NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam, Exams of Nursing

Download NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam and more Exams Nursing in PDF only on Docsity! NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. NR565 Week 5 Study Outline Many questions are written to assess your clinical application of the material from the textbook, in real-world scenarios. Chapter 24: Drugs used in treating infectious diseases (p. 692-760) SEE DRUG CHART BELOW Know the following for each drug class (penicillins, cephalosporins, fluoroquinolones, lincosamides, macrolides, sulfonamides, trimethoprim, nitrofurantoin, lipoglycopeptides): • • Spectrum of coverage for various organisms • • Pharmacodynamics • • Pharmacokinetics • • Pharmacotherapeutics • • Clinical indications & dosing • • ADRs • • Monitoring • • Patient education Antimicrobial resistance Treatment of Group A and Group B beta streptococci Cross sensitivity with cephalosporins Category Bacteriocidal or Bacteriostatic What do they Treat? (Indications) Pharmacokineti cs Pregnancy Category? Safe in pediatrics? Safe in Lactation? Adverse Effe Penicillins (PCN and Amoxicillin) Used in tx bact. URI, pharyngitis strep, otitis media, sinusitis, pna, STI, wound infx Bacteriocidal; inhibits synthesis of bacterial cell wall Pcn - Treat aerobic and gram positive. Red Book recommends penicillin for Group A beta streptococci & for Group B beta streptococci due to low resistance Absorption – from GI tract, depends on agent, ph of stomach/intesti ne, presence of food; high doses can cause GI upset/diarrhea - Catergory B - Safe in lactation - Safe in pediatrics - Does not cross BBB unless inflammatio n - Hypese y - Superin n - GI disturub s - Rash (maculo lar) - Change renal function - Candida Aminopcn – treat gram posivite Distribution – varies in protein NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. anaerobes and gram negative (MSSA, strep, H.flu, E.coli, Klebsiella, Neisseria meningitides); amoxicillin, ampicillin; combined with betalactamase inhib Pcnase-resistant – (pcnase staph, strep, MSSA); not effective against MRSA; cloxacillin, dicloxacillin, methicillin, nafcillin, oxacillin Antipseudomonal – gramneg bacilli (pseudo aeruginosa, enterbacter, morganella); piperacillin, ticarcillin binding, well distributed, inflammation enhance distribution, crosses placenta/breast milk Metabolism – minimal metab except for nafcillin/oxacill in Excretion – primarily unchanged in urine, caution in renal insufficiency (increase half life) infectio - Seizures ability - Decreas oral contrap ves effectiv - Interstit nephriti * Severe, type I allergic reaction to cephalospori carbapenems, o beta-lactamase inhibitors may contraindicate u penicillins. Cephalosporins – 1st Generation (Cephalexin) & 2nd Generation (Cefuroxime) 3rd Generation (ceftriaxone) & 4th Generation (cefepime) 1st – narrow spectrum 5th – broad spectrum Bactericidal Increase in gram neg up the generations and decreases in gram pos. Treat surgical prophylaxis, resp tract infx, strep pharyngitis/sinusi tis, CAP, skin, soft tissues, bones/joints, UTI (2nd line for kids), STI First gram pos and limited gram neg; doesn’t enter CSF, staph aureus, strep, pna/resp infx (cephalexin, cefazolin) Second gram + and H. flu, more potent, broader spectrum, gonorrhea, resp infx (cefaclor (CAP), cefziroxine) Third some gram + and -, not active against MRSA, effective against pseudomonas, less freq dosing, crosses BBB with inflammation Absorption oral, GI tract, rate of absorption delayed by food, IM – absorbed by muscle Distribution widely distributed to most tissue, variation in protein binding, penetration CSF varies by generation Metabolism hepatic metabolism – insignificant Excretion In pregnancy d/t increase fluid shorter half life, lower serum levels and larger Vd Lactation safe Pediatrics in neonates immature renal fx causes increased half life and accumulation; kids – varies by drug - GI distuban (C.diff) - Alterati blood clotting - Combin with alc (disulfir rxn – flushing dizzines n/v, coa problem - Nephrot ty - Superin n - Renal/h c dysfun extends halflife - Anaphy rxn to p don’t gi cephalo NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. crosses BBB in presence of inflammation (approx.. 15% of serum) Metabolism – varied amounts of hepatic metabolism Excretion – excreted through kidney 30-60% of oral dose unchanged; excretion in feces and urine with existing QT prolongation - Cautious in pt with hx of seizures or other CNS disorders Pregnancy - Category C – not recommend ed - Always benefit/risk - Avoid in lactatin mothers: can cause cartilage abnormatliti es in baby Pediatrics - Not recommene d under 18 - Only indication is complicated UTI, pyelonephrit is, post- anthrax exposure Elderly - Increased risk of tendon rupture - Increase risk of CNS confusion Sulfonamides (Bactrim & Bactrim DS) Bactericiostatic inhibit bacterial synthesis of folic acid which is essential for bacterial growth (when sulfonamides combined with trimethoprim bactericidal) Broad spectrum: gram + and gram – Bacterial resistance is prevalent; limited to treat UTI, increase resistance against MRSA Absorption – readily absorbed from GI tract Distribution – widely distributed to all tissues including CNS, variable protein binding Cautions - Renal insufficienc y - G6PD deficiency - Folate deficiency Pregnancy - Category C - Fetal levels 70-90% of maternal - Skin rash/itch - Blood disorder - GI disturba - Photose ity - Availab formula orall (tabs/liq cream NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. Metabolism – hepatic Excretion – renal excretion; acidic urine enhances antibacterial activity level Lactation - Safe Pediatrics - Contraindic ated in children <2 months (silvade for burn ophthal ointmen Nitrofurantoin (Macrobid) Bacteriostatic in low concentrations Bactericidal in high concentrations in urine Inhibits protein synthesis, aerobic metabolism, DNA and RNA synthesis and cell wall synthesis Active against gram + cocci and gram – bacilli (causative agents of UTI) Absorption – macrocrystallin e form very slowly absorbed Distribution – widely distributed to all tissues including CNS, variable protein binding Metabolism – body tissue metabolism Excretion – renal excretion; acidic urine enhances antibacterial activity Cautions - Renal insufficienc y - G6PD deficiency - Folate deficiency Pregnancy - Category B Lactation - Safe Pediatrics - Contraindic ated in children <2 months Elderly - Cannot use if CrCl <40ml/min - Skin rash/itch - Blood disorder - GI disturba - Photose ity - Peripher neuropa - Availab formula orall (tabs/liq cream (silvade for burn ophthal ointmen Trimethoprim Combination drug (trimethoprim- sulfamethoxazole, TMP- SMZ) (Bactrim, Septa) Bactericidal when combine with sulfonamide, provides synergistic effect Antibacterial agent that interferes with