blockade EXCEPT in patients with renal failure, hepatic
failure, or cardiovascular instability
o AE: increased pulse rate, elevated BP & CO, edem a, flushing, rash, bronchospasm,
hypersensitivity rxn
§ Peginterferon Alfa-2a (Pegasys):
o Use: hepatitis C
o Refrigerate; protect from light
Perm ethrin(Acticin, Elim ite, Nix Crem e Rinse, Pronto, Rid, A200 Lice Control)
§
o OTC available with sam e ingredient: Nix
§ PhosLo:
o Calcium acetate
o Use:
§ Oral: control of hyperphosphatem ia in end-stage renal failure; does not
prom ote alum inum absorption
§ IV: calcium supplementation in parenteral nutrition therapy
o MOA: combines with dietary phosphate to form insoluble calcium phosphate which
is excreted in the feces
§ Physostigm ine (Antilirium ):
§ Prednisone (Deltasone, Sterapred):
o M OA: an adrenocortical steroid with salt-retaining properties; it is a synthetic
glucocorticoid analog, which is m ainly used for anti-inflam m atory effects in different
disorders of many organ systems; causes profound & varied metabolic effects, modifies
the im m une response of the body to diverse stim uli, & is also used as replacement
therapy for adrenocortical deficient patients
o Cortiosteriods should be used with caution in patients with DM, HTN, osteoporosis,
glaucom a, cataracts, TB, hepatic im pairment, elderly
§ Propofol (Diprivan):
o General anesthetic; no analgesic properties
o Avoid abrupt discontinuation- titrate slowly
o Propofol emulsion contains soybean oil, egg phosphatide & glycerol
 o “Propofol infusion syndrom e”: sym ptom s include sever, sporadic m etabolic acidosis
&/or lactic acidosis which may be associated with tachycardia, m yocardial dysfunction,
&/or rhabdom yolysis
o Short duration of action: 3-10 m inutes
o If on concurrent parenteral nutrition, m ay need to adjust the am ount of lipid infused
o Provides 1.1 kCal/m L
§ Riopan:
o Magaldrate (antacid) & sim ethicone (antiflatulent) combination
o Substitutes can be found in the Non-Prescription Handbook & Facts & Comparisons
§ Robitussin:
o Robitussin: guaifenesin 100 mg/5 m L-OTC
§ Alcohol free
o Robitussin PE: guaifenesin 200 mg & pseudoephedrine 30 mg/5m L –OTC
§ Alcohol free
o Robitussin CF: guaifenesin 100 mg, pseudoephedrine 30 mg, & dextrom ethorphan
10 mg/5 m L -OTC
§ Alcohol free
o Robitussin DM: guaifenesin 100 mg & dextrom ethorphan 10 mg/5 m L –OTC
§ Alcohol free
§ Ursodiol (Actigall, Urso 250, Urso Forte):
o Use: prevention of gallstones in obese patients experiencing rapid weight loss
o AKA: ursodeoxycholic acid
o MOA: decreases cholesterol content of bile & bile stones by reducing the secretion
of cholesterol from the liver & the fractional reabsorption of cholesterol by the intestines
o Dosing:
§ Gallstone dissolution: 8-10 m g/Kg/day in 2-3 divided doses
§ Gallstone prevention: 300 m g BID
o Use beyond 24 m onths is not established
§ Vecuronium :
o Nondepolarizing neurom uscular blocker agent
o MOA: blocks acetylcholine from binding to receptors on m otor endplate by inhibiting
depolarization
o Onset: 2-4 minutes
o DOA: 30-45 minutes
o Use: adjunct to general anesthesia to facilitate endotracheal intubation & to relax
skeletal muscles during surgery; does not relieve pain or produce sedation
o AE: bradycardia, edem a, flushing, hypersensitivity rxn, hypotension, tachycardia,
rash

Miscellaneous Facts:
§ Danger of decreasing DKA too fast: cerebral edem a
§ Genetic polym orphism exists as acetylation
§ Album in is important for measuring calcium levels
o Corrected calcium = serum calcium + 0.8(4 – patient’s albumin)
§ Caffeine treats respiratory distress in neonates
§ Em ergency bee sting kit:
o Epinephrine & APAP
o EpiPen auto-Injector
§ 0.3 mg SQ dose of 1:1000 epinephrine in a 2 m L disposable prefilled injector
§ Liposyn III (fat em ulsion) is stored at room temperature
§ MedW atch: a list of reported side effect
o Completely voluntarily reported
§ Stain derm atologists use for fungus identification: KOH
§ Kayexlate + sorbitol use: to prevent constipation
o Store at room temperature
§ Hypercalcem ia: alm ost always caused by increased entry of Ca into the extracellular fluid
& decreased renal Ca clearance
o More that 90% of cases are due to prim ary hyperparathyroidism or m alignancy
§ Hypocalcem ia in renal im pairm ent:
 o Phosphorus & calcium levels are altered due to:
§ Phosphorus retention, resulting in a rise in serum phosphorus levels & a
reciprocal fall in calcium levels, with resultant stim ulation of parathyroid hormone
(PTH) secretion
§ Decreased generation of 1,25-dihyroxyvitam in D 3 , further contributing to low
serum calcium levels & decreasing suppression of PTH
o Addition of a phosphate binder prevent GI phosphate absorption:
§ Calcium carbonate 500-1000 m g po with m eals
§ Sevelamer (Renagel): lacks aluminum & calcium
§ Cheilitis: inflam m ation of the lips
§ Herpes sim plex I (cold sore): avoid the sunlight
§ Goodpasture’s syndrom e: glom erulonephritis associated with pulm onary hermorrhage &
circulating antibodies against basem ent m em brane antigens
o Autoim m une disease
§ Resorcinol/ASA/LCD needs to be packaged in what container
o LCD is coal tar- brown glass container
§ Medrol dose pack: decrem ental dosing
§ Polydipsia: excessive thirst
§ Patients with phenylketonuria (PKU) m ust avoid aspartam e

Myasthenia Gravis:
§ An autoim m une disorder that involve antibody-m ediated disruption of postsynaptic nicotinic
acetylcholine receptors at the neurom uscular junction & is often associated with thym us tum ors
§ Treatment:
o Anticholinesterase drugs:
§ Pyridostigm ine
§ Neostigm ine
o Thym ectom y
o Im m unosuppressive drugs
§ High-dose prednisone
§ Azathioprine
§ Cyclosporine
§ Cyclophospham ide

Orange Book:
§ AKA: Approved Drug Products with Therapeutic Equivalence Evaluations
§ Codes:
o A: Drug products that FDA considers to be therapeutically equivalent to other
pharm aceutically equivalent products, i.e., drug products for which:
§ there are no known or suspected bioequivalence problems. These are
designated AA, AN, AO, AP, or AT, depending on the dosage form; or
§ actual or potential bioequivalence problem s have been resolved with adequate
in vivo and/or in vitro evidence supporting bioequivalence. These are designated
AB
§ AA Products in conventional dosage forms not presenting bioequivalence
problem s
§ AB, AB1, AB2, AB3... Products meeting necessary bioequivalence
requirem ents
§ AN Solutions and powders for aerosolization
§ AO Injectable oil solutions
§ AP Injectable aqueous solutions &, in certain instances, intravenous non-
aqueous solutions
§ AT Topical products
o B: Drug products that FDA at this tim e, considers NOT to be therapeutically
equivalent to other pharm aceutically equivalent products, i.e.,
§ drug products for which actual or potential bioequivalence problems have not
been resolved by adequate evidence of bioequivalence. Often the problem is with
specific dosage forms rather than with the active ingredients. These are
designated BC, BD, BE, BN, BP, BR, BS, BT, BX, or B*.
 § B* Drug products requiring further FDA investigation & review to determine
therapeutic equivalence
§ BC Extended-release dosage form s (capsules, injectables & tablets)
§ BD Active ingredients & dosage form s with docum ented bioequivalence
problem s
§ BE Delayed-release oral dosage form s
§ BN Products in aerosol-nebulizer drug delivery system s
§ BP Active ingredients & dosage form s with potential bioequivalence problems
§ BR Suppositories or enem as that deliver drugs for system ic absorption
§ BS Products having drug standard deficiencies
§ BT Topical products with bioequivalence issues
§ BX Drug products for which the data are insufficient to determine
therapeutic equivalence

