NAPLEX SECRET 2015

Calculations:
ung-ointment

WA-while awake

PR-per rectum

BM-bowel movement

1 pint= 473 ml

1 quart = 946 ml

1 gallon = 3785 ml

1 pound = 454 g

Percentage Strength: g/100ml (w/v);

g/100g (w/w)

ml/100ml (v/v) ;

Ratio Strength: (1:X) ex. 0.04% = 0.04g/100ml =

1g/2500ml = 1:2500 **Put in grams
PPM: (parts of drug/1,000,000) parts of whole ex.
0.00022g/100ml = 2.2g/1,000,000 = 2.2PPM

mEq : Electrical charges provided per mole

mOsmol/L = {(g/L)/(g/mole)} x ( # of particles it splits up
into) x 1000
Isotonicity (osmolarity in body fluids, when we want to make
something isotonic to blood): E Value

First find out how much NaCl would make it isotonic.

0.9g/100ml = X g/X mL
E= sodium chloride equivalents of a drug = (58.5 x i) /
(MW of drug x 1.8) *i = dissociation factor of drug
example: if calculated E value is 0.23 and you have
0.4g of drug, this represents 0.4g x .23 = 0.092 g NaCl
Then subtract them from each other.

Fahrenheit = (C x 1.8) +32

pH = pka + log (salt/acid)

For Acids

BMI: (kg/m2) *2.54cm/inch <18.5 = Underweight, 18.524.9 = normal 25-29.9=overweight >30 =obese

pH = 14 pKb + log (base/salt) For Bases

IBW: Male: 50+2.3 (inches above 5 feet) Female: 45.5 +

2.3(inches > 5 feet)

Calcium Carbonate: 40% elemental calcium

Citrate: 21% elemental calcium

Adjusted BW: IBW + 0.4(TBW-IBW)

Absolute Neutrophil Count: WBC x ((%segs+%bands)/100)

CrCl: { (140-age) x weight }/SCr x72

females

Multiply by 0.85 for

Dilutions: (Changing a strength or quantity) Q1 * C1 = Q2 *

C2
Alligation: (Combining two strengths to get a strength in
between) **Watch for ADD TO
**Corrected Calcium: Ca2+(from lab) + {(4-albumin)
x(0.8)}
** Phenytoin correction= PHT measured/{(0.2x Alb) +
0.1}

Choose calcium gluconate over chloride bc it

dissociates less and less chance of binding to
phosphate and precipitating

eAG: (28.7 x A1C) 46.7

Calcium

Anion Gap: Na+-Cl-HCO3- *>12 is high (gapped)

Minimum Weighable Quantity (MWQ) : SR/error
Absolute Bioavailability: F = (AUCextravascular x Doseintravenous)/

(AUCintravenous x Doseextravascular)
IV Bolus VD= Dose/Co or Co = Dose/VD
Oral VD= (Dose x F) /(ke xAUC) Cl=(Dose x F)/AUC
Cl=ke x VD
ke= {ln(Cmax/Cmin)}/ Time interval

Enteral/Parental Nutrition:

Carbs: Enteral (4kcal/gram) Parenteral (Dextrose 3.4

kcal/gram)
Protein: (4kcal/gram)
Fat: Enteral (9kcal/gram) Parenteral IVFE (10% - 1.1
kcal/ml, 20% - 2kcal/ml, 30% -3kcal/ml) *often weekly and
might have to divide by 7 for daily
TEE = BEE x activity factor x stress factor
use protein calories

*usually doesnt

BEE estimate: 15-25kcal/kg (adults)

Daily Fluid Needs: 1500mL + (20mL)(Kg-20)
Nitrogen Intake: grams of protein intake/6.25

Compounding:
Emulsifiers/ Surfactants: Tween (polysorbate), Myrj, Arlacel,
Span, PEG, acacia, sodium laurel sulfate, glyceryl
monostearate

Type 1 Error: Say theres a difference when there is not; The

null hypothesis is true, but is rejected in error. (P-value or
alpha is the chance of a type 1 error). P-value is the
probability that the result obtained was due to chance. P
<0.05 = less than 5% probability it was due to chance.
95% CI means there is a 95% chance that the interval
contains the true population mean.
Type 2 Error: Say theres no difference when there is; The null
hypothesis is false, but is accepted in error.
RR= risk in tx/risk in control
RRR = 1-RR
ARR= Risk in control Risk in tx
NNT (Number Needed to Treat): 1/ARR (decimal, not %)
Cost-Effectiveness analysis How effective the tx was for
what it was supposed to do
Cost-Minimization analysis two drugs health benefits are
equal, just want to find which is cheaper

Thickeners: Agar, carrageenan, gelatin, sorbitol

Cost-Benefit Analysis Outcome in dollars (monetary)

Suspending Agents: acacia, alginic acid, gelatin, gums,

methylcellulose, bentonite

Cost-Utility Analysis Includes Quality of Life variables

Levigation/Wetting Agents for creams and ointments: *must

be compatible with base

Aqueous (O/W): glycerin, propylene glycol, PEG 80

Oleaginous (W/O): Mineral Oil, Castor Oil, Cottonseed
Oil, Tween

Collagenase Ointments are for debridement of skin wounds.

Case-Control: Have a disease and look back for risk factors

Cohort: Prospective or Retrospective. Starts with risk
factors to see if they get a disease.
Cross-Sectional: Looks at a specific point in time.
RCT: interventional
Meta-Analysis: Combining many RCTs and drawing a
conclusion

Benzyl Alcohol used as a solvent and antimicrobial.

Pharmacogenomics:
Statistics:

- 2D6 ultra rapid metabolizers have increased risk of

Codeine Morphine toxicity

-HLA-B*1502 (mainly Asians) on carbamazepine: 510% chance of SJS with carbamazepine

-SLCO1B1 Polymorphism - statin myopathy increased
-HER2/Neu Oncogene needed for Herceptin (trastuzumab)
and Kadcyla (ado-trastuzumab) to work
-Warfarin 2C9*2 and 2C9*3 and VKORC1 (A
haplotype) require lower doses or they will bleed
(Homozygous for *3 is has greatest risk of bleeding)
-HLA-B*5701: If positive for this, do not give Abacavir
(Ziagen)
-2C19: Clopidogrel is a prodrug and needs this enzyme
to convert to active form
-Selzentry (Maraviroc) must be CCR5 positive only to
receive drug

-Sulfa/Sulfonamides Mostly with sulfamethoxazole

(Bactrim, Septra) but should also avoid sulfapyridine,
sulfadiazine, and sulfisoxazole. **For exam also avoid loop
diuretics, thiazide diuretics, sulfonylureas,
acetazolamide, zonisamide, and celocoxib), darunavir
(Prezista). There is no cross-reactivity with sulfites or
sulfates.
-Morphine type opioid allergies do not cross react with
Fentanyl (Duragesic), meperidine (Demerol), or methadone
(Dolophine).
-Peanuts and soy are in the same family and can have
cross reactivity. Soy is in some medications:

-If allergic to eggs avoid:

Drug Allergies/ADRs
-Naranjo scale is used to help pharmacists determine if the
drug caused the ADR.
-Severe Skin Rashes (SJS, TEN, DRESS, TTP) - Stop the
offending agent *corticosteroids CI in TEN
-Stomach upset/Nausea from a drug not a true allergy, it is
an intolerance
- Niacin and Statins taken together have an increased
risk of muscle toxicity.
-Photosensitivity: Sulfa Antibiotics, Tetracyclines,
Fluoroquinolones, Diuretics, Flagyl, Tacrolimus, Cyclosporine,
NSAIDs, voriconazole, methotrexate.
-Penicillins: Allergic to one presumes allergic to all. Small
risk for cephalosporin and carbapenem cross reaction but
should still avoid on the exam.

clevidipine (Cleviprex), propofol (Diprovan), and

progesterone in (Prometrium)

clevidipine (Cleviprex), propofol (Diprovan),

Influenza vaccine (**Flublok is ok)

-True Drug Allergies/Anaphylaxis (Mediated by IgE and

Histamine release):

Swelling, possible hives, bronchoconstriction, low

blood pressure
Tx with epinephrine (Epipen, Epipen Jr., Adrenaclick,
Auvi-Q) and diphenhydramine (25mgx2) *rub the area
after injection *epinephrine is used when they have
trouble breathing

Medication Errors and Patient Safety

-Medication errors are preventable events that may cause
or lead to inappropriate medication use or patient harm. *It is
not an adverse drug reaction (ADR).
-The most common medication error is wrong drug or
dose to patient.

-Root-Cause Analysis (RCA) is done retrospectively to see

what led to a sentinel event. Failure Mode and Effects
Analysis (FMEA) is done prospectively to see what potential
could lead to a problem.
-Error of Omission is leaving something out that is needed
for safety. Error of Commission is when something was
done incorrectly.
-Medication reconciliation is updating the patients
medication list. It should be done at every transition of care.
-REMS is an FDA program that requires specific training and
requirements for certain meds ex: clozapine, isotretinoin
(iPLEDGE), erythropoietin in oncology (APPRISE). Goal is to
make sure the benefits of the drug outweigh the risks.
-Medication guides are FDA-approved printed handouts for
over 300 medications that that tell patients of important
adverse events and should be dispensed every time. Can
be part of REMS.
-Tall man letters can be used for look-alike sound-alike
drugs. ex. celeXA and celeBREX
-Use As Directed is not acceptable
- Alcohol has poor activity against spores like C. Difficile. Use
soap and water to wash hands when in contact.
-Contact precautions for patients colonized with MRSA and
VRE. Airborne precautions for patients with measles, varicella
(chickenpox), and Tuberculosis.
-Barcoding is great and helps prevent errors

FDA Drug Approval/Bioequivalence:

New Drug Approval:
1. Pre-Clinical Animal Research
2. IND-Investigational New Drug

Phase 1- Asses safety/PK/PD parameters with

low doses in 20-80 healthy people
Phase 2- Safety and Efficacy in 100-300
people with indication
Phase 3- Confirm previous studies in 100s1000s of people with the indication at the
dose youre seeking approval.
3. NDA Submitted Either Approved, Rejected, or further
studies requested
Phase 4 Post-marketing studies after NDA
approval
*For changes to an existing drug they can submit a
Supplemental New Drug Application (sNDA) ex. Label,
Dose, Strength, Manufacturing Process, and Indication
Changes
* Abbreviated NDA for generic approval
Orange Book On Bioequivalence:

AB- Therapeutically equivalent and can be

interchanged (brand to generic)
Drugs with a 3-character code under a heading are
considered therapeutically equivalent only to other
drugs with the same 3-character code under that
heading. Example AB1, AB2, AB3

Natural Products/Vitamins:
(They do not have to prove to be safe and effective)
*Many natural products can be hepatotoxic and
elevate liver enzymes (ex. Kava Kava)
- Ginkgo can increase bleeding with no change in INR. Other
that can also do this are garlic, Vitamin E, fish oils, and
ginseng.
- St. Johns Wort for depression is an inducer, serotonergic,
and can cause photosensitivity.

- Saw Palmetto used for BPH

- Ginger for nausea/motion sickness
- Tea Tree Oil for acne
- Lysine for canker sores

- Melatonin for insomnia and jet lag

- Black Cohosh, Estroven (black cohosh + soy), and
Red Clover for menopausal symptoms
- Cranberry can be used for UTI prevention but can increase
risk of kidney stones.
- Folic Acid (B9) started 1 month before pregnancy. 400800mcg daily.
- Pyridoxime (B6) supplemented in Tuberculosis treatments
that have Isoniazid in them
- Thiamine(B1) deficiency can cause Wernickes
encephalopathy.
- Niacin (B3) deficiency causes pellagra
- Vitamin C deficiency can cause scurvy
-Vitamin E should not exceed 150 IU/day
- L-Arginine can have hypotensive effects, its a
precursor to NO.
- Iron: Breast-fed babies need 1mg/kg/day from 4-6 months
old and anemic patients may need supplementation too (ex.
Renal problems or menstruating females)
- Probiotics: If taking antibiotics, dont take the probiotic at
the same time of day as the antibiotic
- Echinacea, zinc, elderberry, garlic, vitamin C- used for
colds/flu. Zinc can cause loss of smell.
- Adequate Calcium and Vitamin D needed for low bone
density, pregnancy (fetus depletes stores), menopause,
children, and men who take steroids or androgen blockers.

Calcium absorption is saturable so doses should be

divided.
1000mg/day for women 19-50 and 1200mg/day
for>50
Citracal (calcium citrate) preferred in low acid
environments (ex. with H2 blocker and PPI use). Can
be taken with or without food. (21% Elemental)
Oscal, Tums (calcium carbonate) has aciddependent absorption, take with food. Smaller
pills than the Citracal and provide more elemental
calcium. (40% Elemental)
Vitamin D: 600IU daily for <70, 800IU daily for
>70 (cholecalciferol (D3) is the preferred
source). Poly Vi Sol multivitamin contains Vit D and
is easy for infants to take. Breast-fed babies or formula
fed babies who drink less than 1 liter/day need 400IUs
Vit D.

Drug Interactions:
Inducers (slow to have this effect): carbamazepine
(Tegetrol), phenytoin (Dilantin), Oxcarbazepine
(Trileptal), smoking, rifampin, St. Johns Wort,
phenobarbital, efavirenz (3A4)
Inhibitors (fast to have this effect): Azole Antifungals,
Macrolides (clarithromycin and erythromycin), cimetidine,
amiodarone, valproate, non-DHP Ca2+ Blockers
(diltiazem and verapamil), protease inhibitors (lopinavir,
ritonavir, etc..), grapefruit, cyclosporine.
Fluoxetine (Prozac,Sarafem) , Duloxetine (Cymbalta),
and Paroxetine (Paxil) are 2D6 inhibitors. (Watch with
certain opioids like tramadol, hydrocodone, and
codeine(prodrug))
**SMX/TMP is a 2C9 inhibitor so caution with warfarin.

Oxycodone and Methadone are metabolized by 3A4

(watch for inducer and inhibitors)

Ototoxicity: salicylates, vancomycin, aminoglycosides,

cisplatin, loop diuretics

Amiodarone use Decrease Digoxin and Warfarin dose by

30-50%. Also use lower doses of Simvastatin, Atorvastatin,
and Lovastatin.

QT Prolongation: Quinolones, Macrolides, Methadone,

TCAs, Some SSRIs (Citalopram and Paroxetine), Azole
antifungals, SMX/TMP, some Protease Inhibitors

Digoxin: Watch for renal dysfunction, hypokalemia, and

additive heart rate lowering drugs such as Beta Blockers,
non-DHP calcium channel blockers, amiodarone, Precedex,
clonidine, and opioids.

Renal Disease and Dosing Considerations:

Grapefruit: 3A4 inhibitor increased SAL statins (rhabdo),

increased bleeding risk with rivaroxaban and ticagrelor,
increased levels of calcineurin inhibitors (tacrolimus and
cyclosporine).
Valproate: used with lamotrigine (Lamictal) can increase
lamotrigine levels and cause a severe rash
MAOi: do not use with SSRI, SNRI, TCAs, bupropion,
buspirone, tramadol, muscle relaxants, triptans, St. Johns
Wort, ephedrine/pseudoephedrine, epi, norepi, dopamine,
meperidine (meperidine blocks serotonin reuptake),
linezolid (Zyvox) etc
Serotonin Syndrome: Tremor, Agitation, Confusion,
Hallucination, Diarrhea, Muscle rigidity, Shivering,
Tachycardia, Sweating, Hyperthermia
Chelation: Tetracyclines and quinolones can chelate so
separated from Al, Ca, Mg, Fe compounds, including dairy.
Bleeding Risk: SNRI, SSRI, NSAIDS, Ginkgo, fish oil,
garlic, grapefruit
*Wellbutrin (Bupropion) Doesnt affect 5HT so doesnt
increase bleeding risk
Hyperkalemia: ACEi, ARB, amiloride, triamterene,
epleronone (Inspra), spironolactone (Aldactone), KCl,
tacrolimus(Prograf), cyclosporine (Neoral), trimethoprim,
canagliflozin (Invokana), drospirenone (Yasmin)

-The level of Albumin in urine can gauge the severity of

kidney damage. (Micro and Macroalbuminuria)
- Serum Creatinine (SCr) is used as a marker of renal function
- BUN increases in renal impairment but not used alone as a
marker b/c it can increase for other reasons such as
dehydration.
-Loop Diuretics inhibit Na+/K+ pump in ascending limb of loop
of Henle

-Thiazide Diuretics inhibit Na+/Cl- pump in the distal tubule

-Aldosterone antagonists/ Potassium Sparing Diuretics work

in the collecting duct

- The goal BP in CKD is <140/90

- ACEis and ARBs are reno-protective in that they slow
down the progression of nephropathy in diabetic and nondiabetics with proteinuria.
- ACEis and ARBs can cause a 30% rise in SCr and is
not a reason to stop therapy. If >30% then it should
be discontinued. SCr and K+ should be monitored 1-2
weeks after initiating.
-Hyperphosphatemia:
1. Restrict Dietary Phosphate
2. Phosphate Binders: Bind Meal-time phosphate in the gut
from the diet so only take them with meals. ****They dont
work if taken after a meal.

Aluminum based (Alternagel)- can accumulate and is

toxic so not used much
Calcium based First line therapy. Calcium
acetate **(Phoslo, Phoslyra) or Calcium
carbonate (Tums) *Can cause hypercalcemia
Aluminum Free, Calcium Free Expensive
o **lanthanum(Fosrenol) - must be chewed
thoroughly.
o **sevelamer(Renvela/Renagel). added benefit
of lowering LDL

-Secondary Hyperparathyroidism: Calcitriol (Rocaltrol)

is given to CKD patients with secondary
hyperparathyroidism to inhibit PTH secretion . It is the
active form of Vitamin D3.

doxercalciferol (Hectoral) and

paricalcitol(Zemplar) are newer active VitD drugs
with less hypercalcemia.
cinacalcet (Sensipar) calcimimetic to
increase sensitivity to calcium and decrease PTH.

-Vitamin D deficiency: Cholecalciferol (D3) and

Ergocalciferol (D2)
-Hyperkalemia: Usually from renal failure and/or drugs that
increase K+. Muscle weakness, bradycardia, chest pain,
paresthesias and fatal arrhythmias may occur.
Treatment:

IV Calcium to stabilize the cardiac tissue

Glucose and Insulin to drive K+ into cells
sodium polystyrene sulfonate (Kayexelate) is a
cation exchange resin given orally or rectally. Rectal
preferred in emergency situations. Side Effects:
Nausea, Vomiting, Constipation, Loss of Appetite.
Loop Diuretics

-Metabolic Acidosis: Tx with sodium bicarbonate or

sodium citrate (Bicitra)

Common: drugs that need dose adjustments in renally

impaired: acyclovir, valacyclovir, amphotericin,
amantadine, , Allopurinol, aminiglycosides, azole antifungals,
antiarrhythmics, aztreonam, colchicine, dabigatran, LMWHs,
macrolides, quinolones, metoclopramide, penicillins,
morphine/codeine, Maraviroc, NRTIs, statins, SMT/TMP,
tramadol, venlafaxine, zolendronic acid.
Drugs not to use in severe renal impairment:
Bisphosphonates, dabigatran(Pradaxa), duloxetine,
fondaparinux (Arixtra), glyburide, Lithium, meperidine,
metformin, NSAIDs, nitrofurantoin, potassium sparing

diuretics, rivaroxaban (Xarelto), tadalafil, tenofovir, tramadol

ER, voriconazole IV.

