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First find out how much NaCl would make it isotonic. 0.

9g/100ml =
NAPLEX SECRET 2017
X g/X mL
Calculations: E= sodium chloride equivalents of a drug = (58.5 x i) /(MW of drug x
1.8) *i = dissociation factor of drug
ung-ointment WA-while awake
example: if calculated E value is 0.23 and you have 0.4g of drug, this
PR-per rectum BM-bowel movement represents 0.4g x .23 = 0.092 g NaCl
1 pint= 473 ml 1 quart = 946 ml Then subtract them from each other.

1 gallon = 3785 ml 1 pound = 454 g Fahrenheit = (C x 1.8) +32

Percentage Strength: g/100ml (w/v); ml/100ml (v/v) ; g/100g (w/w) pH = pka + log (salt/acid) For Acids

Ratio Strength: (1:X) ex. 0.04% = 0.04g/100ml = 1g/2500ml = 1:2500 pH = 14 pKb + log (base/salt) For Bases
**Put in grams eAG: (28.7 x A1C) 46.7
PPM: (parts of drug/1,000,000) parts of whole ex. 0.00022g/100ml = Calcium Carbonate: 40% elemental calcium Calcium Citrate: 21%
2.2g/1,000,000 = 2.2PPM elemental calcium
BMI: (kg/m2) *2.54cm/inch <18.5 = Underweight, 18.5-24.9 = normal 25- Absolute Neutrophil Count: WBC x ((%segs+%bands)/100)
29.9=overweight >30 =obese
Anion Gap: Na+-Cl-HCO3- *>12 is high (gapped)
IBW: Male: 50+2.3 (inches above 5 feet) Female: 45.5 + 2.3(inches > 5 feet)
Minimum Weighable Quantity (MWQ) : SR/error
Adjusted BW: IBW + 0.4(TBW-IBW)
Absolute Bioavailability: F = (AUCextravascular x Doseintravenous)/
CrCl: { (140-age) x weight }/SCr x72 Multiply by 0.85 for females (AUCintravenous x Doseextravascular)
Dilutions: (Changing a strength or quantity) Q1 * C1 = Q2 * C2 IV Bolus VD= Dose/Co or Co = Dose/VD
Alligation: (Combining two strengths to get a strength in between) **Watch
Oral VD= (Dose x F) /(ke xAUC) Cl=(Dose x F)/AUC
for ADD TO
Cl=ke x VD
**Corrected Calcium: Ca2+(from lab) + {(4-albumin) x(0.8)}
ke= {ln(Cmax/Cmin)}/ Time interval
** Phenytoin correction= PHT measured/{(0.2x Alb) + 0.1}
Choose calcium gluconate over chloride bc it dissociates less and Enteral/Parental Nutrition:
less chance of binding to phosphate and precipitating Carbs: Enteral (4kcal/gram) Parenteral (Dextrose 3.4 kcal/gram)
mEq : Electrical charges provided per mole Protein: (4kcal/gram)
mOsmol/L = {(g/L)/(g/mole)} x ( # of particles it splits up into) x 1000 Fat: Enteral (9kcal/gram) Parenteral IVFE (10% - 1.1 kcal/ml, 20% -
Isotonicity (osmolarity in body fluids, when we want to make something 2kcal/ml, 30% -3kcal/ml) *often weekly and might have to divide by 7 for
isotonic to blood): E Value daily
TEE = BEE x activity factor x stress factor *usually doesnt use protein Type 2 Error: Say theres no difference when there is; The null hypothesis is
calories false, but is accepted in error.
BEE estimate: 15-25kcal/kg (adults) RR= risk in tx/risk in control
Daily Fluid Needs: 1500mL + (20mL)(Kg-20) RRR = 1-RR
Nitrogen Intake: grams of protein intake/6.25 ARR= Risk in control Risk in tx
NNT (Number Needed to Treat): 1/ARR (decimal, not %)

Compounding: Cost-Effectiveness analysis How effective the tx was for what it was
supposed to do
Emulsifiers/ Surfactants: Tween (polysorbate), Myrj, Arlacel, Span, PEG,
acacia, sodium laurel sulfate, glyceryl monostearate 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 Case-Control: Have a disease and look back for risk factors
with base Cohort: Prospective or Retrospective. Starts with risk factors to see if they
Aqueous (O/W): glycerin, propylene glycol, PEG 80 get a disease.
Oleaginous (W/O): Mineral Oil, Castor Oil, Cottonseed Oil, Tween Cross-Sectional: Looks at a specific point in time.
RCT: interventional
Collagenase Ointments are for debridement of skin wounds. 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
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 -HLA-B*1502 (mainly Asians) on carbamazepine: 5-10% chance of SJS with
error). P-value is the probability that the result obtained was due to chance. carbamazepine
P <0.05 = less than 5% probability it was due to chance. -SLCO1B1 Polymorphism - statin myopathy increased
95% CI means there is a 95% chance that the interval contains the true -HER2/Neu Oncogene needed for Herceptin (trastuzumab) and Kadcyla
population mean. (ado-trastuzumab) to work
-Warfarin 2C9*2 and 2C9*3 and VKORC1 (A haplotype) require lower -Peanuts and soy are in the same family and can have cross reactivity. Soy is
doses or they will bleed (Homozygous for *3 is has greatest risk of in some medications:
bleeding)
clevidipine (Cleviprex), propofol (Diprovan), and progesterone in
-HLA-B*5701: If positive for this, do not give Abacavir (Ziagen) (Prometrium)
-2C19: Clopidogrel is a prodrug and needs this enzyme to convert to active -If allergic to eggs avoid:
form
clevidipine (Cleviprex), propofol (Diprovan), Influenza vaccine
-Selzentry (Maraviroc) must be CCR5 positive only to receive drug (**Flublok is ok)
-True Drug Allergies/Anaphylaxis (Mediated by IgE and Histamine release):

Drug Allergies/ADRs Swelling, possible hives, bronchoconstriction, low blood pressure


Tx with epinephrine (Epipen, Epipen Jr., Adrenaclick, Auvi-Q) and
-Naranjo scale is used to help pharmacists determine if the drug caused the
diphenhydramine (25mgx2) *rub the area after injection
ADR.
*epinephrine is used when they have trouble breathing
-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 Medication Errors and Patient Safety
- Niacin and Statins taken together have an increased risk of muscle -Medication errors are preventable events that may cause or lead to
toxicity. inappropriate medication use or patient harm. *It is not an adverse drug
reaction (ADR).
-Photosensitivity: Sulfa Antibiotics, Tetracyclines, Fluoroquinolones,
Diuretics, Flagyl, Tacrolimus, Cyclosporine, NSAIDs, voriconazole, -The most common medication error is wrong drug or dose to patient.
methotrexate. -Root-Cause Analysis (RCA) is done retrospectively to see what led to a
-Penicillins: Allergic to one presumes allergic to all. Small risk for sentinel event. Failure Mode and Effects Analysis (FMEA) is done
cephalosporin and carbapenem cross reaction but should still avoid on the prospectively to see what potential could lead to a problem.
exam. -Error of Omission is leaving something out that is needed for safety. Error
-Sulfa/Sulfonamides Mostly with sulfamethoxazole (Bactrim, Septra) but of Commission is when something was done incorrectly.
should also avoid sulfapyridine, sulfadiazine, and sulfisoxazole. **For exam -Medication reconciliation is updating the patients medication list. It
also avoid loop diuretics, thiazide diuretics, sulfonylureas, acetazolamide, should be done at every transition of care.
zonisamide, and celocoxib), darunavir (Prezista). There is no cross-
-REMS is an FDA program that requires specific training and requirements
reactivity with sulfites or sulfates.
for certain meds ex: clozapine, isotretinoin (iPLEDGE), erythropoietin in
-Morphine type opioid allergies do not cross react with Fentanyl oncology (APPRISE). Goal is to make sure the benefits of the drug outweigh
(Duragesic), meperidine (Demerol), or methadone (Dolophine). the risks.
-Medication guides are FDA-approved printed handouts for over 300 Orange Book On Bioequivalence:
medications that that tell patients of important adverse events and should
AB- Therapeutically equivalent and can be interchanged (brand to
be dispensed every time. Can be part of REMS.
generic)
-Tall man letters can be used for look-alike sound-alike drugs. ex. celeXA Drugs with a 3-character code under a heading are considered
and celeBREX therapeutically equivalent only to other drugs with the same 3-
-Use As Directed is not acceptable character code under that heading. Example AB1, AB2, AB3

- Alcohol has poor activity against spores like C. Difficile. Use soap and water
to wash hands when in contact. Natural Products/Vitamins:
-Contact precautions for patients colonized with MRSA and VRE. Airborne (They do not have to prove to be safe and effective)
precautions for patients with measles, varicella (chickenpox), and
Tuberculosis. *Many natural products can be hepatotoxic and elevate liver enzymes (ex.
Kava Kava)
-Barcoding is great and helps prevent errors
- Ginkgo can increase bleeding with no change in INR. Other that can also
do this are garlic, Vitamin E, fish oils, and ginseng.
FDA Drug Approval/Bioequivalence: - St. Johns Wort for depression is an inducer, serotonergic, and can cause
New Drug Approval: photosensitivity.

1. Pre-Clinical Animal Research - Saw Palmetto used for BPH


2. IND-Investigational New Drug - Ginger for nausea/motion sickness
Phase 1- Asses safety/PK/PD parameters with low doses in
- Tea Tree Oil for acne
20-80 healthy people
Phase 2- Safety and Efficacy in 100-300 people with - Lysine for canker sores
indication - Melatonin for insomnia and jet lag
Phase 3- Confirm previous studies in 100s-1000s of
- Black Cohosh, Estroven (black cohosh + soy), and Red Clover for
people with the indication at the dose youre seeking
menopausal symptoms
approval.
3. NDA Submitted Either Approved, Rejected, or further studies - Cranberry can be used for UTI prevention but can increase risk of kidney
requested stones.
Phase 4 Post-marketing studies after NDA approval - Folic Acid (B9) started 1 month before pregnancy. 400-800mcg daily.
*For changes to an existing drug they can submit a Supplemental New Drug - Pyridoxime (B6) supplemented in Tuberculosis treatments that have
Application (sNDA) ex. Label, Dose, Strength, Manufacturing Process, and Isoniazid in them
Indication Changes
- Thiamine(B1) deficiency can cause Wernickes encephalopathy.
* Abbreviated NDA for generic approval
- Niacin (B3) deficiency causes pellagra Inhibitors (fast to have this effect): Azole Antifungals, Macrolides
(clarithromycin and erythromycin), cimetidine, amiodarone, valproate,
- Vitamin C deficiency can cause scurvy
non-DHP Ca2+ Blockers (diltiazem and verapamil), protease inhibitors
-Vitamin E should not exceed 150 IU/day (lopinavir, ritonavir, etc..), grapefruit, cyclosporine.
- L-Arginine can have hypotensive effects, its a precursor to NO. Fluoxetine (Prozac,Sarafem) , Duloxetine (Cymbalta), and Paroxetine
- Iron: Breast-fed babies need 1mg/kg/day from 4-6 months old and anemic (Paxil) are 2D6 inhibitors. (Watch with certain opioids like tramadol,
patients may need supplementation too (ex. Renal problems or hydrocodone, and codeine(prodrug))
menstruating females) **SMX/TMP is a 2C9 inhibitor so caution with warfarin.
- Probiotics: If taking antibiotics, dont take the probiotic at the same time Oxycodone and Methadone are metabolized by 3A4 (watch for inducer and
of day as the antibiotic inhibitors)
- Echinacea, zinc, elderberry, garlic, vitamin C- used for colds/flu. Zinc can Amiodarone use Decrease Digoxin and Warfarin dose by 30-50%. Also use
cause loss of smell. lower doses of Simvastatin, Atorvastatin, and Lovastatin.
- Adequate Calcium and Vitamin D needed for low bone density, pregnancy Digoxin: Watch for renal dysfunction, hypokalemia, and additive heart rate
(fetus depletes stores), menopause, children, and men who take steroids or lowering drugs such as Beta Blockers, non-DHP calcium channel blockers,
androgen blockers. amiodarone, Precedex, clonidine, and opioids.
Calcium absorption is saturable so doses should be divided. Grapefruit: 3A4 inhibitor increased SAL statins (rhabdo), increased bleeding
1000mg/day for women 19-50 and 1200mg/day for>50 risk with rivaroxaban and ticagrelor, increased levels of calcineurin
Citracal (calcium citrate) preferred in low acid environments (ex. inhibitors (tacrolimus and cyclosporine).
with H2 blocker and PPI use). Can be taken with or without food.
Valproate: used with lamotrigine (Lamictal) can increase lamotrigine levels
(21% Elemental)
and cause a severe rash
Oscal, Tums (calcium carbonate) has acid-dependent absorption,
take with food. Smaller pills than the Citracal and provide more MAOi: do not use with SSRI, SNRI, TCAs, bupropion, buspirone, tramadol,
elemental calcium. (40% Elemental) muscle relaxants, triptans, St. Johns Wort, ephedrine/pseudoephedrine,
Vitamin D: 600IU daily for <70, 800IU daily for >70 (cholecalciferol epi, norepi, dopamine, meperidine (meperidine blocks serotonin reuptake),
(D3) is the preferred source). Poly Vi Sol multivitamin contains Vit linezolid (Zyvox) etc
D and is easy for infants to take. Breast-fed babies or formula fed Serotonin Syndrome: Tremor, Agitation, Confusion, Hallucination, Diarrhea,
babies who drink less than 1 liter/day need 400IUs Vit D. Muscle rigidity, Shivering, Tachycardia, Sweating, Hyperthermia
Chelation: Tetracyclines and quinolones can chelate so separated from Al,
Ca, Mg, Fe compounds, including dairy.
Drug Interactions:
Bleeding Risk: SNRI, SSRI, NSAIDS, Ginkgo, fish oil, garlic, grapefruit
Inducers (slow to have this effect): carbamazepine (Tegetrol), phenytoin
(Dilantin), Oxcarbazepine (Trileptal), smoking, rifampin, St. Johns Wort, *Wellbutrin (Bupropion) Doesnt affect 5HT so doesnt increase bleeding
phenobarbital, efavirenz (3A4) risk
Hyperkalemia: ACEi, ARB, amiloride, triamterene, epleronone (Inspra), -Loop Diuretics inhibit Na+/K+ pump in ascending limb of loop of Henle
spironolactone (Aldactone), KCl, tacrolimus(Prograf), cyclosporine (Neoral),
-Thiazide Diuretics inhibit Na+/Cl- pump in the distal tubule
trimethoprim, canagliflozin (Invokana), drospirenone (Yasmin)
-Aldosterone antagonists/ Potassium Sparing Diuretics work in the
Ototoxicity: salicylates, vancomycin, aminoglycosides, cisplatin, loop
collecting duct
diuretics
- The goal BP in CKD is <140/90
QT Prolongation: Quinolones, Macrolides, Methadone, TCAs, Some SSRIs
(Citalopram and Paroxetine), Azole antifungals, SMX/TMP, some Protease - ACEis and ARBs are reno-protective in that they slow down the
Inhibitors progression of nephropathy in diabetic and non-diabetics 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
Renal Disease and Dosing Considerations: 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.
-The level of Albumin in urine can gauge the severity of kidney damage.
(Micro and Macroalbuminuria) doxercalciferol (Hectoral) and paricalcitol(Zemplar) are
newer active VitD drugs with less hypercalcemia.
- Serum Creatinine (SCr) is used as a marker of renal function cinacalcet (Sensipar) calcimimetic to increase sensitivity to
- BUN increases in renal impairment but not used alone as a marker b/c it calcium and decrease PTH.
can increase for other reasons such as dehydration.
-Vitamin D deficiency: Cholecalciferol (D3) and Ergocalciferol (D2) - Well known teratogens: alcohol, ACEi/ARB, benzos, carbamazepine,
phenytoin, valproic acid, topiramate, phenobarbital, isotretinoin, NSAIDs,
-Hyperkalemia: Usually from renal failure and/or drugs that increase K+.
methimazole, lithium, paroxetine (Paxil), tetracyclines, quinolones,
Muscle weakness, bradycardia, chest pain, paresthesias and fatal
warfarin, statins, methotrexate, dutaseride, finasteride.
arrhythmias may occur.
- 2011 FDA issued a warning about SSRIs causing persistent pulmonary
Treatment:
HTN in newborns
IV Calcium to stabilize the cardiac tissue
- Women need 400-800mcg/day folic acid, 1,000mg/day calcium, and
Glucose and Insulin to drive K+ into cells
600IU/day Vit D
sodium polystyrene sulfonate (Kayexelate) is a cation exchange
resin given orally or rectally. Rectal preferred in emergency - Iron for anemic patients. Absorbs better on an empty stomach. Vitamin C
situations. Side Effects: Nausea, Vomiting, Constipation, Loss of increases absorption.
Appetite. - Folic acid >1mg is prescription only
Loop Diuretics
- Nausea/Vomiting: First recommend easting smaller, more frequent meals,
-Metabolic Acidosis: Tx with sodium bicarbonate or sodium citrate (Bicitra) avoid spicy/odorous foods, take naps, and reduce stress. Then, 1st line OTC
by ACOG is pyridoxine (Vitamin B6).

