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NR565 Advanced Pharm Final Study Guide
1. Glycemic Goals in Diabetes: - A1c: <7.0%
- Premeal plasma glucose: 70-130 mg/dL
- Peak post-meal plasma glucose: <180 mg/dL
2. Diabetic Nephropathy Prevention: Diabetic nephropathy is a serious complica- tion of diabetes
characterized by kidney damage. Preventive strategies include:
- Blood Sugar Control: Maintaining tight glycemic control through lifestyle changes and
medication (e.g., metformin, insulin) can slow the progression of kidney dam- age.
- Blood Pressure Management: Keeping blood pressure within target ranges (usually
<130/80 mm Hg) using ACE inhibitors or ARBs can protect kidney function.
- Regular Monitoring: Routine screening for albuminuria (protein in urine) and kidney function
helps detect early changes.
- Lifestyle Modifications: A balanced diet low in sodium and protein, regular physical activity,
and weight management are critical.
- Avoiding Nephrotoxins: Limiting the use of medications that can harm the kidneys (e.g.,
NSAIDs) and avoiding excessive alcohol and smoking.
- Patient Education: Teaching patients about diabetes management and the impor- tance of
regular check-ups.
3. 1st Generation vs 2nd Generation Sulfonylureas: - Both generations reduce glucose levels to
the same extent.
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- How do the generations differ? The second-generation agents are much more potent than the first-generation agents, and hence dosages are much lower (as much as 1000 times lower in some cases).
- With second-generation agents, significant drug-drug interactions are less com- mon, and the outcomes tend to be milder. Because of these differences, the sec- ond-generation agents have nearly completely replaced the first-generation agents in clinical practice.
4. Dipeptidyl Peptidase-4 Inhibitors (DPP4I): Adverse Effects: Generally well tolerated: Rarely,
patients have developed pancreatitis, including fatal hemorrhagic or necrotizing pancreatitis according to post-marketing reports.
5. Dipeptidyl Peptidase-4 Inhibitors (DPP4I): MOA: - Enhances the actions of in- cretin hormones,
endogenous compounds that (1) stimulate the glucose-dependent release of insulin and (2) suppress the postprandial release of glucagon (a hormone that increases glucose production in the liver).
- Both actions help keep blood glucose from climbing too high. How does sitagliptin boost incretin actions? It inhibits DPP-4, an enzyme that inactivates the incretin hormones.
6. GLP-1 Receptor Agonists: MOA: Activates receptors for GLP-1- slowing gastric emptying,
inhibits glucagon, suppresses appetite, and stimulates glucose-depen- dent release of insulin.
7. GLP-1 Receptor Agonists: Monitoring: Patients should monitor blood glucose regularly.
8. Incretin Mimetics: Injectable medications that mimic the action of incretin hor- mones (like
GLP-1) to enhance insulin secretion, suppress glucagon release, slow gastric emptying, and promote satiety, thereby helping to control blood glucose levels in patients with type 2 diabetes.
9. Incretin Mimetics in Pregnancy: Incretin mimetics are generally not recom- mended during
4 / 27 impairment particularly at risk.
14. Pioglitazone (TZD): Adverse Effects: - Weight gain, edema, and an increased risk of heart
failure and bone fractures.
- Long-term use may be associated with an increased risk of bladder cancer.
15. Pioglitazone (TZD): MOA: A thiazolidinedione (TZD) that works by activating PPAR-
³receptors, leading to increased insulin sensitivity in peripheral tissues and improved glucose uptake.
16. Repaglinide (Meglitinide): Patient Education: - Patients should be educated on taking
repaglinide before meals to effectively manage postprandial glucose levels.
- They should also be informed about the risk of hypoglycemia and the importance of monitoring blood glucose.
17. SGLT-2 Inhibitors: Adverse Effects: - MOST COMMON SE include urinary tract infections,
genital mycotic infections, dehydration, and hypotension. Rare but serious effects include diabetic ketoacidosis.
18. SGLT-2 Inhibitors: MOA: Work by blocking the sodium-glucose cotransporter-2 in the kidneys,
which is responsible for reabsorbing glucose from the urine back into the bloodstream. By inhibiting this transporter, they increase the excretion of glucose in urine, leading to lower blood sugar levels.
19. SGLT-2 Inhibitors: Therapeutic Goal: The therapeutic goal of SGLT-2 inhibitors is to improve
glycemic control while also providing cardiovascular and renal benefits, especially in patients with heart failure or chronic kidney disease.