Drugs in Pregnancy:
- As a general rule, try to avoid all drugs during the 1 st
trimester.
- Pregnancy exposure registries are designed to collect
info from women who take various meds during pregnancy
and breastfeeding.
- Well known teratogens: alcohol, ACEi/ARB, benzos,
carbamazepine, phenytoin, valproic acid, topiramate,
phenobarbital, isotretinoin, NSAIDs, methimazole, lithium,
paroxetine (Paxil), tetracyclines, quinolones, warfarin,
statins, methotrexate, dutaseride, finasteride.
- 2011 FDA issued a warning about SSRIs causing
persistent pulmonary HTN in newborns
- Women need 400-800mcg/day folic acid, 1,000mg/day
calcium, and 600IU/day Vit D
- Iron for anemic patients. Absorbs better on an empty
stomach. Vitamin C increases absorption.
- Folic acid >1mg is prescription only
- Nausea/Vomiting: First recommend easting smaller, more
frequent meals, avoid spicy/odorous foods, take naps, and
reduce stress. Then, 1st line OTC by ACOG is pyridoxine
(Vitamin B6).
- GERD/Heartburn/Gas Pains: First recommend easting
smaller, more frequent meals, avoid foods that worsen GERD,
elevate head of bed before sleep. Antacids like Tums are
first line OTC. Many PPIs/H2 blockers are category B
and pretty safe. For gas, simethicone (Gas-X, Mylicon)
are safe.

- Constipation: Increase fluids and physical activity. Fiber

is first line such as psyllium (Metamucil) is safe.
- Cough/Cold/Allergies: First generation antihistamines
are 1st line. Chlorpheniramine (Chlor-Timetron) is the
DOC. Diphenhydramine may also be safe. Non-sedating 2 nd
generations like loratidine and cetirizine are often
recommended by doctors during the 2nd and 3rd trimesters. If
nasal steroids are needed for chronic allergy symptoms,
budesonide (Rhinocort) and beclamethasone
(Beconase AQ) are considered safest.
- Pain: Only recommend acetaminophen (Tylenol) for pain
in pregnancy
-Anticoagulation: UFH is preferred in all stages
- Vaccines: Inactivated Influenza vaccine should be
given each fall whether pregnant or not and in all stages of
pregnancy. *No Live Vaccines one month before and during
pregnancy.
- Antibiotics: Penicillins, Cephalosporins, and
macrolides (except clarithromycin) are considered
safe. Fosfomycin for UTI is safe. Nitrofurantoin for UTI
is safe but at term is CI.**Do not use quinolones
(cartilage damage) or tetracyclines (teeth
discoloration). SMX/TMP can cause hyperbilirubinemia
and kernicterus in the 3rd trimester so do not use. Do not use
Aminoglycosides (Category D). Do not use flagyl in the 1st
trimester.

Bacterial Vaginosis: Clindamycin oral or

metronidazole oral
Chlamydia: Azithromycin 1gm x 1 or
Amoxicillin 500 TID x 7 days
Gonorrhea: Rocephin 250mg x 1 and/or
Azithromycin 2gm x 1 (Covers chlamydia
too)
Trichmoniasis: metronidazole 2gm x 1 or 250
TID/500BID for 7 days

-Vaginal fungal infections: Use topical antifungals for

7 days (ex. clomitrazole)
st

-Asthma: Inhaled Corticosteroids are 1 line

(budesonide preferred). Albuterol inhaler is used for
rescue.
- Hypothyroidism: use levothyroxine (Category A)
-Hyperthyroidism: PTU and Methimazole are
pregnancy D. PTU is used in the 1st trimester and
Methimazole is after that. Both can cause serious liver
damage.

Drug References:
Average wholesale prices and suggested retail prices
of drugs: Red Book
Principles of Immunization: Pink Book from the CDC
Patents, Manufacturing, Industry issues: Pink Sheet
Travelers Health: Yellow Book
Therapeutic equivalence: Orange Book; published by the
FDAs CDER(Center for Drug Evaluation and Research)
Clinical Trials: Clinicaltrials.gov by the national institute of
health
Comprehensive Patient Information: MedlinePlus, FDA,
CDC
Natural Medicines: Natural Medicines Comprehensive
Database and Natural Standards
Pregnancy/Lactation: Breastfeeding: A guide for the
medical profession, Briggs, Lactmed, Micromedex, Hales,
CDC
Pediatrics: AHFS, Micromedex, Harriet Lane, Pediatric
Dosage Handbook, Neofax, Nelson, CDC, Professional
Colleagues

IV Drugs: Trissels, Kings, Package Insert, Micromedex, AHFS

Drug ID: Ident-A-Drug, Micromedex, Facts and Comparisons,
Clin Pharm etc..
Medication Safety: Medwatch (Adverse Reactions) and
Institute for Safe Medication Practices (ISMP)
Foreign Drug ID: Martindales, micromedex

Infectious Disease:
-Gram Positive Stain Purple/Blue, Gram Negative Stain Pink
-Breakpoint: level of MIC at which the bacteria is deemed
susceptible or resistant
-Beta Lactams (Time-Dependent) can be maximized by
extending the infusion time or giving a continuous infusion
Antibacterials:
-Aminoglycosides: (Bactericidal)

bind to 30S and 50s ribosome units and interfere with

protein synthesis
concentration dependent killing and post
antibiotic effect (PAE)
High dose extended interval dosing is less nephrotoxic
and more cost-effective
BBW for Neurotoxicity and Nephrotoxicity
Gent/Tobra: 4-7mg/kg (peak 5-10 trough <2) ,
for synergy ex. with vanco peak (3-4)
Amikacin: 15-20 mg/kg (peak 20-30 trough <5)
(dose based on IBW)

-Penicillins: (Bactericidal except against Enterococci)

bind to PBP and inhibit cell wall synthesis

Time-Dependent Killing
amoxicillin (Amoxil) refrigerate suspension to
improve taste

amoxicillin + clavulanate (Augmentin) refrigerate

suspension
ampicillin + sulbactam (Unasyn)
penicillin VK (Oral) and Penicillin G (IV) take Pen VK
on an empty stomach
piperacillin + tazobactam (Zosyn) anaerobic
coverage and pseudomonas
nafcillin, oxacillin, docloxacillin (PO) antistaph
pcn no renal dose adjusting, is a vesicant
bone marrow suppression with long-term use or
seizures with accumulation

-Cephalosporins: (bactericidal)

same mechanism as PCNs

activity against staph decrease with
generations but strep and gram neg.
increases
1st Gen: cefazolin (Kefzol,Ancef)(iv),
cephalexin (Keflex)(po) - covers PEK
(proteus, Ecoli, Klebsiella)
2nd Gen: cefuroxime (Ceftin,Zinacef)(iv/po),
cefotetan (avoid alcohol) or cefoxitin (cover
some anaerobes) more gram negative
coverage than 1st gen. HNPEK (H.Flu,
Neisseria, proteus, Ecoli, Klebsiella)
3rd Gen: cefdinir(Omnicef)(po), ceftriaxone
(Rocephin)(iv), ceftazidime (Fortaz)
(iv),cefpodoxime (Vantin)(po) less staph
and more strep activity. More gram negative
acitivity covers serratia (HNPEKS).
**Ceftazidime covers Pseudomonas
4th Gen: cefepime (Maxipime)(iv) - best gram
negative activity, covers (HNPEKS) and
Serratia, Pseudomonas , Acinetobacter,
Citrobacter, Enterobacter (SPACE bugs)
5th Gen: ceftaroline (Teflaro)(iv) Best gram
positive activity covers MRSA, no
Pseudomonal coverage

**Ceftriaxone(Rocephin) is the only one

that can be dosed once daily. It should not
be used via Y-site or with calcium
containing stuff. DOC for primary
peritonitis infections.

-Carpapenems: (bactericidal)

same mechanism as PCNs

Broad Spectrum against Gram +/-, Anaerobes,
Pseudomonas (except Ertapenem), AMPC
and ESBLS
imipenem/cilastatin (Primaxin),
meropenem (Merrem), ertapenem
(Invanz), doripenem (Doribax)
Side Effects: Can cause seizures
ertapenem (Invanz) can be dosed once
daily

-Aztreonam(Azactam):

no Gram + activity but good for

Pseudomonas
can be used in PCN allergic patients

-Fluoroquinolones: (Bactericidal)

Inhibit DNA gyrase and topoisomerase IV

concentration dependent killing
ciprofloxacin (Cipro or ciprodex (otic)),
levofloxacin (Levaquin), moxifloxacin
(Avelox or Vigamox (eye)), ofloxacin (Floxin
(otic))
Cipro and Levo have Pseudomonal coverage, not
Moxi
moxi covers some anaerobes
Atypical Coverage
Levo and Moxi referred to as the respiratory
FQs because they have more Strep.
Pneumo coverage

**BBW for Tendon Inflammation/Rupture

and may exacerbate muscle weakness in
Myasthenia Gravis. Pregnancy D for
cartilage damage.
QT prolongation, GI upset, Hepatotoxicity,
seizures, peripheral neuropathy,
**hypoglycemia (sometimes fatal),
peripheral neuropathy, and
photosensitivity.
Cipro Oral Suspension should not be given via
feeding tubes b/c it adheres to the tubing.
Chelation with cations so separate doses
from things like antacids, mutivaitmins etc..
Cipro CI with tizanidine (Zanaflex)

-Macrolides: (Bacteriostatic)

binds to 50S ribosome to inhibit protein

synthesis
azithromycin (Z-Pak, Zithromax),
erythromycin (Erythrocin), clarithromycin
(Biaxin)
Atypical coverage
QT prolongation, GI upset, Hepatotoxicity
erythromycin and clarithromycin are
inhibitors of 3A4
azithromycin has less drug-drug
interactions

-Tetracyclines: (Bacteriostatic)

bind to 30s ribosome to inhibit protein synthesis

tetracycline, doxycycline, minocycline
Photosensitivity
Pregnancy Category D (teeth discoloration
and skeletal growth suppression)
doxycycline IV to PO is 1:1
Chelation with cations

do not use in children < 8 yrs. old

doxy doesnt need renal dose adjusting

-Sulfonamides: (Bactericidal when SMX/TMP are used

together)

inhibit the folic acid pathway

MRSA coverage
Bactrim and Septra
Always in a 5:1 (SMX:TMP)
CI: Pregnancy, Sulfa Allergy, breastfeeding,
anemia due to folate deficiency, marked
renal/hepatic disease, infants <2 months
Side Effects: Photosensitivity, Skin
reactions, hyperkalemia, hypoglycemia,
crystalluria (take with 8oz) of water
IV to PO is 1:1
**Inhibitor of 2C9 so caution with warfarin

-Vancomycin (Vancocin): (Bactericidal)

blocks glycol-peptide polymerization of the cell

wall
can be used orally for C. Diff 125-500mg QID x
10-14 days
Side effects: Nephrotoxicity, Ototoxicity,
infusion rxn/redman syndrome(hypotension,
flushing, chills, etc..- so give 30 min infusion for
each 500mg)
Troughs: 15-20mcg/ml for pneumonia,
endocarditis, osteomyelitis, meningitis, and
bacteremia; 10-15 for others.
MRSA, PRSP, Enterococcus (Not VRE)

-Telavancin (Vibativ): (Bactericidal)

derivative of vancomycin
red man syndrome, nephrotoxicity, QT
prolongation

-Linezolid (Zyvox): (Bacteriostatic)

binds to 23S ribosomal RNA of the 50S subunit

CI with MAOI inhibitors or within 2 weeks
use of them
IV to PO 1:1 (600mg Q12)
MRSA, PRSP, VRE
associated with bone marrow suppression and
peripheral neuropathy

-Daptomycin (Cubicin): (Bactericidal)

o
o
o
o
o
o

depolarizes cell membrane

MRSA, PRSP, VRE
Side Effects: **Myopathy and increased CK
**Do not use for pneumonia b/c its inactivated
by surfactant
can cause false elevations in INR with no
increased bleeding
compatible with NS but not D5W

-Tigacycline (Tygacil):
o
o
o

related to tetracyclines
BBW: increased risk of DEATH
Lipophilic and distributes to tissues so not for
bloodstream infections

**CI: Pregnancy(1st trimester), *Alcohol

and no alcohol for 3 days after
discontinuing
Can increase INR if used with warfarin
IV to PO 1:1
Can cause metallic taste in mouth
Do not refrigerate b/c crystals can form

-Rifaximin(Xifaxan) : for travelers diarrhea and

hepatic encephalopathy
-Fosfomycin: single dose for UTI, ok for pregnancy
-Nitrofurantoin (Macrobid or Macrodantin): for
uncomplicated UTI, **CI with CrCl<60ml/min, rarely
can cause pulmonary toxicity.( Darkens urine rust
colored.)
Refrigeration of antibiotics:
Refrigerate: Penicillins (amoxicillin just for taste),
Cephalosporins (except Cefdinir(Omnicef)), Erythomycin
Do Not Refrigerate: Cefdinir, Azithromycin, Clarithromycin,
Clindamycin, Ciprofloxacin, Levofloxacin, Doxycycline,
Fluconazole, Voriconazole, linezolid (Zyvox), SMT/TMP

-Clindamycin (Cleocin):

binds 50s subunit

Covers gram + (not enterococcus) and
most anaerobes
BBW for severe or fatal colitis
D-test for macrolide-induced resistance
no renal adjustments

-Metronidazole (Flagyl) and Tinidazole (Tindamax):

DNA damage which blocks translation and

protein synthesis
Anaerobes and protozoal infections
BBW for possible carcinogenicity

Specific Disease Treatments with Antibiotics:

Surgery Prophylaxis:

Usually initiated within 60 minutes before the

procedure unless FQ or Vanco is used then its 120
min. before.
Second doses may need to be given for longer
procedures or if there is significant blood loss.
1st or 2nd Gen. Cephalosporins usually given
unless PCN allergy then Vanco is used.

If bowel parts are involved, need anaerobic

coverage such as cefotetan, ertapenem, or
Rocephin with Flagyl

LRTI:

Meningitis:

Most common pathogens: Strep.Pneumo, H.Flu,

Neisseria Meningitis, and Listeria
Tx with Ceftriaxone (Rocephin) + Vancomycin
usually for 7-14 days + dexamethasone
For immunocompromised or >50, add Ampicillin
for Listeria coverage
If Beta Lactam Allergy: Chloramphenicol + Vanco
+ Bactrim (Listeria)

Infective Endocarditis:

Usually from Staph, Strep, or Enterococcus

**Prosthetic valve IE usually from Staph and

requires addition of Rifampin

Gentamicin often used for synergy, peak 3-4

mcg/ml, trough <1, do not use extended-interval
dosing

usually 4-6 weeks of treatment with a PCN,

Cephalosporin (ceftriaxone), or Vanco

Prophylaxis from dental procedure: **

Amoxicillin, clindamycin, or azithromycin 30-60
min before procedure.

URTI:

Acute Otitis Media: Usually use **High dose

amoxicillin 90mg/kg/day or Augmentin
Most are caused by viruses

Acute Bronchitis: Usually Viral Antitussives and

Bronchodilators Used
CAP: usually causes by Strep. Pneumo, H.Flu, or M.
Catarrhalis. Usually use a macrolide, or betalactam + macrolide, or a FQ for 5-10 days
HAP:
Early Onset (<5days): Usually same bugs as
CAP
Late Onset (>5days): Usually MDR pathogens
(MRSA, Pseudomonas). Tx for 7-8 days unless
pseudomonas then its 14 days.

Tuberculosis:

caused by mycobacterium tuberculosis

high contagious
Diagnosed with Tuberculin skin test (aka PPD).
Look for raised area with 48-72 hrs.
Latent usually treated with rifampin and
isoniazid
If active, Tx with RIPE regimen which is
Rifampin, Isoniazide (INH), Pyrazinamide,
and Ethambutol
Direct observed therapy (DOT) if possible to
make sure they take all the meds
Patients should be in isolated, negative
pressure rooms
Recommend pyridoxine (Vit B6) to prevent
neuropathy with isoniazid (INH)
Rifampin and INH taken on an empty
stomach
Ethambutol can cause optic neuritis
pyrazinamide CI in acute gout and hepatic
damage
INH can cause hepatic damage too
rifampin can cause red-orange secretions
and stain contacts

RIPEM if resistant to others

(M=moxifloxacin)

Intra-Abdominal Infections:

Primary peritonitis: mostly from strep and enteric

gram negative rods (PEK). Tx with ceftriaxone
(Rocephin) for 5-7 days.
Secondary peritonitis from traumatic event (surgery,
ulceration, ischemia, obstruction) usually strep, gram
neg. rods and anaerobes

C.Difficile:

Skin and Soft Tissue Infections:

Cellulitis: Affects all layers of the skin and usually

caused by Staph. Aureus or Strep. Pyogenes
abscesses need incision and drainage (I&D)
Purulent(pus): requires MRSA coverage
non-purulent: (Keflex)
IV antibiotics may be necessary for severe infections

Usually from Antibiotic use especially Clindamycin,

Ampilcillin, Cephalosporins, and FQs.
Remove offending agent
avoid anti-motility agents due to risk of toxic
megacolon
wash hands with soap and water to prevent
transmission, alcohol does not kill the spores
Tx: Metronidazole 500mg TID (mild-mod) or Oral
Vanco 125mg QID (mod-severe) or both for severe
complicated 10-14 days with flagyl being IV.
fidaxomicin in clinical trials shows lower recurrence
rates

Travelers Diarrhea

UTI:

Asymptomatic (no fever or urinary symptoms)

does not need to be treated unless pregnant
then you treat for 7 days
Nitrofurantoin (CI if CrCl < 60 ml/min) for
uncomplicated UTI or SMX/TMP
Can use FQ for complicated UTI or SMX/TMP

more common in females b/c of shorter urethra

all male UTIs are considered complicated
Signs/Symptoms: dysuria, urgency, frequency,
burning, nocturia, suprapubic heaviness, hematuria ,
(fever is uncommon)
Positive Urinalysis when there is pyuria/pus in urine
(positive leukocyte esterase, or >10 WBC/ml) and
bacteriuria >105 for uncomplicated or >103 for
complicated.
Phenazopyridine(Azo) often given for urinary pain
(dysuria) can cause red/orange urine. Max of 2
days b/c you dont want to cover symptoms that
can worsen.