Osteopenia/Ostoporosis:
§ T scores are used for diagnosis:
o Osteopenia: T score -1 to -2.5 SD below the young adult m ean
o Osteoporosis: T score # -2.5 SD below the young adult m ean
§ Bisphosphonates:
o Could worsen esophagitis
o Take with a full glass of water fir thing in the AM & at least 30 m inutes before the 1 st
food or beverage of the day
o Maxim ize therapy by taking calcium + vitam in D
o Alendronate (Fosm ax):
§ Prevention dose: 5 mg QD or 35 m g Q week
§ Treatment dose: 10 m g QD or 70 m g Q week
§ Dosage forms: solution & tablet
o Ibandronate (Boniva):
§ Prevention dose: 2.5 m g QD; 150 m g Q m onth m ay be considered
§ Treatment dose: 2.5 m g QD or 150 m g Q m onth
o Risedronate (Actonel):
§ Prevention dose: 5 mg QD or 35 m g Q week m ay be considered
§ Treatment dose: 5 m g QD or 35 m g Q week
§ Selective Estrogen Receptor Modulator:
o Raloxifene (Evista):
§ MOA: estrogen receptor agonist at the skeleton decreases resorption of bone
& overall bone turnover
§ 60 mg QD for treatm ent & prevention of osteoporosis
§ SE: increased risk of throm boem bolism, hot flashes, nausea, dyspepsia,
weight gain
§ Teriparatide (Forteo):
o Parathyroid horm one (PTH) analog for osteoporosis
o MOA: stim ulates osteoblast function, increases GI calcium absorption, increases
renal tubular reabsorption of calcium
o Dosage: injection
o Storage: refrigerate; discard pen 28 days after 1 st injection

OTC:
§ Alum inum hydroxide (ALternaGel, Am phojel):
o Use: for treatm ent of hyperacidity & hyperphosphatem ia
o MOA: neutralizes hydrochloride in stom ach to form Al(Cl)3 salt + H 2 O
o Dose:
§ Hyperphosphatem ia: 300-600 mg TID with m eals (within 20 minutes of m eal)
§ Hyperacidity: 600-1200 m g between m eals & at bedtim e
o Aluminum may accumulate in renal impairm ent
o Dose should be followed with water
§ Antidiarrheal agents:
o Bism uth subsalicylate (Kaopectate)
§ Has both antisecretory & antim icrobial actions while possibly providing anti-
 inflam m atory action as well
§ Atopic derm atisis:
o Hydrocortisone
§ Capsacin (Zostrix, Capzasin):
o MOA: induces the release of substance P, the principle chem om ediator of pain
im pulses from the periphery to the CNS; after repeated application, the neuron is depleted
of substance P
o Apply to the affected area at least 3-4 tim es/day
§ If applied less than this, decreased efficacy
o Strength: 0.025% , 0.075%
§ Delsyn
o Dextrom ethorphan
o Contains 0.26% alcohol
§ Diaper rash:
o Breast-fed infants have less diaper rash than do bottle-fed infants
o Skin protectants to treat:
§ Allantoin, calam ine, cod liver oil (in combination), dim ethicone, kaolin, lanolin
(in com bination), mineral oil, petrolatum , talc, topical cornstarch, white
petrolatum , zinc oxide, zinc oxide ointm ent
o Can use Mycolog cream (triam cinalone & nystatin)
o Candidiasis (?)
§ Fleet’s Phospho-Soda (Sodium Phosphate):
o CI: CHF, ascites, patients on a Na restricted diet
o Saline laxative
§ Gaviscon:
o Alum inum hydroxide & m agnesium trisilicate
o Use: temporary relief of hyperacidity
o Dose: chew 2-4 tablets QID
o Aluminum &/or magnesium m ay accumulate in renal im pairm ent
o Do not swallow tablets whole
§ Loratidine (Claritin, Alavert):
o Nonsedating antihistam ine
o Patients with liver or renal im pairm ent should start with a lower dose (10 mg QOD)
o Do not use in children <2
o Dosing:
§ 2-5 years old: 5 m g QD
§ >6: 10 mg QD
o Take on an empty stomach
o Available as: syrup, tablet, rapidly disintegrating tablets
§ Magnesium citrate (Citro-M ag):
o Saline laxative
o Use: evacuation of bowel prior to surgery & diagnostic procedures or overdose
situations
o CI: renal failure, DM, GI com plications
§ Milk of magnesia:
o Magnesium hydroxide
o Short-term treatment of occasional constipation
§ Nicotine Replacem ent therapy:
o Products: patch, gum , lozenge, inhaler (Nicotrol Inhaler- Rx only), nasal spray
(Nicotrol NS- Rx only)
§ Ostomy care:
o Three basic types of ostom ies:
§ Ileostom y
§ Colostom y (m ost com m on)
§ Urinary diversion
o Effect of food on stom a output:
§ Foods that thicken:
· Applesauce, bananas, bread, butterm ilk, cheese, pasta, potatoes,
pretzels, rice yogurt
 § Foods that loosen:
· Alcohol, chocolate, beans, fried or greasy foods, spicy foods, leafy veg
§ Foods that cause stool odor:
· Asparagus, beans, cheese, eggs, fish, garlic
§ Foods that cause urine odor:
· Asparagus, seafood, spices
§ Foods that combat urine odor:
· Butterm ilk, cranberry juice, yogurt
o Local complications:
§ Local irritation: can occur because the output from the intestines or kidneys
can irritate the skin around the stom a
· Patient can use: karaya powder, pectin base powder, ostom y creams,
or barriers to protect the skin
§ Alakaline derm atitis: occurs in patients with urinary diversions because of
the alkaline nature of the output
· M ajor cause of blood in the pouch because it renders the stoma
extrem ely friable
· Treatm ent is acidification of the urine (cranberry juice 2-3 quarts
daily)
§ Excoriation: caused by erosion of the epiderm is by digestive enzym es
· The eroded or denuded epiderm is m ay bleed, & is painful when
touched when applying the appliance
· Treatm ent: karaya or pectin-based powder m ay be applied to the
peristom al skin prior to application of the pouch, m ore frequent changing
of the pouch
§ Infection: candida species
· 2% miconzaole powder or nystatin powder
o Fitting an ostomy:
§ Pouch opening m ay be cut to fit or presized
· If they are cut to fit, the stoma pattern is traced onto the skin barrier-
wafer surface of the pouch & then cut out before being applied
§ The diam eter of the round stom a is m easured at the base, where the mucosa
m eets the skin, which is considered the widest m easurem ent
§ Oval stomas should be m easured at both their widest & narrowest diam eters
§ A stom a m ay swell if the appliance fits too tightly or slips, or if the patient
falls or experiences a hard blow to the stom a
§ Other consideration include: body contour, stom a location, skin creases &
scars, & type of ostom y
§ To prevent leakage, the pouch should be em ptied when it is 1/3 – 1/2 full
§ The flange & skin barrier m ay be left in place for 3-7 days, depending on the
condition of the skin & skin barrier
§ W ater will not enter the stom a so it is not necessary to cover it while
swim m ing, bathing, or showering
§ Oxym etazoline (Afrin):
o Adrenergic agonist; vasoconstrictor
o Rebound congestion m ay occur with extended use (>3 days)
o Caution in the presence of HTN, DM , hyperthyroidism , CAD, asthm a
o Increased toxicity with MAOI
o Do not use if it changes color or becomes cloudy
o MOA: stim ulates alpha-adrenergic receptors in the arterioles of the nasal mucosa to
produce vasoconstriction
o Approved for >6 years old
§ Poison ivy:
o Urushiol plant
o Urushiol can spread quickly over body
o Vesiclar fluid cannot further spread
§ Or not spread from the exudates of the blisters
o Topical anesthetics: benzocaine & pram oxine
o Hydrocortisone
 o Astringents:
§ Aluminum acetate (Burrow’s solution, Dom eboro Powder), zince oxide, zinc
acetate, sodium bicarbonate, calam ine, witch hazel (ham am elis waters)
o Colloidal oatmeal baths to help to provide skin hydration, to aide in cleansing or
rem oving skin debris, & to allay the drying & tightening sym ptom s
o Antihistam ines
§ Robitussin:
o Guaifenesin: an expectorant used to help loosen phlegm & thin bronchial secretions
to make coughs more productive
§ W arts:
o Plantar warts:
§ Clear Away W art Remover: Salicyclic acid 40%
§ W art off
§ Dr. Scholls Clear Away