bacterial folic acid synthesis Gram + and gram – UTI, intestinal, lower resp tract infx, otitis media, prostatitis, and gonorrhea, preventing pneumocystis carinii in AIDS Absorption – readily absorbed from GI tract Distribution – widely distributed to all tissues including CNS, variable protein binding Metabolism – <20% hepatic Excretion – renal excretion; acidic urine enhances antibacterial activity Cautions - Renal insufficienc y - G6PD deficiency - Folate deficiency Pregnancy - Category D Lactation - Safe Pediatrics - Contraindic ated in children <2 months - Skin rash/itch - Blood disorder - GI disturba - Photose ity - hyperka a - Availab formula orall (tabs/liq cream (silvade for burn ophthal ointmen NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. Combination of antimicrobial agents: - Treat life threatening infections - Prevent of emergence of bacterial resistance - Treat mix aerobic/anaerobic infections - Create synergistic antibacterial activity - Use lower doses of toxic drug Chapter 26: Drugs used in treating eye & ear disorders Contraindications for topical beta blockers- The beta blocker ophthalmic medications are contraindicated in patients with asthma, a history of asthma, chronic obstructive pulmonary disease (COPD), or other pulmonary disease. There may be bronchospasm associated with the use of topical beta blockers, which may prove fatal to patients with respiratory disease. Prophylaxis for opthalmia neonatorum- Erythromycin ophthalmic ointment 0.5% 1 hour after delivery 0.25 to 0.5 inch ribbon in each eye • Any infant younger than 1 month who presents with conjunctivitis should have Gram's stain, antigen detection tests, and cultures of the eye discharge to rule out gonococcal, chlamydial, or HSV origin. • Chlamydia is the most common cause of neonatal conjunctivitis • Gonococcal conjunctivitis is the most serious cause of ophthalmia neonatorum owing to concerns about the bacteria causing blindness o In the newborn, gonococcal conjunctivitis requires intramuscular (IM) ceftriaxone (50 mg/kg, maximum 125 mg) given once o If there are extraocular manifestations, a 7-day course of IM or IV ceftriaxone is warranted. Ceftriaxone is not given to neonates with hyperbilirubinemia; cefotaxime (50 to 100 mg/kg/d divided bid for 7 d) is an alternative used in neonates with hyperbilirubinemia Treatment, dosing and patient education for: • • Glaucoma o beta blockers reduce IOP by interference with the production of aqueous humor induced by cyclic adenosine monophosphate (cAMP) through the ciliary processes in the eye ▪ Headaches and dizziness may occur with the use of beta blockers. Patients may exhibit systemic beta blocker effects with the use of ophthalmic preparations. Symptoms include bradycardia, hypotension, bronchospasm, and, rarely, AV block. o Cholinesterase inhibitors are indirect-acting agents that inhibit the cholinesterase enzyme. Topical application to the eye causes intense miosis (pupil constriction) and muscle contraction. The IOP is reduced by a decreased resistance to aqueous outflow ▪ physostigmine and demecarium- reversible agents ▪ Echothiophate iodide (Phospholine)- irreversible agent ▪ Iris cysts may be seen with cholinesterase inhibitors. o Direct-acting miotics are parasympathomimetic (cholinergic) drugs with muscarinic effects. When applied topically, these drugs produce pupillary constriction, stimulate the ciliary muscles, and increase aqueous humor outflow ▪ Miotics may cause corneal clouding, ciliary spasm, headache, induced myopia, and retinal detachment. Systemic anticholinergic effects if excessive absorption occurs. o Carbonic Anhydrase (CA) inhibitors decrease aqueous humor secretion by slowing the formation of bicarbonate ions. This reduces sodium and fluid transport, leading to decreased aqueous humor production and subsequent decreased IOP. NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. caused by E. coli. In children, additional organisms include Klebsiella in neonates and Proteus in boys. All of the antimicrobial agents mentioned have a spectrum of activity that covers these organisms. • Upper UTIs (e.g., pyelonephritis) involve the same likely organisms because the infections are most often ascended from a bladder infection; E. coli is the identified organism in more than 80% of pyelonephritis cases. Failure of a 3-day course of antimicrobials generally indicates an upper UTI. o The ICSI recommends ciprofloxacin 500 mg twice a day for 7 to 14 days as the first-line drug for nonpregnant adults (2004). Other fluoroquinolones (gatifloxacin 400 mg daily, levofloxacin 250 mg daily, or ofloxacin 400 mg bid) may also be used. The alternative drugs recommended are amoxicillin/clavulanate or an oral cephalosporin with the treatment extending for 14 days. Pregnant patients should be treated with amoxicillin or amoxicillin/clavulanate and followed closely. Treatment of complicated vs. uncomplicated UTI, Recurrent UTI, prevention • Uncomplicated pyelonephritis in adults can usually be treated with an oral antibiotic with a 90% success rate • Acutely ill patients require initiating parenteral therapy in an inpatient observation unit or hospital admission for IV fluids and parenteral antibiotics. • All of the drugs discussed so far may also be used for prophylaxis. The drug of choice for adults for prophylaxis or for recurrent infections (more than three infections in 1 year) is one single-strength tablet of trimethoprim/sulfamethoxazole daily at bedtime for a minimum of 6 months or a self-administered single dose of two double-strength tablets at symptom onset. For children, the recommended dose of trimethoprim/sulfamethoxazole is 2 mg trimethoprim/10 mg sulfamethoxazole per kg as a single bedtime dose. The nitrofurantoin adult dose is 50 to 100 mg at bedtime and for children it is 1 to 2 mg/kg/d in a single dose. • Amoxicillin is no longer recommended for empirical therapy in the United States because up to one-third of the UTI organisms are resistant. Risk factors for UTI • Sexually active women are at higher risk than sexually inactive women for developing UTIs. Indications for referral to urologist • Complicating factors in which short-course (3-day) therapy is not appropriate (ICSI, 2002) include the following: o Symptoms longer than 7 days' duration o Shaking chills (rigors) o Flank pain: midback, severe, new-occurring with onset of UTI symptoms o History of diabetes, pregnancy, immunosuppressed status, renal calculi, renal insufficiency, discharge from hospital or nursing home within the past 2 weeks, four or more UTIs in past year, failure of this drug to treat UTI within the past 4 months, or resident of extended-care facility *For patients with complicating factors, longer treatment protocols are needed or referral may be appropriate. Urine culture should be used to guide therapy. NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. NR565 