Bacterial (80%): enterotoxigenic E.Coli,

Campylobacter jejuni, shigella, salmonella
Viral sometimes
Protozoal sometimes
Tx: Fluoroquinolones are the the DOC plus
loperamide
Hydration is very important
prophylaxis is not recommended but can use
Pepto-Bismol to reduce incidence
No Fever and No blood in stool can use
loperamide: 4mg then 2mg, max 16mg/day

Fungal Infections:

Amphotericin B: (fungicidal)

binds to ergosterol, altering cell membrane

permeability, causing cell death
Comes in conventional and lipid formulation
(Abelcet, Ambisome)
BBW that medication errors occur due to the
mix-up between conventional and lipid
formulation dosing differences. Conventional
has a max dose of 1.5mg/kg/day.
Side Effects: Fever, chills, headache, malaise, rigors,
hypokalemia, hypomagnesemia, **nephrotoxicity
Lipid formulation reduce the risk for infusion
reactions and **nephrotoxicity
If using conventional, pre-medicate for infusion
related reactions with:
acetaminophen or NSAID
Diphenhydramine and/or hydrocortisone
Meperidine to reduce duration of rigors
fluid boluses to reduce nephrotoxicity

Itraconazole (Sporanox), fluconazole (Diflucan),

voriconazole (VFEND), posaconazole (Noxafil)
Ketoconazole (Nizoral topical, generic for tablets)
Fluconazole IV to PO is 1:1
Voriconazole should be taken on an empty
stomach, posaconazole with full meal
Voriconazole CI with many 3A4
substrates/inhibitors/inducers. It starts 1st order
then is 0 order PK so small dose increases can
have large affects (michaelis menton).
Only Fluconazole and Voriconazole penetrate the
CNS well enough to treat fungal meningitis
**All are 3A4 inhibitors
**Side Effects of all: Increase LFTs, QT
prolongation
Side effects of Voriconazole/Posaconazole:
**Visual changes, hallucination
Itraconazole is CI in heart failure

EchinoCANDIns:
Flucytosine (Ancobon): (fungicidal)

penetrates into fungal cells and is converted to

fluorouracil which competes with uracil, interfering with
fungal RNA and protein synthesis
BBW to use extreme caution in renal dysfunction
and closely monitor renal, hepatic, and hematologic
status
Side Effects: Bone marrow suppression, hepatitis,
nephrotoxic increase BUN and Scr

o
o
o
o
o
o

inhibit synthesis of B(1,3) D- Glucan of the cell wall.

DOC for most systemic Candida
Caspofungin (Cancidas), mycafungin (Mycamine),
anidulafungin (Eraxis)
Side effects: Increased LFTs, hypotension, fever,
diarrhea, hypokalemia, hypomagnesemia, rash
good for C. krusei and glabrata too
all once daily and no renal adjustments

Terbinafine (Lamisil):

Azoles: (fungicidal and fungistatic)

decrease ergosterol synthesis and thus cell

membrane formation
Fluconazole is the DOC for thrush in HIV patients
or non-HIV with moderate-severe disease. Nystatin
also good for thrush.
Voriconazole is the DOC for Aspergillus

Inhibits squalene epoxidase

Side effects: Increased

LFTs, headache
Nystatin: Griseofulvin (Grifulvin,Gris-PEG):
photosensitivity & pregn.cat X

Viral Infections:
Influenza:

Neuramidase Inhibitors
o decrease the release of viral particles
o should be used within 48 hours of illness
onset
o Oseltamivir (Tamiflu) Tx: 75mg BID x 5
days Prevention: 75mg BID x 10 days
o Tamiflu can cause vomiting
o Zanamivir (Relenza Diskhaler) BBW
bronchospasm risk
o amanatadine

Antivirals for Herpes Simplex Virus (HSV),

Varicella Zoster Virus (VZV) and Cytomegalovirus
(CMV):
o acyclovir (Zovirax), valacyclovir (Valtrex),
valganciclovir (Valcyte), famciclovir ( Famvir)
ganciclovir (Cytovene), cidofovir (Vistide), foscarnet
(Foscavir)
o **valganciclovir has a BBW for
myelosuppression and
carcinogenic/teratogenic effects. **Prepared
in vertical air hood.
o cidofovir has a BBW for nephropathy
o valganciclovir is taken with food
o ganciclovir and valganciclovir are the DOC for
CMV
o if resistant to acyclovir you will be resistant
to valacyclovir and famciclovir
o Therapy for HSV should be within 24 hours of
symptoms and therapy for VZV should be
within 72 hours of rash.

West Nile Virus: Antivirals do not work well so just

dont get it. Use repellants and wear protective clothing.

Malaria:

Atovaquone/proquanil (Malarone)
Mefloquine (Lariam):CI with Hx of seizures or
psychiatric disorders
Doxycycline (Vibramycin)
Chloroquine (Aralen) QT prolonging, visual
disturbances, retinopathy
Quinine (Qualaquine) CI with prolonged QT and
G6PD deficiency
Primaquine CDC requires screening for G6PD
deficiency

Immunizations:

Federal law requires patients receive the most up to

date version of the Vaccine Information Statement
(VIS) BEFORE EACH vaccine is administered.
Active Immunity produced by the persons own
immune system (permanent). Get it from surviving and
infection or vaccination.
Passive Immunity products like Immunoglobulins are
transferred to a patient (wanes within weeks to
months)
Usually 3 months spacing between anti-body
containing blood products and MMR or Varicella
vaccines. (Zoster is not affected by circulating
antibodies)
Pink Book for recommendations
Simultaneous administration of all vaccines for
which they are eligible is fine and efforts should
be made to do them at one visit on the same day

If live parenteral vaccines (MMR, Varicella, Zoster, and

yellow fever,) or live intranasal influenza (LAIV) are not
administered at the same visit, then separate them
by 4 weeks.
Increasing the dosing interval between multi-dose
vaccines doesnt decrease effectiveness but may delay
more complete protection.
Decreasing the dosing interval between multi-dose
vaccines may interfere with antibody response and
protection.
Side effects:
Local pain, swelling, redness at site
Systemic fever, malaise, myalgia, headache,
loss of appetite (LAIV can cause runny nose)
Allergic or Anaphylactic Hives, difficulty
breathing, hypotension, swelling of mouth and
throat. Severe reactions CIs subsequent dose of
the vaccine. All providers must have emergency
protocols and supplies to treat anaphylaxis.
**Absolute CIs to live vaccines (ex. Zoster,
Varicella, LAIV (Flumist), and MMR): Pregnancy
and Immunosuppression
Tdap: Pregnant women should receive Tdap with each
pregnancy, most effective in weeks 27-36. Also, a onetime dose for those <65 or >65 who have close
contact with children who are less than 6 months.
Tdap is IM.
Pneumovax (PPSV23): All patients > 65 x 1 dose,
19-64 who smoke or have asthma, 2-64 who have
chronic illnesses.
Flu: If a person can eat lightly cooked eggs or if
they only experience hives after eating eggcontaining products, then they can receive
inactivated flu vaccine but should be observed
for 30 min after administration. Inactivated for
everyone > 6 months. Mild-illness is not a CI to
influenza vaccine. LAIV only for healthy people
2-49 years old.

Varvax/Zostavax/MMRV (zoster and chickenpox)

should not be given to anyone with a true
gelatin or neomycin allergy. Store vaccine in
freezer and diluent in fridge or room temp.
HPV vaccine (Gardasil, Cervarix) for males (to reduce
genital warts or anal cancers) or females 9-26 yrs old.
(3 Doses). Males only use Gardasil.
IM is given into the deltoid muscle with a 1
needle (women >200lbs and men >260 lbs need
1 and ). SC is given into the fatty tissue
above the tricep with a 5/8 needle.. PPSV23 is
SC or IM but PPSV13 is IM only.
**LAIV , Varicella/Zoster and MMR are live
**SC is varicella, ZOSTER (Zostavax) and MMR
**Varicella and Zoster are stored in the freezer
Children get DTap and adults get Tdap
***CDC does not recommend using
acetaminophen before a vaccine bc it can
decrease immune response
Never mix vaccines together
In Florida, pharmacists give Influenza, Shingles,
and Pneumococcal Vaccines

Travelers Medicine:

Yellow Book for travel information

Malaria parasite protection is provided by oral meds
prior to travel. Use DEET. Plasmodium Vivax causes
65% of cases in India. Plasmodium falciparum is the
most deadly.
Treatment:
o Mefloquine (Larium): High resistance and
many psychiatric and neurologic side effects.
Once weekly. Started 1-2 weeks before and 4
weeks after
o Chloroquine: Once weekly. Started 1-2 weeks
before and 4 weeks after
o Atovaquone/Proguanil (Malarone):
Started 1-2 days before travel and for 7

days post travel. Well tolerated but CI in

pregnancy. Once Daily.
Primaquine: Once daily. Started 1-2 days
before travel and for 7 days post travel. CI in
pregnancy. CDC requires screening for
G6PD deficiency before use.

Meningococcal vaccine: required for Saudi Arabia.

Also prevalent in the meningitis belt of Africa. Menactra
(2 doses for 9-23 months, 1 for 2-55 yrs), Menveo (2-55
yrs.), Menomume (56 and older). 7-10 days for
protective antibodies.
Yellow Fever Virus Vaccine: for certain parts in subsaharan Africa and South America. Watch for allergies to
eggs and gelatin. It is a live vaccine so dont use in
immunocompromised. ASA and NSAIDs should not be
used b/c of increased risk of bleeding.
Typhoid Fever: bacteria spread through consumption of
food/water contaminated with feces or sexual contact.
Use safe food and water precautions. Vaccine is
Vivitof Berna, 4 capsules, 1 every other day taken
with cool liquid or IM shot > 2 weeks before
exposure.
Altitude Sickness: acetazolamide (Diamox
Sequels). CI in sulfa allergy.
International certificate of vaccination (Yellow
Card)

HIV:
CD4+ counts are the major laboratory indicator
of immune function and need for prophylaxis
against opportunistic infections.
HIV-1 RNA (Viral Load): most important indicator
of response to anti-retroviral therapy (ART).
Used to help assess disease progression and possible

drug resistance. Measured at baseline and then on

a regular basis thereafter.
Spread through blood, semen, and vaginal
secretions. Also spread through vertical transmission
during pregnancy, at birth, or breastfeeding.
**ART is recommended in ALL HIV-infected
patients
**Need adherence of 95% or greater to be
effective long-term
PIs and stavudine associated with
lipodystrophy/lipoatrophy and fat
redistribution/lipohypertrophy
Diarrhea is a common side effect of ART.
Crofelemer(Fulyzaq) is approved for non-infectious
diarrhea in adult patients on ART.

NRTIs: (Abacavir, lamivudine, emtricitabine,

tenofovir, didanosine, stavudine, zidovudine)

**All have BBW for lactic acidosis and

hepatomegaly with steatosis(fatty liver)
Suspend treatment if there is lactic
acidosis or hepatomegaly with steatosis.

abacavir: BBW for severe hypersensitivity

reaction. Must test for HLA-B*5701.
Ziagen (abacavir)
Epzicom (abacavir + lamivudine) Once Daily

emtricitabine: BBW for Hep B exacerbation

once discontinued or HBV resistance. Can
cause hyperpigmentation of soles and feet.
Emtriva (emtricitabine)
**Truvada (emtricitabine + tenofovir): Once
Daily
**Atripla (emtricitabine + tenofovir +
efavirenz): Once Daily. Take on empty stomach.

lamivudine: BBW for Hep B exacerbation once

discontinued or HBV resistance. BBW to not
use Epivir-HBV for HIV(contains lower dose of
lamivudine). Preferred in Pregnancy
Epivir (lamivudine)
Epzicom (abacavir + lamivudine)
tenofovir: BBW for Hep B exacerbation once
discontinued or HBV resistance. Fanconi
syndrome, renal failure, osteomalacia,
decreased bone density.
Viread (tenofovir)
Truvada (tenofovir + emtricitabine)
Atripla (tenofovir + emtricitabine + efavirenz)
Zidovudine: BBW for hematologic toxicity
(neutropenia and anemia) and myopathy.
Preferred in pregnancy.

NNRTIs (Efavirenz, delavirdine, etravirine, nevirapine,

rilpivirine)

**All can cause SJS(rash) and Hepatotoxicity

**Inhibitor of 2C9, 2C19, and 3A4, and
strong INDUCER of 3A4 = many drug
interactions
efavirenz (Sustiva):
600 mg daily on empty stomach. CNS side
effects (vivid dreams, drowsy, impaired
concentration) and psychiatric side effects
(depression, paranoia, mania, suicide).
CNS side effects usually resolve in 2-4
weeks. Pregnancy D
Atripla ( tenofovir + emtricitabine + efavirenz)

Protease Inhibitors: (atazanavir, darunavir, ritonavir,

lopinavir/ritonavir, fosamprenavir, indinavir, nelfinavir,
saquinavir, tipranivir)

**All strong INHIBITORS of 3A4 = many drug

Interactions
**Side Effects: Hyperglycemia, Insulin Resistance,
Diabetes, fat maldistribution, hepatitis, immune
reconstitution syndrome
atazanavir (Reyataz): PR interval prolonging,
hyperbilirubinemia (aka bananvir), rash, take
with 1.5 L of water to reduce nephrolithiasis.
Needs Acid,Avoid acid suppressants b/c they can
decrease levels, take with food and water. (1st
line)
darunavir (Prezista): Rash, Sulfa Allergy (1st line)
ritonavir (Norvir): PR prolonging
lopinavir/ritonavir (Kaletra) : PR prolonging,
Preferred in Pregnancy
Integrase Inhibitors: (Raltegravir, dolutegravir,
elvitegravir)
raltegravir (Isentress): 400mg BID
Fusion Inhibitor: enfurvitide (Fuzeon)
local injection site reactions in 100% of patients
CCR5 antagonist: maraviroc (Selzentry)
only works for CCR5 type HIV so must be
screened before using
BBW for hepatotoxicity
Side Effects: UTRI, fever, rash, musculoskeletal
symptoms, dizziness

Pregnancy: Combivir (lamivudine + zidovudine) +

Kaletra (lopinavir/ritonavir) OR atazanavir + ritonavir
OR nevirapine (NNTRI)

Pre-Exposure Prophylaxis: Truvada 1 tab PO QD

Tx: pegylated interferon (Pegasys or Pegintron):

BBW for many things. (See above)
Ribavirin: BBW for teratogenic. SE:
hemolytic anemia
Protease Inhibitor: (ex. boceprivir): only for
genotype 1
sofosbuvir (Sovaldi): inhibits HCV NS5B RNA
polymerase

Occupational post-exposure prohylaxis - Truvada +

Raltegravir (Isentress) x 4 weeks
Opportunistic Infections:

PCP (CD4<200): Prophylaxis: SMX/TMP Tx:

SMX/TMP +/- corticosteroids
Toxoplasma gondii (CD4<100): Prophylaxis:
SMX/TMP Tx: Pyrimethamine + sulfadiazine
Mycobacterium Avum (CD4<50) Prophylaxis:
Azithromycin Tx: Azithromycin + Ethambutol
CMV Valganciclovir
Cryptococcal Meningitis: Liposomal
Amphotericin B + Flucytosine

Diabetes:

Hepatitis/ Liver Disease:

Hepatic Encephalopathy: From Ammonia Buildup

Tx: Lactulose or rifaximin (Xifaxan) + **low protein
diet

Ascites: Furosemide and Spironolactone

Hepatitis B: Vaccine preventable. Usually treat for 1

year.
Tx: pegylated interferon (Pegasys) : BBW for
many things; exacerbate or cause autoimmune
disorders, infectious disorders, CVA, depression
(20%) **pegylation increases half-life for once
weekly dosing.
NRTIs tenofovir (Viread),* lamivudine
(Epivir HBV) entecavir(Baraclude)

Hepatitis C: Not Vaccine Preventable. 3 different

types (Genotype 1,2, and 3). 1 is the most difficult to
treat and treated for 48 weeks. Genotype 2 and 3
treated for 24 weeks.

Type 1: Autoimmune destruction of beta cells in the

pancreas
Type 2: Insulin resistance or relative deficiency
eAG: (28.7 x A1C) 46.7
Diagnosis: Classic signs
(Polyuria/polydipsia/polyphagia/weight loss) +
A1C > 6.5 % or FPG > 126 or Random >200 or
2hr. glucose > 200 after 75 gram OGTT
Common drugs that alter glucose:
Hyperglycemina- Corticosteroids,
Thiazide/Loop Diuretics, Statins, FQs, Protease
Inhibitors
Hypoglycemia: FQs, Lorcaserin (Belviq satiety
drug)
Treatment Goals: ADA: A1C < 7% Pre-Prandial
70-130 mg/dl Post-Prandial: <180 mg/dl
AACE: A1C < 6.5% PrePrandial <110 mg/dl Post-Prandial: <140 mg/dl
Tx: Lifetstyle Modifations: Weight Loss, Diet, Exercise,
waist circumference <35 for females and < 40 for
males plus Drugs
Nephropathy Screenings: (Annually)
microalbuminuria: 30-299
macroalbuminuria: >300
Add ACEi or ARB
Retinopathy Screening: (Annually)
Foot Screening: (Annually)
All diabetics should inspect their feet daily

Type 2 Diabetes Treatment: Metformin is the

initial treatment. If not at goal in 3 months, add
a second oral agent. If not at goal 3 months from
then, add a 3rd, usually basal insulin.

Drugs:
Biguanides: (Metformin)

*decreased hepatic glucose production, *increase

insulin sensitivity, decrease absorption of glucose
metformin (Glucophage, Glumetza, Fortamet)
(Janumet has sitagliptin)
**BBW: Lactic Acidosis
CI: SCr >1.5 (males) and SCr>1.4 (females).
*Temporarily D/C in patients getting IV contrast
die, hold for 48 hours and once renal function is
normal
Weight Neutral and little to no risk of
hypoglycemia
SE: Diarrhea, Nausea, Vomiting, Flatulence, Vit B12
deficiency, ER tablet shows up in stool sometimes
(ok)
Max daily dose: 2,550 mg
Take with food

Sulfonylureas: (Glipizide, Glimepiride, Glyburide)

stimulate insulin secretion (do not use with

meglitinides)
chlorpropamide (Diabinese), glipizide (Glucotrol,
Glucotrol XL, Glipizide XL), glimepiride (Amaryl),
glyburide (Diabeta)
SE: Hypoglycemia and Weight Gain
**glyburide (Diabeta) should not be used in
renal impairment, it has a renally cleared active
metabolite

Meglitinides: (baby sulfonylyureas)

stimulate insulin secretion (do not use with

sulfonylureas)

repaglinide (Prandin), nateglinide (Starlix)

SE: Hypoglycemia, weight gain, URTI

Thiazolidinediones (TZDs):

PPARy agonists that cause increased insulin

sensitivity
pioglitozone (Actos), rosiglitazone (Avandia)
BBW: do not use in NYHA Class III/IV heart
failure
SE: Peripheral edema, URTI, Weight gain

Alpha-Glucosidase Inhibitors:

delay glucose absorption in intestines

acarbose(Precose)
*taken with first bite of each meal
*Flatulence and diarrhea are common

GLP-1 Agonists: (Incretin Mimics) SQ injections

increase insulin secretion, decrease glucagon

secretion, slow gastric emptying, improve
satiety, may cause weight loss
exenatide (Byetta), exenatide ER (BydureonOnce Weekly), liraglutide (Victoza)
BBW for Bydureon and Victoza only for Thyroid
C-Cell carcinoma
Warning for Pancreatitis
SE:* Nausea (Primary Side Effect), **Weight Loss
Byetta and Victoza 30 days, Bydureon 28 days
room temp

DPP4-Inhibitors:

prevent the breakdown of GLP-1 agonists

sitagliptin (Januvia), sitagliptin + metformin
(Janumet), saxagliptin (Onglyza)
Weight neutral
SE: Nasopharyngitis, URTI, UTI

SGLT2 Inhibitors:

canagliflozin (Invokana)
SE: Female genital mycotic infections, UTIs ,
hyperkalemia, increased urination

Pramlintide (Symlin): Amylin analogue that increases satiety,

prevents glucagon secretion after a meal, slows gastric
emptying. Taken with insulin at mealtime with separate
injections. Reduce mealtime insulin dose by 50%. Can
be for Type 1 or Type 2 diabetics.
Bromocriptine (Cycloset) : Dopamine agonist that works
in CNS to increase insulin sensitivity. Take with food to
decrease nausea.
coselevam (Welchol) bile acid sequestrant, unknown
MOA in diabetes, CI with TG>500. Some meds that need to
be taken 4 hours before administration of this: Sulfonylureas,
Phenytoin, levothyroxine, oral contraceptives

Insulin:

***All insulins have a concentration of 100

units/ml except Humulin R U-500 which is 500
units/ml
**Consider starting Type 2 with insulin if
A1C>10% or BG>300
Rapid-Acting: aspart (Novolog/Novolog Flexpen),
lispro (Humalog/Humalog Kwikpen ), glulisine
(Apidra/ Apidra Solostar) : 28 days
Regular/Short Acting: (Humulin R, Novolin R): 31
days(H) and 42 days(N)
NPH or Intermediate: Humulin N, Novolin N. This
is cloudy and can be mixed with Rapid and Short
acting insulins. Always mix clear before cloudy. 28(H)
and 42(N), pens 14

Long Acting: glargine (Lantus) 28 days, detemir

(Levemir) 42 days

NPH to glargine: If NPH is once daily, 1:1 TDD.

