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565 Pharm Midterm Study Guide Week
- Drug Schedules o Descriptions of each schedule o Examples of drugs in each schedule Schedule I Controlled Substances Substances in this schedule have no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision, and a high potential for abuse. EXAMPLES: heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), peyote, methaqualone, and 3,4-methylenedioxymethamphetamine ("Ecstasy"). Schedule II/IIN Controlled Substances (2/2N) Substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence. Examples of Schedule II narcotics include: hydromorphone (Dilaudid®), methadone (Dolophine®), meperidine (Demerol®), oxycodone (OxyContin®, Percocet®), and fentanyl (Sublimaze®, Duragesic®). Other Schedule II narcotics include: morphine, opium, codeine, and hydrocodone. Examples of Schedule IIN stimulants include: amphetamine (Dexedrine®, Adderall®), methamphetamine (Desoxyn®), and methylphenidate (Ritalin®). Other Schedule II substances include: amobarbital, glutethimide, and pentobarbital. Schedule III/IIIN Controlled Substances (3/3N) Substances in this schedule have a potential for abuse less than substances in Schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence. Examples of Schedule III narcotics include: products containing not more than 90 milligrams of codeine per dosage unit (Tylenol with Codeine®), and buprenorphine (Suboxone®). Examples of Schedule IIIN non-narcotics include: benzphetamine (Didrex®), phendimetrazine, ketamine, and anabolic steroids such as Depo®- Testosterone. Schedule IV Controlled Substances Substances in this schedule have a low potential for abuse relative to substances in Schedule III.
Examples of Schedule IV substances include: alprazolam (Xanax®), carisoprodol (Soma®), clonazepam (Klonopin®), clorazepate (Tranxene®), diazepam (Valium®), lorazepam (Ativan®), midazolam (Versed®), temazepam (Restoril®), and triazolam (Halcion®). Schedule V Controlled Substances Substances in this schedule have a low potential for abuse relative to substances listed in Schedule IV and consist primarily of preparations containing limited quantities of certain narcotics. Generally used for antidiarrheal, antitussive, and analgesic purposes. Examples of Schedule V substances include: cough preparations containing not more than 200 milligrams of codeine per 100 milliliters or per 100 grams (Robitussin AC®, Phenergan with Codeine®), and ezogabine. o Which ones can and cannot be prescribed by nurse practitioners State dependent
- Prescriptive Authority o Understand what prescriptive authority is and who mandates it. (p. 1) Prescriptive authority is the legal right to prescribe drugs. Full prescriptive authority affords the legal right to (1) prescribe independently and (2) prescribe without limitation. Physicians have full prescriptive authority. For nonphysician providers, the degree of prescriptive authority varies. Some have full prescriptive authority, however many have restricted authority. Limitations are generally tied to oversight by a MD or DO as part of the provider’s scope of practice. Whether APRNs possess a full prescriptive authority depends on their legal right to prescribe without a supervisory or collaborative requirement. APRNs are educated to practice and prescribe independently without supervision; however, some state laws require that they practice in collaboration with or under the supervision of a physician. In these situations, some physicians limit the types of drugs that the APRN can prescribe. State laws may place additional restrictions with regard to controlled drugs. Prescriptive authority is determined by state law. The regulation of prescriptive authority is under the jurisdiction of a health professional board. This may be the State Board of Nursing, the State Board of Medicine, or the State Board of Pharmacy, as determined by each state. Although the federal government controls drug regulation, it has no control over prescriptive authority. o What problems arise when it is limited? (p. 3)
- What problems does each medication create for the patient?
➢ Is a medication problem amplified by other drugs the patient
is taking?
➢ If a medication is necessary but problematic, are drugs with fewer
adverse effects available?
- If polypharmacy is an issue, are there ways to decrease the number of medications?
➢ Will a combination drug simplify management?
➢ Is a single drug available (and desirable) for management of
two different conditions? Ideally, these reviews should be carried out in collaboration with the patient or patient’s family so that nothing is overlooked. Medication regimens can then be optimized to eliminate unnecessary drugs, add new drugs, if necessary, and ultimately improve patient satisfaction with care.