Week 6 Study Outline Many questions are written to assess your clinical application of the material from the textbook, in real-world scenarios. Chapter 24: Drugs used in treating infectious diseases (p. 760-796) Know the following for each drug class (antimycobacterials, antivirals, antifungals, anthelminthics and antiprotozoals): • • Spectrum of coverage for various organisms • • Pharmacodynamics • • Pharmacokinetics • • Pharmacotherapeutics • • Clinical indications & dosing • • ADRs • • Monitoring • • Patient education Category Pharmacodynami cs Pharmacokinetics/ Pharmacotherapeut ics Clinical indications & dosing ADRs Monitoring a Patient Educa Antimycobacterials (isoniazid [INH], rifampin [RIF, Rifadin, Rimactane], ethambutol [EMB, Myambutol], pyrazinamide [PZA], and streptomycin) Isoniazid interferes with lipid and nucleic acid biosynthesis in growing organisms. It is also thought that isoniazid and ethambutol Isoniazid is 90% bioavailable but should be taken on an empty stomach because food decreases the peak and extent of absorption. It readily diffuses Resistance to antimycobacter ial drugs has a frequency of about 1 in 106 bacilli. However, with 108 bacilli lesions in an All of the antimycobacterial drugs have risks for hypersensitivity reactions, some of which may be severe. Peripheral Isoniazid shoul used cautiously with careful monitoring for hepatotoxity, especially for th patients who dri alcohol daily, w have active chro NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. inhibit synthesis of mycolic acids. Rifamycins (rifampin, rifabutin, and rifapentine) bind to the beta subunit of mycobacteria DNA-dependent RNA polymerase and inhibit RNA synthesis (bactericidal). into all body fluids, including CSF (90% of serum levels), pleural, and ascitic fluids; tissues; organs; and saliva, sputum, and feces. It also crosses the placenta and enters breast milk. Meals slow the rate of absorption of rifamycins but not the extent of absorption. These drugs may be taken with or without food. Bioavailability of the oral formulations vary between 20% for rifabutin in an HIV-positive person to over 90% for rifampin. All oral antimycobacterials are rapidly and well absorbed in the GI tract after oral administration infected person, resistant mutants are selected out when only one drug is given. Because of the relatively high proportion of adult patients with tuberculosis caused by organisms that are resistant to isoniazid, four drugs are necessary in the initial phase of therapy for the 6-month regimen to be maximally effective Patients with HIV infection are especially at risk for tuberculosis and resistance development neuropathy is the most common adverse reaction with isoniazid- atients predisposed to this adverse reaction include the malnourished, slow acetylators, pregnant women, older adults, diabetics, and patients with chronic liver disease, including alcoholics. Pyridoxine (B6) prevents the development of peripheral neuropathy and is recommended for patients in these at- risk categories. Adverse effects, especially GI upset, are relatively common in the first few weeks of initial phase therapy. However, first-line drugs, particularly rifampin, must not be discontinued because of minor adverse effects. Although taking the drug with food may delay or moderately decrease the absorption, the effects of food have little clinical significance. Patients who have epigastric distress or nausea with this drug should be told that they can take their whole drug protocol with meals or that the hour of dosing can be changed. Administration with food is preferable to liver disease or severe renal dysfunction, wh over 35 years of use drugs of abu are pregnant or immediately postpartum. Peripheral neuropathy and neurotoxicities occur with isoni use. Special cau should be used patients with preexisting peripheral neuropathy and who are pregna are HIV-positiv The most comm adverse reaction associated with rifamycins are G nature: anorexia nausea, vomitin diarrhea, flatule and abdominal Although hepatotoxicity i common than it with isoniazid, hepatotoxicity leading to hepat occurs with rifampin. Cautious use in impairment is recommended f ethambutol, streptomycin, a capreomycin. Ethambutol has caused visual disturbances, including irreversible blindness. Cauti use is advised in patients with inability to NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. However, it must be dosed 3 to 5 times daily, which may be disruptive and promote noncompliance. Famciclovir is dosed 2 to 4 times daily valacyclovir requires one to two doses daily, depending on the indication. how to self-initi the medication. Early initiation drug therapy als increases its effi for treatment of varicella and he zoster, so public education needs emphasize the treatability of th infections. It is particularly important for adolescents or a with chickenpo seek treatment a first sign of rash in the prodroma period if they k they are suscept and have been exposed. Antivirals for influenza Amantadine (Symmetrel) and rimantadine (Flumadine) are FDA approved for prevention and treatment of respiratory infections due to influenza A virus; however, the CDC no longer recommends their use due to high levels (up to 92%) of resistance to influenza A Zanamivir (Relenza), oseltamivir phosphate (Tamiflu), and peramivir (Rapivab) are approved for treatment of acute illness in adults. Zanamivir, oseltamivir, and peramivir are neuraminidase inhibitors and are active against influenza A and B. Neuraminidase is a viral enzyme responsible for cleaving viral attachment to the host cell surface allowing for viral circulation. Oseltamivir is available as an oral tablet and is well absorbed after administration. Oseltamivir is a prodrug of the active compound oseltamivir carboxylate. Zanamivir is a dry powder available for oral inhalation with a provided inhalation device. Approximately 4% to 17% of the inhaled dose of zanamivir is systemically absorbed. Oseltamivir is poorly distributed into breast milk Oseltamivir is almost completely converted to the active metabolite Oseltamivir and zanamivir are approved for the prophylaxis and treatment of influenza types A and B. Peramivir is approved for the treatment of acute influenza in patients age 18 years or older. The CDC does not recommend routine prophylaxis with neuraminidase inhibitors. Judicious use is advised to prevent the development of resistance Bronchitis, cough, and shortness of breath are associated with use of zanamivir. These problems may be related to irritation from inhalation of the drug; however, reactions may be related to the underlying illness because the incidence of reactions was either equal or greater in the placebo- controlled groups. For oseltamivir, nausea and vomiting are the most common adverse effects and occurred more