20. Sitagliptin: Side Effects: Common side effects of sitagliptin include upper res- piratory
infections, headaches, and gastrointestinal issues. There's also a potential risk for pancreatitis.
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21. Sulfonylurea: Contraindications: - Sulfonylureas cause a dose-dependent re- duction in blood
glucose and can thereby cause hypoglycemia. Importantly, regard- less of what the glucose level is—high, normal, or low—sulfonylureas will make it go lower. If the level is high, reducing it will be therapeutic. However, if the level is normal, reducing it will cause mild hypoglycemia. And if the level is already low, reducing it can cause severe hypoglycemia.
- Use these drugs with caution in patients with renal or hepatic dysfunction.
22. Sulfonylurea: MOA: - Sulfonylureas act primarily by stimulating the release of insulin from
pancreatic islets. If the pancreas is incapable of insulin synthesis, sulfonylureas will be ineffective—which is why they do not work in patients with type 1 diabetes. With prolonged use, sulfonylureas may increase target cell sensitivity to insulin.
- Sulfonylureas promote insulin release by binding with and thereby blocking adeno- sine triphosphate (ATP)-sensitive potassium channels in the cell membrane. As a result, the membrane depolarizes, thereby permitting an influx of calcium, which
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27. Levothyroxine Administration: - Levothyroxine is almost always administered by mouth. Oral
doses should be taken once daily on an empty stomach (to enhance absorption). Dosing is usually done in the morning, at least 30 to 60 minutes before eating.
- IV administration is used for myxedema coma and for patients who cannot take levothyroxine orally for an extended period of time. IV doses are approximately 50% of the size of oral doses.
- For most hypothyroid patients, replacement therapy must be continued for life. The treatment provides symptomatic relief but does not produce a cure. Patients must be made fully aware of the chronic nature of their condition. In addition, they should be forewarned that, although therapy will cause symptoms to improve, these improvements do not constitute a reason to interrupt or discontinue drug use.
28. Levothyroxine: Drug Interactions: - Absorption of levothyroxine can be re- duced by the
following drugs: -- Histamine 2 (H2) receptor blockers (e.g., cimetidine [Tagamet]) -- Proton pump inhibitors (e.g., lansoprazole [Prevacid]) Sucralfate (Carafate) -- Cholestyramine (Questran) -- Colestipol (Colestid) -- Aluminum-containing antacids (e.g., Maalox, Mylanta) -- Calcium supplements (e.g., Tums, Os-Cal) -- Iron supplements (e.g., ferrous sulfate) -- Magnesium salts -- Orlistat (Xenical)
- To ensure adequate absorption of levothyroxine, patients should separate admin- istration of levothyroxine and these drugs by 4 hours. As noted earlier, food also reduces absorption.
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- Several drugs can accelerate the metabolism of levothyroxine. Among these are phenytoin (Dilantin), carbamazepine (Tegretol, Carbatrol), rifampin (Rifadin), ser- traline (Zoloft), and phenobarbital. Accordingly, to maintain adequate levothyroxine levels, patients taking these drugs may need to increase their levothyroxine dosage. -- Warfarin: Levothyroxine accelerates the degradation of vitamin K-dependent clotting factors. As a result, the effects of warfarin are enhanced. If thyroid hormone replacement therapy is started in a patient taking warfarin, the dosage of warfarin may need to be reduced. -- Catecholamines: Thyroid hormones increase cardiac responsiveness to cate- cholamines, thereby increasing the risk for catecholamine-induced dysrhythmias. Caution must be exercised when administering catecholamines to patients receiving levothyroxine and other thyroid preparations.
- Other interactions: Levothyroxine can increase the requirements for insulin and digoxin. When converting patients from a hypothyroid to a euthyroid state, dosages of insulin and digoxin may need to be increased.
29. Levothyroxine: Adverse Effects: - When administered in appropriate dosage, levothyroxine
rarely causes adverse effects.
- With an acute overdose, thyrotoxicosis may result. Signs and symptoms include tachycardia, angina, tremor, nervousness, insomnia, hyperthermia, heat intoler- ance, and sweating. The patient should be informed about these signs and instructed to notify the prescriber if they develop.
- Chronic overdosage is associated with accelerated bone loss and increased risk for atrial fibrillation, especially in older adults. Loss of bone increases the risk of fractures.
30. Levothyroxine: Monitoring: Check TSH 6-8 weeks after initiating therapy and after any
dosage change. Check TSH at least once a year after serum TSH is stabilized.