Pain:
§ Pure Mu Agonists: strong opioids for severe pain
o Fentyl:
§ Sublim aze: injection
§ Duragesic: transderm al patch (change Q 3 days)
· 5 patches per box
§ Actiq: lozenge
o Hydrom orphone (Dilaudid):
§ Can cause seizures
§ Dosage forms: tablet, liquid, suppository, injection (a slight yellowish
discoloration has not been associated with loss of potency
o Levoophanol (Levo-Drom oran)
§ Dosage forms: tablet & injection
o Meperidine (Dem erol, Meperitab):
§ MOA: binds to opiate receptors in the CNS, causing inhibition of ascending
pain pathways, altering the perception of & response of pain
§ Dosed Q 3-4 hours
§ Hepatic metabolite, norm eperidine, can buildup & cause seizures
· Do not use in patients with seizure disorders
§ Avoid use with MAOIs
· Isocarboxazid (Marplan)
· Selegiline (Eldepryl, Deprenyl)- Parkinson’s
· Phenelzine (Nardil)
· Tranylcyprom ine (Parnate)
o Methadone (Dolophine, Methdose):
§ Dosage forms: tablet, liquid, injection
o Morphine (Astram orph/PF, Avinza (ER cap), DepoDur, Duram orph, Infumorph,
Kadian (SR), MS Contin (ER or SR), M SIR (IR), Oram orph SR, RMS, Roxanol):
§ MOA: binds to opiate receptors in the CNS, causing inhibition of ascending
pain pathways, altering the perception of & response of pain
§ Can cause: hypotension, bradycardia, respiratory depression
§ Vasodilatory properties
§ Dosage forms:
· Capsules (ER, SR)
· Infusion
· Injection (ER liposom al suspension for lumbar epidural injection)
· Injection, solution
· Solution
· Suppository
· Tablet (CR, ER, SR)
o Oxycodone (OxyIR, Roxicodone, Percocet, OxyContin (CR)):
o Oxymorphone (Num orphan-suppository)
§ Dosage form s: injection & suppository
§ Pure mu agonists: m ild to m oderate pain
 o Codeine (Tylenol #3)
o Hydrocodone:
§ W ith APAP:
· Vicoden 5/500; Vicoden ES 7.5/750; Lorcet or Vicodin HP 10/650;
Lortab 2.5/500, 5/500, 7.5/500, 10/500; Norco 5/325, 7.5/325, 10/325
§ W ith IBU:
· Vicoprofen 7.5/200
o Propoxyphene:
§ Propoxyphene/APAP:
· Darvocet-N-50 (50/325); Darvocet-N-100 (100/650)
· Darvon 32, 65 m g
§ Agonists-antagonists:
o Buprenorphine (Buprenex, Subutex)
o Butorphanol (Stadol)
§ Available as: injection & nasal spray
o Dezocine (Dalgan)
o Nalbuphine (Nubain)
§ Injection only
o Pentazocine:
§ 50 mg tablet: Talwin
§ 50 mg/naloxone 0.5 m g tablet: Talwin NX
§ 12.5/ASA 325 tablet: Talwin Com pound
§ Miscellaneous:
o Tram adol (Ultram )
§ 400 mg max
o Ultracet (Tramadol/APAP 37.5/325)
§ NSAIDS:
o Indom ethacin (Indocin):
§ Dosage:
· Inflam m atory/RA: 25-50 mg/day 2-3 tim es/day; m ax 200 mg/day
§ Dosage forms: IR & SR capsule, injection & suspension
o Ketorolac (Toradol):
§ Do NOT use for m ore than 5 days
§ NMT 40 mg/day po
§ Acular: ophthalm ic dosage form
o Nabum etone (Relafen):
§ For OA & RA
§ Dosing: 1000 m g/day; an additional 500-1000 m g m ay be needed in some
patients; may be administered QD or BID; NMT 2000 mg/day
§ Take with food or m ilk to decrease GI upset
o Diclofenac (Voltaren)
o Etodolac (Lodine)
o Tolm etin (Tolectin)
o Sulindac (Clinoril)
o Fenoprofen (Nalfon)
o Flurbiprofen (Ansaid)
o Ibuprofen (Motrin)
o Ketoprofen (Orudis, Oruvail-SR)
o Naproxen (Naprosyn)
o Oxaprozin (Daypro)
o Meclofenam ate (Meclom en)
o Piroxicam (Feldene)
o Celecoxib (Celebrex)
o Interferes with ACEIs, ARBs, & diuretics
§ Conversions:
o Usual ratio is Morphine 8 to dilaudid 1
o Methadone 10 mg = hydromorphone 7.5 mg (po) & 1.5 mg (IM)

Parkinson’s:
 § A chronic progressive neurologic disorder w ith sym ptom s that present as a variable
com bination of rigidity, tremor, bradykinesia, & changes in posture & am bulation
§ Prim ary Parkinson’s- no identified cause
§ Secondary Parkinson’s- m ay be the result of drug use (i.e. reserpine, metoclopramide,
antipsychotics), infections, trauma, or toxins
§ Progressive degeneration of the substantia nigra in the brain with a decrease in dopaminergic
cells
§ Drug therapy:
o W ant medications that will increase dopam ine or dopam ine activity by directly
stim ulating dopam ine receptors or by blocking acetylcholine activity, which results in
increased dopam ine effects
o Carbidopa-levodopa (Sinem et):
§ MOA; levodopa increases DA; carbidopa prevents m etabolism of levodopa
allowing m ore to enter the blood brain barrier
§ Take on an empty stom ach & eat shortly after to prevent N/V
o Direct stim ulation of DA receptors:
§ Brom ocriptine (Parlodel)
§ Pergolide (Perm ax)
§ Pram ipexole (Mirapex)
§ Ropinirole (Requip)
o Selegiline (Eldepryl, Carbex, Atapryl, Selpak):
§ MOA: inhibits MAOB; increases DA & 5-HT
o Inhibits COMT; increases DA:
§ Entacapone (Com tan)
§ Tolcapone (Tasmar)
o Am antadine (Sym m etrel):
§ MOA: may increase presynaptic release of DA, blocks reuptake
o Blocks acetylcholine, m ay balance DA:
§ Benztropine (Cogentin)
§ Trihexyphenidyl (Artane)
o Vitam in E- antioxidant; mixed results

Pediatrics:
§ EES ointment given in neonate to prevent gonorrhea infection in the eyes
§ Vitam in K is given to babies until they can produce their own
§ Beractant (Survanta):
o Lung surfactant
o Prevention & treatment of respiratory distress syndrom e in prem ature infants
o If <1250 g: at risk for developing or with evidence of surfactant deficiency
o Given within 15 minutes of birth
§ Colfosceril (Exosurf): respiratory surfactant
o Adm inistered intrathecheally
Respiratory distress syndrom e in the newborn: 5 mL (67.5 m g) per kg birthweight
o
INTRATRACHEALLY Q 12 hr for 3 doses
MOA: colfosceril, cetyl alcohol, & tyloxapol com bination, when used as a replacement
o
for deficient endogenous lung surfactant, is effective in reducing the surface tension of
pulm onary fluids, thereby increasing lung com pliance properties in RDS to prevent
alveolar collapse & decrease work in breathing
The possibility exists that it may also im prove ventilation/perfusion matching,
§
independent of its direct effect on lung com pliance
§ Neural tube defects are a result of a decrease in folic acid (while pregnant)
§ Acetam inophen:
o <12 years: 10-15 mg/Kg/dose Q 4-6 hours prn (NMT 5 doses: 2.6 g in 24 hours)
§ Ibuprofen:
o 6 m onths – 12 years
§ Tem perature <102.5°F: 5 m g/Kg/dose
§ Tem perature >102.5°F: 10 m g/Kg/dose
 § Q 6-8 hours; max daily dose: 40 mg/Kg/day
§ Theophylline can be used as a respiratory stim ulant in babies