If NPH is BID, then reduce daily dose 20%

NPH to detemir: 1:1 TDD

For Type 1: 0.6 units/kg/day (Total Daily Dose)

Basal-Bolus: 50% TDD basal, 50% TDD bolus
(divided evenly for 3 meals)
NPH-regular: 2/3 TDD NPH, 1/3 TDD regular (both
divided BID)
For counting carbs: Insulin to carbohydrate ratio:
500/TDD = grams of carb covered by 1 unit
rapid-acting
450/TDD = grams of carb covered by 1 unit
regular-acting
** Correction factor: (Blood Glucose Now - Blood
Glucose Target)/ Correction factor
Correction factor is rule of 1800 for rapid-acting insulin (CF=
1800/TDD) or rule of 1500 for regular-acting Insulin (CF =
1500/TDD)

For Type 2: 0.2 units/kg/day usually long-acting in

the morning
Hypoglycemia: (BG <70 mg/dl)
o

Symptoms: Confusion, sweating, tachycardia,

hunger, blurred vision. **Beta blockers can mask
the symptoms except sweating and hunger.

Treatment: 15-20 grams of glucose ( 3-4 glucose

tabs, 1 serving glucose gel, 4 oz orange juice, 8 oz
milk, 4 oz non-diet soda)

***Glucagon only used if patient is

unconscious or not conscious enough to self-treat
Side Note: NPH and Regular do not require a
prescription.

Autoimmune Disorders:
Immunocompromised: Steroids (oral and injectable
only) at 2mg/kg/day or 20mg prednisone or
prednisone equivalent for 14 days, Diseases (HIV,
Diabetes), Transplant Drugs, Oncology Drugs, Asplenia Drugs,
and immunosuppressant drugs.
Biologic Immune Suppressants: Strong immune
depression
Rheumatoid Arthritis: Chronic, Symmetrical,
Polyarticular, Systemic, and Progressive inflammation of
joints and organs.

Symptoms: joint swelling, morning stiffness, pain,

and eventually bone deformity
Goal is to have them on a DMARD within 3 months of
diagnosis. May also need NSAIDs and steroids.
some people with milder symptoms may be ok with
just non-biologic DMARDs

Treatments:

Non-Biologic DMARDs:
methotrexate (Rheumatrex, Trexall): Low
WEEKLY doses used, not daily. Pregnacy
Category X. SE: stomatitis (inflamed gums and
mouth), alopecia, photosensitivity, increase LFTs.
DO NOT take with alcohol.
hydroxychloroquine (Plaquenil): SE:
pigmentation of skin and hair, rashes. Requires
eye exams every 3 months.
sulfasalazine: CI with sulfa allergy and GI obstruction.
SE: anorexia, oligospermia, rash, folate deficiency,
yellow-orange colored urine, impaired folate
absorption.
minocycline: SE: photosensitivity
leflunomide (Arava): Hepatotoxic, Pregnancy
Category X.
tofactinib (Xeljanz): BBW for increased infections,
lymphomas and other malignancies, risk for
developing active TB.
Biologics: (TNFa Inhibitors and Non-TNF)
**Can all increase risk of infections, screen for
latent TB in all
Require Refrigeration (except etanercept can be
at room temp. for 14 days). Wait until drug is at
room temperature before injecting.
Do not use more than 1 biologic at a time and do
not give live vaccines
TNFa Inhibitors DMARDs:

Pain and Inflammation:

ibuprofen 800mg Q6-8hrs. (Max
3200 mg/day) ; OTC max 1200
mg/day
celocoxib (Celebrex) 100-200 mg
BID

**BBW for SERIOUS INFECTIONS, lymphomas and

other malignancies, risk for developing active
TB.
**Can cause heart failure and hepatotoxicity
etanercept (Enbrel): Sub Q
adalimumab (Humira): Sub Q

 infliximab (Remicade): (IV)Infusion reactions and

delayed hypersensitivity reactions. Given only in
combo with methotrexate.
golimumab (Simponi): Sub Q. Given only in
combo with methotrexate.

Multiple Sclerosis:

Biologic non-TNF DMARDs:

rituximab (Rituxan): Depletes CD20 B Cells. BBW
for severe/fatal infusion reactions, rashes etc.
Given in combo with methotrexate.
abatacept (Orencia)
tocilizumab (Actemra): BBW for serious
infections. Can cause hepatotoxicity.
Systemic Lupus Erythematous (SLE):

o
o
o

Auto-antibodies form that damage tissue. There is

flare-ups with periods of remission.
Butterfly rash on face typical
renal (Nephritis in > 50% of patients,
hematologic, and neurologic manifestations)
Hydralazine can cause drug-induced SLE,
***found by ANA test
Treatment:
Anti-malarials: hydroxychloroquine (Plaquenil) or
chloroquine; may take 6 months to work
Prednisone
mycophenolate mofetil (CellCept): BBW for
increased risk of infection, skin cancers,
congenital malformations. SE: pain, tachycardia,
electrolyte abnormalities (hyperkalemia,
hypomagnesemia, hypocalcemia), hypotension,
hypertension, hypercholesterolemia, diarrhea,
edema,vomiting, tremor, acne etc..
belimumab (Benlysta) : IgG1-labmda antibody that
prevents survival of B cells by blocking the binding of
B lymphocyte stimulator protein (BlyS)

Immune system attacks myelin sheaths on

neurons in the brain and spinal cord
unknown cause
Most patients experience periods of
disease with intervals of remission

Treatment:
interferon beta drugs
glatiramer acetate (Copaxone)
natalizumab (Tysabri): given every 4 weeks, can
cause progressive multifocal
leukoencephalopathy
Many drugs used for symptom control can worsen
other symptoms

Celiac Disease:

Immune response to gluten. Diarrhea,

abdominal pain, bloating, weight loss.
gluten is in wheat, barley, and rye
In many foods and many drug
excipients. The actual drug doesnt
contain gluten.
Check for excipients on package insert and
look for the word starch. The starch will
either be corn, potato, tapioca, or wheat. If it
doesnt say which starch then call the
manufacturer to find out if the starch is
wheat. You can also try the website Gluten
Free Drugs and the journal Hospital Pharmacy.

Thyroid Disorders:

Thyroid hormone productions regulated by Thyroid

Stimulating Hormone (TSH)

Elevations in T4 will inhibit secretion of TSH via

negative feedback loop
T3 is more potent than T4
Its important to measure free T4 levels since it is the
active form

Hypothyroidism:

will have high TSH and low T4 (Hashimotos is

the most common cause)
Tx: levothyroxine (Synthroid, Levothroid, Levoxyl)
Pregnancy Safe
liothyronine (T3,Cytomel), natural thyroid
(porcine T3 and T4, Armour Thyroid)
Drug Causes: Amiodarone, Interferon
Take on an empty stomach 30 min. before
breakfast with a full glass of water
IV to PO is 1:2
Symptoms: Weight Gain, Slow HR, Fatigue,
Constipation, Weak

Prior to transplant donor-recipient compatibility is

done for Human Leukocyte Antigen (HLA) and
ABO blood group.
Allograft: transplant from one individual to
another that have different genotypes
Isograft: transplant from a genetically identical
donor
Autologous Transplant: same patient, tissue
moved to a different site
Many BBWs: Infections, Cancer etc.
Do not use NSAIDs (nephrotoxic) and do not
get live vaccines
If you miss a dose and its been less than 4 hours
take it. If more than 4 hours, skip it.
Maintenance Immunosuppressant Therapy:
o Calcineurin inhibitors: tacrolimus (Prograf)
1st line or cyclosporine (Neoral,
SandIMMUNE) .

Hyperthyroidism:

will have low TSH and high T4 (Graves is the

most common cause)
Tx for Graves: RAI-131 or surgery
Tx Drugs:
propylthiouracil (PTU, Propyl-Thyracil):
used in 1st trimester, preferred in
thyroid storm
methimazole (Tapazole): used in 2nd and
3rd trimesters of pregnancy.
Beta Blockers for symptoms:
palpitations, tremors, tachycardia
Drug Causes: Amiodarone, Interferon

o
o

** Interact with many drugs (3A4 and

PGP substrates). Avoid grapefruit
and St. Johns Wort.

SE: Nephrotoxic, worsen diabetes,

increase BP

mTor Inhibitors: everolimus and sirolimus SE:

worsen lipids
Antiproliferative: myophenolate mofetil
(CellCept) or mycophenolic acid (Myfortic)
are 1st line. They are not interchangeable.
+/- Prednisone

Osteoporosis and Hormone Therapy:

Transplant/Immunosuppression:

Osteoporosis:

Osteoporosis: T score <-2.5

Osteopenia:
T score between -1 and -2.5

PPIs can increase fracture risk

Ensure adequate Calcium and Vitamin D with any
treatment
o calcium citrate (Citracal): 315mg elemental,
larger pill
o calcium carbonate (Oscal, Tums): acid dependent,
500mg elemental
o cholecalciferol (Vit D3) preferred. 600IU for <70,
800IU for 71+
Treatment:
Bisphosphonates (1st line): alendronate
(Fosamax) 70 mg weekly, risendronate
(Actonel,Atelvia), ibandronate (Boniva),
zoledronic acid (Reclast)-yearly infusion. FDA
warning to stop after 3-5 years due to
esophageal cancer, osteonecrosis of jaw, and
atypical femur fracture. Take first thing in the
morning before eating or drinking anything
with 6-8 ounces of water. Stay upright for at
least 30 minutes, 60 min. for Boniva.
raloxifene (Evista): SERM, often used in women
at risk of breast CA. SE: Hot flashes, vaginal
bleeding, amenorrhea etc..
teriparatide (Forteo): Human PTH, for high risk
fractures, Sub Q daily, max: 2 years
denosumab (Prolia): antibody to RANKL
Hormone Therapy:
For women: (Hormone Replacement)
Decreased estrogen at menopause causes high LH
which can result in hot flashes and night sweats. Also
can cause vaginal dryness, painful sex, mood changes
etc..
Use the lowest possible dose for the shortest
amount of time
Estrogen can be used to prevent postmenopausal osteoporosis but not treat it.

Women with a uterus shouldnt use estrogen

alone b/c of endometrial cancer risk. Estrogen +
Progesterone increases breast cancer risk and
use should be limited to 3-5 years.
Topical Vaginal products are best for vaginal
dryness and painful intercourse
Estrogen SE: nausea, bloating, dizziness, breast
tenderness
Vivelle-Dot: estradiol transdermal, applied to lower
abdomen below waistline
Provera: medroxyprogesterone
Premarin, Premarin Vaginal Cream, or Prempro
(with progesterone) : Conjugated Estrogens
paroxetine (Brisdelle) Pregnancy Category X, 2D6
inhibitor
For Men: (Testosterone Replacement)
replacement is controversial
may increase risk for prostate cancer, increase
cholesterol, liver damage, and worsen BPH
Androgel, Axiron, Depo-Testosterone etc..
Gels are flammable until dry
BBW for secondary exposure to women and
children that could cause virilization (male
characteristics)

Contraception and Infertility:

Pregnancy/Infertility:

There are ovulation kits that test to see if LH is

present, first 3 days from a positive result are
the best chances.
Pregnancy test kits are positive if hCG is present
Should be taking 400-800 mcg/day folic acid at
least one month before pregnancy
Infertility Tx: clomiphene (Clomid): SERM
that increases ovulation

Contraception:

Progestin-Only Pills (POPs)

Estrogen and Progestin Pills (COCs)
SE: Nausea, breast tenderness/fullness,
bloating, weight gain, elevated BP. Can take at
night or bedtime to reduce nausea.
Serious adverse effects: **Clotting;
Increased risk from smoking, age, HTN,
diabetes, long bedrest, overweight, and any
that contain drospirenone (Ortho-Evra
Patch, YAZ, Yazmin, Beyaz, Ocella, etc..).
Best to avoid these.
Drospirenone acts as a potassium sparing
diuretic. This is why women like it because
it decreases bloating and weight gain but
high risk for clotting.
Drugs that decrease effectiveness
(Inducers): Rifampin, Anticonvulsants, St.
Johns Wort, PIs and NNRTIs, Cellcept,
Smoking)
Depo-Porvera shot
(medroxyprogesterone): No drug
interactions but it does lower bone
density.
Nuvaring: If out greater than 3 hours in
weeks 2 or 3, need backup for a week
Ortho Evra Patch: if off greater than 24
hours, need backup for a week
nonoxynol-9 is a common spermicide
Emergency Contraception:
Plan B (levonorgestrel): good for 3
days (72 hours) after sex, OTC now for all
ages. If you vomit within 2 hours of
taking, may want to take another dose.
Ella: Good for 5 days after sex,
prescription only
Paragard Copper IUD

Higher than normal doses of regular

daily oral contraceptives can be used

Pain The fifth vital sign

Addition of a non-opioid can often reduce the

amount of opioid needed and provide superior
analgesia
It is important to distinguish between
physiological adaptation(Tolerance) and
addiction
Addiction has strong compulsion and
desire to take drug, despite harm along
with drug-seeking behavior.
Pseudo-addiction: Looks like addiction but could
be from uncontrolled pain
Chronic opioid use needs constipation
prophylaxis
Sedation should be monitored b/c it is the
most important predictor of respiratory
depression, the usual cause of fatality in
overdose.

Acetaminophen:
Tylenol, hydrocodone+APAP (Vicodin, Lortab,
Norco, Lorcet), oxycodone+APAP (Percocet,
Endocet, Roxicet), codeine+APAP (Tylenol #2,3,4),
tramadol+APAP (Ultracet)
**BBW for Hepatotoxic: overdose can be fatal,
(Max: 4000mg/day). Overdose Tx: NAcetylcysteine to restore Glutathione
DOC for pain in pregnancy
**Avoid in heavy drinkers or known hepatitis
(<2gm /day)
Aspirin/NSAIDs:

 ASA irreversibly inhibits while other NSAIDs reversibly

inhibit COX
ASA: Bayer, Bufferin, + caffeine/APAP (Excedrin),
salsalate
ibuprofen (Motrin, Advil), naproxen (Aleve, Naprosyn,
Anaprox), naproxen + esomeprazole (Vimovo),
diclofenac (Voltaren), indomethacin (Indocin),
piroxicam (Feldene), ketorolac (Toradol), sulindac
(Clinoril) preferred with reduced renal function
Selective COX-2 Inhibitors: celecoxib (Celebrex) most selective, meloxicam (Mobic), etodolac
(Lodine), nabumetone (Relafen)
NSAID BBW: CV risks (thrombotic events), GI
(bleeding), CABG contraindicated
naproxen has a lower CV risk
indomethacin (Indocin) has more CNS side effects so
avoid in psych conditions
ketorolac (Toradol) can only be used for 5 days max
Celebrex CI with sulfa allergy
Photosensitivity
Take with food

Opioids:
BBW for respiratory depression
No tolerance to constipation so need a laxative with all
morphine (MS Contin, Avinza, Kadian, Oramorph
SR, Roxanol) *Avinza and Kadian can be opened and
sprinkled on applesauce *PO to IV is 3:1
fentanyl (Duragesic, Abstral, Fentora SL)
hydromorphone (Dilaudid)
oxycodone, Oxycontin, Endocet, Percocet,
Roxicet, Roxicodone: Avoid with 3A4 inhibitors
oxymorphone (Opana): take on empty stomach
methadone (Dolophine): BBW for QT
prolongation, serotonergic
meperidine (Demerol): serotonergic
hydrocodone (Lortab, Lorcet, Norco, Vicodin)
codeine (Tylenol #2,3,4)

tramadol (Ultram, Ultracet): serotonin syndrome

risk, increased seizure risk
tapentadol (Nucynta)
Allergic to morphine, hydrocodone etc.. : Can use
fentanyl, morphine, meperidine

Muscle Relaxants:
o

o
o

baclofen (Lioresal), cyclobenzaprine (Flexeril,

Fexmif), tizanidine (Zanaflex), carisoprodol
(Soma), metaxalone (Skelaxin), methocarbamol
(Robaxin)
cyclobenzaprine and tizanidine can cause
xerostomia (dry mouth)
tizanidine CI with Ciprofloxacin

Neuropathic Pain Agents:

pregabalin (Lyrica) max: 600mg/day

duloxetine (Cymbalta)
gabapentin (Neurontin) max: 3,600 mg/day
amitriptyline (Elavil) - anticholinergic
milnacipran (Savella) - for fibromyalgia

Topical for Localized Pain :

lidocaine (Lidoderm 5%) can cut into smaller
pieces, 12 hours on 12 hours off, approved for postherpetic neuralgia.
Capsaicin
diclofenac (Voltaren Gel)

Migraine:

Good to try and identify any triggers of

migraine.
Triptan drugs are serotonin-receptor
agonists and constrict cranial blood vessels
used to treat acute migraine.

sumatriptan (Imitrex): PO, Nasal spray,

Sub Q
rizatriptan (Maxalt) - eletriptan (Relpax)

Diuretics:

Thiazides: Work on the distal convoluted tubule to

inhibit Na+. Sulfa Allergy. Can cause hypokalemia,
HYPERcalcemia, elevated lipids, hyperuricemia
(gout), hyperglycemia, photosensititivity, rash.
Chlorthalidone (Thalitone)
Hydrochlorothiazide
Metolazone (Zaroxolyn): may work in
reduced renal function more than others.