Common: drugs that need dose adjustments in renally impaired: acyclovir, - GERD/Heartburn/Gas Pains: First recommend easting smaller, more
valacyclovir, amphotericin, amantadine, , Allopurinol, aminiglycosides, frequent meals, avoid foods that worsen GERD, elevate head of bed before
azole antifungals, antiarrhythmics, aztreonam, colchicine, dabigatran, sleep. Antacids like Tums are first line OTC. Many PPIs/H2 blockers are
LMWHs, macrolides, quinolones, metoclopramide, penicillins, category B and pretty safe. For gas, simethicone (Gas-X, Mylicon) are safe.
morphine/codeine, Maraviroc, NRTIs, statins, SMT/TMP, tramadol, - Constipation: Increase fluids and physical activity. Fiber is first line such as
venlafaxine, zolendronic acid. psyllium (Metamucil) is safe.
Drugs not to use in severe renal impairment: Bisphosphonates, - Cough/Cold/Allergies: First generation antihistamines are 1st line.
dabigatran(Pradaxa), duloxetine, fondaparinux (Arixtra), glyburide, Lithium, Chlorpheniramine (Chlor-Timetron) is the DOC. Diphenhydramine may also
meperidine, metformin, NSAIDs, nitrofurantoin, potassium sparing diuretics, be safe. Non-sedating 2nd generations like loratidine and cetirizine are often
rivaroxaban (Xarelto), tadalafil, tenofovir, tramadol ER, voriconazole IV. 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.
Drugs in Pregnancy:
- Pain: Only recommend acetaminophen (Tylenol) for pain in pregnancy
-Anticoagulation: UFH is preferred in all stages
- As a general rule, try to avoid all drugs during the 1st trimester.
- Vaccines: Inactivated Influenza vaccine should be given each fall whether
- Pregnancy exposure registries are designed to collect info from women pregnant or not and in all stages of pregnancy. *No Live Vaccines one
who take various meds during pregnancy and breastfeeding. month before and during pregnancy.
- Antibiotics: Penicillins, Cephalosporins, and macrolides (except Clinical Trials: Clinicaltrials.gov by the national institute of health
clarithromycin) are considered safe. Fosfomycin for UTI is safe.
Comprehensive Patient Information: MedlinePlus, FDA, CDC
Nitrofurantoin for UTI is safe but at term is CI.**Do not use quinolones
(cartilage damage) or tetracyclines (teeth discoloration). SMX/TMP can Natural Medicines: Natural Medicines Comprehensive Database and
cause hyperbilirubinemia and kernicterus in the 3rd trimester so do not use. Natural Standards
Do not use Aminoglycosides (Category D). Do not use flagyl in the 1st Pregnancy/Lactation: Breastfeeding: A guide for the medical profession,
trimester. Briggs, Lactmed, Micromedex, Hales, CDC
Bacterial Vaginosis: Clindamycin oral or metronidazole oral Pediatrics: AHFS, Micromedex, Harriet Lane, Pediatric Dosage Handbook,
Chlamydia: Azithromycin 1gm x 1 or Amoxicillin 500 TID x 7 Neofax, Nelson, CDC, Professional Colleagues
days
IV Drugs: Trissels, Kings, Package Insert, Micromedex, AHFS
Gonorrhea: Rocephin 250mg x 1 and/or Azithromycin 2gm
x 1 (Covers chlamydia too) Drug ID: Ident-A-Drug, Micromedex, Facts and Comparisons, Clin Pharm
Trichmoniasis: metronidazole 2gm x 1 or 250 TID/500BID etc..
for 7 days Medication Safety: Medwatch (Adverse Reactions) and Institute for Safe
-Vaginal fungal infections: Use topical antifungals for 7 days (ex. Medication Practices (ISMP)
clomitrazole) Foreign Drug ID: Martindales, micromedex
st
-Asthma: Inhaled Corticosteroids are 1 line (budesonide preferred).
Infectious Disease:
Albuterol inhaler is used for rescue.
-Gram Positive Stain Purple/Blue, Gram Negative Stain Pink
- Hypothyroidism: use levothyroxine (Category A)
-Breakpoint: level of MIC at which the bacteria is deemed susceptible or
-Hyperthyroidism: PTU and Methimazole are pregnancy D. PTU is used in
resistant
the 1st trimester and Methimazole is after that. Both can cause serious
liver damage. -Beta Lactams (Time-Dependent) can be maximized by extending the
infusion time or giving a continuous infusion
Antibacterials:
Drug References:
-Aminoglycosides: (Bactericidal)
Average wholesale prices and suggested retail prices of drugs: Red Book
bind to 30S and 50s ribosome units and interfere with protein
Principles of Immunization: Pink Book from the CDC synthesis
Patents, Manufacturing, Industry issues: Pink Sheet concentration dependent killing and post antibiotic effect (PAE)
High dose extended interval dosing is less nephrotoxic and more
Travelers Health: Yellow Book
cost-effective
Therapeutic equivalence: Orange Book; published by the FDAs BBW for Neurotoxicity and Nephrotoxicity
CDER(Center for Drug Evaluation and Research)
Gent/Tobra: 4-7mg/kg (peak 5-10 trough <2) , for synergy ex. with covers serratia (HNPEKS). **Ceftazidime covers
vanco peak (3-4) Pseudomonas
Amikacin: 15-20 mg/kg (peak 20-30 trough <5) 4th Gen: cefepime (Maxipime)(iv) - best gram negative
(dose based on IBW) activity, covers (HNPEKS) and Serratia, Pseudomonas ,
Acinetobacter, Citrobacter, Enterobacter (SPACE bugs)
5th Gen: ceftaroline (Teflaro)(iv) Best gram positive
-Penicillins: (Bactericidal except against Enterococci) activity covers MRSA, no Pseudomonal coverage
bind to PBP and inhibit cell wall synthesis **Ceftriaxone(Rocephin) is the only one that can be dosed
Time-Dependent Killing once daily. It should not be used via Y-site or with calcium
amoxicillin (Amoxil) refrigerate suspension to improve taste containing stuff. DOC for primary peritonitis infections.
amoxicillin + clavulanate (Augmentin) refrigerate suspension
ampicillin + sulbactam (Unasyn) -Carpapenems: (bactericidal)
penicillin VK (Oral) and Penicillin G (IV) take Pen VK on an empty
same mechanism as PCNs
stomach
Broad Spectrum against Gram +/-, Anaerobes,
piperacillin + tazobactam (Zosyn) anaerobic coverage and
Pseudomonas (except Ertapenem), AMPC and ESBLS
pseudomonas
imipenem/cilastatin (Primaxin), meropenem (Merrem),
nafcillin, oxacillin, docloxacillin (PO) antistaph pcn no renal
ertapenem (Invanz), doripenem (Doribax)
dose adjusting, is a vesicant
Side Effects: Can cause seizures
bone marrow suppression with long-term use or seizures with
ertapenem (Invanz) can be dosed once daily
accumulation
-Aztreonam(Azactam):
-Cephalosporins: (bactericidal)
no Gram + activity but good for Pseudomonas
same mechanism as PCNs
can be used in PCN allergic patients
activity against staph decrease with generations but strep
and gram neg. increases -Fluoroquinolones: (Bactericidal)
1st Gen: cefazolin (Kefzol,Ancef)(iv), cephalexin (Keflex)(po) Inhibit DNA gyrase and topoisomerase IV
- covers PEK (proteus, Ecoli, Klebsiella) concentration dependent killing
2nd Gen: cefuroxime (Ceftin,Zinacef)(iv/po), cefotetan ciprofloxacin (Cipro or ciprodex (otic)), levofloxacin
(avoid alcohol) or cefoxitin (cover some anaerobes) more (Levaquin), moxifloxacin (Avelox or Vigamox (eye)),
gram negative coverage than 1st gen. HNPEK (H.Flu, ofloxacin (Floxin (otic))
Neisseria, proteus, Ecoli, Klebsiella) Cipro and Levo have Pseudomonal coverage, not Moxi
3rd Gen: cefdinir(Omnicef)(po), ceftriaxone (Rocephin)(iv), moxi covers some anaerobes
ceftazidime (Fortaz)(iv),cefpodoxime (Vantin)(po) less Atypical Coverage
staph and more strep activity. More gram negative acitivity
Levo and Moxi referred to as the respiratory FQs
because they have more Strep. Pneumo coverage
**BBW for Tendon Inflammation/Rupture and may MRSA coverage
exacerbate muscle weakness in Myasthenia Gravis. Bactrim and Septra
Pregnancy D for cartilage damage. Always in a 5:1 (SMX:TMP)
QT prolongation, GI upset, Hepatotoxicity, seizures, CI: Pregnancy, Sulfa Allergy, breastfeeding, anemia due to
peripheral neuropathy, **hypoglycemia (sometimes fatal), folate deficiency, marked renal/hepatic disease, infants <2
peripheral neuropathy, and photosensitivity. months
Cipro Oral Suspension should not be given via feeding tubes Side Effects: Photosensitivity, Skin reactions,
b/c it adheres to the tubing. hyperkalemia, hypoglycemia, crystalluria (take with 8oz) of
Chelation with cations so separate doses from things like water
antacids, mutivaitmins etc.. IV to PO is 1:1
Cipro CI with tizanidine (Zanaflex) **Inhibitor of 2C9 so caution with warfarin
-Vancomycin (Vancocin): (Bactericidal)
blocks glycol-peptide polymerization of the cell wall
-Macrolides: (Bacteriostatic)
can be used orally for C. Diff 125-500mg QID x 10-14 days
binds to 50S ribosome to inhibit protein synthesis Side effects: Nephrotoxicity, Ototoxicity, infusion
azithromycin (Z-Pak, Zithromax), erythromycin rxn/redman syndrome(hypotension, flushing, chills, etc..-
(Erythrocin), clarithromycin (Biaxin) so give 30 min infusion for each 500mg)
Atypical coverage Troughs: 15-20mcg/ml for pneumonia, endocarditis,
QT prolongation, GI upset, Hepatotoxicity osteomyelitis, meningitis, and bacteremia; 10-15 for
erythromycin and clarithromycin are inhibitors of 3A4 others.
azithromycin has less drug-drug interactions MRSA, PRSP, Enterococcus (Not VRE)
-Tetracyclines: (Bacteriostatic) -Telavancin (Vibativ): (Bactericidal)
bind to 30s ribosome to inhibit protein synthesis derivative of vancomycin
tetracycline, doxycycline, minocycline red man syndrome, nephrotoxicity, QT prolongation
Photosensitivity
Pregnancy Category D (teeth discoloration and skeletal
growth suppression) -Linezolid (Zyvox): (Bacteriostatic)
doxycycline IV to PO is 1:1 binds to 23S ribosomal RNA of the 50S subunit
Chelation with cations CI with MAOI inhibitors or within 2 weeks use of them
do not use in children < 8 yrs. old IV to PO 1:1 (600mg Q12)
doxy doesnt need renal dose adjusting MRSA, PRSP, VRE
-Sulfonamides: (Bactericidal when SMX/TMP are used together) associated with bone marrow suppression and peripheral
neuropathy
inhibit the folic acid pathway
-Daptomycin (Cubicin): (Bactericidal) -Nitrofurantoin (Macrobid or Macrodantin): for uncomplicated UTI, **CI
with CrCl<60ml/min, rarely can cause pulmonary toxicity.( Darkens urine
o depolarizes cell membrane
rust colored.)
o MRSA, PRSP, VRE
o Side Effects: **Myopathy and increased CK
o **Do not use for pneumonia b/c its inactivated by surfactant Refrigeration of antibiotics:
o can cause false elevations in INR with no increased bleeding
Refrigerate: Penicillins (amoxicillin just for taste), Cephalosporins (except
o compatible with NS but not D5W
Cefdinir(Omnicef)), Erythomycin
-Tigacycline (Tygacil):
Do Not Refrigerate: Cefdinir, Azithromycin, Clarithromycin, Clindamycin,
o related to tetracyclines Ciprofloxacin, Levofloxacin, Doxycycline, Fluconazole, Voriconazole, linezolid
o BBW: increased risk of DEATH (Zyvox), SMT/TMP
o Lipophilic and distributes to tissues so not for bloodstream
infections
Specific Disease Treatments with Antibiotics:
-Clindamycin (Cleocin):

binds 50s subunit Surgery Prophylaxis:


Covers gram + (not enterococcus) and most anaerobes
Usually initiated within 60 minutes before the procedure unless FQ
BBW for severe or fatal colitis
or Vanco is used then its 120 min. before.
D-test for macrolide-induced resistance
Second doses may need to be given for longer procedures or if
no renal adjustments
there is significant blood loss.
-Metronidazole (Flagyl) and Tinidazole (Tindamax): 1st or 2nd Gen. Cephalosporins usually given unless PCN allergy
DNA damage which blocks translation and protein synthesis then Vanco is used.
Anaerobes and protozoal infections If bowel parts are involved, need anaerobic coverage such as
BBW for possible carcinogenicity cefotetan, ertapenem, or Rocephin with Flagyl
**CI: Pregnancy(1st trimester), *Alcohol and no alcohol for
3 days after discontinuing
Meningitis:
Can increase INR if used with warfarin
IV to PO 1:1 Most common pathogens: Strep.Pneumo, H.Flu, Neisseria
Can cause metallic taste in mouth Meningitis, and Listeria
Do not refrigerate b/c crystals can form Tx with Ceftriaxone (Rocephin) + Vancomycin usually for 7-14 days
+ dexamethasone
-Rifaximin(Xifaxan) : for travelers diarrhea and hepatic encephalopathy For immunocompromised or >50, add Ampicillin for Listeria
-Fosfomycin: single dose for UTI, ok for pregnancy coverage
If Beta Lactam Allergy: Chloramphenicol + Vanco + Bactrim
(Listeria)
Infective Endocarditis: Diagnosed with Tuberculin skin test (aka PPD). Look for
raised area with 48-72 hrs.
Usually from Staph, Strep, or Enterococcus
Latent usually treated with rifampin and isoniazid
**Prosthetic valve IE usually from Staph and requires addition of If active, Tx with RIPE regimen which is Rifampin,
Rifampin Isoniazide (INH), Pyrazinamide, and Ethambutol
Gentamicin often used for synergy, peak 3-4 mcg/ml, trough <1, Direct observed therapy (DOT) if possible to make sure
do not use extended-interval dosing they take all the meds
Patients should be in isolated, negative pressure rooms
usually 4-6 weeks of treatment with a PCN, Cephalosporin
Recommend pyridoxine (Vit B6) to prevent neuropathy
(ceftriaxone), or Vanco
with isoniazid (INH)
Prophylaxis from dental procedure: ** Amoxicillin, clindamycin, or Rifampin and INH taken on an empty stomach
azithromycin 30-60 min before procedure. Ethambutol can cause optic neuritis
pyrazinamide CI in acute gout and hepatic damage
INH can cause hepatic damage too
URTI:
rifampin can cause red-orange secretions and stain
Acute Otitis Media: Usually use **High dose amoxicillin contacts
90mg/kg/day or Augmentin RIPEM if resistant to others (M=moxifloxacin)
Most are caused by viruses
Intra-Abdominal Infections:

Primary peritonitis: mostly from strep and enteric gram negative


LRTI: rods (PEK). Tx with ceftriaxone (Rocephin) for 5-7 days.
Acute Bronchitis: Usually Viral Antitussives and Bronchodilators Secondary peritonitis from traumatic event (surgery, ulceration,
Used ischemia, obstruction) usually strep, gram neg. rods and anaerobes
CAP: usually causes by Strep. Pneumo, H.Flu, or M. Catarrhalis.
Usually use a macrolide, or beta-lactam + macrolide, or a FQ for 5-
Skin and Soft Tissue Infections:
10 days
HAP: Cellulitis: Affects all layers of the skin and usually caused by Staph.
Early Onset (<5days): Usually same bugs as CAP Aureus or Strep. Pyogenes
Late Onset (>5days): Usually MDR pathogens (MRSA, abscesses need incision and drainage (I&D)
Pseudomonas). Tx for 7-8 days unless pseudomonas then its Purulent(pus): requires MRSA coverage
14 days. non-purulent: (Keflex)
IV antibiotics may be necessary for severe infections
Tuberculosis:
caused by mycobacterium tuberculosis
high contagious
UTI: Tx: Fluoroquinolones are the the DOC plus loperamide
more common in females b/c of shorter urethra Hydration is very important
all male UTIs are considered complicated prophylaxis is not recommended but can use Pepto-Bismol to
reduce incidence
Signs/Symptoms: dysuria, urgency, frequency, burning, nocturia,
suprapubic heaviness, hematuria , (fever is uncommon) No Fever and No blood in stool can use loperamide: 4mg then
2mg, max 16mg/day
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. Fungal Infections:
Phenazopyridine(Azo) often given for urinary pain (dysuria) can
cause red/orange urine. Max of 2 days b/c you dont want to cover Amphotericin B: (fungicidal)
symptoms that can worsen. binds to ergosterol, altering cell membrane permeability, causing
Asymptomatic (no fever or urinary symptoms) does not need to be cell death
treated unless pregnant then you treat for 7 days Comes in conventional and lipid formulation (Abelcet, Ambisome)
Nitrofurantoin (CI if CrCl < 60 ml/min) for uncomplicated UTI or BBW that medication errors occur due to the mix-up between
SMX/TMP conventional and lipid formulation dosing differences.
Can use FQ for complicated UTI or SMX/TMP Conventional has a max dose of 1.5mg/kg/day.
C.Difficile: Side Effects: Fever, chills, headache, malaise, rigors, hypokalemia,
hypomagnesemia, **nephrotoxicity
Usually from Antibiotic use especially Clindamycin, Ampilcillin, Lipid formulation reduce the risk for infusion reactions and
Cephalosporins, and FQs. **nephrotoxicity
Remove offending agent If using conventional, pre-medicate for infusion related reactions
avoid anti-motility agents due to risk of toxic megacolon with:
wash hands with soap and water to prevent transmission, alcohol acetaminophen or NSAID
does not kill the spores Diphenhydramine and/or hydrocortisone
Tx: Metronidazole 500mg TID (mild-mod) or Oral Vanco 125mg QID Meperidine to reduce duration of rigors
(mod-severe) or both for severe complicated 10-14 days with flagyl fluid boluses to reduce nephrotoxicity
being IV.
fidaxomicin in clinical trials shows lower recurrence rates
Flucytosine (Ancobon): (fungicidal)
penetrates into fungal cells and is converted to fluorouracil which
Travelers Diarrhea competes with uracil, interfering with fungal RNA and protein synthesis
Bacterial (80%): enterotoxigenic E.Coli, Campylobacter jejuni, BBW to use extreme caution in renal dysfunction and closely monitor
shigella, salmonella renal, hepatic, and hematologic status
Viral sometimes Side Effects: Bone marrow suppression, hepatitis, nephrotoxic increase
Protozoal sometimes BUN and Scr
Azoles: (fungicidal and fungistatic) Viral Infections:
decrease ergosterol synthesis and thus cell membrane formation Influenza:
Fluconazole is the DOC for thrush in HIV patients or non-HIV with
moderate-severe disease. Nystatin also good for thrush. Neuramidase Inhibitors
Voriconazole is the DOC for Aspergillus o decrease the release of viral particles
Itraconazole (Sporanox), fluconazole (Diflucan), voriconazole o should be used within 48 hours of illness onset
(VFEND), posaconazole (Noxafil) Ketoconazole (Nizoral topical, o Oseltamivir (Tamiflu) Tx: 75mg BID x 5 days
generic for tablets) Prevention: 75mg BID x 10 days
Fluconazole IV to PO is 1:1 o Tamiflu can cause vomiting
Voriconazole should be taken on an empty stomach, posaconazole o Zanamivir (Relenza Diskhaler) BBW bronchospasm risk
with full meal o amanatadine
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). Antivirals for Herpes Simplex Virus (HSV), Varicella Zoster Virus
Only Fluconazole and Voriconazole penetrate the CNS well enough (VZV) and Cytomegalovirus (CMV):
to treat fungal meningitis
o acyclovir (Zovirax), valacyclovir (Valtrex), valganciclovir
**All are 3A4 inhibitors
(Valcyte), famciclovir ( Famvir) ganciclovir (Cytovene), cidofovir
**Side Effects of all: Increase LFTs, QT prolongation
(Vistide), foscarnet (Foscavir)
Side effects of Voriconazole/Posaconazole: **Visual changes,
hallucination o **valganciclovir has a BBW for myelosuppression and
Itraconazole is CI in heart failure carcinogenic/teratogenic effects. **Prepared in vertical air
hood.
EchinoCANDIns: o cidofovir has a BBW for nephropathy
o valganciclovir is taken with food
o inhibit synthesis of B(1,3) D- Glucan of the cell wall.
o DOC for most systemic Candida o ganciclovir and valganciclovir are the DOC for CMV
o Caspofungin (Cancidas), mycafungin (Mycamine), anidulafungin (Eraxis) o if resistant to acyclovir you will be resistant to valacyclovir and
o Side effects: Increased LFTs, hypotension, fever, diarrhea, famciclovir
hypokalemia, hypomagnesemia, rash o Therapy for HSV should be within 24 hours of symptoms and
o good for C. krusei and glabrata too therapy for VZV should be within 72 hours of rash.
o all once daily and no renal adjustments