Pharm aceutics:
§ Bioavailability: refers to the rate & extent of absorption
o Absolute bioavailability: the fraction (or % ) of a dose adm inistered non-IV (or
extravascularly) that is systemically available (com pared to an IV dose)
§ If given orally, absolute bioavailability (F) is:
· F = (D IV /D P O ) X (AUC P O /AUC IV )
o Relative bioavailability: the fraction of a dose administered as a test form ulation that
is system ically available as com pared to a reference form ulation:
§ F = (AUC test form ulation /AUC referen ce ) X ( D referen ce /D test form ulation )
§ Compounding:
o Glycerin, talc, starch, witch hazel = suspension
§ Talc is not soluble
§ Starch is not very soluble
o To m ake a oleaginuous base use: white petrolatum
o Trituration: the process of grinding a drug in a m ortar to reduce its particle size
§ Drug color change due to: oxidation
§ Filters:
o 0.22 micron filter does NOT rem ove pyrogens
§ Methylcellulose: a suspending agent (semisynthetic hydrocolloids)
§ Selected dosage forms:
o Butorphanol (Stadol)
§ Injection, intranasal spray
o Calcitonin (Miacaclin)
§ Injection, intranasal spray
§ Stored in refrigerator
o Desm opressin (DDAVP, Stim ate)
§ Injection, intranasal spray, tablets
o All three above come in a nasal inhaler
o Budesonide:
§ Capsules (Entocort), nasal suspension, powder for oral inhalation, suspension
for oral inhalation
o Fluticasone:
§ Aerosol for oral inhalation, cream (Cutivate), ointm ent, powder for oral
inhalation, suspension intranasal spray
§ Rizatriptan (Maxalt), loratadine (Claritin), ondansetron (Zofran) are all available as an orally
disintegrating tablet (ODT)
§ Mg sterate: lubricant in tablet
o Excess will cause alteration in tablet dissolution due to decreased rate of tablet break
down (would slow down)
§ Incom patibility:
o Pick pair of drugs with one acid & one base
§ Storage:
o Liposyn-II
§ Fat em ulsion
§ May be stored at room temperature
§ Do not store partly used bottle for later use
§ Do not use if em ulsion appears to be oiling out
o Room temperature antibiotic suspensions:
§ Clarithrom ycin (Biaxin); sulfam ethoxazole-trim ethoprim (Bactrim);
azithrom ycin (Zithrom ax); cefdinir (Om nicef)
§ Furosem ide has a pka of 3.7 at physiologic pH will it be 25% ionized, 75% ionized, all ionized,
all ionized or can’t determine?
o Furosem ide (one word generic nam e) is an acid; acids are all non-ionized at acidic pH
but are ionized at basic pH; physiologic pH is 7.4 which is quite alkaline compared to 3.7;
m eans furosem ide ionized to non-ionized ratio would be > 1:1000, so totally ionized
o Naproxen pka = 4.2 what would happen at plasm a pH?
 § Sam e as above because naproxen is also an acid
§ Typical pharm aceutical ingredients:
o Antifungal preservative: used in liquid & sem isolid form ulations to prevent growth
of fungi
§ Ex: benzoic acid, butylparaben, ethylparaben, sodium benzoate, sodium
propionate
o Antim icrobial preservative: used in liquid & sem isold form ulations to prevent growth
of m icroorganism s
§ Ex: benzalkonium chloride, benzyl alcohol, cetylpyridinium chloride, phenyl
ethyl alcohol
o Antioxidant: used to prevent oxidation
§ Ex: ascorbic acid, ascorbyl palm itate, sodium ascorbate, sodium bisulfate,
sodium metabisulfite
o Em ulsifying agent: used to prom ote & m aintain dispersion of finely divided droplets
of a liquid in a vehicle in which it is im m iscible
§ Ex: acacia, cetyl alcohol, glyceryl m onostearate, sorbitan m onostearate
o Surfactant: used to reduce surface or interfacial tension
§ Ex: polysorbate 80, sodium lauryl sulfate, sorbitan m onopalm itate
o Plasticizer: used to enhance coat spread over tablets, beads, & granules
§ Ex: glycerin, diethyl palm itate
o Suspending agent: used to reduce sedim entation rate of drug particles dispersed
throughout a vehicle in which they are not soluble
§ Ex: Carbopol, hydroxym ethylcellulose, hydroxypropyl cellulose,
m ethylcellulose, tragacanth
o Binder: used to cause adhesion of powder particles in tablet granulations
§ Ex: acacia, alginic acid, ethylcellulose, starch, povidone
o Diluent: used as fillers to create desired bulk, flow properties, & compression
characteristics in tablet & capsule preparations
§ Ex: kaolin, lactose, m annitol, cellulose, sorbitol, starch
o Disintegrant: used to prom ote disruption of solid m ass into small particles
§ Ex: microcrystalline cellulose, carboxymethylcellulose calcium, sodium
alginate, sodium starch, glycolate, alginic acid
o Glidant: used to im prove flow properties of powder m ixture
§ Ex: colloidal silica, cornstarch, talc
o Lubricant: used to reduce friction during tablet com pression & facilitate ejection of
tablets from the die cavity
§ Ex: calcium stearate, m agnesium stearate, m ineral oil, stearic acid, zinc
stearate
o Hum ectant: used for prevention of dryness of ointm ent & cream s
§ Ex: glycerin, propylene glycol, sorbitol

Pharm acokinetics:
§ Tests used to test for drug absorption in GI:
o Dissolution
o Disintegration: must occur before dissolution can occur
o Hardness: hardness of a tablet influences its ability to break apart in the stomach
o All can be tested in vitro

Pregnancy:
§ Tocolytics (stops labor):
o Magnesium is a tocolytic
§ Labor inducers:
o Prostaglandins and oxytocin both cause labor to start or proceed
o Oxytocin (Pitocin) is parenteral only (usually IV)
o PGE-2 does come in a gel that is applied to ripen the cervix prior to induction of labor
& in suppositories (still technically topical) to induce labor
§ Fetal alcohol syndrom e: facial deform ities (low nasal bridge, flat m idface), postnatal growth
retardation, or mental retardation
§ Treatment of patent ductus arteriosus:
 o *Indocin injection*
§ IV indom ethacin
o Ibuprofen
o Oxygen
o Diuretics
o Purpose of the ductus arteriosus in utero: to shunt blood from the pulm onary artery
to the aorta
§ Hydroxyurea (Droxia, Hydrea): use to increase fetal hem oglobin in sickle cell patients

Priaprism :
§ Causative agents: chlorprom azine, prazosin, trazodone, other phenothiazines,
antihypertensives, anticoagulants, corticosteroids, & any drug used to produce an erection
o PDE-5 inhibitors:
§ Sildenafil (Viagra)
§ Vardenafil (Levitra)
§ Tadalafil (Cialis)
· Can last up to 36 hours

Psoriasis:
§ Chronic, epiderm al proliferative disease characterized by erythematous, dry scaling patches,
recurring rem issions & exacerbations
§ Treatment:
o Mild to moderate disease:
§ Em ollients BID: soft yellow paraffin or aqueous cream ; petrolatum or
Aquaphor cream (greasier & m ore effective)
§ Topical, low potency corticosteroids on delicate skin (face, genitals):
alclometasone dipropionate, triam cinolone acetonide 0.025%, hydrocortisone 2.5%
§ Topical, m edium potency cortisteroids: fluticasone propionate, triamcinolone
acetonide 0.1% , hydrocortisone valerate, mom etasone furoate
§ Topical, strong potency: betam ethasone dipropionate, halcinonide,
fluocinonide, desoxim etasone
§ Topical, super potency: augm ented betam ethasone dipropionate, diflorasone
diacetate, clobetasol propionate, halobetasol propionate
· Lim it use to 2 weeks
· Avoid occlusive dressings
§ Intralesional corticosteroid: 2-5 m g/m L triam cinolone acetonide
§ Coal tar (Estar, PsoriGel) as an alterative to topical steroids
§ Keratolytic agents to decrease scales: salicyclic acid 6% gel
§ UV lam ps & sunlight are effective- best option for pregnancy or young
children
· Anthralin ointm ent 1% or higher prior to light
o Severe disease:
§ Triam cinolone, intralesional m ix
§ Vitam in D analogs (calcipotriene ointment 0.05% - not on face)
§ Acitretin (Soriatane)
§ Tazarotene (Tazorac)
§ Methotrexate, hydroxyurea, azathioprine, or cyclosporine
o Triam cinolone (Aristocort A; Aristocort Forte; Aristospan; Azmacort; Kenalog;
Nasacort AQ; Nasacort HFA; Tri-Nasal; Triderm )