10 / 27 asthma and COPD. It works by inhibiting muscarinic receptors in the airways, leading to bronchodilation and decreased mucus secretion.
36. Monoclonal Antibodies: Monoclonal antibodies, such as omalizumab, are tar- geted therapies
for severe asthma. They bind to specific molecules (e.g., IgE) to reduce inflammation and prevent asthma exacerbations.
37. Bronchodilators: Bronchodilators are medications that relax bronchial smooth muscles,
increasing airflow. They include short-acting (e.g., albuterol) and long-act- ing beta-agonists (LABAs), often used with inhaled corticosteroids.
38. Methylxanthines: Methylxanthines, such as theophylline, are bronchodilators that work by
inhibiting phosphodiesterase, leading to increased cAMP levels and relaxation of bronchial smooth muscle. They are less commonly used due to side effects.
39. Leukotriene Receptor Antagonist: Leukotriene receptor antagonists (e.g., montelukast) block
the action of leukotrienes, which are inflammatory mediators involved in asthma. They help reduce airway inflammation and bronchoconstriction.
40. Glucocorticoids for Asthma: Glucocorticoids (e.g., fluticasone) are anti-in- flammatory agents
used to control chronic asthma by reducing airway inflammation and hyperreactivity. They are often delivered via inhalation.
41. Monoclonal Antibodies: Black Box Warning: Some monoclonal antibodies for asthma have
black box warnings related to the risk of anaphylaxis or malignancy, necessitating careful monitoring and patient education.
42. Asthma Control Assessment: - Three categories: well-controlled, not well-con- trolled, very
poorly controlled
- Questions include: symptoms, nighttime awakenings, SABA use, effect on activity, FEV1,
11 / 27 FEV1/FVC, questionaries, the risk for exacerbations requiring systemic glu- cocorticoids, risk for reduction in lung growth or progressive loss of lung function, risk for adverse effects of treatment, recommendation.
43. Asthma & COPD: Inhalation Devices: Inhalation devices, such as me- tered-dose inhalers
(MDIs) and dry powder inhalers (DPIs), are used to deliver medications directly to the lungs. Proper technique is essential for effective drug delivery.
44. Asthma & COPD: Inhaled Glucocorticoids: Inhaled glucocorticoids are a cor- nerstone of
asthma management, effectively reducing inflammation and preventing exacerbations when used regularly.
45. Asthma & COPD: Systemic Glucocorticoids: Systemic glucocorticoids (e.g., prednisone) are
used for severe asthma exacerbations or when inhaled glucocorti- coids are insufficient. They are effective but come with more side effects.
46. Oral Leukotriene Receptor Antagonists: Oral leukotriene receptor antago- nists, like
montelukast, are used as add-on therapy for asthma management and can be particularly useful in patients with exercise-induced bronchoconstriction.
47. Leukotriene Receptor Antagonists & CYP450: Leukotriene receptor antag- onists can
interact with cytochrome P450 enzymes, affecting the metabolism of certain drugs. Monitoring is recommended when co-administering medications.
48. Leukotriene Receptor Antagonists: Administration: - Educate clients to take at least one hour
before meals or two hours after meals.
- Educate clients that these medications should be scheduled, not PRN.
49. Leukotriene Receptor Antagonists: Monitoring: If neuropsychiatric symp- toms (agitation,
aggression, insomnia, depression, anxiety, suicidal thoughts) occur after treatment initiation, this drug should be discontinued immediately.
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59. Extensively Drug-Resistant Tuberculosis (XDR-TB): Treatment is prolonged (to at least 24
months) and must use second- and third-line drugs, which are less effective than the first-line drugs and are generally more toxic. Initial therapy may consist of five, six, or even seven drugs.
60. Isoniazid: Drug Interactions: Isoniazid can interact with several medications, including
antiepileptics and warfarin, increasing the risk of adverse effects and requiring dosage adjustments.
61. Isoniazid: Indication: Primarily indicated for the treatment and prevention of tuberculosis,
often used in combination with other antitubercular agents.
62. Isoniazid: MOA: Works by inhibiting the synthesis of mycolic acids in the bac- terial cell
wall, leading to the death of Mycobacterium tuberculosis.
63. Overview of Tuberculosis Treatment: Tuberculosis treatment typically involves a combination
of antibiotics for at least six months to ensure the eradication of the bacteria and prevent resistance.
64. Primary Goal of Tuberculosis Treatment: The primary goal of tuberculosis treatment is to
achieve a cure by eradicating the infection, preventing transmission, and minimizing the risk of drug resistance.