frequently than in placebo-controlled groups. Rare cases of severe skin reactions and neuropsychiatric Baseline evalua of renal functio should be consi for older and debilitated patie who are taking oseltamivir or peramivir. For older and debilitated patie monitoring shou include breath sounds (for evid of heart failure development of pneumonia), he sounds, and wei Vital signs will evidence resolu of the influenza development of adverse effects sequelae. As with all antivirals, the importance of ta the full course o therapy and NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. (greater than 90%). The active metabolite is excreted unchanged in the urine. Children 12 years and younger have higher clearance of oseltamivir and its metabolite, resulting in decreased drug exposure. Oseltamivir, peramivir, and zanamivir are listed as Pregnancy Category C. Although zanamivir crosses the placenta in animal studies, fetal blood concentrations were significantly lower than those of the mother. pathogens. The only strongly recommended indication for prophlaxis is to control outbreaks among high- risk individuals in institutional settings In times of pandemic, the neuraminidase inhibitors may be recommended for prophylaxis, particularly when an unvaccinated high-risk patient is exposed to influenza. The individual is vaccinated immediately and started on neuraminidase inhibitors to allow the antibody response to the vaccine to achieve protective concentrations. Treatment is recommended for patients identified with influenza who are hospitalized, have severe disease, or are at risk of developing complications. events have been reported for all three medications. following the la directions shoul stressed. Patients on zanamivir requi instruction on th proper use of th diskhaler. Oseltamivir can taken without re to food. The single most important factor influenza preve is annual vaccination. It i now recommen that all people 6 months and old vaccinated. If asthmatics on zanamivir experience seve bronchospasm a using the diskha an alternative treatment may b needed. Nausea and vom are common wit use of oseltamiv NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. No dosage adjustment is recommended for zanamivir for patients with renal impairment, but because the active metabolite of oseltamivir is excreted renally, adjustment is recommended. Antifungals macrocyclic polyenes- includes amphotericin B (Ambisome, Abelecet, Amphotec)- only in IV formulations Azole group, includes two subgroups, the imidazoles and the triazoles. Imidazoles are used mainly for topical treatment Triazoles include fluconazole (Diflucan), itraconazole (Onmel, Sporanox), posaconazole (Noxafil), and voriconazole (Vfend). - azoles have a broad spectrum of activity that includes Candidaspecies, Cr yptococcus species, the endemic mycoses (blastomycosis, coccidioidomycosis, histoplasmosis), and the dermatophytes. In addition, itraconazole, posaconazole, and voriconazole have reliable activity against Aspergillus species Allylamines, includes terbinafine (Lamisil). Nuclear acid synthesis inhibitors, includes flucytosine (Ancobon)- limited to treatment of Fluconazole is well absorbed after oral administration, with excellent bioavailability (greater than 90%). Itraconazole is available for oral administration as a solution and a capsule. The bioavailability of the capsule and solution are not equivalent. The absorption of the capsule is enhanced when it is taken with food, resulting in a bioavailability of 55%. When taken on an empty stomach, absorption of the solution is about 30% greater than that of the capsule. Patients taking antacids (H2 blockers and proton pump inhibitors) should not take the capsule because absorption is All of the azoles and terbinafine have been associated with hepatotoxicity. Rare cases of hepatitis that are usually reversible with discontinuance of the drug Transaminase elevations are common with the azoles and occur in 2% to 12% of patients. Voriconazole is Pregnancy Category D; the other azoles are Pregnancy Category C. Fluconazole is safe and effective for infants and children. Experience with neonates is limited, but a dosage schedule exists. Although the safety and efficacy of terbinafine have not been established in children, it has Azoles are relatively nontoxic- most common adverse reactions are minor GI symptoms. Patients taking azoles have rarely developed exfoliative skin disorders. Patients who develop rashes should be carefully monitored and the drug discontinued if the lesion progresses. All of the azoles may cause QT prolongation. Fluconazole increases the effects of anticoagulants Itraconazole has been rarely associated with development of heart failure and should be used cautiously in patients with preexisting heart failure or ventricular dysfunction. Voriconazole causes visual disturbances Prompt recognit of liver injury is essential with o antifungal drugs AST, ALT, alkal phosphatase, an bilirubin should monitored prior initiation of ther monthly for 3 to months, and frequently there during treatmen Because of the numerous drug interactions wit azoles, it is important to mo the drug respon concurrent medications. Therapeutic res should be evalu at 6 to 8 weeks initiation of dru therapy for tine infections, 4 to months for fing onychomycosis, 8 to 9 months fo toenail mycoses Monitoring of s drug levels for several azoles is recommended a stated above. NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. Albendazole is rapidly converted by the liver to the primary metabolite, albendazole sulfoxide, which is further converted to other metabolites. Ivermectin is metabolized by CYP450 growth retardation. Drugs used for whipworm infections include pyrantel pamoate, albendazole, and mebendazole. Roundworm infection generally is derived from eating feces- contaminated raw vegetables. The parasite has a larval stage that migrates through the lungs, causing seasonal pneumonitis, but GI symptoms are more common. Massive infections can cause intestinal obstruction. The drug used for roundworm infections is mebendazole. Hookworms comprise pathogens from two genera, A. duodenale and N. americanus. Th e larvae live in the soil and must penetrate the skin to enter the circulation, where they are carried to the lungs. Here hepatotoxicity o blood dyscrasia lbendazole shou swallowed who with a small am of water and a h fat meal to decr GI effects and increase absorpt Mebendazole is taken with a hig meal, but it can chewed or crush Ivermectin mus taken with a ful glass of water o empty stomach hour before a m Pyrantel pamoa can be taken wi regard to meals time of the day. NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. they penetrate the alveoli, crawl up the pharynx, and are swallowed. They attach to the intestinal wall and can cause anemia. Drugs used for hookworm infections