Psychriatric Disorders:
§ ADHD:
o Methylphenidate (Concerta, Methadate, Methylin, Ritalin)
§ M OA: reuptake blockade of catecholam ine (NE & DA) in presynaptic nerve
endings
§ Dosage form of Concerta: 18, 27, 36, 54 m g ER tablets
· NOT SR
o Atom oxetine (Strattera):
§ BBW for suicide ideation in children
 § MOA: NE reuptake inhibitor
§ Dosed once daily (advantage over Concerta)
§ Antidepressants:
o SSRIs:
§ MOA: selectively inhibit the reuptake of 5-HT
§ Citalopram (Celexa)
§ Escitalopram (Lexapro)
§ Fluvoxam ine (Luvox)
§ Sertraline (Zoloft)
· Auxiliary labeling:
o No etoh
o May cause drowsiness or dizziness
o May cause sexual dysfunction
o Take in AM to prevent insom nia in PM
§ Fluoxetine (Prozac):
· Does not require tapering because of its long half life
· Take in AM
§ Paroxetine (Paxil):
· Take in AM to reduce chances of insom nia
· Paxil CR incorporates a degradable polym eric m atrix (Geomatrix) to
control dissolution rate over a period of 4-5 hours
o EC delays the start of drug release until tablets have left the
stomach
§ May take 4 weeks to see effects
o Miscellaneous:
§ Bupropion (W ellbutrin, Zyban):
· MOA: dopam ine reuptake inhibitor
· CI with history of seizure disorder
§ Venlafaxine (Effexor):
· MOA: inhibits the reuptake of 5-HT & NE (& DA at higher doses)
· Referred to as a serotonin-norepinephrine reuptake inhibitor (SNRI)
· XR form ulation is available to decrease GI upset
· Not recom m ended in patients with uncontrolled HTN, recent MI, or CV
disorders
§ Duloxetine (Cym balta):
· MOA: potent inhibitor of 5-HT & NE (no DA activity)
· Indicated for both major depression & diabetic peripheral neuropathic
pain
· CI: uncontrolled narrow-angle glaucom a
§ Trazodone (Desyrel):
· MOA: inhibits 5-HT reuptake & blocks 5-HT 2 A receptors
§ Nefazodone (Serzone):
· MOA: inhibits 5-HT & NE uptake & blocks 5-HT 2 A receptors
§ Mirtazapine (Rem eron):
· MOA: antagonizes presynaptic á-2 autoreceptors & heteroreceptors
that prevent the release of 5-HT & NE (resulting in increased 5-HT & NE
in the synapses); antagonizes 5-HT 2 A & 5-HT 3 receptors, resulting in less
GI upset & less anxiety
o Combinations:
§ Olanzapine & fluoxetine (Sym bax):
· Atypical antipsychotic agent/SSRI
· Use: treatment of depressive episodes associated with bipolar disorder
o MAOIs:
§ MOA: increase the synaptic concentration of NE, 5-HT, & DA by inhibiting
the breakdown enzym e, m onoam ine oxidase
§ Isocarboxazid (Marplan)
§ Phenelzine (Nardil)
§ Tranylcypromine (Parnate)
§ Medications to avoid on MAOIs:
 · Com pazine
· Phenylpropanolam ine: tyram ine-like reaction
· Pseudoephedrine: tyram ine-like reaction
· Meperidine (Demerol): life-threatening serotonin syndrome-like
reaction
· Methyldopa (Aldom et): hypertensive crisis
· Morphine (Roxanol, MS Contin): CNS depression
· Reserpine (Ser-Ap-Es): increased catecholam ines
· Serotonergic agents (i.e. fluoxetine): serotonin syndrom e
o TCAs:
§ M OA: increase the synaptic concentration of 5-HT &/or NE in the CNS by
inhibiting the presynaptic neuronal m em brane’s reuptake of 5-HT or NE
§ Am itriptyline (Elavil)
· Off label use: neuropathic pain
§ Nortriptyline (Pam elor, Aventyl)
§ Im ipram ine (Tofranil)
§ Doxepin (Sinequan)
§ Clom ipram ine (Anafranil)
§ Desipram ine (Norpram in)
§ Antipsychotics:
o Atypical:
§ Arpiprazole (Abilify):
· AE: insom nia, +/- weight gain
· Once daily dosing benefit
· Partial dopam ine agonist
§ Clozapine (Clozaril, FazaClo-ODT:
· For refractory schizophrenia only
· A Dibenzodiazepine
· AE: sedation, weight gain, hypersalivation, seizure risk
· W eekly CBC with diff required
o W BC <3500 or ANC <1500 MUST discontinue
§ Olanzapine (Zyprexa, Zydis-ODT):
· MOA: a thienobenzodiazepine antipsychotic that is believed to work
by antagonizing dopam ine & serotonin activities
o It is a selective m onoam inergic antagonist with high affinity
binding to 5-HT 2A & 5-HT 2C , dopam ine D 1-4 , m uscarinic M 1-5 ,
histam ine H 1 & á-1 receptor sites
o Binds weakly to GABA-A, BZD, & beta-adrenergic receptors
· AE: sedation, orthostasis
§ Quetiapine (Seroquel):
· A dibenzothiazepine
· Low EPS risk
§ Risperidone (Resperdal):
· Benzisoxazole
· Use: schizophrenia, bipolar
· Dosage form s: injection, solution, tablet, ODT
§ Ziprasidone (Geodon)
Benzisothiazoyl
·
· AE: +/- sedation, +/- weight gain, QT prolongation
o Typical:
§ Chlorprom azine (Thorazine)
§ Fluphenzaine (Prolixin)
§ Haloperidol (Haldol)
· SE: Hyper-, hypotension, tachycardia, arrhythm ias, torsade de
points, EPS, anxiety, alopecia, rash, gynecomastia, jaundice, blurred
vision
§ Thioridazine (Mellaril)
· BBW : QT prolongation
 § Thiothixene (Navane)
a psychotropic agent derived from thioxanthene & clinically useful in
·
the tx of schizophrenia
Sim ilarities in chemical & pharm acological properties exist between
·
this agent & piperazine phenothiazines
§ Anxiolytic agents:
o Benzodiazepines:
§ MOA: potentiate the actions of GABA by increasing the influx of Cl ions into
neurons
§ Alprazolam (Xanax, Niravam -ODT)
§ Chlordiazepoxide (Librium )
· Available as injection
o Prior to reconstitution, keep refrigerated & protected from light
o Should be used im m ediately following reconstitution
§ Clonazepam (Klonopin)
· Available as an orally disintegrating wafer
§ Clorazepate (Tranxene)
§ Diazepam (Valium )
· Available as injection
o Potency is retained for up to 3 m onths when kept at room
tem p
§ Estazolam (Prosam )
§ Flurazepam (Dalm ane)
§ Halazepam (Paxipam )
§ Lorazepam (Ativan)
· Available as an injection
· Intact vials should be refrigerated & protected from light
· Do not use if discolored
· Injectable vials may be stored at room temperature for up to 60 days
· Parenteral admixture is stable at room temperature for 24 hours
§ Oxazepam (Serax)
§ Prazepam (Centrax)
§ Quazepam (Doral)
§ Tem azepam (Restoril)
§ Trazolam (Halcion)
§ Lorazepam , oxazepam , & tem azepam (LOT) are conjugated & preferred in
patients with hepatic dysfunction & elderly patients
§ Chlordiazepoxide, diazepam , & lorazepam available for IV use
§ Never abruptly discontinue
§ Avoid in pregnancy- cause cleft palate
o Buspirone (BuSpar):
§ MOA: unknown. It exhibits high affinity for serotonin (5-HT 1 A ) receptors,
m oderate affinity for brain D2-dopam ine receptors & no significant affinity for
benzodiazepine receptors. It has no effect on GABA binding.
§ Non-FDA labeled indication: depression
§ Non-sedating
§ No grapefruit
§ Take consistently either with or without food
§ EPS treatment:
o Dystonia: state of abnorm al tonicity, som etim es described sim plistically as a severe
“m uscle spasm ”
§ Benzotropine mesylate 2 mg
§ Diphenhydram ine 50 m g IV or IM
§ Diazepam 5-10 m g by slow IV push
§ Lorazepam 1-2 m g IM
o Akathisia: inability to sit still & being functionally m ortor restless
§ Diazepam 5 m g TID
 § Propanolol 10 m g QD
§ Nadolol 80 mg QD
· Beta 2 selective are less effective
o Pseudoparkinsonism : an AP-induced extrapyramidal side effect, resembles idiopathic
Parkinson’s Disease
§ Patient may have slurred speech & a drooping face
§ Trihexyphenidyl 2-5 m g TID
§ Diphenhydram ine 25-50 m g TID
§ Biperiden (Akineton) 2 m g TID
§ Amantadine
o Tardive dyskinesia: syndrom e characterized by abnorm al involuntary movem ents
occurring late in onset in relation to initiation or AP therapy
§ No FDA approved agents
§ á-tocopherol (vitam in E) 1200-1600 IU has been tried
§ Mood stabilizers:
o Bipolar
o Lithium (Eskalith CR, Lithobid, Eskalith, Cibalith-S--syrup):
§ Use: bipolar disorder
§ CI: renal disease, severe CVD, pregnancy
§ SE: hyponatrem ia
§ Monitor thyroid function
§ “Lithium does everything that sodium will do”
§ Reaches steady state in 4-5 days
· Obtain level 2-8 hours post-dose
· Toxicity:
o Mild (serum levels 1.5-2):
§ GI upset (N/V/D), muscle weakness, fatigue, fine hand
tremor, difficulty with concentration & m emory
o Moderate (2-2.5):
§ Ataxia, lethargy, nystagm us, worsening confusion,
severe GI upset, coarse tremors, increased deep tendon
reflexes
o Severe (>3):
§ Severely im paired consciousness, com a, seizures,
respiratory com plications, death
§ Dosage forms: capsules, syrup, tablet (IR, CR, slow release)
§ DI:
· Increase Li levels:
o NSAIDS
o ACEI
o Fluoxetine
o Metronidazole
o Diuretics
o Sodium depletion: low sodium diet, excessive sweating,
vomiting/diarrhea, salt deficiency
· Decrease Li levels:
o Theophylline
o Caffeine
o Pregnancy
o Osmotic diuretics (m annitol, urea)
§ Pregnancy category: D
o Divalproex sodium (Depakote)
o Carbam azepine (Tegretol)
§ Tourette’s Syndrom e:
o Sim ple tics & 1 st line of therapy is short acting benzodiazepines
o Next is clonidine which does not cause tardive dyskinesia in these patients
o Interm ediate acting benzodiazepines (Ativan) are also useful
o For severe cases, the choice is an antipsychotic such as haloperidol (Haldol) or
pim ozide (Orap) but these can cause tardive dyskinesia, dysphoria, & pseudoparkinson’s
 § Anon-sedating anxiolytic for the elderly: buspirone (Buspar)
o Has a high affinity for 5-HT & dopam ine receptors
o Does not affect benzodiazepine GABA receptors