Terbinafine (Lamisil): Inhibits squalene epoxidase West Nile Virus: Antivirals do not work well so just dont get it. Use
Side effects: Increased LFTs, headache repellants and wear protective clothing.
Nystatin: Griseofulvin (Grifulvin,Gris-PEG): photosensitivity & pregn.cat X
Malaria: Decreasing the dosing interval between multi-dose vaccines may
interfere with antibody response and protection.
Atovaquone/proquanil (Malarone)
Side effects:
Mefloquine (Lariam):CI with Hx of seizures or psychiatric Local pain, swelling, redness at site
disorders Systemic fever, malaise, myalgia, headache, loss of
Doxycycline (Vibramycin) appetite (LAIV can cause runny nose)
Chloroquine (Aralen) QT prolonging, visual disturbances, Allergic or Anaphylactic Hives, difficulty breathing,
retinopathy hypotension, swelling of mouth and throat. Severe
Quinine (Qualaquine) CI with prolonged QT and G6PD reactions CIs subsequent dose of the vaccine. All providers
deficiency must have emergency protocols and supplies to treat
anaphylaxis.
Primaquine CDC requires screening for G6PD deficiency
**Absolute CIs to live vaccines (ex. Zoster, Varicella, LAIV
(Flumist), and MMR): Pregnancy and Immunosuppression
Immunizations: Tdap: Pregnant women should receive Tdap with each pregnancy,
most effective in weeks 27-36. Also, a one-time dose for those <65
Federal law requires patients receive the most up to date version of or >65 who have close contact with children who are less than 6
the Vaccine Information Statement (VIS) BEFORE EACH vaccine is months. Tdap is IM.
administered. Pneumovax (PPSV23): All patients > 65 x 1 dose, 19-64 who smoke
Active Immunity produced by the persons own immune system or have asthma, 2-64 who have chronic illnesses.
(permanent). Get it from surviving and infection or vaccination. Flu: If a person can eat lightly cooked eggs or if they only
Passive Immunity products like Immunoglobulins are transferred experience hives after eating egg-containing products, then they
to a patient (wanes within weeks to months) can receive inactivated flu vaccine but should be observed for 30
Usually 3 months spacing between anti-body containing blood min after administration. Inactivated for everyone > 6 months.
products and MMR or Varicella vaccines. (Zoster is not affected by Mild-illness is not a CI to influenza vaccine. LAIV only for healthy
circulating antibodies) people 2-49 years old.
Pink Book for recommendations Varvax/Zostavax/MMRV (zoster and chickenpox) should not be
Simultaneous administration of all vaccines for which they are given to anyone with a true gelatin or neomycin allergy. Store
eligible is fine and efforts should be made to do them at one visit vaccine in freezer and diluent in fridge or room temp.
on the same day HPV vaccine (Gardasil, Cervarix) for males (to reduce genital warts
If live parenteral vaccines (MMR, Varicella, Zoster, and yellow or anal cancers) or females 9-26 yrs old. (3 Doses). Males only use
fever,) or live intranasal influenza (LAIV) are not administered at the Gardasil.
same visit, then separate them by 4 weeks. IM is given into the deltoid muscle with a 1 needle (women
Increasing the dosing interval between multi-dose vaccines doesnt >200lbs and men >260 lbs need 1 and ). SC is given into the fatty
decrease effectiveness but may delay more complete protection. 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 vaccine so dont use in immunocompromised. ASA and NSAIDs should
**SC is varicella, ZOSTER (Zostavax) and MMR not be used b/c of increased risk of bleeding.
**Varicella and Zoster are stored in the freezer Typhoid Fever: bacteria spread through consumption of food/water
Children get DTap and adults get Tdap contaminated with feces or sexual contact. Use safe food and water
***CDC does not recommend using acetaminophen before a precautions. Vaccine is Vivitof Berna, 4 capsules, 1 every other day
vaccine bc it can decrease immune response taken with cool liquid or IM shot > 2 weeks before exposure.
Never mix vaccines together Altitude Sickness: acetazolamide (Diamox Sequels). CI in sulfa allergy.
In Florida, pharmacists give Influenza, Shingles, and Pneumococcal International certificate of vaccination (Yellow Card)
Vaccines

Travelers Medicine: HIV:


Yellow Book for travel information CD4+ counts are the major laboratory indicator of immune function
Malaria parasite protection is provided by oral meds prior to travel. and need for prophylaxis against opportunistic infections.
Use DEET. Plasmodium Vivax causes 65% of cases in India. Plasmodium HIV-1 RNA (Viral Load): most important indicator of response to
falciparum is the most deadly. anti-retroviral therapy (ART). Used to help assess disease
Treatment: progression and possible drug resistance. Measured at baseline and
o Mefloquine (Larium): High resistance and many then on a regular basis thereafter.
psychiatric and neurologic side effects. Once weekly. Spread through blood, semen, and vaginal secretions. Also spread
Started 1-2 weeks before and 4 weeks after through vertical transmission during pregnancy, at birth, or
o Chloroquine: Once weekly. Started 1-2 weeks before and breastfeeding.
4 weeks after **ART is recommended in ALL HIV-infected patients
o Atovaquone/Proguanil (Malarone): Started 1-2 days **Need adherence of 95% or greater to be effective long-term
before travel and for 7 days post travel. Well tolerated
PIs and stavudine associated with lipodystrophy/lipoatrophy and
but CI in pregnancy. Once Daily.
fat redistribution/lipohypertrophy
o Primaquine: Once daily. Started 1-2 days before travel
Diarrhea is a common side effect of ART. Crofelemer(Fulyzaq) is
and for 7 days post travel. CI in pregnancy. CDC requires
approved for non-infectious diarrhea in adult patients on ART.
screening for G6PD deficiency before use.

Meningococcal vaccine: required for Saudi Arabia. Also prevalent in NRTIs: (Abacavir, lamivudine, emtricitabine, tenofovir, didanosine,
the meningitis belt of Africa. Menactra (2 doses for 9-23 months, 1 for stavudine, zidovudine)
2-55 yrs), Menveo (2-55 yrs.), Menomume (56 and older). 7-10 days
**All have BBW for lactic acidosis and hepatomegaly with
for protective antibodies.
steatosis(fatty liver)
Yellow Fever Virus Vaccine: for certain parts in sub-saharan Africa and
Suspend treatment if there is lactic acidosis or
South America. Watch for allergies to eggs and gelatin. It is a live
hepatomegaly with steatosis.
abacavir: BBW for severe hypersensitivity reaction. Must test for side effects (depression, paranoia, mania, suicide). CNS
HLA-B*5701. side effects usually resolve in 2-4 weeks. Pregnancy D
Ziagen (abacavir) Atripla ( tenofovir + emtricitabine + efavirenz)
Epzicom (abacavir + lamivudine) Once Daily

emtricitabine: BBW for Hep B exacerbation once discontinued or Protease Inhibitors: (atazanavir, darunavir, ritonavir, lopinavir/ritonavir,
HBV resistance. Can cause hyperpigmentation of soles and feet. fosamprenavir, indinavir, nelfinavir, saquinavir, tipranivir)
Emtriva (emtricitabine) **All strong INHIBITORS of 3A4 = many drug Interactions
**Truvada (emtricitabine + tenofovir): Once Daily **Side Effects: Hyperglycemia, Insulin Resistance, Diabetes, fat
**Atripla (emtricitabine + tenofovir + efavirenz): Once Daily. maldistribution, hepatitis, immune reconstitution syndrome
Take on empty stomach. atazanavir (Reyataz): PR interval prolonging, hyperbilirubinemia
(aka bananvir), rash, take with 1.5 L of water to reduce
lamivudine: BBW for Hep B exacerbation once discontinued or nephrolithiasis. Needs Acid,Avoid acid suppressants b/c they can
HBV resistance. BBW to not use Epivir-HBV for HIV(contains decrease levels, take with food and water. (1st line)
lower dose of lamivudine). Preferred in Pregnancy darunavir (Prezista): Rash, Sulfa Allergy (1st line)
Epivir (lamivudine) ritonavir (Norvir): PR prolonging
Epzicom (abacavir + lamivudine) lopinavir/ritonavir (Kaletra) : PR prolonging, Preferred in Pregnancy
tenofovir: BBW for Hep B exacerbation once discontinued or
HBV resistance. Fanconi syndrome, renal failure, osteomalacia,
Integrase Inhibitors: (Raltegravir, dolutegravir, elvitegravir)
decreased bone density.
Viread (tenofovir) raltegravir (Isentress): 400mg BID
Truvada (tenofovir + emtricitabine)
Atripla (tenofovir + emtricitabine + efavirenz) Fusion Inhibitor: enfurvitide (Fuzeon)

Zidovudine: BBW for hematologic toxicity (neutropenia and local injection site reactions in 100% of patients
anemia) and myopathy. Preferred in pregnancy. CCR5 antagonist: maraviroc (Selzentry)

only works for CCR5 type HIV so must be screened before using
NNRTIs (Efavirenz, delavirdine, etravirine, nevirapine, rilpivirine) BBW for hepatotoxicity
Side Effects: UTRI, fever, rash, musculoskeletal symptoms, dizziness
**All can cause SJS(rash) and Hepatotoxicity
**Inhibitor of 2C9, 2C19, and 3A4, and strong INDUCER of
3A4 = many drug interactions Pregnancy: Combivir (lamivudine + zidovudine) + Kaletra
efavirenz (Sustiva): (lopinavir/ritonavir) OR atazanavir + ritonavir OR nevirapine (NNTRI)
600 mg daily on empty stomach. CNS side effects (vivid
dreams, drowsy, impaired concentration) and psychiatric Pre-Exposure Prophylaxis: Truvada 1 tab PO QD
Occupational post-exposure prohylaxis - Truvada + Raltegravir (Isentress) Diabetes:
x 4 weeks
Opportunistic Infections: Type 1: Autoimmune destruction of beta cells in the pancreas
Type 2: Insulin resistance or relative deficiency
PCP (CD4<200): Prophylaxis: SMX/TMP Tx: SMX/TMP +/- eAG: (28.7 x A1C) 46.7
corticosteroids Diagnosis: Classic signs (Polyuria/polydipsia/polyphagia/weight
Toxoplasma gondii (CD4<100): Prophylaxis: SMX/TMP Tx: loss) + A1C > 6.5 % or FPG > 126 or Random >200 or 2hr. glucose >
Pyrimethamine + sulfadiazine 200 after 75 gram OGTT
Mycobacterium Avum (CD4<50) Prophylaxis: Azithromycin Tx: Common drugs that alter glucose:
Azithromycin + Ethambutol Hyperglycemina- Corticosteroids, Thiazide/Loop Diuretics,
CMV Valganciclovir Statins, FQs, Protease Inhibitors
Cryptococcal Meningitis: Liposomal Amphotericin B + Flucytosine Hypoglycemia: FQs, Lorcaserin (Belviq satiety drug)
Treatment Goals: ADA: A1C < 7% Pre-Prandial 70-130 mg/dl
Post-Prandial: <180 mg/dl
Hepatitis/ Liver Disease: AACE: A1C < 6.5% Pre-Prandial <110 mg/dl Post-
Hepatic Encephalopathy: From Ammonia Buildup Prandial: <140 mg/dl
Tx: Lactulose or rifaximin (Xifaxan) + **low protein diet Tx: Lifetstyle Modifations: Weight Loss, Diet, Exercise, waist
circumference <35 for females and < 40 for males plus Drugs
Ascites: Furosemide and Spironolactone Nephropathy Screenings: (Annually)
microalbuminuria: 30-299
Hepatitis B: Vaccine preventable. Usually treat for 1 year. macroalbuminuria: >300
Tx: pegylated interferon (Pegasys) : BBW for many things; Add ACEi or ARB
exacerbate or cause autoimmune disorders, infectious disorders,
Retinopathy Screening: (Annually)
CVA, depression (20%) **pegylation increases half-life for once
Foot Screening: (Annually)
weekly dosing.
All diabetics should inspect their feet daily
NRTIs tenofovir (Viread),* lamivudine (Epivir HBV)
Type 2 Diabetes Treatment: Metformin is the initial treatment. If
entecavir(Baraclude)
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.
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. Drugs:
Genotype 2 and 3 treated for 24 weeks. Biguanides: (Metformin)
Tx: pegylated interferon (Pegasys or Pegintron): BBW for many
*decreased hepatic glucose production, *increase insulin sensitivity,
things. (See above)
decrease absorption of glucose
Ribavirin: BBW for teratogenic. SE: hemolytic anemia
Protease Inhibitor: (ex. boceprivir): only for genotype 1 metformin (Glucophage, Glumetza, Fortamet) (Janumet has
sofosbuvir (Sovaldi): inhibits HCV NS5B RNA polymerase sitagliptin)
**BBW: Lactic Acidosis GLP-1 Agonists: (Incretin Mimics) SQ injections
CI: SCr >1.5 (males) and SCr>1.4 (females). *Temporarily D/C in increase insulin secretion, decrease glucagon secretion, slow
patients getting IV contrast die, hold for 48 hours and once renal gastric emptying, improve satiety, may cause weight loss
function is normal
exenatide (Byetta), exenatide ER (Bydureon-Once Weekly),
Weight Neutral and little to no risk of hypoglycemia liraglutide (Victoza)
SE: Diarrhea, Nausea, Vomiting, Flatulence, Vit B12 deficiency, ER BBW for Bydureon and Victoza only for Thyroid C-Cell carcinoma
tablet shows up in stool sometimes (ok)
Warning for Pancreatitis
Max daily dose: 2,550 mg
SE:* Nausea (Primary Side Effect), **Weight Loss
Take with food
Byetta and Victoza 30 days, Bydureon 28 days room temp
Sulfonylureas: (Glipizide, Glimepiride, Glyburide)
DPP4-Inhibitors:
stimulate insulin secretion (do not use with meglitinides)
prevent the breakdown of GLP-1 agonists
chlorpropamide (Diabinese), glipizide (Glucotrol, Glucotrol XL,
sitagliptin (Januvia), sitagliptin + metformin (Janumet), saxagliptin
Glipizide XL), glimepiride (Amaryl), glyburide (Diabeta)
(Onglyza)
SE: Hypoglycemia and Weight Gain
Weight neutral
**glyburide (Diabeta) should not be used in renal impairment, it
SE: Nasopharyngitis, URTI, UTI
has a renally cleared active metabolite
SGLT2 Inhibitors:
Meglitinides: (baby sulfonylyureas)
canagliflozin (Invokana)
stimulate insulin secretion (do not use with sulfonylureas)
SE: Female genital mycotic infections, UTIs , hyperkalemia,
repaglinide (Prandin), nateglinide (Starlix)
increased urination
SE: Hypoglycemia, weight gain, URTI
Pramlintide (Symlin): Amylin analogue that increases satiety, prevents
Thiazolidinediones (TZDs): glucagon secretion after a meal, slows gastric emptying. Taken with insulin
PPARy agonists that cause increased insulin sensitivity at mealtime with separate injections. Reduce mealtime insulin dose by
pioglitozone (Actos), rosiglitazone (Avandia) 50%. Can be for Type 1 or Type 2 diabetics.
BBW: do not use in NYHA Class III/IV heart failure Bromocriptine (Cycloset) : Dopamine agonist that works in CNS to increase
SE: Peripheral edema, URTI, Weight gain insulin sensitivity. Take with food to decrease nausea.
coselevam (Welchol) bile acid sequestrant, unknown MOA in diabetes, CI
Alpha-Glucosidase Inhibitors: with TG>500. Some meds that need to be taken 4 hours before
administration of this: Sulfonylureas, Phenytoin, levothyroxine, oral
delay glucose absorption in intestines
contraceptives
acarbose(Precose)
*taken with first bite of each meal
*Flatulence and diarrhea are common
Insulin: Hypoglycemia: (BG <70 mg/dl)