Loops: work in the ascending loop of Henle to inhibit

Na+. Sulfa Allergy except ethacrynic acid.
Ototoxic. Can cause hypokalemia, HYPOcalcemia,
hyperuricemia (gout), elevated lipids, hyperglycemia,
photosensititivity.
furosemide (Lasix): Oral Loop Dose
Equivalency = 40mg
bumetanide = 1mg
Torsemide (Demadex) = 20mg
ethacrynic acid (Edecrin) = 50mg

Potassium-Sparing: Work in the DCT and collecting

ducts. CI in CrCl <30 ml/min and hyperkalemia.
triamterene (Dyrenium)
triamterene + HCTZ (Maxzide, Dyazide)
amiloride(Midamor)
spironolactone (Aldactone): Can cause
gynecomastia and breast tenderness. BBW
for tumor risk.
epleronone (Inspra): for Heart Failure and
HTN

Prophylaxis: Beta blockers like metoprol and propanolol

Gout:

Over-produce or under-excrete uric acid

Purines Xanthine Oxidase Uric Acid
People can be hyperuricemic and never get a gout
attack
Drugs that increase uric acid: Diuretics, Niacin, ASA
(High dose), Pyrazinamide, Cyclosporine, Tacrolimus

Tx: Acute attack:

colchicine (Colcrys) 1.2mg orally then
0.6mg one hour later (do not exceed 1.8mg).
N/V/D in 80% of patients. Only good
within the first 36 hours of onset
NSAIDs: Indomethacin, naproxen,
sulindac, celebrex (off-label)
Systemic Corticosteroids: prednisone,
methylprednisolone
Urate Lowering Therapy: When initiating
therapy, there is in increased risk of gout attacks
so make sure to give colchicine or NSAIDs
prophylactically for 6 months.
allopurinol (Zyloprim): can cause
hypersensitivity reactions
febuxostat (Uloric)
probenecid: requires adequate renal function
pegloticase (Kystexxa) Uricase that turns uric
acid into allantoin

Hypertension

RAAS Inhibitors:
***All have a BBW to discontinue if pregnant. CI in
renal artery stenosis, angioedema, and pregnancy.
All can cause hyperkalemia too.
Angioedema (swelling of lips, mouth, tongue,
face, neck) more common in blacks. If they

get angioedema, all others in the class including

ARBs and Aliskiren are CI. It can be fatal.

ACE Inhibitors:
***Can cause dry cough. If so, switch to
ARB.
benazepril (Lotensin)
enalapril (Vasotec)
lisinopril (Prinvil, Zestril)
quinapril (Accupril)
ramipril (Altace)
ARBs:
valsartan (Diovan)
losartan (Cozaar)
olmesartan (Benicar): ***Can cause Spruelike enteropathy (severe diarrhea)
telmesartan (Micardis)
irbesartan (Avapro)
Direct Renin Inhibitor:
aliskiren (Tekturna)
Do not use with with ACEi or ARB in
patients with diabetes

labetalol (Trandate): Alpha and Beta Blocker. 1st

line often in HTN in pregnancy.
Side note: Beta Blockers with ISA: (acebutolol, carteolol,
penbutolol, pindolol)- They dont decrease HR as much.
Calcium Channel Blockers:
***Can cause peripheral edema and gingival
hyperplasia.
Non-DHP: (Work in the heart, mainly for arrhythmias)
3A4 substrates and inhibitors
diltiazem (Cardizem)
verapamil (Calan, Verelan): Can be constipating
DHP: (For HTN and Angina)

amlodipine (Norvasc)
nifedipine (Adalat CC, Procardia XL, Procardia)
nicardipine (Cardene): Comes IV also
clevidipine (Cleviprex): Do no use with soy or egg
allergy

Beta Blockers:
***NOT FIRST LINE FOR HYPERTENSION
ANYMORE
Can alter blood glucose levels
propranolol (Inderal): Non-selective
atenolol (Tenormin)
metoprolol tartrate (Lopressor): Take with food
metoprolol succinate (Toprol XL): Used in heart
failure too. Max in HF is titrating to 200mg/day.
nebivolol (Bystolic): Also releases Nitric Oxide
carvedilol (Coreg): Used in heart failure too.
Alpha and Beta Blocker. Take with food.
Dosing conversions between Coreg and Coreg CR:
3.125 BID Coreg10mg Coreg CR Daily,
6.25BID20mg, 12.5mg BID40mg, 25mg BID80mg

Centrally acting alpha 2 agonists:

clonidine (Catapres, Catapres-TTS patch): Patch is
applied weekly. Do not stop abruptly or it can
cause severe hypertension. Has many off-label uses
(opioid withdrawal, anxiety, sleep etc.) Has many side
effects (bradycardia, drowsiness, sexual dysfunction,
depression, nasal stuffiness)
gaunfacine (Tenex): Intuniv is for ADHD
Direct Vasodilators:
Hydralazine
directly vasodilates arteries, litte effect on veins
Hydralazine: can cause a rare lupus-like syndrome

Alpha Blockers: (Used mostly for BPH, not first line for HTN)
terazosin (Hytrin)
doxazosin (Cardura, Cardura XL)

bile acid sequestrant can increase TGs

4 groups should be initiated on statin therapy:

Clinical ASCVD including coronary heart
disease (ACS, S/P MI, stable or unstable
angina, coronary or arterial
revascularization), stroke, TIA, or PAD.
LDL > 190
Diabetes and 40-75 yrs. old with LDL
between 70-189
40-75 yrs. old with LDL between 70-189
with estimated 10-year ASCVD risk > 7.5%

Combo Products:

amlodipine + benazepril (Lotrel)

amlodipine + valsartan (Exforge)
lisinopril + HCTZ (Prinzide, Zestoretic)
losartan + HCTZ (Hyzaar)
valsartan + HCTZ (Diovan HCT)
olmesartan + HCTZ (Benicar HCT)
bisoprolol + HCTZ (Ziac)
triamterene + HCTZ (Dyazide, Maxide)

The appropriate statin intensity is based on the

patients level of risk:

JNC 8 (Joint National Committee):

> 60 yrs. old (<150/90)
< 60 yrs. old (<140/90)
>18 yrs. old with CKD or Diabetes (<140/90)
Non-Blacks Initial Tx (including Diabetes): ACEi,
ARB, CCB, or Thiazide
Blacks Initial Tx (including Diabetes): CCB or
Thiazide
If CKD, must have ACEi or ARB regardless of race

Dyslipidemia:

LDL = TC HDL (TG/5)

Non-statin therapies are not recommended
unless statins are not tolerated
Statins, fibrate, and niacin require LFT check at
baseline. For statins, recheck in 4-12 weeks
after initiation or titration then every 3-12
months thereafter.
fibrates (when TG are high) and fish oil can
increase LDL

High Intensity Statins: (decreases LDL > 50%)

o Atorvastatin 40-80mg/day
o Rosuvastatin 20-40mg/day
Moderate Intensity: (decreases LDL 30-49%)
o Atorvastatin 10-20mg/day
o Rosuvastatin 5-10mg/day
o Simvastatin 20-40mg/day
o Pravastatin 40-80mg/day
o Lovastatin 40mg/day
o Pitavastatin 2-4mg/day
Low Intensity: (Decreases LDL <30%)
o Simvastatin 10 mg/day
o Pravastatin 10-20mg/day
o Lovastatin 20mg/day
o Pitavastatin 1mg/day

Statins:
HMG-CoA reductase inhibitors
**Liver enzymes need to be monitored. Stop drug
if ALT or AST > 3 times upper limit of normal
Obviously they can cause rhabdomyolysis .
Increased risk with Niacin or gemfibrozil (Lopid)
use
CI in Pregnancy

 SAL are 3A4 substrates

simvastatin (Zocor), simvastatin + ezetimibe
(Vytorin) 20mg, **take in the evening.
Do not exceed 10mg/day with verapamil, diltiazem, or
dronedarone
Do not exceed 20mg/day with amiodarone,
amlodipine, or ranolazine
atorvastatin (Lipitor): equivalent dose: 10mg
Do not use with cyclosporine
Do not exceed 20mg/day with clarithromycin or
lopinavir/ritonavir
Do not exceed 40mg/day with nelfinavir and boceprevir
(Hep C)
lovastatin (Mevacor, Altoprev) 40mg,
**Mevacor with evening meal, Altoprev
bedtime.
Do not exceed 20mg/day with verapamil,
diltiazem, or dronedarone
Do not exceed 40mg/day with amiodarone
rosuvastatin(Crestor) 5mg
pravastatin (Pravachol) 40mg
pitavastatin (Livalo): most potent, 2mg

Cholesterol absorption inhibitor:

ezetimibe (Zetia)
simvastatin + ezetimibe (Vytorin)
Bile Acid sequestrant:
colesevelam (Welchol): also approved for Type 2 DM
to decrease A1C. Take with meals and liquid. Can
cause constipation, bloating, gas, cramping,
increased triglycerides or neutral, sipping or
holding in mouth can lead to tooth decay.
Many meds need to be taken 4 hours before or 46 hours after or it can bind them.

ex. Oral Contraceptives, phenytoin,

levothyroxine, olmesartan, sulfonylureas,
tetracyclines and many others.

Fibrates: PPARa Activators

fenofibrate, fenofibric acid (Tricor, Trilipix)
**Only Trilipix has indication for use with a statin
gemfibrozil (Lopid): avoid if on a statin
Can increase LDL if triglycerides are high
Can cause myopathy and hepatoxicity
Niacin: (nicotinic acid or Vit B3)
ER Niacin (Niaspan 500, 750, or 1,000 mg):***
Less flushing and Less Hepatotoxic
Hepatotoxic (monitor LFTs) and causes
Flushing/Itching. Can cause hyperuricemia
(gout) and orthostatic hypotension.
Slo-Niacin: Highest risk of hepatotoxicity
IR Max: 6 gm/day ER/CR Max: 2gm/day
Flush-free doesnt work for cholesterol
Fish Oils:
Not completely understood
Omega-3 acid (Lovaza) or Vascepa
Indicated as an adjunct in patients with TGs
>500
Can increase LDL up to 44% (Only Lovaza).
Vascepa can cause joint pain (arthralgia)
Can prolong bleeding time

Heart Failure:

Most commonly caused by ischemic heart disease

(MI) and HTN
Non-Pharmacologic Therapy:
monitor body weight daily

 notify provider if symptoms worsen or weight

increases
sodium restriction to 1500 mg/day
weight reduction
exercise as tolerated
omega-3 fats are good
Avoid NSAIDs including COX-2 inhibitors

Pharmacotherapy:
**ACEi/ARB and Beta Blockers improve
survival and should be used in ALL heart
failure patients (Except when CI). Titrate
drug to target doses (from clinical trials).
Diuretics (Usually Loop)should be used to
control fluid volume (not shown to alter
survival)
Aldosterone Receptor Antagonist: Reduce
morbidity and mortality and should be
added to those who progress to NYHA
Class III/IV.
**Amlodipine has a neutral effect on heart
failure. Good for further BP control.
It is a class effect with ACEi/ARBs but not
with Beta-Blockers. Only certain BetaBlockers are used.
Beta Blockers for HF:
Metoprolol succinate (Toprol XL): Target
dose is 200mg daily
Carvedilol (Coreg, Coreg CR): Target
dose for IR is 25mg BID (Unless >85kg
then its 50mg BID) and for Coreg CR is
80mg daily.
Bisoprolol (Zebeta): Target Dose: 10mg daily
Beta blockers are only stopped if
hypotension or hypoperfusion is present.
Aldosterone Antagonists:

spironolactone (Aldactone) : Target

dose 25mg/day
epleronone (Inspra): Target dose
50mg/day

Hydralazine/Nitrate:
Hydralazine is a direct arterial dilator
that decreases afterload. Nitrates
are venous vasodilators that reduce
preload.
Indicated for Black people with NYHA
Class III/IV heart failure who are
symptomatic despite optimal
therapy.
can be used in patients who cannot
tolerate ACEi/ARBs
isosorbide dinitrate/Hydralazine
(BiDil): CI with PDE-5 inhibitors
isosorbide mononitrate (Monoket): CI
with PDE-5 inhibitors

Digoxin (Lanoxin):
Inhibits the Na+/K+ ATP pump resulting in
positive inotropic (force) and negative
chronotropic (rate)
Does not improve survival but can
decrease hospitalizations
Improves symptoms, exercise tolerance,
and QOL
Antidote: DigiFab
Lower doses for renal insufficiency,
smaller, older, female
Therapeutic range for HF: 0.5-0.9 ng/ml
(Higher for Afib)
Signs of toxicity: 1st signs are nausea,
vomiting, loss of appetite, bradycardia.

Blurred Vision, altered color perception,

greenish-yellow halos, confusion, delirium.
Hypokalemia, hypomagnesemia, and
hypercalcemia increase the risk of toxicity

Acute Decompensated Heart Failure:

Congestion: Diuretics and/or IV vasodilators
Hypoperfusion or Cardiogenic Shock: Milrinone or
Dobutamine
Vasodilators used in ADHF:
o
Nitroglycerin: Venous at low dose, Arterial at
higher doses, effectiveness limited to 2-3 days.
o
Nitroprusside (Nitropress): equal arterial and
venous, protect from light by covering with foil or
opaque material, blue solution indicates
degradation to cyanide.
o
nesiritide (Natrecor): B-type natriuretic peptide,
arterial and venous dilation.

o
o
o
o
o

LMWH:
o binds to antithrombin and inactivates Factor Xa mostly
and some Factor IIa.
o BBW for hematomas and subsequent paralysis
with spinal punctures.(Bleeds then pushes on the
spine)
o enoxaparin (Lovenox)
**VTE prophylaxis: 30mg SC BID
CrCl<
30ml/min, 30mg SC daily.
**Tx of VTE and UA/NSTEMI: 1mg/kg SC BID
CrCl< 30ml/min, 1mg/kg SC daily
**Tx for STEMI (<75): 30mg IV bolus plus
1mg/kg SC followed by 1mg/kg Q12 (Max
100mg for 1st two doses)
STEMI (>75) No bolus, just 0.75mg/kg SC
Q12 (Max 75mg for 1st two doses)
o dalteparin (Fragmin)
o Anti-Xa levels can be monitored but not done
routinely unless Pregnant or Mechanical heart
valve, severe renal impairment, extreme
weights.
o no antidote but protamine can help some

Anticoagulation:

Some risk factors for VTE: Surgery, Major Trauma,

Immobility, Cancer, previous VTE, Pregnancy, estrogen
or SERM use etc..
Heparin and LMWH can cause HIT: Body forms
antibodies to heparin which leads to further platelet
activation and pro-thrombotic state. Diagnosed by a
profound drop in platelets >50% from baseline.
**Argatroban is the DOC if this happens. DTIs
do not cross react with heparin induced
antibodies.

Unfractionated Heparin:

binds to antithrombin and inactivates Factor Xa and

IIa.
VTE prophylaxis: 5,000 units SC Q8-12hrs

Also used for VTE treatment and ACS/STEMI treatment

VTE: 80 units/kg IV bolus then 18 units/kg/hr

infusion
ACS/STEMI: 60 units/kg IV bolus then 12 units/kg/hr
inusion
Do not mix-up the heparin injection with the HepFlush
heparin line flushes
monitor aPTT and want to be 1.5-2.5 x control
Antidote: Protamine; 1mg will reverse 100 units;
max 50mg.
unpredictable anticoagulant response
IV and SC
osteoporosis with long term use

Factor Xa inhibitors:

Fondaparinux (Arixtra):

 INJECTABLE SubQ indirect factor Xa

inhibitor. Works via antithrombin like heparins.
CI in severe renal impairment (CrCl <30
ml/min)
no antidote

Rivaroxaban (Xarelto):
o ORAL direct factor Xa inhibitor.
o A fib: 20mg PO QD (CrCl > 50); 15 mg PO QD (CrCl
15-50) with evening meal
o DVT prophylaxis (after knee/hip replacements):
10mg PO QD without regards to meals
o DVT/PE Tx: 15 mg PO BID x 21 days then 20mg PO
QD with food
o **Can start when INR is < 3.0
o 3A4 substrate
o Do not use with CrCl< 15 ml/min
o no antidote

Apixaban (Eliquis): Similar to Xarelto

Direct Thrombin Inhibitors: (factor IIa)

directly inhibit Factor IIa (Thrombin)

Argatroban: Used in patients with HIT, no
antidote
bivalrudin (Angiomax)
dabigatran (Pradaxa) :
o **ORAL
o For non-valvular A-Fib
o 150 BID; 75 BID if CrCl 15-30 ml/min
o **Can start when INR is < 2.0
o Swallow whole, do not put in NG tube.
o 50% have dyspepsia
o **Keep in original container and keep lid
tightly closed to protect from moisture.
Discard after 4 months of opening bottle.
o Store in cool, dry place. Not in a bathroom
o no monitoring or antidote
Warfarin (Coumadin, Jantoven):

Inhibits Vit K epoxide reductase which depletes Factors

2,7,9,10, and protein C and S.
When starting, it is pro-thrombotic so use
parenteral anticoagulation for a minimum of 5
day and until INR is therapeutic for 24 hours
INR usually 2-3
For mechanical heart valves in the mitral or aorta
and mitral often 2.5-3.5 is wanted
Pregnancy Category X
Antidote: Vitamin K; Oral is preferred when INR >
10 without bleeding. If major bleeding then IV Vit K
infused slowly and four factor PCC (Kcentra) for urgent
warfarin reversal (can cause anaphylaxis-like
reaction). Kcentra has heparin in it, so dont use
with HIT. Avoid SC Vit K b/c of variable absorption and
avoid IM due to hematoma.
Side Effects: Bleeding, Skin Necrosis, Purple Toe
Syndrome
S-enantiomer more potent
Pharmacogenomincs: 2C9*2 and *3 require
lower doses
VKOR polymorphisms require
lower doses

Chronic Stable Angina:

plaque buildup in coronary arteries reduces blood flow to

heart
Could be from Prinzmetals angina which is vasospasm of
coronary arteries, not plaque. Calcium channel blockers
preferred for this type.
Predictable chest pain

Treatment:
Beta blockers are 1st line
ASA or Clopidogrel (for ASA allergy)

 SL or spray nitroglycerin for immediate relief.