Questions:
§ Mother has gestational diabetes, what is likely to occur when the baby is born. Mother also
has epilepsy & is taking tegretol.
o I. high birth weight II. Baby may have congenital abnorm alities III. B aby is
likely to have diabetes
o Answer: I & II
o Tegretol is a class D drug
§ W hat strength will Albuterol 0.5% end up based on an order to mix it with 2.5 m L normal
saline?
o 0.083%
§ Isosorbide dinitrate is dosed BID, what regim en is best 7 am & 12 noon, 7 am & 7 pm , 9 am
& 9 pm , 8 am & 5 pm ?
o 8 am & 5 pm to allow nitrate free period (sam e as rem oving NTG patches at bedtime)
§ W hat substitute can you use for desitin ointm ent (Balm ex, Boudreaux’s Butt Paste)?
o Zinc oxide
§ Precose counseling inform ation:
o I. Take 30 minutes before m eal II. Causes gas III. Should not take if
m eal skipped
o Answer: II & III
§ W hat treatm ent would increase antibiotic com pliance? Patient receiving zithrom ax 1 tsp QD
x 5days
o Augm ent, ceftriaxone, cefuroxim e axetil, doxycycline
o Answer: the usual m ethod to im prove compliance for any type of drug is to reduce
the num ber of doses that m ust be taken each day & to give a drug with the fewest
uncom fortable or dangerous SE (I would chose ceftriaxone- IM single dose treatment)
§ W hich of the following could you give a patient on NTG?
o I. Cialis II. Muse (alprostadil) III. Caverject (alprostadil)
o Answer: II & III- alprostadil is prostaglandin used for erectile dysfunction & patent
ductus arteriosus
§ Available as: intracavernosal Kit, intracavernosal powder for solution,
intracavernosal solution, intraurethral Suppository, & intraurethral solution
§ Alprostadil (Prostin VR)
§ Patient requesting antihistamine eye drop & having a dark spot in vision- refer to MD
§ W hich of the following is available in a liquid form ulation?
o I. NTG II. Hydroxyzine III. Digoxin
o Answer: II & III
§ W hich is the shortest acting insulin?
o Hum ulin N, Hum ulin U, Hum alog, or regular
o Answer: Hum alog
§ W ho should not get a flu shot?
o An infant in day care; 32 yo type II diabetic; 65 yo retired lady; 35 yo nurse working
in hospital
§ Answer: 32 yo type II diabetic
§ W hich of the following cannot be self m onitored?
o Glucose level; K level; cholesterol levels; horm one used in pregnancy test
o Answer: K levels
§ Cytoxan is most sim ilar to mechloretham ine, procarbazine, or 5-FU?
o Answer: mechloretham ine
§ A patient with Traveler’s diarrhea too PeptoBismol 4 tsp Q ½ hour. After 3 days he began
experiencing ringing in the ears. W hat does he have? Bismuth toxicity or salicylate toxicity?
o Answer: salicylate toxicity
o Bism uth toxicity would cause neurotoxicity
§ W hich of the following are OTC hemorrhoid treatm ents:
o I. TUCKs pads II. Nupercainal ointment III. Rowasa
o Answer: I & II
§ W hich of the following is an ER Morphine?
o A. MSIR B. MS Contin C. Diluadid D. Oxycontin
o Answer: B
§ W hich of the following agents should be adm inistered to a person exposed to Anthrax?
o A. Flagyl B. Cipro C. Zovirax D. Valtrex
o Answer: B
§ Erythrom ycin exhibits its anti-infective properties by- blocking protein synthesis via binding
& inhibition of the 50-S subunit of bacterial ribosom es
§ Patient has pseudom em branous colitis & allergy to metronidazole. W hich of the patient’s
medications could have caused the pseudom embrane colitis?
o A. Ibuprofen B. Tylenol C. Flagyl D. Cleocin E. Zantac
o Answer: D
o This person could be treated with?
§ A. Flagyl B. Vancom ycin C. Doxycycline D. Lincom ycin E .
Am picillin
§ Answer: B
o The DOC for the treatment of pseudom embraneous colitis is:
§ A. Metronidazole B. Erythrom ycin C. Clindam ycin D. Am picillin E .
Lincom ycin
§ Answer: A
§ W hich of the following NSAIDs has an ophthalm ic preparation:
o A. Ibuprofen B. Naproxen C. Diclofenac D. Ketoprofen
o Answer: C- Voltaren
§ Cedax acts by- inhibiting the use of pencillin binding proteins in bacterial cell wall synthesis
§ Acetylcysteine in the treatm ent of CF is best given:
o A. IV B. By inhalation C. IM D. Orally
o Answer: B
§ A patient is given a rx for fentanyl 100 m cg/hr patch for 1 m onth. How m any boxes should
you dispense?
o A. 1 B. 2 C. 3 D. 4 E. 5
o Answer: 2; 1 patch= 3 days, so you need 10 patches; com es in boxes of 5 patches so
you need 2
§ W hich of the following is not an erythropoetin form ulation?
o A. Epogen B. Procrit C. Aranesp D. Neupogen
o Answer: Neupogen
§ W hich of the following fluoroquinolones has an otic preparation?
o Answer: ofloxacin (Floxin- also has an ophthalmic);
o Eye drops only: levofloxacin, gatifloxacin, m oxifloxacin
§ The use of this agent is CI in children?
o A. Erythrom ycin B. Bactrim C. Ciprofloxacin D. Cephalexin
o Answer: C
§ W hat is the recom m ended daily dosage of calcium for an adult?
o A. 300-500 m g B. 600-800 m g C. 800-1000 m g D. 100-1500 m g
o Answer: D
§ Due to difficulty in coordinating their inhalations, older patients should use:
o A. Nebulizer B. Peak flow m eter C. Spacers D. Spirom eter
o Answer: C
§ Monitoring of asthm a at hom e can be done with:
o A. Nebulizer B. Peak flow m eter C. Spacers D. Spirom eter
o Answer: B
§ A patient using a One-Touch m achine will also need:
o A. Ketostix B. Cuff C. Lancing device D. Sphygm om anom eter
o Answer: C
§ W hich drug does not have imm unom odulating effects?
o A. Prednisone B. Cyclosporin C. 5-FU D. Interferon alpha E. Infliximab
o Answer: 5-FU
§ W hich of the following is used in the treatm ent of RA?
o I. Gold II. NSAID III. Im m unosuppressant
o Answer: all of the above
 § Patient received a Z-pack on 11/25, what day will the patient finish the pack?
o A. 11/29 B. 11/30 C. 11/28
o Answer: A
§ A hypertensive patient that has a cold can be treated with:
o I. guaifenesin II. Dextrom ethorphan III. Diphenhydram ine
o Answer: I & II
§ W hat would you give for an H. pylori infection?
o A. Am photericin B B. Cipro C. Clarithrom ycin D. Levaquin
o Answer: C
§ Cyclosporine is available as:
o I. Rapam une II. Sandim une III. Neoral
o Answer: II & III (Rapam une is Sirolim us)
§ W hich sm oking cessation products are available OTC?
o I. Patch II. Nasal Spray III. Nasal Inhaler
o Answer: I only
§ Have a patient profile, patient is allergic to PCN & sulfa, they give you the option to treat with
bactrim , augm entin, 2 cephalosporings, or biaxin
o Answer: Biaxin
§ A person with Aspergillus could be treated with:
o I. Am pho B II. Itraconazole III. Ketoconazole
o Answer: I & II
§ Given patient profile; patient is on vicoden ES & taking acetam inophen what else can the
patient take?
o I. APAP II. ASA III. IBU
o Answer: II & III
§ W hich of the following would be used to treat poison ivy?
o I. calam ine II. Hydrocortisone III. Aluminum acetate (Dom boro’s solution)
o Answer: I, II, III
§ Vitam in K is available as:
o I. injection II. Tablet III. Solution
o Answer: I & II