***All insulins have a concentration of 100 units/ml except o Symptoms: Confusion, sweating, tachycardia, hunger, blurred
Humulin R U-500 which is 500 units/ml vision. **Beta blockers can mask the symptoms except
**Consider starting Type 2 with insulin if A1C>10% or BG>300 sweating and hunger.
Rapid-Acting: aspart (Novolog/Novolog Flexpen), lispro o Treatment: 15-20 grams of glucose ( 3-4 glucose tabs, 1 serving
(Humalog/Humalog Kwikpen ), glulisine (Apidra/ Apidra Solostar) : glucose gel, 4 oz orange juice, 8 oz milk, 4 oz non-diet soda)
28 days ***Glucagon only used if patient is unconscious or not
Regular/Short Acting: (Humulin R, Novolin R): 31 days(H) and 42 conscious enough to self-treat
days(N)
Side Note: NPH and Regular do not require a prescription.
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
Autoimmune Disorders:
Long Acting: glargine (Lantus) 28 days, detemir (Levemir) 42 days
Immunocompromised: Steroids (oral and injectable only) at 2mg/kg/day
or 20mg prednisone or prednisone equivalent for 14 days, Diseases (HIV,
NPH to glargine: If NPH is once daily, 1:1 TDD. If NPH is BID, then
Diabetes), Transplant Drugs, Oncology Drugs, Asplenia Drugs, and
reduce daily dose 20%
immunosuppressant drugs.
NPH to detemir: 1:1 TDD Biologic Immune Suppressants: Strong immune depression
Rheumatoid Arthritis: Chronic, Symmetrical, Polyarticular, Systemic, and
For Type 1: 0.6 units/kg/day (Total Daily Dose) Progressive inflammation of joints and organs.
Basal-Bolus: 50% TDD basal, 50% TDD bolus (divided evenly for 3 meals) Symptoms: joint swelling, morning stiffness, pain, and eventually
NPH-regular: 2/3 TDD NPH, 1/3 TDD regular (both divided BID) bone deformity
Goal is to have them on a DMARD within 3 months of diagnosis.
For counting carbs: Insulin to carbohydrate ratio:
May also need NSAIDs and steroids.
500/TDD = grams of carb covered by 1 unit rapid-acting some people with milder symptoms may be ok with just non-
450/TDD = grams of carb covered by 1 unit regular-acting biologic DMARDs
Treatments:
** Correction factor: (Blood Glucose Now - Blood Glucose Target)/
Correction factor Pain and Inflammation:

Correction factor is rule of 1800 for rapid-acting insulin (CF= 1800/TDD) or ibuprofen 800mg Q6-8hrs. (Max 3200 mg/day) ;
rule of 1500 for regular-acting Insulin (CF = 1500/TDD) OTC max 1200 mg/day
celocoxib (Celebrex) 100-200 mg BID

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


Non-Biologic DMARDs: Biologic non-TNF DMARDs:
methotrexate (Rheumatrex, Trexall): Low WEEKLY doses used, not rituximab (Rituxan): Depletes CD20 B Cells. BBW for severe/fatal
daily. Pregnacy Category X. SE: stomatitis (inflamed gums and infusion reactions, rashes etc. Given in combo with methotrexate.
mouth), alopecia, photosensitivity, increase LFTs. DO NOT take abatacept (Orencia)
with alcohol. tocilizumab (Actemra): BBW for serious infections. Can cause
hydroxychloroquine (Plaquenil): SE: pigmentation of skin and hair, hepatotoxicity.
rashes. Requires eye exams every 3 months.
sulfasalazine: CI with sulfa allergy and GI obstruction. SE: anorexia, Systemic Lupus Erythematous (SLE):
oligospermia, rash, folate deficiency, yellow-orange colored urine,
impaired folate absorption. Auto-antibodies form that damage tissue. There is flare-ups with
minocycline: SE: photosensitivity periods of remission.
leflunomide (Arava): Hepatotoxic, Pregnancy Category X. Butterfly rash on face typical
tofactinib (Xeljanz): BBW for increased infections, lymphomas and renal (Nephritis in > 50% of patients, hematologic, and neurologic
other malignancies, risk for developing active TB. manifestations)
Hydralazine can cause drug-induced SLE, ***found by ANA test
Biologics: (TNFa Inhibitors and Non-TNF)
**Can all increase risk of infections, screen for latent TB in all
Treatment:
Require Refrigeration (except etanercept can be at room temp.
o Anti-malarials: hydroxychloroquine (Plaquenil) or chloroquine; may
for 14 days). Wait until drug is at room temperature before
take 6 months to work
injecting.
o Prednisone
Do not use more than 1 biologic at a time and do not give live
o mycophenolate mofetil (CellCept): BBW for increased risk of
vaccines
infection, skin cancers, congenital malformations. SE: pain,
tachycardia, electrolyte abnormalities (hyperkalemia,
TNFa Inhibitors DMARDs: hypomagnesemia, hypocalcemia), hypotension, hypertension,
**BBW for SERIOUS INFECTIONS, lymphomas and other hypercholesterolemia, diarrhea, edema,vomiting, tremor, acne etc..
malignancies, risk for developing active TB. o belimumab (Benlysta) : IgG1-labmda antibody that prevents
**Can cause heart failure and hepatotoxicity survival of B cells by blocking the binding of B lymphocyte
etanercept (Enbrel): Sub Q stimulator protein (BlyS)
adalimumab (Humira): Sub Q
infliximab (Remicade): (IV)Infusion reactions and delayed Multiple Sclerosis:
hypersensitivity reactions. Given only in combo with Immune system attacks myelin sheaths on neurons in the
methotrexate. brain and spinal cord
golimumab (Simponi): Sub Q. Given only in combo with unknown cause
methotrexate. Most patients experience periods of disease with intervals
of remission
Treatment: Tx: levothyroxine (Synthroid, Levothroid, Levoxyl) Pregnancy
interferon beta drugs Safe
glatiramer acetate (Copaxone) liothyronine (T3,Cytomel), natural thyroid (porcine T3 and T4,
natalizumab (Tysabri): given every 4 weeks, can cause progressive Armour Thyroid)
multifocal leukoencephalopathy Drug Causes: Amiodarone, Interferon
Many drugs used for symptom control can worsen other symptoms Take on an empty stomach 30 min. before breakfast with a full
glass of water
IV to PO is 1:2
Celiac Disease: Symptoms: Weight Gain, Slow HR, Fatigue, Constipation, Weak
Immune response to gluten. Diarrhea, abdominal pain, Hyperthyroidism:
bloating, weight loss.
will have low TSH and high T4 (Graves is the most common
gluten is in wheat, barley, and rye
cause)
In many foods and many drug excipients. The actual
Tx for Graves: RAI-131 or surgery
drug doesnt contain gluten.
Tx Drugs:
Check for excipients on package insert and look for the
propylthiouracil (PTU, Propyl-Thyracil): used in 1st
word starch. The starch will either be corn, potato,
trimester, preferred in thyroid storm
tapioca, or wheat. If it doesnt say which starch then call the
methimazole (Tapazole): used in 2nd and 3rd trimesters
manufacturer to find out if the starch is wheat. You can
of pregnancy.
also try the website Gluten Free Drugs and the journal
Beta Blockers for symptoms: palpitations, tremors,
Hospital Pharmacy.
tachycardia
Drug Causes: Amiodarone, Interferon

Thyroid Disorders:
Thyroid hormone productions regulated by Thyroid Stimulating Transplant/Immunosuppression:
Hormone (TSH) Prior to transplant donor-recipient compatibility is done for
Elevations in T4 will inhibit secretion of TSH via negative feedback Human Leukocyte Antigen (HLA) and ABO blood group.
loop Allograft: transplant from one individual to another that have
T3 is more potent than T4 different genotypes
Its important to measure free T4 levels since it is the active form Isograft: transplant from a genetically identical donor
Hypothyroidism: Autologous Transplant: same patient, tissue moved to a
different site
will have high TSH and low T4 (Hashimotos is the most
Many BBWs: Infections, Cancer etc.
common cause)
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 raloxifene (Evista): SERM, often used in women at risk of breast
than 4 hours, skip it. CA. SE: Hot flashes, vaginal bleeding, amenorrhea etc..
Maintenance Immunosuppressant Therapy: teriparatide (Forteo): Human PTH, for high risk fractures, Sub Q
o Calcineurin inhibitors: tacrolimus (Prograf) 1st line or daily, max: 2 years
cyclosporine (Neoral, SandIMMUNE) . denosumab (Prolia): antibody to RANKL
Hormone Therapy:
** Interact with many drugs (3A4 and PGP
substrates). Avoid grapefruit and St. Johns Wort. For women: (Hormone Replacement)
Decreased estrogen at menopause causes high LH which can result
SE: Nephrotoxic, worsen diabetes, increase BP in hot flashes and night sweats. Also can cause vaginal dryness,
painful sex, mood changes etc..
o mTor Inhibitors: everolimus and sirolimus SE: worsen lipids Use the lowest possible dose for the shortest amount of time
o Antiproliferative: myophenolate mofetil (CellCept) or Estrogen can be used to prevent post-menopausal osteoporosis
mycophenolic acid (Myfortic) are 1st line. They are not but not treat it.
interchangeable. Women with a uterus shouldnt use estrogen alone b/c of
o +/- Prednisone 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
Osteoporosis and Hormone Therapy: intercourse
Osteoporosis: Estrogen SE: nausea, bloating, dizziness, breast tenderness
Vivelle-Dot: estradiol transdermal, applied to lower abdomen
Osteoporosis: T score <-2.5
below waistline
Osteopenia: T score between -1 and -2.5
Provera: medroxyprogesterone
PPIs can increase fracture risk
Premarin, Premarin Vaginal Cream, or Prempro (with
Ensure adequate Calcium and Vitamin D with any treatment
progesterone) : Conjugated Estrogens
o calcium citrate (Citracal): 315mg elemental, larger pill
paroxetine (Brisdelle) Pregnancy Category X, 2D6 inhibitor
o calcium carbonate (Oscal, Tums): acid dependent, 500mg elemental
o cholecalciferol (Vit D3) preferred. 600IU for <70, 800IU for 71+ For Men: (Testosterone Replacement)
Treatment: replacement is controversial
Bisphosphonates (1st line): alendronate (Fosamax) 70 mg may increase risk for prostate cancer, increase cholesterol, liver
weekly, risendronate (Actonel,Atelvia), ibandronate (Boniva), damage, and worsen BPH
zoledronic acid (Reclast)-yearly infusion. FDA warning to stop Androgel, Axiron, Depo-Testosterone etc..
after 3-5 years due to esophageal cancer, osteonecrosis of jaw, Gels are flammable until dry
and atypical femur fracture. Take first thing in the morning BBW for secondary exposure to women and children that could
before eating or drinking anything with 6-8 ounces of water. cause virilization (male characteristics)
Stay upright for at least 30 minutes, 60 min. for Boniva.
nonoxynol-9 is a common spermicide
Emergency Contraception:
Contraception and Infertility:
Plan B (levonorgestrel): good for 3 days (72 hours)
Pregnancy/Infertility: after sex, OTC now for all ages. If you vomit within 2
hours of taking, may want to take another dose.
There are ovulation kits that test to see if LH is present, first
Ella: Good for 5 days after sex, prescription only
3 days from a positive result are the best chances.
Paragard Copper IUD
Pregnancy test kits are positive if hCG is present
Higher than normal doses of regular daily oral
Should be taking 400-800 mcg/day folic acid at least one
contraceptives can be used
month before pregnancy
Infertility Tx: clomiphene (Clomid): SERM that increases
ovulation Pain The fifth vital sign
Addition of a non-opioid can often reduce the amount of
Contraception: opioid needed and provide superior analgesia
Progestin-Only Pills (POPs) It is important to distinguish between physiological
Estrogen and Progestin Pills (COCs) adaptation(Tolerance) and addiction
SE: Nausea, breast tenderness/fullness, bloating, weight Addiction has strong compulsion and desire to take drug,
gain, elevated BP. Can take at night or bedtime to reduce despite harm along with drug-seeking behavior.
nausea. Pseudo-addiction: Looks like addiction but could be from
Serious adverse effects: **Clotting; Increased risk from uncontrolled pain
smoking, age, HTN, diabetes, long bedrest, overweight, and Chronic opioid use needs constipation prophylaxis
any that contain drospirenone (Ortho-Evra Patch, YAZ, Sedation should be monitored b/c it is the most important
Yazmin, Beyaz, Ocella, etc..). Best to avoid these. predictor of respiratory depression, the usual cause of
Drospirenone acts as a potassium sparing diuretic. This is fatality in overdose.
why women like it because it decreases bloating and
weight gain but high risk for clotting.
Acetaminophen:
Drugs that decrease effectiveness (Inducers): Rifampin,
Anticonvulsants, St. Johns Wort, PIs and NNRTIs, Tylenol, hydrocodone+APAP (Vicodin, Lortab, Norco, Lorcet),
Cellcept, Smoking) oxycodone+APAP (Percocet, Endocet, Roxicet), codeine+APAP
Depo-Porvera shot (medroxyprogesterone): No drug (Tylenol #2,3,4), tramadol+APAP (Ultracet)
interactions but it does lower bone density. **BBW for Hepatotoxic: overdose can be fatal, (Max:
Nuvaring: If out greater than 3 hours in weeks 2 or 3, need 4000mg/day). Overdose Tx: N-Acetylcysteine to restore
backup for a week Glutathione
Ortho Evra Patch: if off greater than 24 hours, need backup DOC for pain in pregnancy
for a week **Avoid in heavy drinkers or known hepatitis (<2gm /day)
Aspirin/NSAIDs: tramadol (Ultram, Ultracet): serotonin syndrome risk, increased
seizure risk
ASA irreversibly inhibits while other NSAIDs reversibly inhibit COX
tapentadol (Nucynta)
ASA: Bayer, Bufferin, + caffeine/APAP (Excedrin), salsalate
ibuprofen (Motrin, Advil), naproxen (Aleve, Naprosyn, Anaprox), Allergic to morphine, hydrocodone etc.. : Can use fentanyl, morphine,
naproxen + esomeprazole (Vimovo), diclofenac (Voltaren), meperidine
indomethacin (Indocin), piroxicam (Feldene), ketorolac (Toradol),
sulindac (Clinoril) preferred with reduced renal function
Muscle Relaxants:
Selective COX-2 Inhibitors: celecoxib (Celebrex) - most selective,
meloxicam (Mobic), etodolac (Lodine), nabumetone (Relafen) o baclofen (Lioresal), cyclobenzaprine (Flexeril, Fexmif), tizanidine
NSAID BBW: CV risks (thrombotic events), GI (bleeding), CABG (Zanaflex), carisoprodol (Soma), metaxalone (Skelaxin),
contraindicated methocarbamol (Robaxin)
naproxen has a lower CV risk o cyclobenzaprine and tizanidine can cause xerostomia (dry mouth)
indomethacin (Indocin) has more CNS side effects so avoid in psych o tizanidine CI with Ciprofloxacin
conditions
ketorolac (Toradol) can only be used for 5 days max Neuropathic Pain Agents:
Celebrex CI with sulfa allergy
pregabalin (Lyrica) max: 600mg/day
Photosensitivity
duloxetine (Cymbalta)
Take with food
gabapentin (Neurontin) max: 3,600 mg/day
amitriptyline (Elavil) - anticholinergic
Opioids: milnacipran (Savella) - for fibromyalgia

BBW for respiratory depression Topical for Localized Pain :


No tolerance to constipation so need a laxative with all lidocaine (Lidoderm 5%) can cut into smaller pieces, 12 hours on
morphine (MS Contin, Avinza, Kadian, Oramorph SR, Roxanol) 12 hours off, approved for post-herpetic neuralgia.
*Avinza and Kadian can be opened and sprinkled on applesauce Capsaicin
*PO to IV is 3:1 diclofenac (Voltaren Gel)
fentanyl (Duragesic, Abstral, Fentora SL)
hydromorphone (Dilaudid)
oxycodone, Oxycontin, Endocet, Percocet, Roxicet, Roxicodone:
Migraine:
Avoid with 3A4 inhibitors Good to try and identify any triggers of migraine.
oxymorphone (Opana): take on empty stomach Triptan drugs are serotonin-receptor agonists and constrict
methadone (Dolophine): BBW for QT prolongation, serotonergic cranial blood vessels used to treat acute migraine.
meperidine (Demerol): serotonergic sumatriptan (Imitrex): PO, Nasal spray, Sub Q
hydrocodone (Lortab, Lorcet, Norco, Vicodin) rizatriptan (Maxalt) - eletriptan (Relpax)
codeine (Tylenol #2,3,4)
Prophylaxis: Beta blockers like metoprol and propanolol
Gout: Metolazone (Zaroxolyn): may work in reduced renal
function more than others.
Over-produce or under-excrete uric acid
Purines Xanthine Oxidase Uric Acid Loops: work in the ascending loop of Henle to inhibit Na+. Sulfa
People can be hyperuricemic and never get a gout attack Allergy except ethacrynic acid. Ototoxic. Can cause hypokalemia,
Drugs that increase uric acid: Diuretics, Niacin, ASA (High dose), HYPOcalcemia, hyperuricemia (gout), elevated lipids,
Pyrazinamide, Cyclosporine, Tacrolimus hyperglycemia, photosensititivity.
furosemide (Lasix): Oral Loop Dose Equivalency = 40mg
Tx: Acute attack:
bumetanide = 1mg
colchicine (Colcrys) 1.2mg orally then 0.6mg one hour Torsemide (Demadex) = 20mg
later (do not exceed 1.8mg). N/V/D in 80% of patients. ethacrynic acid (Edecrin) = 50mg
Only good within the first 36 hours of onset
NSAIDs: Indomethacin, naproxen, sulindac, celebrex Potassium-Sparing: Work in the DCT and collecting ducts. CI in CrCl
(off-label) <30 ml/min and hyperkalemia.
Systemic Corticosteroids: prednisone, triamterene (Dyrenium)
methylprednisolone triamterene + HCTZ (Maxzide, Dyazide)
Urate Lowering Therapy: When initiating therapy, there is in amiloride(Midamor)
increased risk of gout attacks so make sure to give colchicine or spironolactone (Aldactone): Can cause gynecomastia and
NSAIDs prophylactically for 6 months. breast tenderness. BBW for tumor risk.
epleronone (Inspra): for Heart Failure and HTN
allopurinol (Zyloprim): can cause hypersensitivity reactions
febuxostat (Uloric) RAAS Inhibitors:
probenecid: requires adequate renal function ***All have a BBW to discontinue if pregnant. CI in renal artery
pegloticase (Kystexxa) Uricase that turns uric acid into stenosis, angioedema, and pregnancy. All can cause hyperkalemia too.
allantoin
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
Hypertension fatal.