Long acting nitrates can be used for chronic therapy as
an add-on but require nitrate-free intervals.
o
nitroglycerin SL tabs (Nitrostat 0.3, 0.4,
0.6mg)
o
nitroglycerin SL 0.4mg (400mcg) spray
(Nitromist, Nitrolingual pump spray): do
not shake, prime it
o
isosorbide mononitrate IR/ER (Monoket)
take when you wake up and then 2nd dose
5 hours later
o
SE: HEADACHE (gets less bothersome),
dizziness
Moderate to high dose statin if not CI
Annual Influenza
Ranolazine (Renexa) also an option for angina. QT
prolongation, no effect on HR or BP. (anti-anginal)

Anticoagulants (Heparin, LMWH, fondaparinux,

bivalrudin):
P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor):
Prasugrel not for CABG. Clopidogrel requires 2C19 for
activation.
Beta Blocker: within 24 hours without CI
ACE inhibitor: within 24 hours without CI
PCI is usually preferred if facilities are available.
Fibrinolytics used when facilities for PCI are not available or
when PCI cannot be done within 90 min. Fibrinolytics should
be started within 30 min. of arrival to hospital.
Fibrinolytics: alteplase, tenecteplase
NSAIDs not recommended post-MI due to risk of reinfarction. (Use ASA or Tylenol)

Acute Coronary Syndromes: (UA/NSTEMI/STEMI):

UA: chest pain, enzyme negative, no or transient EKG

changes
NSTEMI: chest pain, cardiac enzymes (troponins, CKMB), no or transient EKG changes
STEMI: chest pain, cardiac enzymes (troponins, CKMB), ST Elevation

Initial Treatment: (MONA)

Antiarrhythmics:

Morphine, Oxygen, Nitrates, Aspirin (162-325mg, then

81mg daily)

Then, other therapies added based on what is

planned for the patient (GAP-BA)

GP 11b/IIIa anatagonist (abciximab (ReoPro),

eptifibatide (Integrelin), tirofiban): Abciximab
irreversibly blocks. Can cause bleeding,
thrombocytopenia, hypotension.

Usually from myocardial ischemia or infarction. Also

from things that damage the heart like HTN, heart
failure, hyperthyroidism, infection etc..
Electrolyte imbalances can cause arrhythmias
(potassium, sodium, magnesium, calcium)
Drugs, including drugs to treat arrhythmias can
cause it.
Afib is the most common supraventricular
arrhythmia and usually results in a rapid
ventricular response.
QT prolongation is a risk factor for Tosades de
Pointes, usually drug-induced and can lead to
sudden cardiac death.
Additive QT Prolongation: Class 1a and Class III
antiarthymics, quinolones, macrolides,
SMX/TMP, azole antifungals, TCAs, some SSRIs
(Citalopram, paroxetine, fluoxetine,
escitalopram), antipsychotics, methadone, 5HT3

anatagonists (ondansetron), PIs, anti-cancer

drugs etc..
Class Ia: (quinidine and procainamide) block
sodium and potassium channels. Additive QT
prolongation.
Class Ib: (lidocaine) pure sodium channel blockers.
Only for ventricular arrhythmias. Cross BBB
and so can have CNS effects.
Class Ic: (flecainide, propafenone) sodium channel
blocker. CI in heart failure and acute MI.
Class II: Beta Blockers (esmolol, propranolol)
used to slow ventricular rate.
Class III: (amiodarone (Cordarone, Pacerone,
Nexterone), dofetilide (Tikosyn, has REMS
program calls TIPS), dronedarone, ibutilide,
sotalol) mainly block potassium channels.
Amiodarone is the DOC if they have
concomitant Heart Failure. It can cause
Corneal deposits, photosensitivity,
neuropathy, increased LFTs and blue-grayish
skin, pulmonary fibrosis. All have Additive QT
prolongation.
Class IV: Calcium Channel Blockers (diltiazem,
verapamil)
Others: Digoxin (Lanoxin): Hypokalemia,
hypomagnesemia, and hypercalcemia
increase risk of digoxin toxicity.
**Therapeutic range for Afib: 0.8-2 ng/ml.
Enhances vagal tone.

soluble guanylate cyclase stimulator: riociguat

(Adempas): CI with PDE-5
PDE-5 inhibitors: sildenafil (Revalo) or Tadalafil
(Adcirca) : Different Brands and doses than used in ED.
CI with nitrates. If a patient is taking a PDE-5 inhibitor
and has chest pain, hold nitrates for 24 hours with
sildenafil and vardenafil and 48 hours for tadalafil
(tadalafil has longer half-life).
Group 2 is PH, which is pulmonary venous HTN form leftsided heart failure.

Asthma:

bronchial hyper-responsiveness and underlying

inflammation
chronic inflammatory disorder of the airways
Having patients demonstrate correct technique is often
a good idea
Wheezing, breathlessness, chest tightness,
coughing; often at night or early in the morning
Common Triggers: Allergens, Drugs (NSAIDs,
ASA, non-selective BBs), Cold air or humid hot air,
smoke, chemicals, Respiratory Infections.
Inhaled steroids are the preferred controller
(sometimes with LABA). Inhaled rapid-acting beta
agonist preferred reliever for acute bronchospasm
and prevention of EIB (Exercise-Induced
Bronchospasm).

SABA: (For Rescue PRN)

Pulmonary Arterial Hypertension:

Group 1 is PAH: can be idiopathic, genetic, liver disease, HIV
etc.
Warfarin titrated to INR of 1.5-2.5
prostacyclin analogues
endothelin receptor antagonists

albuterol (ProAir, Proventil, Ventolin)

levalbuterol (Xopenex)
If using SABA > 2 days/week then increase
maintenance therapy

LABA: (***BBW to only used with steroids, not

monotherapy b/c increased risk of death)

Once asthma is controlled, assess for stepdown

therapy (removal of LABA) without loss of asthma
control.
salmeterol + fluticasone (Advair Diskus or HFA)
fomoterol + budesonide (Symbicort)

Inhaled Corticosteroids: (1st line therapy)

beclamethasone (QVAR): ** preferred in pregnancy

budesonide (Pulmicort)
fluticasone (Flovent)
mometasone (Asmanex)
SE: Oral Candidiasis (Thrush), dysphonia, cough.
**Prevent thrush with spacer or rinsing mouth with
warm water and spit after use

has phenyalanine in it for a sweetener so dont

use in PKU
Theophylline:

Omalizumab (Xolair):

Oral Steroids: (for severely uncontrolled asthma)

Cortisone, hydrocortisone (Solu-Cortef),

methylprednisolone (Medrol, Medrol Dosepak,
Solu-Medrol), Prednisone, Prednisolone (Millipred,
Orapred, Prelone), triamcinolone (Kenalog),
dexamethasone (Decadron), betamethasone
If on it more than 10-14 days, requires a taper
Long-Term SE: Cushing Syndrome, Immunosuppression,
Acne, Insomnia/Nervousness, Hypokalemia, Amenorrhea,
Osteoporosis, Weight Gain, Diabetes, GI Bleed etc..
Methylprednisolone 4mg =
Prednisone/Prednisolone 5mg = 0.75mg
Dexamethasone

Leukotriene Receptor Antagonist:

montelukast (Singulair):
10mg QD, 1-5 yrs. old (4mg), 5-14yrs. old
(5mg)
can cause headache and neuropsychiatric
behavior
For EIB, only works in 50% of patients,
take 2 hours before exercise

not the most effective and has many drug

interactions/side effects
Therapeutic range: 5-15 mcg/ml
SE: nausea, loose stools
Aminophylline to Theophylline multiple by 0.8
Theophylline to Aminophylline divide by 0.8

For severe, allergic asthma. Inhibits IgE binding

on mast cells and basophils
Should always be given in the doctors office
can cause Anaphylaxis

COPD:

causes by cigarette smoke and other noxious

chemicals
dyspnea, chronic cough/sputum production
smoking cessation is the only thing that slows the
progression
SABA and SAMA: Ipratropium (Atrovent),
ipratropium + albuterol (Combivent Respimat)
LABA and LAMA: tiotropium (Spiriva Handihaler)
or aclidinium (Tudorza) More effective and more
convenient. SE: Dry mouth.
PDE-4 inhibitor: roflumilast (Daliresp): increases CAMP
and decreases lung inflammation
Steroids: long term monotherapy are not
recommended in COPD, not very effective. Used in
combo with LABA. (Advair and Symbicort)
Get Vaccines

Smoking Cessation:

Counseling and medication are more effective used

together than either alone. Strong correlation

between counseling intensity and quitting

success.
5 As: Ask, Advise, Assess, Assist, Arrange
(Follow Up)
Patients often fail when they do not use enough
NRT for a clinical effect.
Gum, Lozenge, and Patch are OTC only to 18 yrs.
and older
Nicotine Gum (Nicorette 2mg or 4mg) max: 24
pieces/day. Tapered dose. One Q1-2hrs. x 6weeks,
then Q2-4 hrs. x 3 weeks, then Q4-8 hrs. x 3 weeks.
Avoid acidic beverages (15 min. before or during Tx,
water is ok.) <25 cigs/day = 2mg >25 cigs/day
=4mg
Nicotine Lozenges (Commit 2mg or 4mg) max: 20
lozenges/day. <30min to smoke in the AM =4mg;
>30min to smoke =2mg
Nicotine Patches (Nicoderm CQ 7mg, 14mg, 21mg):
Can remove to avoid insomnia. Local skin reaction
common. <10 cigs/day = 14mg >10cigs/day=21
mg. 6 weeks (21mg), then 2 weeks (14mg), then 2
weeks (7mg) or 6 weeks (14mg), then 2 weeks (7mg)
Nicotine Inhaler: Frequent, continuous puffing for 20
min. Clean mouthpiece. In cold temps, keep in warm
area like pocket. Once a cartridge is open, only good
for 1 day.
e-cigarettes: not FDA approved, but popular
Buproprion SR (Zyban, Buproban): Start 1 week
before quitting, max: 450mg/day bc of seizures.
SE: Dry mouth/insomnia. BBW for neuropsychiatric
events.
Varenicline (Chantix): Nicotine agonist/ antagonist;
Start 1 week before quitting. Do not use with
nicotine products. BBW for neuropsychiatric
events. Insomnia and Vivid Dreams.
Get Vaccines: Smokers 19-64 should get the
Pneumovax

Only gum and lozenge nicotine are pregnancy C,

others are D.

Allergic Rhinitis, Cough and Cold:

Allergic Rhinitis Hay Fever:

Avoid exposure to allergens

Moderate to severe: Intranasal Steroids 1st line :
fluticasone (Flonase or Vermyst), mometasone
(Nasonex), triamcinolone (Nasacort),
beclamethasone (Qnasl or Beconase),
budesonide (Rhinacort)
Mild to Moderate: Oral antihistamines (Usually 2nd
Gen): Good for sneezing, itching, rhinorrhea, but has
**minimal effect on congestion.
diphenhydramine (Benadryl): 1st gen, 2550mg PO Q4-6 hrs. Sedating.
chlorpheniramine (Chlor-Trimeton): 1st gen
preferred in pregnancy
cetirizine (Zyrtec)
levocetirizine (Xyzal)
loratidine (Claritin)
desloratidine (Clarinex)
fexofenadine (Allegra)
azelastine (Astelin): Intranasal
Decongestants: alpha agonists that cause
vasoconstriction to reduce congestion:
Oral: phenylephrine (Sudafed PE) : low
bioavailability
pseudoephedrine (Sudafed): Max
able to buy: 3.6 g/day or 9 g/month, Max
intake is 240mg/day.
Nasal: Oxymetazoline (Afrin) or
phenylephrine (Neo-Synephrine). Limit use
to < 3days to prevent rebound congestion

Others: cromolyn (Nasalcrom), Intranasal ipratropium

(for rhinorrhea to dry mucus), Singulair, Nasal
irrigation

Cold/Cough:

Zinc: can decrease duration of a cold

Vitamin C: may help prevent a cold
Usually a Viral Infection (ex. Rhinovirus)
Advise patients to stay well hydrated
Humidifiers and Vaporizers can be useful. Do not use
topical menthol or camphor in children less than
2 yrs. old.
Children: OTC cough/cold/pain or aches products
should not be used in children < 4 yrs. old.
Combo cough/cold products should not be used in
children <2 per FDA or <6 per American Academy
of Pediatrics. Do not use ASA due to risk of
Reyes syndrome.
ibuprofen (5-10 mg/kg Q 6-8 hrs.)
Formulation 50 mg/1.25mL or 100mg/5ml
APAP (10-15 mg/kg Q4-6 hrs.)
Formulation 160 mg/5mL
Use calibrated syringe for measuring if its
an oral liquid dispensed
Decongestant: Do not use in children < 6 yrs. old
except PSE (not < 4 yrs.). If pregnant, use
intranasal spray like Oxymetazoline or
phenylephrine b/c oral PSE can decrease blood
flow to infant.

Cough:

Dextromethorphan (Delsym or DM in the

name): Many mechanisms but is also a serotonin
reuptake inhibitor. Often abused by people when taken
in larger doses due to its ketamine/PCP like
hallucinagenic affects. Probably safe during
pregnancy.

Antihistamines: dont work for cold symptoms. May

help cough.
Codeine: Never dispense codeine to a
breastfeeding woman; can cause fatal
respiratory depression in an infant.
Gauifenasin (Mucinex): decrease phlegm viscosity,
unclear benefit.

Cystic Fibrosis:

genetic disorder that disrupts CFTR protein causing

abnormal transport of sodium and chloride across cells
leads to thick, viscous lung secretions, difficulty
breathing, infections, and digestive complication
(Kills the pancreas).
Infections usually intermittent at first and
eventually become chronic where they may need
inhaled antibiotics.
If intermittent pseudomonas, treat with two IV antipseudomonal agents.
Most common bugs: Staph. Aureus, H. Flu,
Pseudomonas.

Treatment:
Bronchodilators: Use before giving inhaled
antibiotics to help antibiotic get in.
Hypertonic Saline (Hypersal): hyrdrates airway
mucus to thin secretions
DNAse enzyme: dornase alfa (Pulmozyme) to
thin mucous
Inhaled antibiotics: Tobramycin Inhaled
Solution (TOBI) or TOBI Podhaler or
Aztreonam Lysine Inhalation (Cayston) to
prevent and treat lung and sinus infections with
chronic infections. Take doses TOBI 6 hours apart
and Cayston 4 hours apart. Solutions stored in
fridge, Podhaler xcapsules at room temp. in a dry
place. 28 days on, 28 days off cycle.

 Oral Azithromycin: to reduce airway

inflammation and disrupt Pseudomonas biofilm
High Fat, calorie-dense diet
Pancreatic Enzymes: Peancrealipase
(Creon,Pancreaze, Zenpep, Viokase): contains
lipase, amylase, and protease. Dose adjusted
based on lipase component until stools are
normalized. Given before meals and snacks.
Snacks get 50% of the dose. They are not
interchangeable. Viokase is taken with a PPI b/c
its not enteric coated.
Vitamin ADEK
Insulin
Ivacaftor (Kalydeco): used for G551D mutations (45% of population have this type). Taken with highfat meal.

Oncology:

Treated with surgical, radiation, chemotherapy,

hormone therapy, biological therapy, targeted therapy,
immunotherapy and/or vaccines.
Majority of adverse effects are due to damaging noncancerous cells that divide rapidly. Thus, nausea,
vomiting, alopecia, and myelosuppression are
common.
Myelosuppression: All except asparaginase,
bleomycin, and vincristine. Cells generally recover
after 3-4 weeks post-treatment.
o Anemia: Serum Ferritin, transferrin saturation
(TSAT), and total iron binding capacity may be
ordered b/c ESAs like (epoeitin (Epogen) and
darbopoetin (Aranesp) will not work well unless
iron levels are adequate. ESAs can shorten
survival and increase risk for tumor
progression in some cancers. Must enroll in and
comply with the ESA APPRISE Oncology Program

REMS to use these agents with cancer. Also only

used if HgB < 10. Not used when anticipation is cure
b/c they can cause thrombosis and tumor
progression. SC and IV
o Neutropenia: Colony stimulating factors (CSFs)
can be given prophylactically to patients at high-risk
for febrile neutropenia. Sargramostim (Leukine),
Filgrastim (Neupogen), and Pegfilgrastim
(Neulasta). They can cause bone pain.
o Thrombocytopenia: Chemo might get placed on
hold, dose reduction, or a transfusion(<10,000 or
<20,000 with active bleed)
Hepatotoxic: Many
Nephrotoxic/ Bladder Toxic: Many; Hydration helps
flush drug out. Amifostene used to reduce risk of
cisplatin renal toxicity. Mesna(Mesnex) given with
ifosfamide to prevent hemorrhagic cystitis.
Mucositis: high risk with 5-FU, capecitabine, irinotecan,
and methotrexate. Use saline rinses daily.
Hand-Foot Syndrome: 5-FU, and capecitabine
Clotting: Often from SERMS
Alopecia: Taxanes and anthracyclines
Cardiotoxicity: Anthracyclines
Nausea/Vomiting: Most Chemo Drugs especially
cisplatin, doxorubicin, epirubicin, cyclophosphamide,
isofosfamide. CTZ receptors are 5HT, Dopamine, Ach,
Histamine, Opioid, and Substance P.
o usually uses a combination of anti-emetic drugs
o Ondansetron (Zofran, Zuplez film),
granisetron (Granisol), dolasetron (Anzemet),
palonosetron (Aloxi): 5-HT3 antagonists, risk of
QT prolongation
o prochlorperazine (Compro) and promethazine
(Phenergan): block dopamine receptors in CNS.
SE: sedation, lethargy, acute EPS
o dexamethasone (Decadron)
o aprepitant(Emend) and fosaprepitant (Emend
IV): substance P/Neurokinin-1 receptor antagonist

dronabinol (Marinol): Cannabinoid. SE: drowsy,

euphoria, increased appetite

Some Chemo drugs used in many cancers:

Alkylators: Cyclophosphamide (Cytoxan) and

ifosfamide (Ifex). They cross-link DNA preventing
replication. SE: Bladder Toxicity/BBW
***Hemorrhagic Cystitis so give Mesnex to
prevent.

Anthracyclines: DOXOrubicin(Adriamycin) and

DAUNOrubicin (Cerubidine). Intercalate into DNA.
SE: BBW ***Cardiotoxicity,
Vesicant/Extravasation, red urine/body
secretions. Do not exceed lifetime dose of 450550 mg/m2 with DOXOrubicin and 400-550 with
DAUNOrubicin. Extravasation is treated with
dexrazoxane (Totect) or DMSO.
Platinums: cisplatin (Platinol), carboplatin
(Paraplatin), oxaliplatin (Eloxatin). Cross link DNA
causing apoptosis. SE: Nephrotoxic, Ototoxic,
neuropathy. Cisplatin has severe N/V.
Amifostene to reduce cisplatin nephrotoxicity.
Methotrexate: folate antimetabolite that prevents
DNA synthesis in the S-Phase. Leucovorin rescue to
decrease toxicity. SE: Hand-foot syndrome

(treat with atropine), Delayed Diarrhea (treat with

loperamide)
Topoisomerase 2 inhibitors: etoposide(VePesid).
Blocks coiling and uncoiling of DNA in G2 Phase with
single strand breaks. SE: Hypotension
Taxanes: paclitaxel (Taxol) and docetaxel
(Taxotere): Inhibit microtubule function in M-Phase.
Must use non-pvc IV bag and tubing. SE: peripheral
neuropathy. BBW for neutropenia. Always give
before platins.
Vinca Alkaloids: vincristine (Vincasar) and
vinblastine (Velban): Inhibit microtubule function in
M-Phase. SE: Vesicants, nerve
damage/neuropathy (mostly vincristine). BBW:
Intrathecal injections are fatal. Use
hyaluronidase for extravasation.