include pyrantel pamoate, albendazole, and mebendazole. The larvae of the threadworm are found in warm, moist soil in the tropics and the southern United States. The larvae may penetrate the skin or be ingested. Pulmonary and GI symptoms are common. The drug used for threadworm infections is ivermectin. Ivermectin may be prescribed off-label to selected patients with scabies. It is particularly effective in treating scabies in patients who are immunocompr omised. The dose is 200 mcg/kg given as a single NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. dose. Because ivermectin is not ovicidal, it should be repeated in 1 to 2 weeks. Antiprotozoals Metronidazole (Flagyl) is effective at managing bacterial as well as parasitic infections and is therefore discussed separately from the other antibiotics classes. Nitazoxanide (Alinia) is used in the treatment of diarrhea caused by G. lamblia and C. parvum. Tinidazole (Tindamax) is approved for treatment of amebiasis, bacterial vaginosis, giardiasis, and trichomoniasis. Metronidazole is a nitroimidazole that disrupts DNA and protein synthesis. Nitazoxanide interferes with the pyruvate ferredoxin oxidoreductase (PFOR) enzyme- dependent electron transfer reaction, which is essential to anaerobic energy metabolism in the protozoa Tinidazole is an antibacterial and antiprotozoal agent with mechanism of action similar to metronidazole. Oral metronidazole is readily absorbed and widely distributed into most tissue and fluids, including CSF, breast milk, alveolar, bone, liver abscesses, vaginal secretions, seminal fluid, as well as crossing the placenta. Following Cautious use is recommended with metronidazole for patients with a history of blood dyscrasias. Seizures have occurred as an adverse reaction, and patients with a history of seizure disorder or neurological problems should use this drug with caution. Severe hepatic dysfunction may decrease plasma clearance, and metronidazole should be used cautiously with these patients. Tinidazole is also a nitroimidazole and has the same precautions and contraindications. The pharmacokinetics of nitazoxanide in patients with compromised renal or hepatic function has not been studied. It must be administered with caution to patients with hepatic and biliary disease and to patients with renal disease or a combination of the Both nitazoxanide and tinidazole are available only for oral administration. Metronidazole and tinidazole have antiparasitic and antibacterial properties. They are used against the common protozoal infections by T. vaginalis, G. lamblia, and E. histolytica. Met ronidazole is also used to treat less common parasites, such as the protozoon Bala ntidium coli (with an oral dose of 750 mg 3 times daily for 5 days), as an alternative to tetracycline, and to treat the helminth Drac unculus medinensis, or guinea worm (with an oral dose of 250 mg 3 times daily Anorexia, nausea, abdominal pain, dizziness, and headache commonly occur with metronidazole. Dry mouth and a metallic taste may also develop. Although irritating, these adverse reactions are mild and transient. Infrequent adverse reactions include diarrhea, glossitis, rashes, leukopenia, seizures, aseptic meningitis, and peripheral neuropathy. Taking the drug with meals lessens the GI irritation. GI irritation with abdominal pain, nausea, and diarrhea are the main adverse reactions for nitazoxanide. Adverse effects associated with tinidazole are similar to those for metronidazole. For most of the conditions treat with metronidaz resolution of symptoms indic effective treatm and further evaluation is no required. For giardiasis tr with any of thes drugs, symptom may persist for weeks or month after the organis eradicated beca of the lactose intolerance brou on by the infect If symptoms pe three stool samp should be collec and cultured sev days apart abou 4 weeks after completion of treatment. Although oral metronidazole a tinidazole can b taken without re to meals, they s be taken with fo snacks to decrea GI irritation. Nitazoxanide s be taken with fo and the oral suspension shou shaken well bef administration. NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. Bacterial vaginosis diagnosis and treatment • Bacterial vaginosis develops when the bacterial flora are altered, with loss of the normally predominant lactobacilli and overgrowth of strict and facultative aerobic species such as Bacteroides, Peptococcus, Mobiluncus, Gardnerella, Streptococcus, and Mycoplasma. • The infection manifests with foul-odored, clear, copious vaginal discharge with a pH greater than 4.5, positive “whiff test,” and few WBCs. • Untreated bacterial vaginosis has been associated with pelvic inflammatory disease, cervicitis, abnormal Pap smear cytology, preterm labor, and low birth weight. During pregnancy, symptomatic women are screened and treated if they are at high risk for preterm delivery. • Treatment of low-risk and symptomatic women during pregnancy is controversial. Metronidazole, 500 mg orally twice daily for 7 days, or metronidazole intravaginal gel, 1 full applicator twice daily for 5 days, is the drug of first choice for bacterial vaginosis. Dosing in pregnant women is 500 mg twice a day for 7 days or 250 mg 3 times a day for 7 days • The recommended dose of tinidazole in nonpregnant females with bacterial vaginosis is a 2 g oral dose once daily for 2 days taken with food or a 1 g oral dose once daily for 5 days taken with food. • Use of tinidazole in pregnant women has not been studied. It is not necessary to treat sexual partners of women with bacterial vaginosis unless balanitis is present. Antimycobacterial treatment guidelines for TB • Isoniazid is the most active drug for the treatment of tuberculosis. • Treatment regimens include initial phase and continuation phases. Initial phases have four drugs (isoniazid [INH], rifampin [RIF], pyrazinamid [PZA], and ethambutol [EMB]) given for 2 months followed by continuation phases, usually with two drugs (INH and another drug, most often RIF) given for 4 to 7 months. • The first-line antimycobacterial drugs should be administered together; split dosing should be avoided. Fixed-dose combination preparations may be more easily administered than single-drug tablets and may decrease the risk for acquired drug resistance and drug errors. Two combination formulations have been approved for use in the United States: INH/RIF (Rifamate) and INH/RIF/PZA (Rifater). It should be noted that for patients weighing more than 90 kg, the dose of PZA in the three-drug combination is insufficient and additional PZA tablets are necessary Table 24-28 Dosage Schedule: Selected Antimycobacterials treat the extraintestinal form of the disease IV or orally. NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. more cases in the center within 60 days and unvaccinated children attend, prophylaxis is recommended