Diuretics:
ACE Inhibitors:
Thiazides: Work on the distal convoluted tubule to inhibit Na+. Sulfa ***Can cause dry cough. If so, switch to ARB.
Allergy. Can cause hypokalemia, HYPERcalcemia, elevated lipids, benazepril (Lotensin)
hyperuricemia (gout), hyperglycemia, photosensititivity, rash. enalapril (Vasotec)
Chlorthalidone (Thalitone) lisinopril (Prinvil, Zestril)
Hydrochlorothiazide quinapril (Accupril)
ramipril (Altace)
ARBs: Non-DHP: (Work in the heart, mainly for arrhythmias)
valsartan (Diovan) 3A4 substrates and inhibitors
losartan (Cozaar) diltiazem (Cardizem)
olmesartan (Benicar): ***Can cause Sprue-like verapamil (Calan, Verelan): Can be constipating
enteropathy (severe diarrhea)
telmesartan (Micardis)
irbesartan (Avapro) DHP: (For HTN and Angina)
Direct Renin Inhibitor: amlodipine (Norvasc)
aliskiren (Tekturna) nifedipine (Adalat CC, Procardia XL, Procardia)
Do not use with with ACEi or ARB in patients with diabetes nicardipine (Cardene): Comes IV also
clevidipine (Cleviprex): Do no use with soy or egg allergy
Beta Blockers:
***NOT FIRST LINE FOR HYPERTENSION ANYMORE Centrally acting alpha 2 agonists:
Can alter blood glucose levels clonidine (Catapres, Catapres-TTS patch): Patch is applied weekly.
propranolol (Inderal): Non-selective Do not stop abruptly or it can cause severe hypertension. Has
atenolol (Tenormin) many off-label uses (opioid withdrawal, anxiety, sleep etc.) Has
metoprolol tartrate (Lopressor): Take with food many side effects (bradycardia, drowsiness, sexual dysfunction,
metoprolol succinate (Toprol XL): Used in heart failure too. Max in depression, nasal stuffiness)
HF is titrating to 200mg/day. gaunfacine (Tenex): Intuniv is for ADHD
nebivolol (Bystolic): Also releases Nitric Oxide
carvedilol (Coreg): Used in heart failure too. Alpha and Beta
Direct Vasodilators:
Blocker. Take with food.
Dosing conversions between Coreg and Coreg CR: Hydralazine
3.125 BID Coreg10mg Coreg CR Daily, 6.25BID20mg, 12.5mg directly vasodilates arteries, litte effect on veins
BID40mg, 25mg BID80mg Hydralazine: can cause a rare lupus-like syndrome
labetalol (Trandate): Alpha and Beta Blocker. 1st line often in HTN
in pregnancy. Alpha Blockers: (Used mostly for BPH, not first line for HTN)
terazosin (Hytrin)
Side note: Beta Blockers with ISA: (acebutolol, carteolol, penbutolol,
doxazosin (Cardura, Cardura XL)
pindolol)- They dont decrease HR as much.
Combo Products:

Calcium Channel Blockers: amlodipine + benazepril (Lotrel)


amlodipine + valsartan (Exforge)
***Can cause peripheral edema and gingival hyperplasia. lisinopril + HCTZ (Prinzide, Zestoretic)
losartan + HCTZ (Hyzaar)
valsartan + HCTZ (Diovan HCT) The appropriate statin intensity is based on the patients level of risk:
olmesartan + HCTZ (Benicar HCT)
High Intensity Statins: (decreases LDL > 50%)
bisoprolol + HCTZ (Ziac)
o Atorvastatin 40-80mg/day
triamterene + HCTZ (Dyazide, Maxide) o Rosuvastatin 20-40mg/day
Moderate Intensity: (decreases LDL 30-49%)
o Atorvastatin 10-20mg/day
JNC 8 (Joint National Committee): o Rosuvastatin 5-10mg/day
> 60 yrs. old (<150/90) o Simvastatin 20-40mg/day
< 60 yrs. old (<140/90) o Pravastatin 40-80mg/day
>18 yrs. old with CKD or Diabetes (<140/90) o Lovastatin 40mg/day
Non-Blacks Initial Tx (including Diabetes): ACEi, ARB, CCB, or o Pitavastatin 2-4mg/day
Thiazide Low Intensity: (Decreases LDL <30%)
Blacks Initial Tx (including Diabetes): CCB or Thiazide o Simvastatin 10 mg/day
If CKD, must have ACEi or ARB regardless of race o Pravastatin 10-20mg/day
o Lovastatin 20mg/day
o Pitavastatin 1mg/day

Dyslipidemia:
Statins:
LDL = TC HDL (TG/5)
HMG-CoA reductase inhibitors
Non-statin therapies are not recommended unless statins are not **Liver enzymes need to be monitored. Stop drug if ALT or AST > 3
tolerated times upper limit of normal
Statins, fibrate, and niacin require LFT check at baseline. For Obviously they can cause rhabdomyolysis . Increased risk with
statins, recheck in 4-12 weeks after initiation or titration then Niacin or gemfibrozil (Lopid) use
every 3-12 months thereafter. CI in Pregnancy
fibrates (when TG are high) and fish oil can increase LDL SAL are 3A4 substrates
bile acid sequestrant can increase TGs simvastatin (Zocor), simvastatin + ezetimibe (Vytorin) 20mg,
**take in the evening.
4 groups should be initiated on statin therapy: Do not exceed 10mg/day with verapamil, diltiazem, or dronedarone
Clinical ASCVD including coronary heart disease (ACS, S/P Do not exceed 20mg/day with amiodarone, amlodipine, or
MI, stable or unstable angina, coronary or arterial ranolazine
revascularization), stroke, TIA, or PAD.
atorvastatin (Lipitor): equivalent dose: 10mg
LDL > 190
Do not use with cyclosporine
Diabetes and 40-75 yrs. old with LDL between 70-189
Do not exceed 20mg/day with clarithromycin or lopinavir/ritonavir
40-75 yrs. old with LDL between 70-189 with estimated
Do not exceed 40mg/day with nelfinavir and boceprevir (Hep C)
10-year ASCVD risk > 7.5%
lovastatin (Mevacor, Altoprev) 40mg, **Mevacor with Hepatotoxic (monitor LFTs) and causes Flushing/Itching. Can
evening meal, Altoprev bedtime. cause hyperuricemia (gout) and orthostatic hypotension.
Do not exceed 20mg/day with verapamil, diltiazem, or Slo-Niacin: Highest risk of hepatotoxicity
dronedarone IR Max: 6 gm/day ER/CR Max: 2gm/day
Do not exceed 40mg/day with amiodarone Flush-free doesnt work for cholesterol
rosuvastatin(Crestor) 5mg
Fish Oils:
pravastatin (Pravachol) 40mg
pitavastatin (Livalo): most potent, 2mg Not completely understood
Omega-3 acid (Lovaza) or Vascepa
Indicated as an adjunct in patients with TGs >500
Cholesterol absorption inhibitor: Can increase LDL up to 44% (Only Lovaza). Vascepa can cause joint
pain (arthralgia)
ezetimibe (Zetia)
Can prolong bleeding time
simvastatin + ezetimibe (Vytorin)
Bile Acid sequestrant:
colesevelam (Welchol): also approved for Type 2 DM to decrease Heart Failure:
A1C. Take with meals and liquid. Can cause constipation, bloating, Most commonly caused by ischemic heart disease (MI) and HTN
gas, cramping, increased triglycerides or neutral, sipping or holding Non-Pharmacologic Therapy:
in mouth can lead to tooth decay. monitor body weight daily
Many meds need to be taken 4 hours before or 4-6 hours after or it notify provider if symptoms worsen or weight increases
can bind them. sodium restriction to 1500 mg/day
ex. Oral Contraceptives, phenytoin, levothyroxine, olmesartan, weight reduction
sulfonylureas, tetracyclines and many others. exercise as tolerated
omega-3 fats are good
Avoid NSAIDs including COX-2 inhibitors
Fibrates: PPARa Activators
fenofibrate, fenofibric acid (Tricor, Trilipix) **Only Trilipix has Pharmacotherapy:
indication for use with a statin **ACEi/ARB and Beta Blockers improve survival and
gemfibrozil (Lopid): avoid if on a statin should be used in ALL heart failure patients (Except when
Can increase LDL if triglycerides are high CI). Titrate drug to target doses (from clinical trials).
Can cause myopathy and hepatoxicity Diuretics (Usually Loop)should be used to control fluid
Niacin: (nicotinic acid or Vit B3) volume (not shown to alter survival)
Aldosterone Receptor Antagonist: Reduce morbidity and
ER Niacin (Niaspan 500, 750, or 1,000 mg):*** Less flushing
mortality and should be added to those who progress to
and Less Hepatotoxic
NYHA Class III/IV.
**Amlodipine has a neutral effect on heart failure. Good Digoxin (Lanoxin):
for further BP control.
Inhibits the Na+/K+ ATP pump resulting in positive inotropic
It is a class effect with ACEi/ARBs but not with Beta-
(force) and negative chronotropic (rate)
Blockers. Only certain Beta-Blockers are used.
Does not improve survival but can decrease
Beta Blockers for HF: hospitalizations
Improves symptoms, exercise tolerance, and QOL
Metoprolol succinate (Toprol XL): Target dose is 200mg
Antidote: DigiFab
daily
Lower doses for renal insufficiency, smaller, older, female
Carvedilol (Coreg, Coreg CR): Target dose for IR is
Therapeutic range for HF: 0.5-0.9 ng/ml (Higher for Afib)
25mg BID (Unless >85kg then its 50mg BID) and for
Signs of toxicity: 1st signs are nausea, vomiting, loss of
Coreg CR is 80mg daily.
appetite, bradycardia. Blurred Vision, altered color
Bisoprolol (Zebeta): Target Dose: 10mg daily
perception, greenish-yellow halos, confusion, delirium.
Beta blockers are only stopped if hypotension or
Hypokalemia, hypomagnesemia, and hypercalcemia
hypoperfusion is present.
increase the risk of toxicity
Aldosterone Antagonists:
Acute Decompensated Heart Failure:
spironolactone (Aldactone) : Target dose
Congestion: Diuretics and/or IV vasodilators
25mg/day
Hypoperfusion or Cardiogenic Shock: Milrinone or Dobutamine
epleronone (Inspra): Target dose 50mg/day
Vasodilators used in ADHF:
o Nitroglycerin: Venous at low dose, Arterial at higher doses,
Hydralazine/Nitrate: effectiveness limited to 2-3 days.
o Nitroprusside (Nitropress): equal arterial and venous, protect
Hydralazine is a direct arterial dilator that
from light by covering with foil or opaque material, blue
decreases afterload. Nitrates are venous
solution indicates degradation to cyanide.
vasodilators that reduce preload.
o nesiritide (Natrecor): B-type natriuretic peptide, arterial and
Indicated for Black people with NYHA Class III/IV
venous dilation.
heart failure who are symptomatic despite optimal
therapy.
can be used in patients who cannot tolerate
Anticoagulation:
ACEi/ARBs Some risk factors for VTE: Surgery, Major Trauma, Immobility,
isosorbide dinitrate/Hydralazine (BiDil): CI with Cancer, previous VTE, Pregnancy, estrogen or SERM use etc..
PDE-5 inhibitors Heparin and LMWH can cause HIT: Body forms antibodies to
isosorbide mononitrate (Monoket): CI with PDE-5 heparin which leads to further platelet activation and pro-
inhibitors 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: Factor Xa inhibitors:
o binds to antithrombin and inactivates Factor Xa and IIa. Fondaparinux (Arixtra):
o VTE prophylaxis: 5,000 units SC Q8-12hrs INJECTABLE SubQ indirect factor Xa inhibitor. Works via
antithrombin like heparins.
o Also used for VTE treatment and ACS/STEMI treatment CI in severe renal impairment (CrCl <30 ml/min)
VTE: 80 units/kg IV bolus then 18 units/kg/hr infusion no antidote
ACS/STEMI: 60 units/kg IV bolus then 12 units/kg/hr inusion
Rivaroxaban (Xarelto):
o Do not mix-up the heparin injection with the HepFlush heparin line
o ORAL direct factor Xa inhibitor.
flushes
o A fib: 20mg PO QD (CrCl > 50); 15 mg PO QD (CrCl 15-50) with
o monitor aPTT and want to be 1.5-2.5 x control
evening meal
o Antidote: Protamine; 1mg will reverse 100 units; max 50mg.
o DVT prophylaxis (after knee/hip replacements): 10mg PO QD
o unpredictable anticoagulant response
without regards to meals
o IV and SC
o DVT/PE Tx: 15 mg PO BID x 21 days then 20mg PO QD with food
o osteoporosis with long term use
o **Can start when INR is < 3.0
o 3A4 substrate
LMWH:
o Do not use with CrCl< 15 ml/min
o binds to antithrombin and inactivates Factor Xa mostly and some
o no antidote
Factor IIa.
o BBW for hematomas and subsequent paralysis with spinal Apixaban (Eliquis): Similar to Xarelto
punctures.(Bleeds then pushes on the spine)
Direct Thrombin Inhibitors: (factor IIa)
o enoxaparin (Lovenox)
**VTE prophylaxis: 30mg SC BID CrCl< 30ml/min, 30mg SC directly inhibit Factor IIa (Thrombin)
daily. Argatroban: Used in patients with HIT, no antidote
**Tx of VTE and UA/NSTEMI: 1mg/kg SC BID CrCl< bivalrudin (Angiomax)
30ml/min, 1mg/kg SC daily dabigatran (Pradaxa) :
**Tx for STEMI (<75): 30mg IV bolus plus 1mg/kg SC o **ORAL
followed by 1mg/kg Q12 (Max 100mg for 1st two doses) o For non-valvular A-Fib
STEMI (>75) No bolus, just 0.75mg/kg SC Q12 (Max 75mg o 150 BID; 75 BID if CrCl 15-30 ml/min
for 1st two doses) o **Can start when INR is < 2.0
o dalteparin (Fragmin) o Swallow whole, do not put in NG tube.
o Anti-Xa levels can be monitored but not done routinely unless o 50% have dyspepsia
Pregnant or Mechanical heart valve, severe renal impairment, o **Keep in original container and keep lid tightly closed to
extreme weights. protect from moisture. Discard after 4 months of opening bottle.
o no antidote but protamine can help some o Store in cool, dry place. Not in a bathroom
o no monitoring or antidote
Warfarin (Coumadin, Jantoven): o nitroglycerin SL 0.4mg (400mcg) spray (Nitromist,
Nitrolingual pump spray): do not shake, prime it
Inhibits Vit K epoxide reductase which depletes Factors 2,7,9,10,
o isosorbide mononitrate IR/ER (Monoket) take when
and protein C and S.
you wake up and then 2nd dose 5 hours later
When starting, it is pro-thrombotic so use parenteral
o SE: HEADACHE (gets less bothersome), dizziness
anticoagulation for a minimum of 5 day and until INR is
Moderate to high dose statin if not CI
therapeutic for 24 hours
Annual Influenza
INR usually 2-3
Ranolazine (Renexa) also an option for angina. QT prolongation, no
For mechanical heart valves in the mitral or aorta and mitral often
effect on HR or BP. (anti-anginal)
2.5-3.5 is wanted
Pregnancy Category X
Antidote: Vitamin K; Oral is preferred when INR > 10 without Acute Coronary Syndromes: (UA/NSTEMI/STEMI):
bleeding. If major bleeding then IV Vit K infused slowly and four UA: chest pain, enzyme negative, no or transient EKG changes
factor PCC (Kcentra) for urgent warfarin reversal (can cause
NSTEMI: chest pain, cardiac enzymes (troponins, CK-MB), no or
anaphylaxis-like reaction). Kcentra has heparin in it, so dont use
transient EKG changes
with HIT. Avoid SC Vit K b/c of variable absorption and avoid IM due
STEMI: chest pain, cardiac enzymes (troponins, CK-MB), ST Elevation
to hematoma.
Side Effects: Bleeding, Skin Necrosis, Purple Toe Syndrome Initial Treatment: (MONA)
S-enantiomer more potent Morphine, Oxygen, Nitrates, Aspirin (162-325mg, then 81mg daily)
Pharmacogenomincs: 2C9*2 and *3 require lower doses
Then, other therapies added based on what is planned for the patient
VKOR polymorphisms require lower doses (GAP-BA)
GP 11b/IIIa anatagonist (abciximab (ReoPro), eptifibatide (Integrelin),
tirofiban): Abciximab irreversibly blocks. Can cause bleeding,
Chronic Stable Angina:
thrombocytopenia, hypotension.
plaque buildup in coronary arteries reduces blood flow to heart
Anticoagulants (Heparin, LMWH, fondaparinux, bivalrudin):
Could be from Prinzmetals angina which is vasospasm of coronary
arteries, not plaque. Calcium channel blockers preferred for this type. P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor): Prasugrel not for
Predictable chest pain CABG. Clopidogrel requires 2C19 for activation.
Treatment: Beta Blocker: within 24 hours without CI