Monoclonal antibodies: (Inhibit growth factors that

promote cancer cell growth)
Traztuzumab (Herceptin): HER2/Neu overexpression required for use. Cardiotoxicity
Cetuximab (Erbitux): EGFR positive =
good response, K-ras mutation = poor
Rituximab (Rituxan): Targets CD-20, also
used in RA
Prostate Cancer:

Pyrimidine Analogues: capecitabine (Xeloda) and

Fluorouracil (5-FU). Inhibits pyrimidine synthesis in
the S-Phase. SE: Hand Foot syndrome. CI with DPD
deficiency. Leucovorin increases efficacy of 5-FU.
Topoisomerase 1 inhibitors: ironotecan
(Camptosar). Block coiling and uncoiling of DNA in SPhase with single strand breaks. SE: Acute Diarrhea

Antiandrogens: bicalutamide (Casodex) and

flutamide (Eulexin)
LHRH agonists: goserelin (Zoladex) and leuprolide
(Lupron): start antiandrogen 1 week before to prevent
tumor flare.
Breast Cancer: (hormonal therapy to prevent recurrence,
not the actual conventional chemo treatment)

 Oral Ferrous Sulfate is 1st line (not SR or

Enteric Coated). Absorption is enhanced by
acidic gastric environment. Take 1 hour
before meals b/c food will decrease
absorption.
325 mg PO TID
SE: Nausea/Constipation. May want to use
docusate stool softener.
Separate from chelators: FQ, tetracyclines,
bisphosphonates etc..
Iron overdose is the leading cause of poisoning
deaths in young children. Antidote for
overdose is deferoxamine.
IV iron: sodium ferric gluconate (Ferrlecit)
or Iron sucrose (Venofer). Usually used for
hemodialysis. Iron dextran has a BBW for
anaphylaxis.

Must have ER/PR+ cancer for these to work

Aromatase Inhibitors: anastrozole (Arimidex),
letrozole (Femara), exemestane (Aromasin).
Inhibit conversion of androgens to estrogen. SE:
Osteoporosis, menopausal symptoms.
SERMs: tamoxifen (Soltamox), fulvestrant
(Faslodex), raloxifene (Evista)- Also for
osteoporosis. Estrogen antagonists in breast but
agonists in other tissues. SE: DVT/PE, menopausal
symptoms. Tamoxifen increases risk of endometrial
cancer.
Chronic Myeloid Leukemia:
imatinib (Gleevec) : Tyrosine Kinase Inhibitor (TKI).
Requires testing for bcr-abl fusion gene.
Non-small cell lung cancer:
erlotinib (Tarceva): TKI targeting EGFR
Multiple Myeloma:

Folate or B12 Deficiency Anemia: MCV (>100)

and MCH High (Macrocytic)
can lead to neurological consequences
Pernicious anemia is when there is a lack of
intrinsic factor required for gut absorption of
B12 and folate. The Schilling test can
diagnose this. They will require lifelong B12
replacement, usually by B12 injection.
cyanocobalamin (B12) and folic acid
(folate/vitamin B9)
metformin may decrease B12 absorption

Anemia of Chronic Disease: MCV and MCH normal

Chronic Kidney Disease: causes anemia via
deficiency in erythropoietin. May need
ESAs at the lowest possible dose started
when Hgb is < 10. Transferrin should be at
least 20% and ferritin should be at least
100 ng/ml prior to starting ESA.

Signs of myeloma (CRAB): Calcium elevated, renal

failure, anemia, bone lesions
cancer of plasma cells in bone marrow
Thalidomide (Thalomid) and its derivatives. Do not
get pregnant while using, very teratogenic.

Anemia:

Decrease in RBCs and/or Hgb and Hct.

Mainly caused by impaired production, increased
destruction, or blood loss.
Iron is essential for Hgb formation. If iron is low, ESAs
will not work so correct iron first.
Most people can use oral supplementation for iron. Iron
IV is often used for hemodialysis.
Iron Deficiency Anemia: MCV (<80) and MCH Low
(Microcytic)

Sickle Cell Disease:

genetic disorder that causes shape of Hgb and RBC to

change. They cannot transport oxygen properly and
get stick in smaller blood vessels.
This can deprive tissues of oxygen leading to
ischemia and pain (sickle cell crisis or vasoocclusive crisis)
ACS is the leading cause of death in SCD. 35% of
infants die from infections. Chronic anemia is likely.
Treatment: Vaccines, Antibiotics, Analgesics,
Folic Acid, and Hydroxyurea (stimulates fetal
Hgb)

IV Drugs, Fluids, and Antidotes:

Peripheral IV: placed in a small vein

Central IV: placed in a large vein. Example is a
peripherally inserted central catheter (PICC). Can give
meds that would be overly irritating to peripheral veins
like higher doses or greater volumes. Disadvantages:
higher bleeding risk, infection,
thromboembolism, and more difficult to insert.
Concern with PVC:
Leaching: Drugs pull out DEHP from bag:
tacrolimus, temsirolimus, teniposide,
cabazitaxel, docetaxel, ixacabepilone, and
paclitaxel.
Sorption: PVC bag pulls in drug: Amiodarone,
carmustine, lorazepam, sufentanil,
thiopental, insulin, nitroglycerin.
Colloids and Crystalloids: Colloids do not readily
cross capillaries (stay in veins) and may provide more
intravascular volume expansion than equal volumes of
crystalloids, but they are expensive. Crystalloids are
less costly and safer.

Shock: (Hypovelemic, Cardiogenic, Distribuitive,

Obstructive, Neurogenic)
Fluid Resuscitation is 1st line
Vasopressors: not effective without adequate
fluid.
o
Dobutamine: B1 Inotrope that increases
HR, Contractility, and CO.
o
Dopamine: At medium doses B1 (SV/CO), at
higher doses a1 (vasoconstriction)
o
Epinephrine (Adrenaline): alpha and beta.
o
Norepinephrine(Levophed): a1 (mostly)
and beta
o
Phenylephrine (Neo-Synephrine): all a1
(vasoconstriction)
o
Vasopressin: V1 and V2 agonist
(vasoconstriction)
***The vasoconstrictors can cause peripheral
ischemia and necrosis (gangrene)
***If extravasation, treat with phentolamine
(alpha blocker)

ICU sedation, analgesia, and delirium:

Optimize analgesia first, usually fentanyl,
morphine, hydromorphone
Sedation usually with benzos (midazolam),
propofol, or dexmedetomidine (Precedex).
Propofol can cause infusion reactions that result
in cardiac arrhythmias and death.
Patients should frequently be assessed
with a validated sedation scale to adjust
therapies.
The ACCM recommends using Precedex to
sedate patients with delirium.

Commonly used agents for agitation and

sedation:

 lorazepam (Ativan)
midazolam
propolol (Diprivan): propofol infusion related
syndrome(PRIS), rare but can be fatal.
Hypertriglycerides
dexmedetomidine (Precedex): **Sedation
without Respiratory Depression
morphine: has active metabolite M6G,
hypotension from histamine release
fentanyl: less hypotension than morphine b/c no
histamine release
hydromorphone (Dilaudid)
haloperidol (Haldol): QT prolongation, EPS
Acid-Base Homeostasis:

pH < 7.35 is acidosis, pH > 7.45 is alkalosis

Metabolic or Respiratory
Anion gap: Na+ - (Cl- + HCO3-)
> 12 is gapped

Anesthesia:

Sodium: Dont correct more than 12mEq/L in 24

hours to prevent central pontine myelinosis which is a
devastating neurological complication.
Potassium: IV potassium should not be faster than
10-20 mEq/hr.

Stress Ulcer Prophylaxis:

Critical illness leads to reduced blood flow to gut which

results in breakdown of gastric mucosal defense
mechanisms
Patients without risk factors should not receive
prophylaxis (Mechanical Vent, Coagulopathy, Sepsis,
Brain Injury, Burns, Renal Failure, High Dose Steroids)
H2 blockers

VTE prevention:

High Risk: Surgery, trauma, immobility, cancer,

previous VTE, pregnancy, estrogen etc..

must be closely monitored

Inhaled anesthetics can cause malignant
hyperthermia and should be given dantrolene.
Neuromuscular blockers: cisatracurium (Nimbex)
and Vecuronium . Do not provide sedation or
analgesia.

IV compatibility resources:

Trissels
King Guide

Poison Management:

Electrolyte Disorders:

UFH: 5,000 units SC BID-TID

LMWH: Enoxapin 30mg SC BID or 40mg SC Daily.
If CrCl<30, use 30mg SQ Daily

Insecticide Poisoning/Nerve Agents:

Organophosphates that inhibit acetlycholinesterase,
leads to increase Ach. MUDDLES: miosis (pinpoint
pupils), urination, diarrhea, diaphoresis, lacrimation,
excitation, salivation

Antidotes for select toxicities:

APAP: N-acetylcysteine
Anticholinesterase: Atropine
Benzos: Flumazenil (Romazicon)
Beta Blockers: Glucagon
Digoxin: Digoxin Immune Fab (Digifab)
Heparin: Protamine
Iron: deferoxamine (Desferal)
Isoniazid: (Pyridoxine Vit B6)
Opioids: Naloxone
Warfarin: phytonadione (Mephyton) = Vitamin K

Depression:

Inform patients that physical symptoms such a slow

energy improve within a few weeks but psychological
symptoms may take a month or longer.
All drug therapies should be given with competent,
concurrent psychotherapy. (rarely done)
To avoid withdrawal when discontinuing, the
drug should be tapered.
Withdrawal symptoms: anxiety, agitation,
insomnia, dizziness, flu-like symptoms.
(Paroxetine and some others carry a high-risk)
Should do a 6-8 week trial at an adequate dose before
concluding its not working well.
Going to or from an MAOi requires 2 week washout
period except fluoxetine requires 5 weeks
because of its long half-life. MAO interaction can
be lethal if taken with other serotonergics.
Pregnancy:
FDA warning that SSRIs can cause
persistent pulmonary hypertension in the
newborn (PPHN).
Paroxteine (Paxil) is category D,
paroxetine (Brisdelle) is category X.
Brisdelle is for menopausal symptoms.
PTSD:
After a life-threatening experience or an event
that involves a threat to life or serious injury.
Many physical, cognitive, emotional, and
behavioral symptoms.
Sertraline and Paroxetine are FDA
approved for this

SSRIs:

BBW for increased risk of suicidal thinking in

children, adolescents, and young adults (18-24)
can cause persistent pulmonary hypertension in
the newborn (PPHN)

SE: increased bleeding risk, sexual dysfunction (not

erection), insomnia, somnolence, SIADH
(hyponatremia)
Fluoxetine (Prozac): Can take 90mg/week, 2D6
inhibitor, most activating so take in the morning
if you have insomnia with it. Sarafem is used for
pre-menstrual dysphoric disorder.
Paroxetine (Paxil): 2D6 inhibitor
Sertraline (Zoloft)
Citalopram (Celexa): **QT prolongation risk with
>40mg/day, or >20mg/day and over 60, or liver
disease, or 2C19 poor metabolizers.
Escitalopram (Lexapro): Can also cause QT
prolongation

DNRI: (DA and NE reuptake inhibitor)

bupropion (Wellbutrin); Zyban or Buproban for

smoking cessation
CI: do not use in seizure disorder, do not exceed
450mg/day (seizures), do not use in bipolar, do
not use in anorexic
No effects on 5HT so no sexual dysfunction or
bleeding
SE: insomnia and dry mouth

SNRIs:

SE: same as SSRI plus Increased BP, urethral

resistance,
venlafaxine (Effexor)
desvenlafaxine (Pristiq)
duloxetine (Cymbalta): CYP2D6 inhibitor
levomilnacipran (Fetzima)

Mixed SSRI and 5HT-1A partial agonists:

vilazodone (Viibryd)
vortioxetine (Brintellex)

Other:

mirtazapine (Remeron): inhibits 5HT reuptake

and a1-blocker and antihistamine
SE: sedation and weight gain from
increased appetite
used in oncology and skilled nursing
homes to help with sleep and weight gain
in elderly
trazodone: inhibits 5HT reuptake and a1-blocker and
5HT2A/C blocker. Mainly used for sedation, rarely
as antidepressant.
SE: sedation and priapism

Tricyclics:

NE and 5HT reuptake inhibitors primarily but also

anticholinergic and antihistamine
more side effects than others
Tertiary or Secondary amines: Secondary are more
selective for NE but might not be as effective
QT prolonging, Orthostasis, Anticholinergic (Dry
mouth, blurred vision, urinary retention,
constipation), sedation, weight gain etc..
Amitriptyline (Elavil)
Doxepin
deispramine
nortriptyline (Pamelor)

MAOi:

Inhibit monoamine oxidase which normally breaks

down catecholamines 5HT, DA, NE, EPI.
Not commonly used but watch for drug-drug and
drug-food interactions

Can lead to hypertensive crisis, serotonin

syndrome, and psychosis if combined with other
drugs.
isocarboxazid (Marplan)
phenelzine (Nardil)
tranylcypromine (Parnate)
selegiline

Treatment resistant depression:

aripiprazole (Abilify)
olanzapine/fluoxetine (Symbyax)
quetiapine (Seroquel)

Schizophrenia/Psychosis:

***BBW for all anti-psychotics is increased death

in elderly with dementia-related psychosis,
primarily due to increase strokes and infection.
chronic relapsing, remitting episodes that are a result
of excess dopamine
Has positive and negative signs
Positive Signs: Hallucinations, delusions (false
beliefs)
Negative Signs: Anhedonia (loss of interest), lack of
emotion, poor hygiene, social withdrawal
Treatment adherence can be difficult to obtain
One of the highest suicide rate
1st Gens (more EPS and sedation, less weight
gain/metabolic SE), 2nd Gens (Less EPS, more
weight gain/metabolic SE)
Neuroleptic Malignant Syndrome: Extreme Muscle
Rigidity and Hyperthermia (rare and mainly with
1st gens.)
Clozapine has high efficacy but has many BBWs and
side effects. It should be considered for those who
have failed with trying two others.

ODTs useful for cheeking where patients will cheek

the medicine and then spit it in the toilet.
Quetiapine has a low risk for movement
disorders and is recommended for psychosis
with parkinsons disease.
CV risk: Ziprasidone and Thioridazine have
highest QT prolonging risk
Weight Gain/Metabolic Effects: Clozapine,
Olanzapine, Quetiapine, Risperidone, and
Paliperidone.
Prolactin: Inhibiting dopamine can increase milk
production and lead to osteoporosis. Highest
risk with Risperidone and Paliperidone.

1st Gens:
Block D2 and 5HT2A
Thioridazine, Haloperidol (Haldol),
Chlorpromazine, Loxapine, Perphenazine,
Fluphenazine, Thiothixene
All cause EPS (Dystonia, Akathisia,
Parkinsonism, TD, Dyskinesia etc..) and are
sedating. Tardive Dyskinesia (TD) can be
irreversible (higher in elderly females).

Ziprasidone (Geodon): High QT prolongation

risk
Aripiprazole (Abilify)
Paliperidone (Invega): increased Prolactin
Risperidone (Risperdal): increased Prolactin
Lurasidone (Latuga)

Bipolar Disorder:

Show periods of mania and depression. Bipolar I is

more severe. Bipolar II has less severe mania
(Hypomania) that does not have psychotic features or
need hospitalization.
Mood Stabilizer (lithium, valproate,
carbamazepine (Equetro), lamotrgine) are defined
as drugs that can treat mania or depression without
inducing either.
1st gen antipsychotics can push them to
depressive state but 2nd gens do not and some
2nd gens have antidepressant effects.
Antidepressants can push them to mania so only
use them if there is a mood stabilizer also.
Treatment: Mood Stabilizer, 2nd Gen
Antipsychotic, or Combo of both.

Mood Stabilizers:
2nd Gens:
Block D2 and 5HT2A (except Abilify, it blocks 5HT2A
but is a partial agonist at D2 and 5HT1A)
**Weight gain/metabolic side effects.
Clozapine (Clozaril): most effective but can
cause agranulocytosis ,*seizures, and
myocarditis. REMS- Patients must register
with the Clozaril registry. Only pharmacies
registered for this can dispense it.
Olanzapine (Zyprexa):
Quetiapine (Seroquel): least movement issues

valproate/valproic acid (Depakene, Depacon,

Stavzor): BBW teratogenic, hepatic failure,
pancreatitis; inhibits 2C9
Divalproex (Depakote): BBW teratogenic,
hepatic failure, pancreatitis
lamotrigine (Lamictal): BBW skin reactions (SJS
and TEN), not used in mania.
Lithium (Lithobid): DO NOT USE IN RENAL
IMPAIRMENT (100% renally cleared); Therapeutic
range is 0.6-1.2 mEq/L trough. SE: GI, Cognitive,
cogwheel rigidity, hand tremor, weight gain,

polyuria,polydipsia, serotonergic. Maintain

adequate fluid intake and keep salt constant.
2nd Gen Antipsychotics used:
Aripiprazole (Abilify), quetiapine (Seroquel),
risperidone (Risperdal), ziprasidone (Geodon),
lurasidone (Latuda), olanzapine (Zyprexa)

Parkinson Disease:

Substantia nigra part of brain has cells that make

dopamine. When they are damaged and stop making
dopamine. This is what causes the disease.
Tremor, bradykinesia (slow movements), rigidity
(stiffness), postural instability
Most have depression from it and tricyclics
(nortriptyline) seem to work best
Psychosis can happen in later stages and
*quetiapine (Seroquel) is preferred.
***Drug induced (Dopamine Blockers):
prochlorperazine (D2 blocker for nausea),
antipsychotics, metoclopramide (Reglan: D2
blocker and prokinetic from muscarinic activity).

Treatment:
carbidopa/levodopa (Sinemet): 70-100 mg of
carbidopa is needed to prevent the peripheral
conversion of Levodopa to DA by dopa
decarboxylase. Can cause brown, black or dark
urine. Can cause unusual sexual urges and priapism.
entacapone (Comtan): inhibits COMT to prevent
peripheral breakdown of levodopa.
pramipexole (Mirapex) and ropinirole (Requip):
Dopamine agonists. Also bromocriptine.
amantadine (Symmetrel): blocks dopamine
reuptake and increases release. SE: Toxic
delirium and livedo reticularis (redish skin
mottling). Also used in Flu as a neuramidase
inhibitor.

benztropine (Cogentin) and trihexphenidyl:

anticholinergics so mainly used in younger patients
MAO-B inhibitors: selegiline, zeleplar, rasagiline
(Azilect). Azilect can be used as initial monotherapy.

Alzheimers

most common type of dementia

memory loss, irritability, difficulty planning and
organizing, personality changes
Pathophysiology: Amyloid plaques and neurofibrillary
tangles Decreased Ach
Drugs that can worse dementia:
Anticholinergics, Antipsychotics, Anithistamines,
Barbiturates, Benzos, Skeletal Muscle relaxants, and
other CNS depressants.