- Be familiar with physiological changes of aging that impact pharmacological treatments Drug sensitivity varies with age. Infants and older adults are especially sensitive to drugs. In the very young patient, heightened drug sensitivity is the result of organ immaturity. In older adults, heightened sensitivity results largely from decline in organ function. Other factors that affect sensitivity in older adults are the presence of multiple comorbidities and treatment with multiple drugs. The drug-metabolizing capacity of infants is limited. The liver does not develop its full capacity to metabolize drugs until approximately 1 year aker birth. During the time before hepatic maturation, infants are especially sensitive to drugs, and care must be taken to avoid injury. Similarly, the ability of older adults to metabolize drugs is commonly decreased. Drug dosages may need to be reduced to prevent drug toxicity. The kidneys of newborns are not fully developed. Until their kidneys reach full capacity (a few months aker birth), infants have a limited capacity to excrete drugs. This must be accounted for when medicating an infant. In older adults, renal function oken declines. Older adults have smaller kidneys and fewer nephrons. The loss of nephrons results in decreased blood filtration. In addition, vessel changes such as atherosclerosis reduce renal blood flow. As a result, renal excretion of drugs is decreased. - Be familiar with Beer’s Criteria List that identifies drugs with a high likelihood of causing adverse effects in older adults. Drugs on the list should be avoided in patients over 65 except when the benefits significantly outweigh the risks. - Know CYP450 inducers and inhibitors (pp. 17-18)
Most drug metabolism that takes place in the liver is performed by the hepatic microsomal enzyme system, also known as the P450 system. The term P450 refers to cytochrome P450, a key component of this enzyme system. It is important to appreciate that cytochrome P450 is not a single molecular entity but rather a group of 12 closely related enzyme families. Three of the cytochrome P450 (CYP) families—designated CYP1, CYP2, and CYP3—metabolize drugs. The other nine families metabolize endogenous compounds (e.g., steroids, fatty acids). Each of the three P450 families that metabolize drugs is composed of multiple forms, each of which metabolizes only certain drugs. To identify the individual forms of cytochrome P450, designations such as CYP1A2 (metabolizes acetaminophen), CYP2D6 (metabolize cardiovascular drugs 2D echo) and CYP3A4 (most common) are used to indicate specific members of the CYP1, CYP2, and CYP3 families, respectively. Drugs that are metabolized inhibitors. Inducers act on the liver to stimulate enzyme synthesis. This process is known as induction. By increasing the rate of drug metabolism, the amount of active drug is decreased and plasma drug levels fall. If dosage adjustments are not made to accommodate for this, a drug may not achieve therapeutic levels. They are Carbamazepine, rifampin, alcohol, phenytoin, griseofulvin, phenobarbital, sulfonylureas. Pneumonic is CRAP GPS induces my rage to memorize. Inhibitors act on the liver through a process known as inhibition. By slowing the rate of metabolism, inhibition can cause an increase in active drug accumulation. This can lead to an increase in adverse effects and toxicity. They are Valproate, Ketoconazole, Isoniazid, Sulfonamides, Chloramphenicol, Amiodarone, Erythromycin, Quinidine, Grapefruit juice. https://youtu.be/OhIopfQm9_w (Video helps breakdown how it works.)