Beta blockers are 1st line ACE inhibitor: within 24 hours without CI
ASA or Clopidogrel (for ASA allergy) PCI is usually preferred if facilities are available. Fibrinolytics used when
SL or spray nitroglycerin for immediate relief. Long acting nitrates facilities for PCI are not available or when PCI cannot be done within 90
can be used for chronic therapy as an add-on but require nitrate- min. Fibrinolytics should be started within 30 min. of arrival to hospital.
free intervals.
Fibrinolytics: alteplase, tenecteplase
o nitroglycerin SL tabs (Nitrostat 0.3, 0.4, 0.6mg)
NSAIDs not recommended post-MI due to risk of re-infarction. (Use ASA neuropathy, increased LFTs and blue-grayish skin, pulmonary
or Tylenol) fibrosis. All have Additive QT prolongation.
Class IV: Calcium Channel Blockers (diltiazem, verapamil)
Others: Digoxin (Lanoxin): Hypokalemia, hypomagnesemia,
Antiarrhythmics: and hypercalcemia increase risk of digoxin toxicity.
**Therapeutic range for Afib: 0.8-2 ng/ml. Enhances vagal
Usually from myocardial ischemia or infarction. Also from things
tone.
that damage the heart like HTN, heart failure, hyperthyroidism,
infection etc..
Electrolyte imbalances can cause arrhythmias (potassium,
sodium, magnesium, calcium)
Pulmonary Arterial Hypertension:
Drugs, including drugs to treat arrhythmias can cause it. Group 1 is PAH: can be idiopathic, genetic, liver disease, HIV etc.
Afib is the most common supraventricular arrhythmia and
Warfarin titrated to INR of 1.5-2.5
usually results in a rapid ventricular response.
prostacyclin analogues
QT prolongation is a risk factor for Tosades de Pointes, usually
endothelin receptor antagonists
drug-induced and can lead to sudden cardiac death.
soluble guanylate cyclase stimulator: riociguat (Adempas): CI with
Additive QT Prolongation: Class 1a and Class III antiarthymics, PDE-5
quinolones, macrolides, SMX/TMP, azole antifungals, TCAs, PDE-5 inhibitors: sildenafil (Revalo) or Tadalafil (Adcirca) : Different
some SSRIs (Citalopram, paroxetine, fluoxetine, escitalopram), Brands and doses than used in ED. CI with nitrates. If a patient is
antipsychotics, methadone, 5HT3 anatagonists (ondansetron), taking a PDE-5 inhibitor and has chest pain, hold nitrates for 24
PIs, anti-cancer drugs etc.. hours with sildenafil and vardenafil and 48 hours for tadalafil
Class Ia: (quinidine and procainamide) block sodium and (tadalafil has longer half-life).
potassium channels. Additive QT prolongation.
Class Ib: (lidocaine) pure sodium channel blockers. Only for Group 2 is PH, which is pulmonary venous HTN form left-sided heart failure.
ventricular arrhythmias. Cross BBB and so can have CNS
effects.
Class Ic: (flecainide, propafenone) sodium channel blocker. CI in
Asthma:
heart failure and acute MI. bronchial hyper-responsiveness and underlying inflammation
Class II: Beta Blockers (esmolol, propranolol) used to slow chronic inflammatory disorder of the airways
ventricular rate. Having patients demonstrate correct technique is often a good idea
Class III: (amiodarone (Cordarone, Pacerone, Nexterone), Wheezing, breathlessness, chest tightness, coughing; often at night
dofetilide (Tikosyn, has REMS program calls TIPS), or early in the morning
dronedarone, ibutilide, sotalol) mainly block potassium Common Triggers: Allergens, Drugs (NSAIDs, ASA, non-selective
channels. Amiodarone is the DOC if they have concomitant BBs), Cold air or humid hot air, smoke, chemicals, Respiratory
Heart Failure. It can cause Corneal deposits, photosensitivity, Infections.
Inhaled steroids are the preferred controller (sometimes with LABA). Leukotriene Receptor Antagonist:
Inhaled rapid-acting beta agonist preferred reliever for acute
montelukast (Singulair):
bronchospasm and prevention of EIB (Exercise-Induced Bronchospasm).
10mg QD, 1-5 yrs. old (4mg), 5-14yrs. old (5mg)
SABA: (For Rescue PRN) can cause headache and neuropsychiatric behavior
albuterol (ProAir, Proventil, Ventolin) For EIB, only works in 50% of patients, take 2 hours before
levalbuterol (Xopenex) exercise
has phenyalanine in it for a sweetener so dont use in PKU
If using SABA > 2 days/week then increase maintenance
therapy Theophylline:
not the most effective and has many drug interactions/side effects
LABA: (***BBW to only used with steroids, not monotherapy b/c
Therapeutic range: 5-15 mcg/ml
increased risk of death)
SE: nausea, loose stools
Once asthma is controlled, assess for stepdown therapy (removal of Aminophylline to Theophylline multiple by 0.8
LABA) without loss of asthma control. Theophylline to Aminophylline divide by 0.8
salmeterol + fluticasone (Advair Diskus or HFA)
Omalizumab (Xolair):
fomoterol + budesonide (Symbicort)

Inhaled Corticosteroids: (1st line therapy) For severe, allergic asthma. Inhibits IgE binding on mast cells and
basophils
beclamethasone (QVAR): ** preferred in pregnancy Should always be given in the doctors office
budesonide (Pulmicort)
can cause Anaphylaxis
fluticasone (Flovent)
mometasone (Asmanex) COPD:
SE: Oral Candidiasis (Thrush), dysphonia, cough. **Prevent thrush
causes by cigarette smoke and other noxious chemicals
with spacer or rinsing mouth with warm water and spit after use
dyspnea, chronic cough/sputum production
Oral Steroids: (for severely uncontrolled asthma) smoking cessation is the only thing that slows the progression
Cortisone, hydrocortisone (Solu-Cortef), methylprednisolone (Medrol, SABA and SAMA: Ipratropium (Atrovent), ipratropium + albuterol
Medrol Dosepak, Solu-Medrol), Prednisone, Prednisolone (Millipred, (Combivent Respimat)
Orapred, Prelone), triamcinolone (Kenalog), dexamethasone LABA and LAMA: tiotropium (Spiriva Handihaler) or aclidinium
(Decadron), betamethasone (Tudorza) More effective and more convenient. SE: Dry mouth.
If on it more than 10-14 days, requires a taper PDE-4 inhibitor: roflumilast (Daliresp): increases CAMP and
Long-Term SE: Cushing Syndrome, Immunosuppression, Acne, decreases lung inflammation
Insomnia/Nervousness, Hypokalemia, Amenorrhea, Osteoporosis, Steroids: long term monotherapy are not recommended in COPD,
Weight Gain, Diabetes, GI Bleed etc.. not very effective. Used in combo with LABA. (Advair and
Methylprednisolone 4mg = Prednisone/Prednisolone 5mg = 0.75mg Symbicort)
Dexamethasone Get Vaccines
Smoking Cessation: Avoid exposure to allergens
Moderate to severe: Intranasal Steroids 1st line : fluticasone
Counseling and medication are more effective used together than
(Flonase or Vermyst), mometasone (Nasonex), triamcinolone
either alone. Strong correlation between counseling intensity and
(Nasacort), beclamethasone (Qnasl or Beconase), budesonide
quitting success.
(Rhinacort)
5 As: Ask, Advise, Assess, Assist, Arrange (Follow Up)
Mild to Moderate: Oral antihistamines (Usually 2nd Gen): Good for
Patients often fail when they do not use enough NRT for a clinical sneezing, itching, rhinorrhea, but has **minimal effect on
effect. congestion.
Gum, Lozenge, and Patch are OTC only to 18 yrs. and older diphenhydramine (Benadryl): 1st gen, 25-50mg PO Q4-6
Nicotine Gum (Nicorette 2mg or 4mg) max: 24 pieces/day. Tapered hrs. Sedating.
dose. One Q1-2hrs. x 6weeks, then Q2-4 hrs. x 3 weeks, then Q4-8 chlorpheniramine (Chlor-Trimeton): 1st gen preferred in
hrs. x 3 weeks. Avoid acidic beverages (15 min. before or during Tx, pregnancy
water is ok.) <25 cigs/day = 2mg >25 cigs/day =4mg cetirizine (Zyrtec)
Nicotine Lozenges (Commit 2mg or 4mg) max: 20 lozenges/day. levocetirizine (Xyzal)
<30min to smoke in the AM =4mg; >30min to smoke =2mg loratidine (Claritin)
Nicotine Patches (Nicoderm CQ 7mg, 14mg, 21mg): Can remove to desloratidine (Clarinex)
avoid insomnia. Local skin reaction common. <10 cigs/day = 14mg fexofenadine (Allegra)
>10cigs/day=21 mg. 6 weeks (21mg), then 2 weeks (14mg), then 2 azelastine (Astelin): Intranasal
weeks (7mg) or 6 weeks (14mg), then 2 weeks (7mg) Decongestants: alpha agonists that cause vasoconstriction to
Nicotine Inhaler: Frequent, continuous puffing for 20 min. Clean reduce congestion:
mouthpiece. In cold temps, keep in warm area like pocket. Once a Oral: phenylephrine (Sudafed PE) : low bioavailability
cartridge is open, only good for 1 day. pseudoephedrine (Sudafed): Max able to buy: 3.6
e-cigarettes: not FDA approved, but popular g/day or 9 g/month, Max intake is 240mg/day.
Buproprion SR (Zyban, Buproban): Start 1 week before quitting, Nasal: Oxymetazoline (Afrin) or phenylephrine (Neo-
max: 450mg/day bc of seizures. SE: Dry mouth/insomnia. BBW for Synephrine). Limit use to < 3days to prevent rebound
neuropsychiatric events. congestion
Varenicline (Chantix): Nicotine agonist/ antagonist; Start 1 week Others: cromolyn (Nasalcrom), Intranasal ipratropium (for
before quitting. Do not use with nicotine products. BBW for rhinorrhea to dry mucus), Singulair, Nasal irrigation
neuropsychiatric events. Insomnia and Vivid Dreams.
Cold/Cough:
Get Vaccines: Smokers 19-64 should get the Pneumovax
Only gum and lozenge nicotine are pregnancy C, others are D. Zinc: can decrease duration of a cold
Vitamin C: may help prevent a cold
Usually a Viral Infection (ex. Rhinovirus)
Allergic Rhinitis, Cough and Cold: Advise patients to stay well hydrated
Humidifiers and Vaporizers can be useful. Do not use topical
Allergic Rhinitis Hay Fever:
menthol or camphor in children less than 2 yrs. old.
Children: OTC cough/cold/pain or aches products should not be Treatment:
used in children < 4 yrs. old. Combo cough/cold products should Bronchodilators: Use before giving inhaled antibiotics to help
not be used in children <2 per FDA or <6 per American Academy of antibiotic get in.
Pediatrics. Do not use ASA due to risk of Reyes syndrome. Hypertonic Saline (Hypersal): hyrdrates airway mucus to thin
ibuprofen (5-10 mg/kg Q 6-8 hrs.) Formulation 50 secretions
mg/1.25mL or 100mg/5ml DNAse enzyme: dornase alfa (Pulmozyme) to thin mucous
APAP (10-15 mg/kg Q4-6 hrs.) Formulation 160 Inhaled antibiotics: Tobramycin Inhaled Solution (TOBI) or
mg/5mL TOBI Podhaler or Aztreonam Lysine Inhalation (Cayston) to
Use calibrated syringe for measuring if its an oral liquid prevent and treat lung and sinus infections with chronic
dispensed infections. Take doses TOBI 6 hours apart and Cayston 4 hours
Decongestant: Do not use in children < 6 yrs. old except PSE (not < apart. Solutions stored in fridge, Podhaler xcapsules at room
4 yrs.). If pregnant, use intranasal spray like Oxymetazoline or temp. in a dry place. 28 days on, 28 days off cycle.
phenylephrine b/c oral PSE can decrease blood flow to infant. Oral Azithromycin: to reduce airway inflammation and disrupt
Pseudomonas biofilm
Cough: High Fat, calorie-dense diet
Dextromethorphan (Delsym or DM in the name): Many Pancreatic Enzymes: Peancrealipase (Creon,Pancreaze,
mechanisms but is also a serotonin reuptake inhibitor. Often abused Zenpep, Viokase): contains lipase, amylase, and protease. Dose
by people when taken in larger doses due to its ketamine/PCP like adjusted based on lipase component until stools are
hallucinagenic affects. Probably safe during pregnancy. normalized. Given before meals and snacks. Snacks get 50% of
Antihistamines: dont work for cold symptoms. May help cough. the dose. They are not interchangeable. Viokase is taken with a
Codeine: Never dispense codeine to a breastfeeding woman; can PPI b/c its not enteric coated.
cause fatal respiratory depression in an infant. Vitamin ADEK
Gauifenasin (Mucinex): decrease phlegm viscosity, unclear benefit. Insulin
Ivacaftor (Kalydeco): used for G551D mutations (4-5% of
population have this type). Taken with high-fat meal.
Cystic Fibrosis:
genetic disorder that disrupts CFTR protein causing abnormal
transport of sodium and chloride across cells Oncology:
leads to thick, viscous lung secretions, difficulty breathing, Treated with surgical, radiation, chemotherapy, hormone therapy,
infections, and digestive complication (Kills the pancreas). biological therapy, targeted therapy, immunotherapy and/or
Infections usually intermittent at first and eventually become vaccines.
chronic where they may need inhaled antibiotics. Majority of adverse effects are due to damaging non-cancerous cells
If intermittent pseudomonas, treat with two IV anti-pseudomonal that divide rapidly. Thus, nausea, vomiting, alopecia, and
agents. myelosuppression are common.
Most common bugs: Staph. Aureus, H. Flu, Pseudomonas.
Myelosuppression: All except asparaginase, bleomycin, and o Ondansetron (Zofran, Zuplez film), granisetron (Granisol),
vincristine. Cells generally recover after 3-4 weeks post-treatment. dolasetron (Anzemet), palonosetron (Aloxi): 5-HT3 antagonists,
o Anemia: Serum Ferritin, transferrin saturation (TSAT), and total risk of QT prolongation
iron binding capacity may be ordered b/c ESAs like (epoeitin o prochlorperazine (Compro) and promethazine (Phenergan):
(Epogen) and darbopoetin (Aranesp) will not work well unless block dopamine receptors in CNS. SE: sedation, lethargy, acute
iron levels are adequate. ESAs can shorten survival and increase EPS
risk for tumor progression in some cancers. Must enroll in and o dexamethasone (Decadron)
comply with the ESA APPRISE Oncology Program REMS to use o aprepitant(Emend) and fosaprepitant (Emend IV): substance
these agents with cancer. Also only used if HgB < 10. Not used P/Neurokinin-1 receptor antagonist
when anticipation is cure b/c they can cause thrombosis and o dronabinol (Marinol): Cannabinoid. SE: drowsy, euphoria,
tumor progression. SC and IV increased appetite
o Neutropenia: Colony stimulating factors (CSFs) can be given
prophylactically to patients at high-risk for febrile neutropenia.
Sargramostim (Leukine), Filgrastim (Neupogen), and Some Chemo drugs used in many cancers:
Pegfilgrastim (Neulasta). They can cause bone pain. Alkylators: Cyclophosphamide (Cytoxan) and ifosfamide (Ifex).
o Thrombocytopenia: Chemo might get placed on hold, dose They cross-link DNA preventing replication. SE: Bladder
reduction, or a transfusion(<10,000 or <20,000 with active bleed) Toxicity/BBW ***Hemorrhagic Cystitis so give Mesnex to prevent.
Hepatotoxic: Many
Nephrotoxic/ Bladder Toxic: Many; Hydration helps flush drug out. Anthracyclines: DOXOrubicin(Adriamycin) and DAUNOrubicin
Amifostene used to reduce risk of cisplatin renal toxicity. (Cerubidine). Intercalate into DNA. SE: BBW ***Cardiotoxicity,
Mesna(Mesnex) given with ifosfamide to prevent hemorrhagic Vesicant/Extravasation, red urine/body secretions. Do not exceed
cystitis. lifetime dose of 450-550 mg/m2 with DOXOrubicin and 400-550
Mucositis: high risk with 5-FU, capecitabine, irinotecan, and with DAUNOrubicin. Extravasation is treated with dexrazoxane
methotrexate. Use saline rinses daily. (Totect) or DMSO.
Hand-Foot Syndrome: 5-FU, and capecitabine
Clotting: Often from SERMS Platinums: cisplatin (Platinol), carboplatin (Paraplatin), oxaliplatin
Alopecia: Taxanes and anthracyclines (Eloxatin). Cross link DNA causing apoptosis. SE: Nephrotoxic,
Cardiotoxicity: Anthracyclines Ototoxic, neuropathy. Cisplatin has severe N/V.
Nausea/Vomiting: Most Chemo Drugs especially cisplatin, Amifostene to reduce cisplatin nephrotoxicity.
doxorubicin, epirubicin, cyclophosphamide, isofosfamide. CTZ
receptors are 5HT, Dopamine, Ach, Histamine, Opioid, and Methotrexate: folate antimetabolite that prevents DNA synthesis in
Substance P. the S-Phase. Leucovorin rescue to decrease toxicity. SE: Hand-foot
o usually uses a combination of anti-emetic drugs syndrome
Pyrimidine Analogues: capecitabine (Xeloda) and Fluorouracil (5- LHRH agonists: goserelin (Zoladex) and leuprolide (Lupron): start
FU). Inhibits pyrimidine synthesis in the S-Phase. SE: Hand Foot antiandrogen 1 week before to prevent tumor flare.
syndrome. CI with DPD deficiency. Leucovorin increases efficacy of Breast Cancer: (hormonal therapy to prevent recurrence, not the actual
5-FU. conventional chemo treatment)