for children and personnel. Prophylactic treatment of meningococcal meningitis • Rifampin is also used to treat several nonmycobacterial infections. It is used as prophylaxis for close contacts of people with meningococcal infections caused by N. meningitidis, including household members, children and personnel in nurseries and day-care centers, and closed populations such as in college dormitories and military barracks. Health-care personnel with intimate exposure to index cases (such as mouth-to-mouth resuscitation) should receive prophylactic therapy. Prophylaxis for adults is oral rifampin 600 mg every 12 hours for four doses (two days). The dose for children is 10 mg/kg every 12 hours for four doses (two days). Spectrum of antiviral coverage for various organisms • Acyclovir is active against herpes simplex virus (HSV) 1 and 2; varicella-zoster virus (VZV); and, to a lesser extent, Epstein-Barr virus (EBV), CMV, and herpes virus 6 (HSV-6), which is implicated as the cause of roseola and other febrile diseases in childhood. • Valacyclovir is converted to acyclovir after oral administration and is active against the same viruses. • Famciclovir is active against HSV-1 and HSV-2, VZV, EBV, and hepatitis B virus. • cross-resistance occurs with acyclovir, valacyclovir, and famciclovir. NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. Cardinal symptoms of chronic bronchitis which indicate antibiotic use • Chronic bronchitis, a condition largely confined to smokers, is defined as a recurrent daily cough with sputum production that persists for at least 3 months in at least 2 consecutive year • The common organisms found in the sputum of patients with chronic bronchitis are most commonly viruses, as well as H. influenzae, S. pneumoniae, M. pneumoniae, and M. catarrhalis • Throat swab with Gram's stain and culture are unreliable in these patients because the respiratory tract is normally colonized below the vocal cords. • The decision to use antimicrobial drugs may be based on the presence of at least two of the three cardinal symptoms: increased sputum volume, increased sputum purulence, and increased dyspnea. • A radiograph of the chest may be required to rule out bronchopneumonia. • Recovery usually begins 3 to 4 days after antibiotics are initiated. Amoxicillin/clavulanic acid, macrolides, and double-strength sulfamethoxazole/trimethoprim are all appropriate first-line choices • Resistant organisms require selection of an antibiotic agent based on susceptibilities. Patients who don't respond to first-line therapy should be treated with a respiratory fluoroquinolone (levofloxacin, moxifloxacin, gemifloxacin). The length of treatment is 7 to 14 days. Ch. 23: Drugs that affect the skin Animal and human bite prophylaxis • Topical diphenhydramine is applied to the affected area 3 to 4 times a day for up to 7 days • Severe pruritis- Doxepin cream (Prudoxin) is applied in a thin layer 4 times a day in 3- to 4-hour intervals for up to 8 days of treatment. Treatment for longer than 8 days may result in higher systemic levels of doxepin. Other available topical antipruritics that are safer to use than doxepin are the emollients Aveeno cream (colloidal oatmeal-based) and Sarna anti-itch lotion. Types of tinea infections and treatment Tinea capitis-ringworm of the scalp. • Occurs mainly in children, although it may be seen at all ages. • Trichophyston causes “black dot” tinea, which presents with tiny black dots that are the remains of broken hair shafts, flush with the scalp. • Definitive diagnosis is obtained by fungal culture. As fungal cultures may take 2 to 4 weeks for results, treatment is begun while awaiting results. • Microscopy by performing KOH examination of spores on the hair shaft provides the most rapid means of diagnosis. • Treatment of tinea capitis consists of oral antifungal therapy with griseofulvin and biweekly shampooing with sporicidal shampoo. • Tinea capitis should always be treated with a systemic antifungal. The treatment of choice is griseofulvin, with treatment to continue for 2 to 4 months, or for at least 2 weeks after negative laboratory examinations are obtained. Griseofulvin is absorbed more easily with a high-fat meal (whole milk, cheese, or ice cream), and the patient should be instructed about this point when beginning treatment. • The patient should also be treated with a sporicidal shampoo such as selenium sulfide or ketoconazole. The patient should shampoo with either the selenium sulfide 2.5% shampoo or ketoconazole 2% shampoo twice weekly until clear. Close contacts should be empirically treated with sporicidal shampoo twice per week. • If the patient is not responding to therapy, a culture should be obtained. Cases resistant to griseofulvin may be treated with systemic terbinafine, fluconazole, or itraconazole, based on the sensitivity of the organism as determined by culture. Resistance to griseofulvin is not common. By obtaining a fungal culture from the patient at the beginning of therapy, the provider will have sensitivity studies on which to base the treatment decision if there is no response after 4 weeks of treatment. NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. Tinea corporis- superficial fungal infection of the skin, also known as ringworm. • Tinea corporis presents as an annular lesion with raised borders and center clearing. There may be scaling and some erythema. • It is spread by direct contact with an infected person or animal. • Diagnosis is made by KOH scrapings, Wood's lamp, or fungal culture. • Treatment is topical antifungal cream, with miconazole, tolnaftate, or clotrimazole the most common medications used. • Other topical antifungals may be used, including terbinafine, butenafine, sulconazole, naftifine, ciclopirox olamine, ketoconazole, and econazole. Tinea cruris is also known as jock itch. • Superficial fungal infection of the groin, upper thighs, and intertriginous folds. • It is more common in males and rarely occurs before adolescence. • The lesions are pruritic, erythematous, scaly, well-demarcated patches with central clearing. • The treatment for tinea cruris is the same topical antifungal medications that are used for tinea corporis, with the same dosing schedule. Tinea pedis is a superficial fungal infection of the skin of the feet, commonly called athlete's foot. • Tinea pedis is more common in males and rarely occurs before puberty. • Diagnosis is made by the classic clinical presentation of scaling, maceration, fissuring, and inflammation on the feet, especially in the inner digital areas. • Treatment for tinea pedis is the same topical agents used for tinea corporis. • Length of treatment is extended with tinea pedis, often with 4 weeks of treatment needed. Tinea versicolor is a superficial fungal infection of the skin caused by yeasts in the genus Malassezia. • Clinically, tinea