65. Pyrazinamide: Indication: Pyrazinamide is used in combination therapy for active
tuberculosis, particularly during the initial phase of treatment.
66. Rifabutin: Adverse Effects: Rifabutin can cause uveitis (inflammation of the middle layer of
the eye (uvea)), gastrointestinal disturbances, and changes in urine color. Monitoring is necessary.
67. Rifampin: Adverse Effects: Common adverse effects of rifampin include hepa- totoxicity,
orange discoloration of bodily fluids, and gastrointestinal upset. Regular liver function tests are
14 / 27 recommended.
68. Rifampin: MOA: Inhibits bacterial RNA synthesis by binding to the DNA-depen- dent RNA
polymerase, effectively killing Mycobacterium tuberculosis.
69. TB and HIV Coinfection: - Between 2-20% of patients with HIV also develop TB. Because of
their reduced ability to fight infection, these patients require aggressive therapy that lasts several months longer. In some instances, treatment has lasted 30 months or more.
- Drug interactions between TB and HIV medications are a common problem.
70. Tuberculosis Treatment Regimens: Standard treatment regimens for tubercu- losis typically
include a combination of isoniazid, rifampin, ethambutol, and pyraz- inamide for the initial phase, followed by continued treatment with isoniazid and rifampin.
71. Proton Pump Inhibitors (PPIs): MOA: Proton pump inhibitors (PPIs) reduce gastric acid
production by irreversibly inhibiting the H+/K+ ATPase enzyme in the gastric parietal cells. This leads to decreased acidity in the stomach, promoting healing of the gastric lining and alleviating symptoms of acid-related conditions.
72. Discontinuation of PPIs: Discontinuing PPIs should be done gradually to avoid rebound acid
hypersecretion. Patients may experience increased acid secretion and gastrointestinal symptoms after stopping, so tapering the dose or switching to a different medication may be necessary.
73. PPIs: Adverse Effects: Common adverse effects of PPIs include headaches, gastrointestinal
disturbances (nausea, diarrhea), and a potentially increased risk of infections (e.g., Clostridium difficile) and bone fractures with long-term use. There may also be concerns about nutrient malabsorption (e.g., magnesium, vitamin B12).
74. PPIs: Therapeutic Use: - Most effective drugs for suppressing gastric acid secretion.
- Indications include gastric and duodenal ulcers and GERD.
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83. Drug Selection for Peptic Ulcer Disease (PUD): - H. pylori: all patients with gastric or
duodenal ulcers and documents of H. pylori infection should be treated with antibiotics.
- NSAID-Induced: can be treated with any ulcer medication, but H2 receptor blockers and PPIs are preferred. Ideally, the NSAID would be discontinued.
84. NSAID-Induced Ulcer Prophylaxis: Prophylaxis for NSAID-induced ulcers may involve the use of
PPIs or misoprostol to protect the gastric mucosa in patients at high risk for ulcers due to NSAID use, particularly in those with a history of ulcer disease or gastrointestinal complications.
85. PPI Alternatives: Alternatives to PPIs for managing acid-related disorders in- clude H
receptor antagonists (e.g., famotidine), antacids, sucralfate, and lifestyle modifications (dietary changes, weight management, smoking cessation).
86. Laxatives in Pregnancy: Laxatives may be used during pregnancy to relieve constipation, a
common issue due to hormonal changes and pressure on the intestines. Generally, bulk-forming and osmotic laxatives (e.g., polyethylene glycol) are considered safer options, while stimulant laxatives (e.g., senna) should be used cautiously and under medical supervision.
87. Osmotic Laxatives: Contraindications: Osmotic laxatives, such as lactulose and magnesium
hydroxide, are contraindicated in certain conditions, including:
- Severe renal impairment
- Intestinal obstruction
- Bowel perforation
- Gastrointestinal conditions that could worsen with increased intraluminal pressure
88. Lubiprostone: Indications: Lubiprostone is indicated for the treatment of chronic idiopathic
constipation, irritable bowel syndrome with constipation (IBS-C), and opioid-induced
17 / 27 constipation in patients who are not responding to other treat- ments. It works by increasing fluid secretion in the intestines to facilitate bowel movements.