Topoisomerase 1 inhibitors: ironotecan (Camptosar). Block coiling Must have ER/PR+ cancer for these to work
and uncoiling of DNA in S-Phase with single strand breaks. SE: Acute Aromatase Inhibitors: anastrozole (Arimidex), letrozole (Femara),
Diarrhea (treat with atropine), Delayed Diarrhea (treat with exemestane (Aromasin). Inhibit conversion of androgens to
loperamide) estrogen. SE: Osteoporosis, menopausal symptoms.
SERMs: tamoxifen (Soltamox), fulvestrant (Faslodex), raloxifene
Topoisomerase 2 inhibitors: etoposide(VePesid). Blocks coiling and (Evista)- Also for osteoporosis. Estrogen antagonists in breast but
uncoiling of DNA in G2 Phase with single strand breaks. SE: agonists in other tissues. SE: DVT/PE, menopausal symptoms.
Hypotension Tamoxifen increases risk of endometrial cancer.
Chronic Myeloid Leukemia:
Taxanes: paclitaxel (Taxol) and docetaxel (Taxotere): Inhibit
imatinib (Gleevec) : Tyrosine Kinase Inhibitor (TKI). Requires testing
microtubule function in M-Phase. Must use non-pvc IV bag and
for bcr-abl fusion gene.
tubing. SE: peripheral neuropathy. BBW for neutropenia. Always
give before platins. Non-small cell lung cancer:
erlotinib (Tarceva): TKI targeting EGFR
Vinca Alkaloids: vincristine (Vincasar) and vinblastine (Velban):
Multiple Myeloma:
Inhibit microtubule function in M-Phase. SE: Vesicants, nerve
damage/neuropathy (mostly vincristine). BBW: Intrathecal Signs of myeloma (CRAB): Calcium elevated, renal failure, anemia,
injections are fatal. Use hyaluronidase for extravasation. bone lesions
cancer of plasma cells in bone marrow
Thalidomide (Thalomid) and its derivatives. Do not get pregnant
Monoclonal antibodies: (Inhibit growth factors that promote cancer while using, very teratogenic.
cell growth)
Traztuzumab (Herceptin): HER2/Neu over-expression
required for use. Cardiotoxicity Anemia:
Cetuximab (Erbitux): EGFR positive = good response, K-
ras mutation = poor Decrease in RBCs and/or Hgb and Hct.
Rituximab (Rituxan): Targets CD-20, also used in RA Mainly caused by impaired production, increased destruction, or
blood loss.
Prostate Cancer:
Iron is essential for Hgb formation. If iron is low, ESAs will not work
Antiandrogens: bicalutamide (Casodex) and flutamide (Eulexin) so correct iron first.
Most people can use oral supplementation for iron. Iron IV is often Sickle Cell Disease:
used for hemodialysis.
genetic disorder that causes shape of Hgb and RBC to change. They
Iron Deficiency Anemia: MCV (<80) and MCH Low (Microcytic)
cannot transport oxygen properly and get stick in smaller blood
Oral Ferrous Sulfate is 1st line (not SR or Enteric Coated).
vessels.
Absorption is enhanced by acidic gastric environment. Take
1 hour before meals b/c food will decrease absorption. This can deprive tissues of oxygen leading to ischemia and pain
325 mg PO TID (sickle cell crisis or vaso-occlusive crisis)
SE: Nausea/Constipation. May want to use docusate stool ACS is the leading cause of death in SCD. 35% of infants die from
softener. infections. Chronic anemia is likely.
Separate from chelators: FQ, tetracyclines, Treatment: Vaccines, Antibiotics, Analgesics, Folic Acid, and
bisphosphonates etc.. Hydroxyurea (stimulates fetal Hgb)
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 IV Drugs, Fluids, and Antidotes:
(Venofer). Usually used for hemodialysis. Iron dextran has a
Peripheral IV: placed in a small vein
BBW for anaphylaxis.
Central IV: placed in a large vein. Example is a peripherally inserted
central catheter (PICC). Can give meds that would be overly
Folate or B12 Deficiency Anemia: MCV (>100) and MCH High
irritating to peripheral veins like higher doses or greater volumes.
(Macrocytic)
Disadvantages: higher bleeding risk, infection, thromboembolism,
can lead to neurological consequences
and more difficult to insert.
Pernicious anemia is when there is a lack of intrinsic factor
Concern with PVC:
required for gut absorption of B12 and folate. The Schilling
Leaching: Drugs pull out DEHP from bag: tacrolimus,
test can diagnose this. They will require lifelong B12
temsirolimus, teniposide, cabazitaxel, docetaxel,
replacement, usually by B12 injection.
ixacabepilone, and paclitaxel.
cyanocobalamin (B12) and folic acid (folate/vitamin B9)
metformin may decrease B12 absorption
Sorption: PVC bag pulls in drug: Amiodarone, carmustine,
lorazepam, sufentanil, thiopental, insulin, nitroglycerin.
Anemia of Chronic Disease: MCV and MCH normal
Colloids and Crystalloids: Colloids do not readily cross capillaries
Chronic Kidney Disease: causes anemia via deficiency in
(stay in veins) and may provide more intravascular volume
erythropoietin. May need ESAs at the lowest possible
expansion than equal volumes of crystalloids, but they are
dose started when Hgb is < 10. Transferrin should be at
expensive. Crystalloids are less costly and safer.
least 20% and ferritin should be at least 100 ng/ml prior to
starting ESA.
Shock: (Hypovelemic, Cardiogenic, Distribuitive, Obstructive,
Neurogenic)
Fluid Resuscitation is 1st line
Vasopressors: not effective without adequate fluid. fentanyl: less hypotension than morphine b/c no histamine release
o Dobutamine: B1 Inotrope that increases HR, hydromorphone (Dilaudid)
Contractility, and CO. haloperidol (Haldol): QT prolongation, EPS
o Dopamine: At medium doses B1 (SV/CO), at higher
Acid-Base Homeostasis:
doses a1 (vasoconstriction)
o Epinephrine (Adrenaline): alpha and beta. pH < 7.35 is acidosis, pH > 7.45 is alkalosis
o Norepinephrine(Levophed): a1 (mostly) and beta Metabolic or Respiratory
o Phenylephrine (Neo-Synephrine): all a1 Anion gap: Na+ - (Cl- + HCO3-) > 12 is gapped
(vasoconstriction) Electrolyte Disorders:
o Vasopressin: V1 and V2 agonist (vasoconstriction)
Sodium: Dont correct more than 12mEq/L in 24 hours to prevent
***The vasoconstrictors can cause peripheral ischemia and central pontine myelinosis which is a devastating neurological
necrosis (gangrene) complication.
***If extravasation, treat with phentolamine (alpha blocker) Potassium: IV potassium should not be faster than 10-20 mEq/hr.

ICU sedation, analgesia, and delirium: Stress Ulcer Prophylaxis:


Optimize analgesia first, usually fentanyl, morphine, Critical illness leads to reduced blood flow to gut which results in
hydromorphone breakdown of gastric mucosal defense mechanisms
Sedation usually with benzos (midazolam), propofol, or
Patients without risk factors should not receive prophylaxis
dexmedetomidine (Precedex). Propofol can cause infusion
(Mechanical Vent, Coagulopathy, Sepsis, Brain Injury, Burns, Renal
reactions that result in cardiac arrhythmias and death.
Failure, High Dose Steroids)
Patients should frequently be assessed with a validated
H2 blockers
sedation scale to adjust therapies.
The ACCM recommends using Precedex to sedate patients VTE prevention:
with delirium. High Risk: Surgery, trauma, immobility, cancer, previous VTE,
pregnancy, estrogen etc..
UFH: 5,000 units SC BID-TID
Commonly used agents for agitation and sedation: LMWH: Enoxapin 30mg SC BID or 40mg SC Daily. If CrCl<30, use
lorazepam (Ativan) 30mg SQ Daily
midazolam Anesthesia:
propolol (Diprivan): propofol infusion related syndrome(PRIS), rare
but can be fatal. Hypertriglycerides must be closely monitored
dexmedetomidine (Precedex): **Sedation without Respiratory Inhaled anesthetics can cause malignant hyperthermia and should
Depression be given dantrolene.
morphine: has active metabolite M6G, hypotension from Neuromuscular blockers: cisatracurium (Nimbex) and Vecuronium
histamine release . Do not provide sedation or analgesia.
IV compatibility resources: Should do a 6-8 week trial at an adequate dose before concluding
its not working well.
Trissels
Going to or from an MAOi requires 2 week washout period except
King Guide
fluoxetine requires 5 weeks because of its long half-life. MAO
Poison Management: interaction can be lethal if taken with other serotonergics.
Insecticide Poisoning/Nerve Agents: Organophosphates that inhibit Pregnancy:
acetlycholinesterase, leads to increase Ach. MUDDLES: miosis FDA warning that SSRIs can cause persistent pulmonary
(pinpoint pupils), urination, diarrhea, diaphoresis, lacrimation, hypertension in the newborn (PPHN).
excitation, salivation Paroxteine (Paxil) is category D, paroxetine (Brisdelle) is
category X. Brisdelle is for menopausal symptoms.
PTSD:
Antidotes for select toxicities:
After a life-threatening experience or an event that involves
APAP: N-acetylcysteine a threat to life or serious injury.
Anticholinesterase: Atropine Many physical, cognitive, emotional, and behavioral
Benzos: Flumazenil (Romazicon) symptoms.
Beta Blockers: Glucagon Sertraline and Paroxetine are FDA approved for this
Digoxin: Digoxin Immune Fab (Digifab)
SSRIs:
Heparin: Protamine
Iron: deferoxamine (Desferal) BBW for increased risk of suicidal thinking in children, adolescents,
Isoniazid: (Pyridoxine Vit B6) and young adults (18-24)
Opioids: Naloxone can cause persistent pulmonary hypertension in the newborn
Warfarin: phytonadione (Mephyton) = Vitamin K (PPHN)
SE: increased bleeding risk, sexual dysfunction (not erection),
insomnia, somnolence, SIADH (hyponatremia)
Fluoxetine (Prozac): Can take 90mg/week, 2D6 inhibitor, most
Depression:
activating so take in the morning if you have insomnia with it.
Inform patients that physical symptoms such a slow energy improve Sarafem is used for pre-menstrual dysphoric disorder.
within a few weeks but psychological symptoms may take a month Paroxetine (Paxil): 2D6 inhibitor
or longer. Sertraline (Zoloft)
All drug therapies should be given with competent, concurrent Citalopram (Celexa): **QT prolongation risk with >40mg/day, or
psychotherapy. (rarely done) >20mg/day and over 60, or liver disease, or 2C19 poor
To avoid withdrawal when discontinuing, the drug should be metabolizers.
tapered. Escitalopram (Lexapro): Can also cause QT prolongation
Withdrawal symptoms: anxiety, agitation, insomnia,
dizziness, flu-like symptoms. (Paroxetine and some others
carry a high-risk)
DNRI: (DA and NE reuptake inhibitor) QT prolonging, Orthostasis, Anticholinergic (Dry mouth, blurred
vision, urinary retention, constipation), sedation, weight gain etc..
bupropion (Wellbutrin); Zyban or Buproban for smoking cessation Amitriptyline (Elavil)
CI: do not use in seizure disorder, do not exceed 450mg/day Doxepin
(seizures), do not use in bipolar, do not use in anorexic deispramine
No effects on 5HT so no sexual dysfunction or bleeding nortriptyline (Pamelor)
SE: insomnia and dry mouth
MAOi:
SNRIs:
Inhibit monoamine oxidase which normally breaks down
SE: same as SSRI plus Increased BP, urethral resistance, catecholamines 5HT, DA, NE, EPI.
venlafaxine (Effexor) Not commonly used but watch for drug-drug and drug-food
desvenlafaxine (Pristiq) interactions
duloxetine (Cymbalta): CYP2D6 inhibitor Can lead to hypertensive crisis, serotonin syndrome, and psychosis
levomilnacipran (Fetzima) if combined with other drugs.
isocarboxazid (Marplan)
phenelzine (Nardil)
Mixed SSRI and 5HT-1A partial agonists:
tranylcypromine (Parnate)
vilazodone (Viibryd) selegiline
vortioxetine (Brintellex)
Treatment resistant depression:
Other:
aripiprazole (Abilify)
mirtazapine (Remeron): inhibits 5HT reuptake and a1-blocker and olanzapine/fluoxetine (Symbyax)
antihistamine quetiapine (Seroquel)
SE: sedation and weight gain from increased appetite
used in oncology and skilled nursing homes to help with
sleep and weight gain in elderly
Schizophrenia/Psychosis:
trazodone: inhibits 5HT reuptake and a1-blocker and 5HT2A/C
blocker. Mainly used for sedation, rarely as antidepressant. ***BBW for all anti-psychotics is increased death in elderly with
SE: sedation and priapism dementia-related psychosis, primarily due to increase strokes and
infection.
Tricyclics:
chronic relapsing, remitting episodes that are a result of excess
NE and 5HT reuptake inhibitors primarily but also anticholinergic dopamine
and antihistamine Has positive and negative signs
more side effects than others Positive Signs: Hallucinations, delusions (false beliefs)
Tertiary or Secondary amines: Secondary are more selective for NE Negative Signs: Anhedonia (loss of interest), lack of emotion, poor
but might not be as effective hygiene, social withdrawal
Treatment adherence can be difficult to obtain Clozapine (Clozaril): most effective but can cause
One of the highest suicide rate agranulocytosis ,*seizures, and myocarditis. REMS- Patients
1st Gens (more EPS and sedation, less weight gain/metabolic SE), must register with the Clozaril registry. Only pharmacies
2nd Gens (Less EPS, more weight gain/metabolic SE) registered for this can dispense it.
Neuroleptic Malignant Syndrome: Extreme Muscle Rigidity and Olanzapine (Zyprexa):
Hyperthermia (rare and mainly with 1st gens.) Quetiapine (Seroquel): least movement issues
Clozapine has high efficacy but has many BBWs and side effects. It Ziprasidone (Geodon): High QT prolongation risk
should be considered for those who have failed with trying two Aripiprazole (Abilify)
others. Paliperidone (Invega): increased Prolactin
ODTs useful for cheeking where patients will cheek the medicine Risperidone (Risperdal): increased Prolactin
and then spit it in the toilet. Lurasidone (Latuga)
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 Bipolar Disorder:
risk
Show periods of mania and depression. Bipolar I is more severe.
Weight Gain/Metabolic Effects: Clozapine, Olanzapine,
Bipolar II has less severe mania (Hypomania) that does not have
Quetiapine, Risperidone, and Paliperidone.
psychotic features or need hospitalization.
Prolactin: Inhibiting dopamine can increase milk production and
Mood Stabilizer (lithium, valproate, carbamazepine (Equetro),
lead to osteoporosis. Highest risk with Risperidone and
lamotrgine) are defined as drugs that can treat mania or depression
Paliperidone.
without inducing either.
1st Gens: 1st gen antipsychotics can push them to depressive state but 2nd
Block D2 and 5HT2A gens do not and some 2nd gens have antidepressant effects.
Thioridazine, Haloperidol (Haldol), Chlorpromazine, Antidepressants can push them to mania so only use them if there
Loxapine, Perphenazine, Fluphenazine, Thiothixene is a mood stabilizer also.
All cause EPS (Dystonia, Akathisia, Parkinsonism, TD, Treatment: Mood Stabilizer, 2nd Gen Antipsychotic, or Combo of
Dyskinesia etc..) and are sedating. Tardive Dyskinesia (TD) both.
can be irreversible (higher in elderly females). Mood Stabilizers:
valproate/valproic acid (Depakene, Depacon, Stavzor): BBW
teratogenic, hepatic failure, pancreatitis; inhibits 2C9
Divalproex (Depakote): BBW teratogenic, hepatic failure,
2nd Gens: pancreatitis
Block D2 and 5HT2A (except Abilify, it blocks 5HT2A but is a lamotrigine (Lamictal): BBW skin reactions (SJS and TEN), not used
partial agonist at D2 and 5HT1A) in mania.
**Weight gain/metabolic side effects.
Lithium (Lithobid): DO NOT USE IN RENAL IMPAIRMENT (100% amantadine (Symmetrel): blocks dopamine reuptake and increases
renally cleared); Therapeutic range is 0.6-1.2 mEq/L trough. SE: GI, release. SE: Toxic delirium and livedo reticularis (redish skin
Cognitive, cogwheel rigidity, hand tremor, weight gain, mottling). Also used in Flu as a neuramidase inhibitor.
polyuria,polydipsia, serotonergic. Maintain adequate fluid intake benztropine (Cogentin) and trihexphenidyl: anticholinergics so
and keep salt constant. mainly used in younger patients
MAO-B inhibitors: selegiline, zeleplar, rasagiline (Azilect). Azilect can
2nd Gen Antipsychotics used:
be used as initial monotherapy.
Aripiprazole (Abilify), quetiapine (Seroquel), risperidone
(Risperdal), ziprasidone (Geodon), lurasidone (Latuda), olanzapine Alzheimers
(Zyprexa) most common type of dementia
Parkinson Disease: memory loss, irritability, difficulty planning and organizing,
personality changes
Substantia nigra part of brain has cells that make dopamine. When Pathophysiology: Amyloid plaques and neurofibrillary tangles
they are damaged and stop making dopamine. This is what causes Decreased Ach
the disease. Drugs that can worse dementia: Anticholinergics, Antipsychotics,
Tremor, bradykinesia (slow movements), rigidity (stiffness), Anithistamines, Barbiturates, Benzos, Skeletal Muscle relaxants,
postural instability and other CNS depressants.
Most have depression from it and tricyclics (nortriptyline) seem to
work best Treatment:
Psychosis can happen in later stages and *quetiapine (Seroquel) is Acetlycholinesterase Inhibitors are the mainstay of treatment.
preferred. Some improve a little and some dont. Even without showing clinical
***Drug induced (Dopamine Blockers): prochlorperazine (D2 improvement, they may have slower progression vs if they didnt
blocker for nausea), antipsychotics, metoclopramide (Reglan: D2 take the medication.
blocker and prokinetic from muscarinic activity). Gingko Biloba is used by some, studies are unclear but it can
Treatment: increase bleeding