versicolor appears as hyper- or hypopigmented coalescing scaly macules on the trunk and upper arms. • The treatment for tinea versicolor consists of topical application of selenium sulfide shampoo or a topical antifungal. • Selenium sulfide shampoo is applied to the tinea versicolor patch and left on for 10 to 15 minutes every day for 1 week. Selenium sulfide can be used prophylactically once a month. • The topical azoles miconazole, clotrimazole, and econazole may be used twice a day for 2 to 4 weeks in the treatment of tinea versicolor. Treatment of onychomycosis • Onychomycosis, also known as tinea unguium, is a fungal infection of the nail, either fingernail or toenail. Treatment of onychomycosis usually involves months of treatment with a systemic antifungal medication. Topical treatment is usually not effective, with the exception of ciclopirox nail lacquer (Penlac). When treating onychomycosis, medications such as terbinafine and itraconazole appear to have higher rates of cure than griseofulvin. Clearing of onychomycosis takes months of treatment regardless of treatment modality. • Itraconazole may be used for first-line therapy in adult patients with onychomycosis. It may be dosed in one of two methods, either daily dosing or pulse dosing. The daily dosing regimen for adults with toenail onychomycosis is 200 mg daily for 12 weeks. The pulse regimen for adults with toenail involvement is 400 mg/d for 1 week per month for 3 to 4 consecutive months. If only the fingernail area is involved, the adult dose is 200 mg bid for 7 days, then 3 weeks without treatment, and then 200 mg bid for for 2 months. Safety in children has not been established. For onychomycosis, the pediatric pulse dose is 5 mg/kg/d for 1 week per month for 3 to 4 consecutive months. For any patient who takes itraconazole for more than 8 consecutive weeks, liver enzymes and electrolytes should be drawn prior to and every 8 weeks during treatment. Itraconazole should not be administered to pregnant women or women considering pregnancy. • Systemic terbinafine is also used as first-line treatment for onychomycosis in adults (Lipner & Scher, 2014). The dose for treating onychomycosis of the fingernail is 250 mg daily for 6 weeks. To treat an infected toenail, the dose is 250 mg daily for 12 weeks. Liver enzymes and complete blood count (CBC) should be monitored every 6 weeks if treatment lasts longer than 6 weeks. • Griseofulvin has been used extensively in the treatment of onychomycosis as second-line therapy and has a proven safety profile in adults and children. The medication should be administered for at least 4 months NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. Herbal supplement use/recommendation • In the 1970s, Linus Pauling first brought forward the idea that vitamin C prevents and alleviates episodes of the common cold. Although this has still not been scientifically proven, many patients continue to take vitamin C at the first sign of a cold. • Zinc lozenges have also been proposed as a treatment for the common cold. It is thought that zinc ions inhibit rhinovirus replication in vitro. • In light of these studies, zinc lozenges may decrease URI symptoms in some patients. Zinc nasal gels (Zicam) should be avoided after reports of permanent anosmia and an FDA warning to avoid their use. NR565 Week 7 & Final Exam Study Outline Many questions are written to assess your clinical application of the material from the textbook, in real-world scenarios. Week 7 Readings: Chapter 34: Gastroesophageal reflux and peptic ulcer disease Know the following for each drug class (antacids, antidiarrheals, cytoprotectives, antiemetics, histamine 2 receptor antagonists, prokinetics, proton pump inhibitors and laxatives): • • Pharmacodynamics • • Pharmacokinetics • • Pharmacotherapeutics • • Clinical indications & dosing • • ADRs • • Monitoring • • Patient education Treatment, dosing and patient education for: GERD • Lifestyle modifications and OTC antacids are a logical first step for treatment of heartburn, dyspepsia, or mild nonerosive GERD. Most patients have tried an OTC antacid before they seek health care. This step alone may be sufficient. • H2RAs may be sufficient if symptoms are mild and no erosive disease is evident. Tachyphylaxis may occur with H2RAs. • PPIs are first-line therapy for patients with moderate or severe GERD or erosive disease. PPI therapy continues for 8 weeks and 70% to 80% of patients should have complete relief with PPIs • Maintenance PPI therapy should be prescribed for patients who have symptoms that recur after PPI therapy is discontinued or patients with complications such as erosive esophagitis or Barrett's esophagitis. The patient should be reassessed in 6 to 12 months to determine if he or she can be weaned off therapy. Patients who do not respond to PPIs need to be referred to a gastroenterology specialist. • H2RAs may be prescribed in infants and children with GERD, although this is not recommended by guidelines. • Alternatively, a trial of 2 to 4 weeks of PPIs may be started in older children or adolescents. If the patient does not improve, treatment continues for 8 to 12 weeks. After 12 weeks of therapy, the PPI should be discontinued. If symptoms recur, the PPI should be restarted. If there is no response to the initial 2 to 4 week trial of PPIs, the patient should be referred to a gastroenterology specialist • The FDA has approved four PPIs for use in children: omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), and rabeprazole (Aciphex Sprinkle Delayed-Release Capsules). Because the long- NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. term effects of their use in children are not known, there is some concern regarding chronic acid suppression. Long-term PPI treatment has been associated with increased rates of community-acquired pneumonia, gastroenteritis, and entercolitis • Metoclopramide has adverse reactions in children, including restlessness, insomnia, somnolence, dystonia, and extrapyramidal symptoms. • Antacids are generally safe in older adults, but antacids with constipation as an adverse reaction may be more problematic for them. In addition, many antacids have high sodium content, and some older adults are on low- to moderate-sodium diets. Among the H2RAs, famotidine (Pepcid) is generally safe in the older population but should be used with caution in cases of renal insufficiency. Nizatidine (Axid) may cause asymptomatic ventricular tachycardia and carries a risk of hepatocellular injury. • PPIs are generally safe in the elderly and provide rapid relief of symptoms and healing of erosive esophagitis (Poh et al, 2010; Scholl, Dellon, & Shaheen, 2010). Patients with hepatic impairment will have decreased clearance of PPIs and may need a dosage adjustment. Of concern are drug interactions associated with PPIs that are metabolized by CYP2C19 