Treatment:

Acetlycholinesterase Inhibitors are the mainstay

of treatment.
Some improve a little and some dont. Even without
showing clinical improvement, they may have slower
progression vs if they didnt take the medication.
Gingko Biloba is used by some, studies are unclear
but it can increase bleeding

Achesterase Inhibitors:
donepezil (Aricept, Aricept ODT)
rivastigmine (Exelon, Exelon patch): take with
food
galantamine (Razadyne, Razadyne ER)
SE: GI (N/V/loose stools), bradycardia, insomnia,
fainting
NMDA receptor antagonist:
memantine (Namenda): only for modsevere disease with or w/o Aricept

ADHD:

Inattention, hyperactivity, impulsivity

1st line therapy is stimulants; atomoxetine
(Strattera) is a non-stimulant that can be tried
afterwards or 1st line if the prescriber is
concerned of abuse.

Stimulants:

Methyphenidate: Ritalin XR/SR/LA, Concerta

(IR/ER combined from OROS system), Metadate
CD (IR/ER beads), Daytrana (patch)
Dexmethylphenidate (Focalin, Focalin XR)
Dextroamphetamine and amphetamine
(Adderall, Adderall XR)
Dextroamphetamine IR (Dexedrine, Dextrostat)
Lisdexamfetamine (Vyvanse): can mix capsule
contents with water and take stat.
Focalin XR, Adderall XR, Metadate CD, and Ritalin LA
can be taken whole or sprinkled on applesauce.

Non-stimulants:

Gaunfacine (Intuniv) or clonidine ER (Kapvay) are most

often adjuncts
atomoxetine (Strattera): NE reuptake inhibitor

** LOT (Lorazepam, Oxazepam, Temazepam): less

harmful in elderly and hepatic impairment bc they are
metabolized to inactive compounds.
**Benzos Pregnancy D: Due to cleft palate and lip

Insomnia:

Fear and worry are the primary symptoms along with

tachycardia, SOB, insomnia, fatigue.
Anxiety disorders interfere with the ability to lead a
normal life.
SSRIs and SNRIs are primarily used
Buspirone (Buspar) is a 2nd line option, 5HT1 partial
agonist, pregnancy B
Benzodiazepines:
lorazepam (Ativan)
alprazolam (Xanax)
clonazepam (Klonopin)
diazepam (Valium)
chlordiazepoxide (Librium)

Lifestyle changes are the preferred treatment

Hypnotics are over-prescribed

Sleep Drugs:

Anxiety:

temazepam (Restoril)
midazolam (Versed)
estazolam
triazolam (Helcion)
clorazepate (Tranzene)
oxazepam (Serax)

zolpidem (Ambien, Ambien CR)

zaleplon (Sonata)
eszopiclone (Lunesta)
temazepam (Restoril)
lorazepam (Ativan)
Other: Ramelteon (Rozerem): melatonin receptor
agonist
trazodone
diphenyhydramine(Benadryl): antihistamine, DO
NOT USE IN ELDERLY

Epilepsy/Seizures:

Unprovoked seizures or abnormal electrical storm in

the brain
Partial or Generalized. Partials can spread and become
secondarily generalized.
Status Epilepticus: seizure lasting more than 5
minutes or 2 or more seizures between where there is
incomplete recover of consciousness. Its a medical
emergency. (Lorazepam is the DOC)

Pregnancy: Carbemazepine, clonazepam,

phenobarbital/primidone, phenytoin/phosphenytoin,
topiramate, and valproate are Pregnancy Category
D. Valproate for migraine prophylaxis is
Category X. All other are category C.
**All require MedGuide for risk of suicidality
Most AEDs can lower Vit D so all patients on
these should supplement with Vit D and Calcium.
Discontinuing always requires a taper to prevent
seizures
Many Drug Interactions:
Inducers: carbamazepine, oxcarbazepine,
phenytoin, fosphenytoin, phenobarbital,
primidone, topiramate.
Inhibitors: Valproate

hyperplasia, hirsutism, connective tissue

changes, coarsening of facial features, folate
deficiency, hepatoxic.
Supplementation with B12, folate, calcium
and Vit D recommended
If the albumin is low, the true phenytoin
level will be higher than it appears.
PHT correction= PHT measured/(0.2x Alb)
+ 0.1

Therapeutic range: 50-100 mcg/mL

BBW: Hepatic Failure, **Teratogenic
(neural tube defects, spina bifida) and
Pancreatitis
SE: Dose-related thrombocytopenia,
alopecia, low IQ in children if exposed in utero,
pancreatitis, tremor.
If the albumin is low, the true valproate
level will be higher than it appears, use
phenytoin formula.

Treatment:

Benzos: clonazepam
Carbamazepine (Tegetrol, Carbatrol, Epitol): Fast
sodium channel blocker and also stimulates release of
ADH.
Therapeutic range: 4-12 mcg/mL
BBW: Skin reactions (SJS and TEN) usually
2-8 weeks after initiation. If Asian, must test
for HLA-B*1502. Can cause aplastic anemia
and agranulocytosis.
SE: SIADH, hepatotoxic.
Phenobarbital (Luminal) and primidone: Enhance
GABA mediated chloride influx. Primidone is a
prodrug of phenobarbital.
Phenytoin (Dilantin,Phenytek) and
Fosphenytoin: Fast sodium channel blockers.
Has saturable michaelis-menton kinetics.
Therapeutic range: 10-20 mcg/ml
BBW: Phenytoin max rate: 50mg/min IV and
Fosphenytoin max rate: 150mg PE/min IV
SE: Dose-related toxicity (ataxia, slurred
speech, nystagmus), skin thickening, gingival

Valproate/Valproic Acid (Depakene, Stavzor,

Depacon) and Divalproez (Depakote):

Lamotrigine (Lamictal):
BBW: Skin reactions (SJS and TEN).
Titration schedule depends on if currently
taking another AED (inducer or inhibitor).
Pregancy C
Levetiracetam (Keppra): ** No significant drug
interactions, Pregnancy C
Oxcarbazepine (Trileptal, Oxtellar XR): Skin
Reactions SJS and TEN, Hyponatremia
Pregabalin (Lyrica): SE: peripheral edema,
weight gain
Gabapentin (Neurontin) SE: edema, weight gain
Topiramate (Topamax): SE: metabolic acidosis,
oligohydrosis/hyperthermia, nephrolithiasis

Additional: ASA (not within 24 hours of TPA), HTN

management, Hyperglycemia Management (140180)

zonisamide (Zonegran): Sulfa Moiety. Skin Reactions

(SJS and TEN)
felbamate (Felbatol): BBW for Aplastic Anemia and
Hepatic Failure
lacosamide (Vimpat): No significant drug interactions

GERD:

Stroke:

Ischemic or Hemorrhagic

Hemorrhagic Treatment:
compression stocking to prevent VTE, no
anticoagulants
Intracerebral Hemorrhage: Mannitol
(Osmitrol): Increases the osmotic pressure
to reduce the intracranial pressure.
Subarachnoid Hemorrhage: nifedipine
(Nymalize)

Treatment:

Antacids:
calcium (Tums), magnesium (Milk of Magnesia),
magnesium + aluminum or calcium (Maalox,
Mylanta), Mag-Al-Simethicone (Maalox Max,
Mylanta Max), Gaviscon.
Neutralizes acid within minutes and lasts 12 hours.
SE: Magnesium can make you poop,
Aluminum can cause constipation.

H2 Blockers:
famotidine (Pepcid AC, Pepcid AC Max),
ranitidine (Zantac), cimetidine (Tagamet),
nizatidine (Axid).
Avoid cimetidine due to drug interactions
(3A4 inhibitor).
All must be renally adjusted.
Can worsen dementia/delirium/confusion.
May increase GI infections and risk of
pneumonia.

PPIs: block the final step in acid production (H +/K+)

ATPase pump.

Ischemic Stroke Prevention:

Correct modifiable risk factors: HTN, Diabetes,
Dyslipidemia, Weight, Smoking etc..
Primary prevention: Recommended for Afib
Secondary Prevention: Previous Cardioembolic
Strokeantiacoags
Previous Non-Cardioembolic
antiplatelets (ASA, Clopidogrel)
Ischemic Treatment:
TPA: alteplase (Activase); treatment must
be initiated within 3 hours of symptom
onset. Must confirm clot with head CT
before use. Max dose: 90mg IV over 60 min.
SE: Major Bleeding

LES muscle tone is reduced and allows for backflow of

stomach contents
Avoid: Nicotine, caffeine, spicy foods, alcohol, fatty
foods, citrus, chocolate, spearmint.
Weight loss shows the best evidence for improvement
**can exacerbate asthma

omeprazole (Prilosec), omeprazole/sodium

bicarb (Zegerid), pantoprazole (Protonix),
lanzoprazole (Prevacid), esomeprazole
(Nexium), rabeprazole (Aciphex),
esomeprazole + naproxen (Vimovo),
dexlanzoprazole (Dexilant)
not indicated for PRN use
May increase risk of C. Difficile,
**Osteoporosis, pneumonia in hospitalized
patients.
pantoprazole and esomeprazole are the
only IV PPIs
PPIs inhibit 2C19
Avoid omeprazole and esomeprazole with
Clopidogrel (Plavix)
Cytoprotective Agents: Misoprostol (Cytotec) and
Sucralfate (Carafate)
Metoclopramide (Reglan): dopamine antagonist,
at higher doses it also blocks 5HT in CTZ, enhanced
response to Ach in GI which accelerates gastric
emptying and increases LES tone.

Triple Therapy: PPI + Clarithromycin +

Amoxicillin x 14 days
Quadruple Therapy: PPI + metronidazole +
tetracycline + bismuth x 10-14 days
NSAID-Induced Ulcer:
direct irritation and inhibition of prostaglandin
synthesis messes up GI mucosal barrier
Selective COX-2 inhibitors have less ulcer risk but more
CV risks.
PPI decreases the ulcer risk

Constipation/Diarrhea/and Bowel Prep:

Constipation:
OTC laxatives should be limited to 7 days unless
under medical supervision
Stool softener (Docusate) is good for ironinduced constipation
Opioids are the worse drug offenders for
constipation. Others are anticholinergics, Iron, and
Verapamil.
Opioids usually require a stimulant laxative
(Senna or Bisacodyl) +/- Docusate

Peptic Ulcer Disease:

from mucosal erosion in the GI tract

Three most common causes: H. Pylori, NSAIDs,
Stress in critical illness/mechanical ventilation.

H.Pylori:
spiral gram negative bacteria that like acid
environments
eating usually lessens the ulcer pain
Diagnosis: Urea Breath Test and Fecal Antigen
Test. PPI, H2 blockers, bismuth, and
antibiotics should be discontinued 4 weeks
before tests to avoid false negative.
Treatment: ** Do not make drug substitutions, use
these drugs.

Bowel Prep:
o
o
o
o
o

colonoscopy requires bowel prep

Sodium phosphate can cause fluid and electrolyte
abnormalities, risky in renal or cardiac disease.
Ok to consume clear liquid diet (Water, broths, juices,
coffee, tea, etc.
Do not consume anything with red, blue, or purple food
coloring. No alcohol. No solids or Semi-Solids.
PEGs usually used (Golytely, Miralax, Carbowax)

Drugs for constipation:

Bulk-Producers: psyllium (Metamucil), calcium

polycarbophil (FiberCon), methylcellulose (Citrucel).
DOC in pregnancy and 1st line for constipation.
Emollients, Lubricants (Stool Softener): docusate
sodium (Colace), mineral oil
Stimulant: Senna (Ex-Lax), bisacodly (Dulcolax).
Caution that brand names can refer to multiple
products.
Osmotics: PEG, Lactulose, Gycerin, Sorbitol, Salines
(various ions)
Rx Agents: Lubiprostone (Amitiza) Nausea
(30%),

Short courses of oral or IV steroids: Prednisone

or budesonide (Entocort). Budesonide
preferred for ileum or colon problems, it has
extensive first pass so lower systemic exposure.
Maintenance therapy to reduce inflammation
and flare-ups.
mesalamine (Asacol, Pentasa, Canasa,
Rowasa)
methotrexate
TNF Inhibitors: adalimumbad (Humira),
infliximab (Remicade), golimumab
(Simponi), natalizumab (Tysabri): for
refractory diseases.

alvimopan (Entereg) blocks opioid

receptors in the gut
For STAT treatments and Bowel Preps: bisacodyl
rectal, magnesium salts (MOM), lactulose, sorbitol,
sodium phosphate (Osmoprep), polyethylene glycol
(Golytely, Miralax, Carbowax).
Diarrhea:
Most cases are viral, some bacterial (E.Coli), some drugs
(antibiotics, Mg), some diseases.
Antidiarrheals: Bismuth Subsalicylate (PeptoBismol), loperamide (Immodium), diphenoxylate +
atropine (Lomotil)
Treatment should include fluids and electrolytes,
especially in children.
Not used with C. Difficile infections, body needs to
clear the toxin, not retain it.
Rule out lactose intolerance by avoiding dairy.

Inflammatory Bowel Disease:

Ulcerative Colitis and Crohns Disease: Idiopathic
Bowel Inflammation
Treatment:
Anti-diarrheals: Immodium, Lomitil
Anti-spasmodics: dicyclomine(Bentyl)

Erectile Dysfunction:

Reduced blood flow to the penis. Often caused by

diabetes, HTN, heart disease, nerve damage, drugs
(antidepressants, blood pressure meds, antipsychotics,
finasteride, dutaseride, cimetidine, opioids, chemo,
nictotine), hormone imbalances (testosterone), stress
etc..

PDE5 inhibitors:
***CI with nitrates
Do not confuse with PAH/BPH drugs/doses:
sildenafil (Revatio): 20mg TID
tadalafil (Adcirca): 40mg QD for PAH or tadalafil
(Cialis): 5mg QD for BPH
sildenafil (Viagra): 1 hour before sex, start at
50mg unless >65 use 25mg
vardenafil (Levitra, Staxyn ODT): 1 hour
before sex. ,start at 10mg unless > 65 use
5mg

 tadalafil (Cialis): 1 hour before sex: start with

10mg or 2.5-5mg if using more than twice a
week.
avanfil (Stendra): 30 min before sex

BPH:

The patients perception of severity of BPH symptoms

guides the selection of treatment.

Treatment: Watchful waiting, Surgery, or Drugs

Alpha Blockers: terazosin (Hytrin), doxazosin
(Cardura), tamsulosin (Flomax), silodosin
(Rapaflo). SE: abnormal ejaculation, orthostatic
hypotension, floppy iris syndrome during
cataract surgery, priapism
5 Alpha-Reductase Inhibitors: dutaseride (Avodart)
or finasteride (Proscar) **Only used if the
prostate is enlarged.
PDE-5 Inhibitor: tadalafil (Cialis) 5mg QD

Overactive Bladder:

overactive detrusor muscle acted on by M3 receptor

Behavioral treatments are 1st line
Anticholingerics are 2nd line: Extended-Release
preferred due to lower rate of dry mouth.
oxybutynin, oxybutynin XL (Ditropan XL),
Oxybutynin patch (Oxytrol)
**Oxytrol patch is available OTC for women
>18 yrs. old
tolterodine (Detrol)
fesoterodine (Toviaz)
solifenasin (Vesicare)
darifenesin (Enablex)
trospium (Sanctura)
SE: Dry mouth, constipation, dizziness
(mainly with older agents like oxybutynin)

Glaucoma/Conjuctivitis/Opthalmics and
Otics:
Glaucoma: Increase IOP
Beta Blockers: decrease aqueous humor production.
Timolol (Timoptic)
CAI: decrease aqueous humor production.
dorzolamide (Trusopt), dorzolamide + timolol
(Cosopt)
Prostglandin Analougues: Increase outflow.
travoprost (Travatan Z), bimatoprost (Lumigan),
latanoprost (Xalatan). **Store latanoprost in
fridge. SE: brown pigment in iris or eyelash
growth.
Alpha-2 agonist: increase outflow and reduce
production. brimonidine (Alphagan P),
brimonidine + timolol (Combigan)

Conjuctivitis: (bacterial, viral, allergens)

Allergic: OTC naphazoline/pheniramine (Visine) or
ketotifen (Zaditor, Alaway)
Bacterial: azithromycin (Azasite), moxifloxacin
(Vigamox), besifloxacin (Besivance),
tobramysin/dexamethasone (Tobradex) + many
others.
Otic:
Eye drops can be used in the ears but never use
eardrops in the eyes

Common Skin Conditions:

Acne: From Androgens and bacteria (P.acnes) and

fatty acids in oil glands
Benzoyl Peroxide is the most effective OTC
treatment. Salicylic Acid is mildly useful.

***Different brands have different active

ingredients. Check labels.

Rx: tretinoin topical (Retin A, Avita) or

Adapalene (Differin). Pea sized amount
spread over entire face. May take 4-12 weeks
to see response and initially may worsen.
Limit sun exposure.
Rx: Oral Isotretinoin: ***Only for very severe
acne, Pregnancy X (Severe birth defects),
must be on 2 forms of birth control, must
have 2 negative pregnancy tests, only filled
by a pharmacy that is registered and
activated with the IPLEDGE program. **Do
not use with Vitamin A supplements, or
tetracyclines, steroid, progestin only pills
contraceptives, or St.Johns Wort.
Rx: Antibiotics: minocycline ER (Solodyn)
Oral, or topical antibiotics like Clindamycin
(Cleocin, Clindamax, Clindagel, Evoclin) or
clindamycin + benzoyl peroxide (Duac)

Dandruff: eczema or fungal

First try dandruff shampoos daily with selenium
sulfide (Selsun). Leave in for 5 min. then wash
out.
Then try Rx ketoconazole shampoo (Nizoral AD). Apply twice weekly.
Skin Fungal Infections:
athletes foot, jock itch, ringworm, candida etc.
Terbinafine (Lamisil AT) and butenafine
(Lotrimin Ultra) are highly effective.
Clomitrazole (Lotrimin), miconazole (Monistat,
Lotrimin), tolnaftate (Tinactin).

Toenail or Fingernail fungal infection

(Onychomycosis):
topical usually not potent enough
potassium hydroxide (KOH) smear needed
for diagnosis
Oral itraconazole (Sporanox) or Oral
Terbinafine (Lamisil, Terbinex) used most
often.
**itraconazole BBW to not use in heart
failure.
Vaginal Fungal Yeast Infection:
cottage cheese discharge, itching,
burning, pain during urination
miconazole (Monistat), Tioconazole
(Vagistat) etc..
1 or 3 day treatment (unless pregnant
then 7-10)
Insert at night before bed when laying
down so medicine stays in.
Eczema:
inflammation linked to allergies/allergens
itchy, red, dry, scaly, skin rashes
Treatment: Topical Steroids, Moisturizers,
and Hydration
If topical steroids fail: tacrolimus
(Protopic) or pimecrolimus (Elidel)
Lice:
Permethrin: OTC drug of choice for lice.
Must also remove the live lice and nits
inspecting carefully with a comb. Also used for
scabies (mites)
Lindane not used much anymore due to
neurotoxicity.
Genital Warts:
Imiquimod cream (Aldara)
Alopecia:

 finasteride (Propecia): pregnancy category

X so women shouldnt handle.
minoxidil (Rogaine) topical OTC