carbidopa/levodopa (Sinemet): 70-100 mg of carbidopa is needed Achesterase Inhibitors:


to prevent the peripheral conversion of Levodopa to DA by dopa donepezil (Aricept, Aricept ODT)
decarboxylase. Can cause brown, black or dark urine. Can cause rivastigmine (Exelon, Exelon patch): take with food
unusual sexual urges and priapism. galantamine (Razadyne, Razadyne ER)
entacapone (Comtan): inhibits COMT to prevent peripheral SE: GI (N/V/loose stools), bradycardia, insomnia, fainting
breakdown of levodopa.
NMDA receptor antagonist:
pramipexole (Mirapex) and ropinirole (Requip): Dopamine
agonists. Also bromocriptine. memantine (Namenda): only for mod-severe
disease with or w/o Aricept
ADHD: temazepam (Restoril)
midazolam (Versed)
Inattention, hyperactivity, impulsivity estazolam
1st line therapy is stimulants; atomoxetine (Strattera) is a non- triazolam (Helcion)
stimulant that can be tried afterwards or 1st line if the prescriber is clorazepate (Tranzene)
concerned of abuse. oxazepam (Serax)
Stimulants: ** LOT (Lorazepam, Oxazepam, Temazepam): less harmful in elderly and
Methyphenidate: Ritalin XR/SR/LA, Concerta (IR/ER combined hepatic impairment bc they are metabolized to inactive compounds.
from OROS system), Metadate CD (IR/ER beads), Daytrana (patch) **Benzos Pregnancy D: Due to cleft palate and lip
Dexmethylphenidate (Focalin, Focalin XR)
Dextroamphetamine and amphetamine (Adderall, Adderall XR) Insomnia:
Dextroamphetamine IR (Dexedrine, Dextrostat) Lifestyle changes are the preferred treatment
Lisdexamfetamine (Vyvanse): can mix capsule contents with water Hypnotics are over-prescribed
and take stat.
Sleep Drugs:
Focalin XR, Adderall XR, Metadate CD, and Ritalin LA can be taken
whole or sprinkled on applesauce. zolpidem (Ambien, Ambien CR)
zaleplon (Sonata)
Non-stimulants:
eszopiclone (Lunesta)
Gaunfacine (Intuniv) or clonidine ER (Kapvay) are most often temazepam (Restoril)
adjuncts lorazepam (Ativan)
atomoxetine (Strattera): NE reuptake inhibitor Other: Ramelteon (Rozerem): melatonin receptor agonist
trazodone
Anxiety:
diphenyhydramine(Benadryl): antihistamine, DO NOT USE
Fear and worry are the primary symptoms along with tachycardia, IN ELDERLY
SOB, insomnia, fatigue.
Anxiety disorders interfere with the ability to lead a normal life.
SSRIs and SNRIs are primarily used Epilepsy/Seizures:
Buspirone (Buspar) is a 2nd line option, 5HT1 partial agonist,
Unprovoked seizures or abnormal electrical storm in the brain
pregnancy B
Partial or Generalized. Partials can spread and become secondarily
Benzodiazepines:
generalized.
lorazepam (Ativan)
alprazolam (Xanax) Status Epilepticus: seizure lasting more than 5 minutes or 2 or more
clonazepam (Klonopin) seizures between where there is incomplete recover of
diazepam (Valium) consciousness. Its a medical emergency. (Lorazepam is the DOC)
chlordiazepoxide (Librium)
Pregnancy: Carbemazepine, clonazepam, phenobarbital/primidone, If the albumin is low, the true phenytoin level will be
phenytoin/phosphenytoin, topiramate, and valproate are higher than it appears.
Pregnancy Category D. Valproate for migraine prophylaxis is PHT correction= PHT measured/(0.2x Alb) + 0.1
Category X. All other are category C.
**All require MedGuide for risk of suicidality Valproate/Valproic Acid (Depakene, Stavzor, Depacon) and
Most AEDs can lower Vit D so all patients on these should Divalproez (Depakote):
supplement with Vit D and Calcium.
Discontinuing always requires a taper to prevent seizures Therapeutic range: 50-100 mcg/mL
Many Drug Interactions: BBW: Hepatic Failure, **Teratogenic (neural tube defects,
Inducers: carbamazepine, oxcarbazepine, phenytoin, spina bifida) and Pancreatitis
fosphenytoin, phenobarbital, primidone, topiramate. SE: Dose-related thrombocytopenia, alopecia, low IQ in
Inhibitors: Valproate children if exposed in utero, pancreatitis, tremor.
If the albumin is low, the true valproate level will be
Treatment:
higher than it appears, use phenytoin formula.
Benzos: clonazepam
Carbamazepine (Tegetrol, Carbatrol, Epitol): Fast sodium channel Lamotrigine (Lamictal):
blocker and also stimulates release of ADH. BBW: Skin reactions (SJS and TEN). Titration schedule
Therapeutic range: 4-12 mcg/mL depends on if currently taking another AED (inducer or
BBW: Skin reactions (SJS and TEN) usually 2-8 weeks after inhibitor).
initiation. If Asian, must test for HLA-B*1502. Can cause Pregancy C
aplastic anemia and agranulocytosis. Levetiracetam (Keppra): ** No significant drug interactions,
SE: SIADH, hepatotoxic. Pregnancy C
Phenobarbital (Luminal) and primidone: Enhance GABA mediated Oxcarbazepine (Trileptal, Oxtellar XR): Skin Reactions SJS and TEN,
chloride influx. Primidone is a prodrug of phenobarbital. Hyponatremia
Phenytoin (Dilantin,Phenytek) and Fosphenytoin: Fast sodium Pregabalin (Lyrica): SE: peripheral edema, weight gain
channel blockers. Has saturable michaelis-menton kinetics. Gabapentin (Neurontin) SE: edema, weight gain
Therapeutic range: 10-20 mcg/ml Topiramate (Topamax): SE: metabolic acidosis,
BBW: Phenytoin max rate: 50mg/min IV and Fosphenytoin oligohydrosis/hyperthermia, nephrolithiasis
max rate: 150mg PE/min IV zonisamide (Zonegran): Sulfa Moiety. Skin Reactions (SJS and TEN)
SE: Dose-related toxicity (ataxia, slurred speech, felbamate (Felbatol): BBW for Aplastic Anemia and Hepatic Failure
nystagmus), skin thickening, gingival hyperplasia, hirsutism, lacosamide (Vimpat): No significant drug interactions
connective tissue changes, coarsening of facial features,
folate deficiency, hepatoxic.
Supplementation with B12, folate, calcium and Vit D
recommended
Stroke: Antacids:
calcium (Tums), magnesium (Milk of Magnesia), magnesium
Ischemic or Hemorrhagic + aluminum or calcium (Maalox, Mylanta), Mag-Al-
Hemorrhagic Treatment: Simethicone (Maalox Max, Mylanta Max), Gaviscon.
Neutralizes acid within minutes and lasts 1-2 hours.
compression stocking to prevent VTE, no anticoagulants
SE: Magnesium can make you poop, Aluminum can cause
Intracerebral Hemorrhage: Mannitol (Osmitrol): Increases
constipation.
the osmotic pressure to reduce the intracranial pressure.
Subarachnoid Hemorrhage: nifedipine (Nymalize)
Ischemic Stroke Prevention: H2 Blockers:
Correct modifiable risk factors: HTN, Diabetes, Dyslipidemia, famotidine (Pepcid AC, Pepcid AC Max), ranitidine (Zantac),
Weight, Smoking etc.. cimetidine (Tagamet), nizatidine (Axid).
Primary prevention: Recommended for Afib Avoid cimetidine due to drug interactions (3A4 inhibitor).
Secondary Prevention: Previous Cardioembolic Strokeantiacoags All must be renally adjusted.
Can worsen dementia/delirium/confusion.
Previous Non-Cardioembolic antiplatelets
May increase GI infections and risk of pneumonia.
(ASA, Clopidogrel)
Ischemic Treatment:
TPA: alteplase (Activase); treatment must be initiated PPIs: block the final step in acid production (H+/K+) ATPase pump.
within 3 hours of symptom onset. Must confirm clot with omeprazole (Prilosec), omeprazole/sodium bicarb (Zegerid),
head CT before use. Max dose: 90mg IV over 60 min. pantoprazole (Protonix), lanzoprazole (Prevacid),
SE: Major Bleeding esomeprazole (Nexium), rabeprazole (Aciphex),
Additional: ASA (not within 24 hours of TPA), HTN esomeprazole + naproxen (Vimovo), dexlanzoprazole
management, Hyperglycemia Management (140-180) (Dexilant)
not indicated for PRN use
May increase risk of C. Difficile, **Osteoporosis, pneumonia
GERD: in hospitalized patients.
pantoprazole and esomeprazole are the only IV PPIs
LES muscle tone is reduced and allows for backflow of stomach
PPIs inhibit 2C19
contents
Avoid omeprazole and esomeprazole with Clopidogrel
Avoid: Nicotine, caffeine, spicy foods, alcohol, fatty foods, citrus,
(Plavix)
chocolate, spearmint.
Cytoprotective Agents: Misoprostol (Cytotec) and Sucralfate
Weight loss shows the best evidence for improvement
(Carafate)
**can exacerbate asthma
Metoclopramide (Reglan): dopamine antagonist, at higher doses it
Treatment: also blocks 5HT in CTZ, enhanced response to Ach in GI which
accelerates gastric emptying and increases LES tone.
Peptic Ulcer Disease: Bowel Prep:

from mucosal erosion in the GI tract o colonoscopy requires bowel prep


Three most common causes: H. Pylori, NSAIDs, Stress in critical o Sodium phosphate can cause fluid and electrolyte abnormalities, risky in
illness/mechanical ventilation. renal or cardiac disease.
o Ok to consume clear liquid diet (Water, broths, juices, coffee, tea, etc.
H.Pylori: o Do not consume anything with red, blue, or purple food coloring. No
spiral gram negative bacteria that like acid environments alcohol. No solids or Semi-Solids.
eating usually lessens the ulcer pain o PEGs usually used (Golytely, Miralax, Carbowax)
Diagnosis: Urea Breath Test and Fecal Antigen Test. PPI, H2
blockers, bismuth, and antibiotics should be discontinued 4 Drugs for constipation:
weeks before tests to avoid false negative.
Bulk-Producers: psyllium (Metamucil), calcium polycarbophil
Treatment: ** Do not make drug substitutions, use these drugs.
(FiberCon), methylcellulose (Citrucel). DOC in pregnancy and 1st line
for constipation.
Triple Therapy: PPI + Clarithromycin + Amoxicillin x 14 days
Emollients, Lubricants (Stool Softener): docusate sodium (Colace),
mineral oil
Quadruple Therapy: PPI + metronidazole + tetracycline +
Stimulant: Senna (Ex-Lax), bisacodly (Dulcolax). Caution that brand
bismuth x 10-14 days
names can refer to multiple products.
NSAID-Induced Ulcer: Osmotics: PEG, Lactulose, Gycerin, Sorbitol, Salines (various ions)
direct irritation and inhibition of prostaglandin synthesis messes Rx Agents: Lubiprostone (Amitiza) Nausea (30%),
up GI mucosal barrier alvimopan (Entereg) blocks opioid receptors in the gut
Selective COX-2 inhibitors have less ulcer risk but more CV risks.
PPI decreases the ulcer risk
For STAT treatments and Bowel Preps: bisacodyl rectal,
magnesium salts (MOM), lactulose, sorbitol, sodium phosphate
(Osmoprep), polyethylene glycol (Golytely, Miralax, Carbowax).
Constipation/Diarrhea/and Bowel Prep:
Diarrhea:
Constipation:
Most cases are viral, some bacterial (E.Coli), some drugs (antibiotics,
OTC laxatives should be limited to 7 days unless under medical Mg), some diseases.
supervision Antidiarrheals: Bismuth Subsalicylate (Pepto-Bismol), loperamide
Stool softener (Docusate) is good for iron-induced constipation (Immodium), diphenoxylate + atropine (Lomotil)
Opioids are the worse drug offenders for constipation. Others are Treatment should include fluids and electrolytes, especially in
anticholinergics, Iron, and Verapamil. children.
Opioids usually require a stimulant laxative (Senna or Bisacodyl) Not used with C. Difficile infections, body needs to clear the toxin, not
+/- Docusate retain it.
Rule out lactose intolerance by avoiding dairy.
Inflammatory Bowel Disease: vardenafil (Levitra, Staxyn ODT): 1 hour before sex. ,start at
10mg unless > 65 use 5mg
Ulcerative Colitis and Crohns Disease: Idiopathic Bowel tadalafil (Cialis): 1 hour before sex: start with 10mg or 2.5-5mg
Inflammation if using more than twice a week.
Treatment: avanfil (Stendra): 30 min before sex
Anti-diarrheals: Immodium, Lomitil
Anti-spasmodics: dicyclomine(Bentyl) BPH:
Short courses of oral or IV steroids: Prednisone or The patients perception of severity of BPH symptoms guides the
budesonide (Entocort). Budesonide preferred for ileum or selection of treatment.
colon problems, it has extensive first pass so lower systemic
exposure. Treatment: Watchful waiting, Surgery, or Drugs
Maintenance therapy to reduce inflammation and flare- Alpha Blockers: terazosin (Hytrin), doxazosin (Cardura), tamsulosin
ups. (Flomax), silodosin (Rapaflo). SE: abnormal ejaculation, orthostatic
mesalamine (Asacol, Pentasa, Canasa, Rowasa) hypotension, floppy iris syndrome during cataract surgery,
priapism
methotrexate 5 Alpha-Reductase Inhibitors: dutaseride (Avodart) or finasteride
TNF Inhibitors: adalimumbad (Humira), infliximab (Proscar) **Only used if the prostate is enlarged.
(Remicade), golimumab (Simponi), natalizumab (Tysabri): PDE-5 Inhibitor: tadalafil (Cialis) 5mg QD
for refractory diseases.

Overactive Bladder:
Erectile Dysfunction:
overactive detrusor muscle acted on by M3 receptor
Reduced blood flow to the penis. Often caused by diabetes, HTN, Behavioral treatments are 1st line
heart disease, nerve damage, drugs (antidepressants, blood Anticholingerics are 2nd line: Extended-Release preferred due to
pressure meds, antipsychotics, finasteride, dutaseride, cimetidine, lower rate of dry mouth.
opioids, chemo, nictotine), hormone imbalances (testosterone), oxybutynin, oxybutynin XL (Ditropan XL), Oxybutynin patch
stress etc.. (Oxytrol)
PDE5 inhibitors: **Oxytrol patch is available OTC for women >18 yrs. old
tolterodine (Detrol)
***CI with nitrates
fesoterodine (Toviaz)
Do not confuse with PAH/BPH drugs/doses:
solifenasin (Vesicare)
sildenafil (Revatio): 20mg TID
darifenesin (Enablex)
tadalafil (Adcirca): 40mg QD for PAH or tadalafil (Cialis): 5mg QD
trospium (Sanctura)
for BPH
sildenafil (Viagra): 1 hour before sex, start at 50mg unless >65 SE: Dry mouth, constipation, dizziness (mainly with older
use 25mg agents like oxybutynin)
Glaucoma/Conjuctivitis/Opthalmics and Otics: Rx: tretinoin topical (Retin A, Avita) or Adapalene (Differin).
Pea sized amount spread over entire face. May take 4-12
Glaucoma: Increase IOP weeks to see response and initially may worsen. Limit sun
Beta Blockers: decrease aqueous humor production. Timolol exposure.
(Timoptic)
Rx: Oral Isotretinoin: ***Only for very severe acne, Pregnancy
CAI: decrease aqueous humor production. dorzolamide (Trusopt), X (Severe birth defects), must be on 2 forms of birth control,
dorzolamide + timolol (Cosopt) must have 2 negative pregnancy tests, only filled by a
pharmacy that is registered and activated with the IPLEDGE
Prostglandin Analougues: Increase outflow. travoprost (Travatan program. **Do not use with Vitamin A supplements, or
Z), bimatoprost (Lumigan), latanoprost (Xalatan). **Store tetracyclines, steroid, progestin only pills contraceptives, or
latanoprost in fridge. SE: brown pigment in iris or eyelash growth. St.Johns Wort.

Rx: Antibiotics: minocycline ER (Solodyn) Oral, or topical


Alpha-2 agonist: increase outflow and reduce production.
antibiotics like Clindamycin (Cleocin, Clindamax, Clindagel,
brimonidine (Alphagan P), brimonidine + timolol (Combigan)
Evoclin) or clindamycin + benzoyl peroxide (Duac)

Dandruff: eczema or fungal


Conjuctivitis: (bacterial, viral, allergens)
First try dandruff shampoos daily with selenium sulfide
Allergic: OTC naphazoline/pheniramine (Visine) or ketotifen (Selsun). Leave in for 5 min. then wash out.
(Zaditor, Alaway) Then try Rx ketoconazole shampoo (Nizoral A-D). Apply
Bacterial: azithromycin (Azasite), moxifloxacin (Vigamox), twice weekly.
besifloxacin (Besivance), tobramysin/dexamethasone (Tobradex) +
many others. Skin Fungal Infections:
athletes foot, jock itch, ringworm, candida etc.
Otic:
Terbinafine (Lamisil AT) and butenafine (Lotrimin Ultra) are
Eye drops can be used in the ears but never use eardrops in the eyes highly effective. Clomitrazole (Lotrimin), miconazole
(Monistat, Lotrimin), tolnaftate (Tinactin).
***Different brands have different active ingredients.
Common Skin Conditions: Check labels.

Acne: From Androgens and bacteria (P.acnes) and fatty acids in oil Toenail or Fingernail fungal infection (Onychomycosis):
glands topical usually not potent enough
Benzoyl Peroxide is the most effective OTC treatment. potassium hydroxide (KOH) smear needed for diagnosis
Salicylic Acid is mildly useful. 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

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