89. Laxative Patient Education: Patients using laxatives should be educated on:
- Proper dosage and timing
- The importance of dietary fiber and hydration
- Potential side effects and the risk of dependency
- When to seek medical advice if constipation persists or worsens
90. Causes of Laxative Abuse: - Body image issues and eating disorders (e.g., bulimia
nervosa)
- Misconceptions about bowel regularity and weight loss
- Psychological stress and anxiety related to bowel habits
- Poor education about healthy bowel function and diet
91. Opioids for Diarrhea: Opioids are the most effective antidiarrheal agents.
92. Opioids for Diarrhea: MOA: Opioids, such as loperamide (Imodium), act on the mu-opioid
receptors in the gut to slow gastrointestinal motility. This results in increased transit time, reduced fecal water loss, and an overall decrease in the frequency of bowel movements, providing relief from diarrhea.
93. Glucocorticoids for Inflammatory Bowel Disease (IBD): Glucocorticoids (e.g., prednisone) are
used to reduce inflammation and manage acute flare-ups in IBD. They work by suppressing the immune response and decreasing inflammation in the gut.
94. Immunosuppressants for IBD: Immunosuppressants (e.g., azathioprine, mer- captopurine)
help to control inflammation by inhibiting the immune system. They are often used for long-
19 / 27 such as dizziness, sedation, and impaired cognition. They should be used cautiously in patients with a history of substance abuse or psychiatric disorders.
104. Cannabinoids: Indications: Cannabinoids (e.g., dronabinol, nabilone) are indicated
for the treatment of chemotherapy-induced nausea and vomiting.
105. Serotonin Receptor Antagonists: Serotonin receptor antagonists (e.g., on- dansetron)
are used to prevent nausea and vomiting, especially in chemotherapy and post-operative settings. They work by blocking 5-HT3 receptors in the gastroin- testinal tract and central nervous system.
106. Black Cohosh: Indications: Black cohosh is used for treating symptoms of
menopause, including hot flashes, vaginal dryness, palpitations, depression, irri- tability, and sleep disturbance.
107. Coenzyme Q-10: Benefits: Coenzyme Q-10 is an antioxidant that serves a vital role in
cellular energy production. It is used to treat heart failure, muscle injury caused by statins, and mitochondrial encephalomyopathies.
108. Cranberry Juice: Cranberry juice is used to prevent urinary tract infections (UTIs) and to
decrease urine odor in patients with urinary incontinence. It is effective in preventing recurrent UTIs in older adult women and women in their teens or 20s.
109. Supplement Drug Interactions: Drug interactions can vary based on the specific
supplement or medication in question. For example, cranberry juice may increase the risk of bleeding in patients taking warfarin; garlic can increase the risk of bleeding in patients taking antiplatelet drugs or anticoagulants; and St. John's wort can induce CYP3A4, affecting the metabolism of various drugs, including oral contraceptives and warfarin.
110. Echinacea: Adverse Effects and Interactions: Echinacea can cause allergic reactions,
20 / 27 including acute asthma, urticaria, angioedema, and anaphylaxis, partic- ularly in individuals allergic to plants in the daisy family. It can oppose the effects of immunosuppressant drugs.
111. Echinacea: Patient Education: Patients should be advised to avoid echinacea in the
presence of autoimmune diseases due to the potential for immune suppres- sion with long-term use. Caution should also be exercised in immuno-compromised patients.
112. Effectiveness Comparison: Black Cohosh vs. Butterbur: Early studies sup- ported the
effectiveness of black cohosh for menopausal symptoms, but more recent meta-analyses have found insufficient evidence to support its use. Butterbur has been rated highly effective for migraine prevention, receiving a Level A recommen- dation from the AAN.
113. Feverfew Active Ingredient: The active compounds in feverfew are partheno- lide and
other constituents that contribute to its effects.
114. Feverfew Contraindications: Feverfew should be avoided by pregnant women due to the
potential risk of uterine contractions. It can also suppress platelet aggregation, thus increasing the risk of bleeding.
115. Flaxseed: MOA: Flaxseed provides soluble plant fiber and alpha-linolenic acid, which can
reduce serum cholesterol levels. The lignans in flaxseed have both mild estrogenic and antiestrogenic actions.
116. Garlic: Drug Interactions: Garlic has significant antiplatelet effects, thus in- creasing the
risk of bleeding in patients taking antiplatelet drugs or anticoagulants. It can also reduce levels of cyclosporine and saquinavir.
117. Ginger Root: MOA: The mechanism by which ginger suppresses nausea and vomiting is
unclear, but it is believed to involve the blockade of serotonin (5-HT3) receptors located in the chemoreceptor trigger zone of the medulla and on afferent vagal neurons in the GI tract. Ginger may also stimulate intestinal motility, salivation, and gastric mucus production, and suppress GI