and CYP3A4, including interactions with warfarin, phenytoin, diazepam, and clopidrogrel • Elderly patients taking PPIs are at increased risk of community-acquired pneumonia, Clostridium difficile infections, and possible bone fractures in immobile patients • Long-term use of PPIs presents concerns. One concern is the development of precancerous cells due to hypochlorhydria, with enterochromaffin cell–like hyperplasia changes found in chronic PPI use. Another concern is an increase in hip fractures in at-risk patients who are on PPIs longer than 2 years and on higher doses of PPIs. Vitamin B12 deficiency is also a concern with chronic acid suppression. PUD • PUD is a chronic inflammatory condition of the stomach and duodenum. It is the result of increased acid and pepsin secretion; impaired mucosal cytoprotection; use of NSAIDs; H. pylori; personal factors such as genetics, smoking, and stress; or a combination of these causes. Definitive diagnosis is via esophagogastroduodenoscopy. • The incidence of gastric ulcers differs from that of duodenal ulcers. Gastric ulcer disease is about one- fourth as common as duodenal ulcer disease. • Diagnosis of ulcerative disease involves radiographic and endoscopic evaluation of the upper GI tract and testing for H. pylori colonization. • Treatment- step 1 involves lifestyle modifications and OTC antacids or histamine2 blockers. Most patients have tried some step 1 interventions before they seek health care. • Step 2 for patients with uncomplicated gastric ulcers includes testing and treating for H. pylori and acid suppressive therapy with PPIs. Multiple treatment regimens for H. pylori eradication are available, including combining a PPI and two antibiotics for 14 days • Duodenal and gastric ulcers recur in up to 80% of patients treated with drugs to reduce gastric acid but not treated for eradication of H. pylori infection. By comparison, 6% to 15% of patients have recurrent ulcers when their H. pylori infection is cured. • Gastric Ulcer Disease o H. pylori is seen in 75% to 85% of patients with gastric ulcers. Gastric acid secretion may be normal or less than normal. o Another suggested contributing factor is increased duodenal gastric reflux of bile across an incompetent pyloric sphincter. An increased concentration of bile salts disrupts the gastric mucosa and decreases the electrical potential across the gastric mucosal membrane. o Pyloric stenosis has also been given as a possible cause of gastric ulcer formation. With pyloric deformity, gastric emptying is poor, resulting in stasis and antral distention. This distention leads to increased gastrin release and gastric acid production. • Duodenal Ulcer Disease NR 565 Advanced Pharmacology Fundamentals Week 5 Final Exam Study Guide Comprehensive Exam Study Guide (100% Verified Questions and Answers Latest Updated 2024/2025. o Infection with H. pylori is the major cause of duodenal ulcers. With the exception of patients taking NSAIDs, 95% to 100% of patients with duodenal ulcer are infected with this organism. o Once H. pylori is acquired, colonization continues for life unless the organism is eliminated by antimicrobial treatment or the usually late-in-life development of atrophic gastritis IBS • Atropine is used for both PUD and IBS. Dicyclomine is used for the management of irritable bowel syndrome in patients who do not respond to the usual interventions with sedation and diet. o The initial adult dose of atropine for both indications is 400 mcg every 4 to 6 hours. Doses may be increased, if necessary, to 600 mcg. For children, the dose is 10 mcg/kg every 4 to 6 hours. The dose is not to exceed 400 mcg. Children are especially sensitive to the adverse reactions associated with atropine, and every effort should be made to keep the dose as low as possible o Symptoms of poisoning in infants and children differ from adult symptoms. They include burning sensations in the mouth; difficulty in swallowing; rash; blurred vision; tachycardia; tachypnea; fever up to 109.8°F; muscle incoordination; and eventually seizure, respiratory paralysis, and death. The antidote for atropine poisoning is physostigmine. • Steroids and sulfasalazine are needed to control diarrhea exacerbated by inflammatory bowel disease. Loperamide, 4 mg initially followed by doses of 2 to 4 mg 4 times a day, may be used as adjunct therapy, and it may lead to substantial clinical improvement, especially if combined with added fiber in the diet and anticholinergics. If clinical improvement is not observed with doses of 16 mg/day for at least 10 days, symptoms are unlikely to be controlled by further use of this drug. o • Propantheline is indicated for its antisecretory activity in the management of peptic ulcer disease o The oral dose of propantheline for adults is 15 mg 30 minutes before meals and 30 mg at bedtime. For patients with mild manifestations, older adults, and patients of small stature, the dose is 7.5 mg 3 times a day. The safety and efficacy of this drug for treating peptic ulcer in children have not been established. There is a dosage schedule published for antisecretory and antispasmodic use in children, but it is an unlabeled use. The dose for children is 1.5 mg/kg a day in three or four divided doses for antisecretory indications and 2 to 3 mg/kg a day in four to six divided doses given every 4 to 6 hours for antispasmodic indications • The only oral dose of dicyclomine shown to be effective is 160 mg/day in four equally divided doses. However, because of adverse effects, the initial dose is 80 mg/day in four equally divided doses. The dose is then increased if tolerated. For patients who have difficulty with swallowing, a syrup form is available with the same dosage range. A formulation for IM administration is also available. The dose is 80 mg/day in four equally divided doses (NIH, 2007). Traveler’s diarrhea • Bismuth subsalicylate appears to have antibacterial and antisecretory properties and is used to treat traveler's diarrhea in doses of two tablets or 2 fluid oz before each meal and at bedtime (4 times/d) for up to 3 weeks during brief periods of high risk • The management of traveler's diarrhea can be divided into prevention and treatment. The most important risk factor for acquiring this disorder is the patient's destination. High-risk areas include Central and South America, Africa, the Middle East, Mexico, and Asia. Intermittent-risk areas include Eastern Europe, South Africa, and a number of the Caribbean islands. Enterotoxigenic E. coli is the most common causative organism found in traveler's diarrhea, followed by Campylobacter, Shigella, and Salmonella. Oral antimicrobials are also used for both prevention and treatment of this disorder; the provider should refer to the CDC Travel Web site (www.cdc.gov/travel) for current antimicrobial recommendations. Black box warning for metoclopramide