Raynaud’s Phenom enon:

§ Reversible vasospasm of the digital arteries that can result in ischem ia of the digits
§ Avoid exposure to cold
§ CCB’s (i.e. nifedipine) are the preferred initial agents
§ Alternative vasodilators, such as prazosin (Minipress), m ay be helpful
§ Aggregated by beta blockers

References:
§ USP-NF:
o Officially recognized by the Federal Governm ent in establishing standards for drugs
o Official m onographs that describe drug structure, solubities, assays, & therapeutic
category with lim ited inform ation of dosage, dosage form s, etc.
o Official tests (dissolution, disintegration) & definition of dosage form s
o No dosing or pharmacology
§ USP DI (Microm edex):
o Volum e I: DI for the health care professional
§ Extensive inform ation on about over 11,000 drug products available in the US
§ Includes pharm acology, AE, CI
o Volume II: advice for the patient
§ Easy to understand inform ation to assist health professionals in providing
comprehensive patient education
o Volum e III: approved drug products & legal requirem ents
§ Addresses regulatory inform ation for prescribing & dispensing drugs in the
US
§ Also includes the complete FDA orange book
§ Orange Book Com panion:
o Contains extensive patent & m arket exclusivity inform ation for FDA-approved drugs
 & national drug code classifications
§ Rem ington’s Pharm aceutical Sciences:
o An encyclopedia of pharmacy with inform ation of pharmacology of drugs, theoretical
science, sterilization, isotonicity, healthcare products, practical pharm acy practice, etc
o Probably the best source of inform ation not readily available in other references
o E-values
§ Facts & Comparisons:
o Looseleaf publication with m onthly updates
o Lists both rx & OTC drugs by therapeutic categories with concise information
concerning pharm acology, dispensing inform ation, ingredients
o Has a list of drugs from Canada
§ AHFS Drug Inform ation:
o In-depth drug inform ation addressing pharmacology & use of drugs
o Intended mainly for use by institutional RPhs
o Updates available regularly online
o Hass off-label use
§ Am erican Druggist Blue Book & Drug Topics Red Book:
o Both consist of alphabetical listing of drugs, OTCs, cosm etics, & other items sold in
pharm acies
o W holesale prices, AW Ps, some suggested retail prices, NDC #’s & package sizes are
included
o Other sections list manufacturer address, product IDs, & pharm acy organizations
§ Physician’s Desk Reference (PDR):
o Yearly publication:
§ W hite pages: manufacturer’s index of products
§ Pink pages: product nam es listed by trade nam e
§ Blue pages: products listed by therapeutic categories
§ Yellow pages: generic nam es with trade nam es; colored product
identifications
o Rem aining bulk of PDR contains drug descriptions listed by com panies (often consists
of PI information, but not always)
§ Listing in this section is voluntary
§ Martindale’s Extra Pharm acopeia:
o Very com prehensive listing of inform ation concerning drugs, especially those from
Europe
§ Handbook of Nonprescription Drugs (APhA):
o OTC products by category
o Extensive list of com m ercial products with m anufacturer & ingredients
o PDR Nonprescription Drugs Book is not as com plete
§ Merck Manual:
o Describes diseases by diagnostic sym ptoms & suggested therapy
§ Merck Index:
o Alphabetical listing of chemicals with data concerning solubility, structures, etc.

Sepsis:
§ Hypotension
§ Drotrecogin alpha (Xigris):
o Recom binant human activated protein C
o Has antithrombic, anti-inflam m atory, & profibrinolytic properties
o Dosed 24 mcg/kg body weight/hr
o CI: increased risk of hemorrhage
o MOA: inhibits factors Va & VIIIa, lim iting throm botic effects

Shingles (Herpes Zoster):

§ W et dressings with tap water or 5% alum inum acetate (Burrow’s) applied 30-60 m inutes 4-6
times per day
§ Lotions such as calam ine
Treatment of complications:
o 2 n d bacterial skin infections:
 § Silver sulfadiazine
o Postherpetic neuralgia & zoster-associated pain:
§ Am itriptyline 25 m g QHS
§ Lidocaine (Lidoderm ) patch 5% applied after skin rash closure over painful
areas (lim it 3 patches sim ultaneously) for up to 12 hours
§ Gabapentin 100-600 m g TID
§ Pregabalin 50-100 m g TID
· Lim ited by AE
§ Capsaicin (Zostrix) cream

Silicosis:
§ A form of pneum oconiosis resulting from occupational exposure to & inhalation of silica dust
over a period of years
§ Characterized by a slowly progressive fibrosis of the lungs, which m ay result in im pairment
of lung function
§ Predisposes person to pulm onary tuberculosis

Statistics:
§ Mean: the average of a set of values
§ Median: the middle value in a set of m easurem ent
§ Mode: the value that appears m ost frequently
§ Statistically significant: the likelihood (probability) of obtaining a given result by chance
o p < 0.05
§ Standard deviation: statistical index of the degree of deviation from central tendency,
nam ely, of the variability within a distribution
§ T Test: used to compare two groups

Tests:
§ Blood glucose kits:
o Testing without pricking finger: Clinitest Tabs & TesTap- used to test urine sugar
then correlate to blood sugar
§ Cholesterol Kits
o Advanced cholesterol test kit
§ Need to avoid for at least 4 hours prior to testing: iron, prozac, vitamin c,
APAP
§ Hem e guaiac exam :
o Vitam in C (antioxidant) can interfere with test
o Visual lim itations can lim it test
o Hem orrhoids (blood would cause a false +)
o Exam ple test: EZ detector
§ Patient with a high PTT & receiving heparin:
o Could hold it then restart it at a lower dose
§ Patient on lovenox & warfarin:
o Appropriate to monitor:
§ APTT (no)
§ PT (yes for warfarin)
§ INR (yes for warfarin)
§ Ovulation tests:
o Test a rise in leutinizing horm one (LH) as an indicator for ovulation
o Exam ples include: First Response, Ovutim e, Q-Test
§ Pregnancy tests:
o Measure a rise in the level of chorionic gonadotropin (HCG, CG) that begins the 2 n d
week of pregnancy & peeks at about 8 weeks
§ Detect contraception 2 weeks after last m issed period
§ Take first thing in the AM
§ Taking BP:
o Patients should refrain from sm oking or caffeine ingestion for 30 m in
o Measurem ent should begin after being seating at least 5-m in
o Proper size cuff should be used
 § The bladder should encircle at least 80% of the arm & the width of the cuff
should be at least 2/3 the length of the upper arm
o Position cuff 1 inch above antecubital crease
o Ask patient about previous readings
o Inflate cuff rapidly to approxim ately 30 m m Hg above previous readings
o Deflate slowly & listen for Korotkoff sounds
o W ait 1-2 minutes before repeating
o Fluctuation of BP by 10 mm Hg from m orning to night is normal
§ Urine glucose test kits:
o Clinitest tabs
§ Test method: copper sulfate
§ Urine & water mix in test tube, add reduction m ethod tablet, wait for reaction
end, see resulting color on chart
o Chem strip-uG
§ Test method: glucose oxidase
§ Dip stick into urine and wait for color to develop, then read on chart
o Clinistix, Diastix, TesTape
§ Test method: glucose oxidase
§ Dip stick in urine read color change on chart; dextrose only
o The copper sulfate m ethod is better quantitatively but is subject to m ore interferences
(false +)
o The glucose oxidase method is less subject to interferences but is less accurate
Vaccines:
§ Active im m unity: protection produced by an individual’s own im m une system
o Vaccination: process of producing active im m unity via use of vaccines
§ Passive im m unity: protection produced by an anim al or hum an & transferred to another
o Ex: im m unity infants receive from m other
o One source of passive imm unity is antitoxins, which contain antibodies against a
known toxin
o Im m unoglobins (hep A)
§ Live vaccines:
o Influenza (live-attenuated), m easles, m um ps, rubella, typhoid oral, *varicella*,
vaccinia (sm all pox), yellow fever
§ Avoid with AIDS
§ Inactivated vaccines: anthrax, diphtheria, H. flu type b, hepatitis A & B, influenza, Japanese
encephalitis, m eningococcal, pertassis (acellular), pneum ococcal (polysaccharide & conjugate),
rabies, tetanus, typhoid (injectable)
§ Vaccine ok for pregnancy: flu (2 nd or 3 rd trim ester) & tetanus
o AVOID MMR for the rubella part & varicella
o AVOID live viruses
o Do not give till 2 n d trimester
o Hepatitis B, inactivated polio, & pneum ococcal are all recomm ended if indicated
§ Vaccine needed in asthm a patients: influenza
§ Vaccines that com e PO & IV:
o Polio
§ IPOL: inactivated, trivalent injectable vaccine
§ OPV: oral- discontinued in US because of elim ination of wild-type disease
§ Vaccines that need to be reconstituted:
o Hib
o Meningococcal (Menom une)
o MMR (MMR II)
o Varicella (Varivax)- for chickenpox
§ Prevnar: vaccine against a collection of bacteria that cause pneumonia
o Used in children up to 5 years old & usually delayed until child is 2
§ Pneumovax 23 cannot
§ Patients with spleenectomy:
o Pneum ococcal vaccine is most essential
o Can also give: Hep A & B, MMR, varicella, flu
§ Vaccines grown in eggs: influenza (CI), measles (“should receive it”), mum ps (not a CI)
 § Vaccines that can be given around 2 m onths of age: hepB, DTaP (diphtheria, tetanus,
pertussis), Hib (haem ophilus influenza type b), IPV (polio), PCV (pneum ococcal)
§ Diphtheria & tetanus: give Q 10 years
§ Hepatitis is given: 0, 1, then at 6 m onths