- Be familiar with opioid agonists (p. 26) Agonists are molecules that activate receptors. Because neurotransmitters, hormones, and other endogenous regulators activate the receptors to which they bind, all of these compounds are considered agonists. When drugs act as agonists, they simply bind to receptors and mimic the actions of the body's own regulatory molecules. For example, dobutamine is a drug that mimics the action of NE at receptors on the heart, thereby causing heart rate and force of contraction to increase. In terms of the modified occupancy theory, an agonist is a drug that has both affinity and high intrinsic activity. Affinity allows the agonist to bind to receptors, whereas intrinsic activity allows the bound agonist to activate or turn on receptor function. Full agonists bind tightly to the opioid receptors and undergo significant conformational change to produce maximal effect. Examples of full agonists include codeine, fentanyl, heroin, hydrocodone, methadone, morphine, and oxycodone. by P450 hepatic enzymes are substrates. Drugs that increase the rate of drug metabolism are inducers. Drugs that decrease the rate of drug metabolism are called
Tricyclics, SNRI (can use for migraine) Localized neuropathic pain, OA, localized MS pain- lidocaine, capsaicin, topical NSAIDS RA, OA, rotator cuff disease, radiculopathies- epidural, intro articular glucocorticoid injections, arthrocentesis
- Know what a morphine milligram equivalent is and when to use it. Amount of morphine in milligrams that is equivalent to strength of opioid prescribed. Allows for comparison between strength of different types of opioids. - Be familiar with Prescription Drug Monitoring Program (PDMP) o What it is Electronic databases enable providers to access information regarding a patient's prescription history of controlled substances. Nearly all states have implemented PDMPs, and some states require providers to check the PDMP before prescribing controlled substances. According to the CDC (2020), PDMPs have shown promising results in changing prescribing behaviors, decreasing the use of multiple providers by patients, and decreasing substance abuse treatment admissions. o When to use it To check what other controlled medications a patient might be prescribed, check every 3 months and prior to every prescription opioid given for chronic pain, check for high doses and combination of Opioid and benzos puts patient at a high risk of OD. - Know the outcomes of renal and hepatic insufficiency with opioid therapy. Experience greater peak effect & longer duration of action, thus reducing respiratory depression. - Know risk factors of opioid use disorder. Property, unemployment, family hx, personal hx, in contact with high-risk people or environment. - Know signs of drug diversion.
Strange stories, specific drug requests, reluctance to cooperate, too high/low understanding of medications, strange symptoms.
- When is it appropriate to prescribe naloxone? When patient is taking benzodiazepines with opioid, high dose of opioids (50 MME/per day), hx of OD, concurrent ETOH or substance abuse. - Be familiar with drugs that are not safe to take with opioids. Benzodiazepines & other opioid medications. - Be familiar with the PEG Assessment Scale. Pain average, interference with enjoyment of life, and interference with general activity, tracks patient outcomes. Clinically meaningful improvement has been defined as a 30% improvement in scores for both pain and function. Monitoring progress toward patient-centered functional goals, such as walking the dog or walking around the block, returning to part-time work, attending family sports or recreational activities, can also contribute to the assessment of functional improvement. - Patient and provider responsibilities in opioid drug therapy Patient responsibilities- take meds as prescribed, keep appointments with provider, commit to all recommended therapies. Provider responsibility- risk/benefits throughout treatment & every 3 months, recommend multimodal approach (nonopioid with opioid), review PDMP and UDT. - How to approach conversations about Opioid Use Disorder Listen to patient, recognize uniqueness, open-ended questions, positive non-verbal communication, discuss concern, emphasizing commitment to safety, risks associated, next steps, treatment options. - What types of pain can be treated by psychotropic medications? Chronic pain- SNRI (Effexor, Cymbalta), neuropathy, DM neuropathy, postherpetic neuralgia, fibromyalgia. Week 3 - Lifespan considerations including pregnancy
- Be familiar with treatment guidelines of hypertension. **_o When one medication would be preferred over another based-on patient factors
- Mechanism of action and related physiological outcomes_** o Cardiac glycosides o Verapamil o Organic nitrates **_o Calcium channel blockers
- Contraindications_** o Beta-blockers o ACE Inhibitors **_o Ranolazine
- Be familiar with clinical tools used to determine how to treat hyperlipidemia
- Alternative treatment strategies for stain intolerant patients_** Week 4 **_- Be familiar with the treatment for osteoarthritis
- Treatment of gout_** o When to use which medication o Contraindicated medications o Side effects of medications o Medications requiring dosage adjustments based on renal or hepatic insufficiency o Medications typically co-administered with gout treatment
o Complications of untreated gout
- Treatment of osteoporosis **_o Patient education for common osteoporosis medications
- Blackbox warnings
- Drug Interactions_** **_o NSAIDs
- Mechanism of action o NSAIDs
- DMARDs_** o Examples o Baseline data needed for drugs in this class o Baseline diagnostics needed for drugs in this class o Patient teaching for drugs in this class o Instruction needed regarding RA treatment and oral contraceptives **_o Pregnancy considerations Prescription Writing
- Medications you will need to know for the prescription writing questions include:_** o Lortab o Lisinopril o Losartan o Amlodipine o Codeine