Vitamins/Minerals/Elem ents:
§ Elem ental calcium :
o Calcium carbonate: 40%
§ Tums contains 500 m g of calcium carbonate, therefore 200 m g of element
calcium is provided
o Calcium phosphate tribasic: 39%
o Calcium citrate: 24%
§ Elem ental Iron:
o Ferrous fum arate (Fem iron, Fum erin, Feostat): 33%
o Ferrous sulfate (Feosol, Fer-in-Sol): 20%
o Ferrous gluconate (Fergon): 12%
o IV iron:
§ Iron dextran (InFeD)
· Risk of anaphylaxis: must receive a test dose
§ Sodium ferric gluconate (Ferrlecit)
§ Iron sucrose (Venofer)
§ Can cause hypotension
o Patient instructions:
§ Take on an em pty stom ach
· If unable to tolerate: adm inister with a sm all snack
· Avoid dairy products or tea
· Take with OJ if possible
§ Take 1 hour before or 3 hours after any antacids
§ May darken stools
§ May cause: constipation or diarrhea, N/V
§ W ater soluble vitam ins:
o Vitam in C (ascorbic acid)
§ Deficiency: Scurvy
o Thiam ine (B 1 ):
§ Sulfur
§ Deficiency: Beriberi; W ernicke-Korsakoff syndrom e
o Riboflavin (B 2 ):
§ W ill im part a red-green-orange fluorescence to urine
o Niacin (B 3 )
§ Nicotinic acid
§ Niacinam ide (micotinam ide)
· No hypolipidem ic or vasodilating effect
o Pryidoxine (B 6 ):
§ Deficiency: convulsions
§ Higher requirements for patients on isoniazid, oral contraceptive, or
hydralazine therapy
o Folic acid:
§ Deficiency: m egaloblastic anem ia
§ Dietary sources: leafy green vegetables, beef liver & citrus fruits
o Cyanocobalam in (B 1 2 ):
§ Has cobalt
§ Deficiency: pernicious anem ia, m acrocytic anem ia
§ Fat soluble vitam ins:
o Vitamin A:
§ Reinoids, Retinol, Retinoic acid, Cartenoids, Beta carotene
§ Deficiency: dry eye (Xerophthalm ia), night blindness, nyctalopia
§ Neom ycin, m ineral oil, cholestyram ine adm inistration may also cause vitamin
A malabsorption
o Vitam in D:
 § Cholecalciferol (D 3 ); ergocalciferol
§ Deficiency: Rickets
o Vitam in E:
§ Tocopherols; alpha-tocopherol; tocotrienol
§ Prevents hem olytic anem ia
o Vitam in K:
§ Phytonadione (K 1 ), M enaquinone (K 2 ), M enadione (K 3 )

W eight Loss:
§ Noradrenergic Agents:
o Metham phetam ine
o Amphetam ine
o Dextroamphetam ine (Dexedrine)
o Benzphetam ine (Didrex)
o Am phetam ine/dextroam phetam ine m ixture (Adderall)
o Phendimetrazine (Prelu-2, Bontril, Plegine, X-Trazine)
o Phenterm ine (Fastin, Oby-trim , Adipex-P, Ionam in)
o Diethylpropion (Tenuate)
o Mazindol (Mazanor, Sanorex)
§ Serotonergic Agents:
o Fluoxetine (Prozac) & Sertraline (Zoloft)- unlabeled uses
§ Noradrenergic/Serotonergic Agents:
o Sibutram ine (Meridia)
§ CYP3A4
§ Strength: 5, 10 & 15 m g capsules
§ Gastrointestinal Lipase Inhibitor:
o Orlistat (Xenical)
§ Oily spotting; fecal incontinence
§ Absorption of fat soluble vitam ins may be decreased
§ Strength: 120 m g capsule

W ilson’s Disease:
§ An autosom al recessive disorder that results in progressive copper overload
§ The average age at presentation of liver dysfunction is 10-15 years
§ Neuropsychiatric disorders can m anifest later
§ Treatment:
o Copper-chelating agents:
§ Penicillam ine (Cuprim ine, Depen)
· MOA: chelates with lead, copper, mercury, & other heavy metals to
form stable, soluble com plexes that are excreted in urine
§ Trientine (Syprine):
· M OA: an oral chelating agent structurally dissim ilar from
penicillam ine & other available chelating agents
§ Zinc salts

W omen’s Health:
§ Birth Control:
o Sunday start for BC pills m eans: start the pack on the Sunday after the period starts
o Estrogen:’
§ Prevent developm ent of a dom inant follicle by suppression of FSH; does not
block ovulation
· SE: breast tenderness, heavy bleeding, headache
o Progestin:
§ Blocks ovulation; contributes to production of thick & im perm eable cervical
m ucus; contributes to involution & atrophy of endom etrium
· SE: depression, headache, irritability
o Progesterone: decreases the risk of endom etrial cancer
o Progestin-only (minipill):
§ Appropriate for use in breastfeeding wom en
 § Efficacy is less than that of combined oral contraceptives
§ Free of cardiovascular risks associated with estrogen-containing products
§ Ortho Micronor, Errin, Nor-QD, Nora-BE, Cam ila, Ovrette
o Biphasic oral contraceptives: Ortho-Novum 10/11, Necon 10/11
o Yasm in:
§ Ethinyl estradiol & drospirenone
· Drospirenone is a spironolactone analogue with antim ineralocorticoid
& antiandrogenic activity
§ PMS:
o Symptoms: depressed m ood, m ood swings, irritability, difficulty concentrating,
fatigue, edem a, breast tenderness, headaches, sleep disturbances
§ Postm enopausal horm one replacem ent therapy:
o W om en with an intact uterus m ust be treated with estrogen + progestin
o W om en with out a uterus- estrogen only
o Ingredients in Prem Pro or Premphase: conjugated estrogen & m edroxyprogesterone
o Medroxyprogesterone (Provera) is with ERT to decrease the risk of endom etrial cancer
§ Levonorgestrel (Plan B, Mirena-intrauterine system ):
o For em ergency contraception: 1 tablet (0.75 mg) asap within 72 hours of unprotected
sexual intercourse; a 2 n d tablet (0.75 m g) should be taken 12 hours after the 1 st dose; can
be used at any tim e during the m enstrual cycle

Zollinger-Ellison Syndrom e:
§ A triad of:
o Markedly elevate gastric acid secretion
o Peptic ulcer disease
o A gastrinom a or non-beta islet cell tum or of the pancreas or duodenal wall which
produces gastrin
§ DOC:
o PPIs:
§ Om eprazole 60-120 mg/day
§ Lansoprazole 60-180 mg/day
§ Rabeprazole 60-100 mg/day
§ Pantoprazole 40-240 mg/day
o H2 blockers:
§ Cim etidine 300 mg Q6h; up to 1.25-5 gm /day
§ Ranitidine 150 mg Q12h; up to 6 gm /day
§ Fam otidine 20 m g at bedtim e; up to 800 m g QD