NR565/ NR 565 Advanced Pharmacology CareoftheFundamentals Midterm Exam Review: Question, Exams of Nursing

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NR565/ NR 565 Advanced Pharmacology

CareoftheFundamentals Midterm Exam Review:

Questions and Verified Answers Chamberlain

1. Which schedule drugs can APRNs prescribe ?: DEA license will allow for prescribing of Schedules 2-5. There can be restrictions as noted in collaborative agreement. May be facility/state dependent.
2. Who determines and regulates prescriptive authority ?: Determines: Also known as independent prescribing. APRNS can prescribe without limitation and is state dependent. Includes "legend" (prescription) and controlled drugs, health/med- ical services, DME, etc. Regulates: State board of nursing, regulated by health professional board. Federal government controls drug regulations but has no control over prescriptive authority.
3. How does limited prescriptive authority impact patients within the health-

2 / 14 care system ?: Limited prescriptive authority creates numerous barriers to quality, affordable, and accessible patient care. For example, restrictions on the distance of the APRN or PA from the physician providing supervision or collaboration may prevent outreach to area of greatest need. An increase in patient waits.

4. What are the key responsibilities of prescribing ?: The ability to prescribe medications is both a privilege and a burden. Have a documented provider- patient relationship, do not prescribe medications to family or friends or yourself, Document a thorough history and physical examination, include any discussions you have with the patient about risk factors, side effects, or therapy options, have documented plan regarding drug monitoring or titration, if you consult additional providers not that you did so. Use the references provided in the following boxes to assist in safely and rationally choosing one medication over another. Be sensible, accept responsibility, do not fear it, know constraints and limitations, always learn and update, keep Rx pads in safe place, confirm allergies, verify medication list with patient, do not let insurance dictate quantity of Rx, Charting is key (particularly with off label use), Provide use and rationale.
5. What should be used to make prescribing decisions ?: The best way to keep

3 / 14 your patients (and yourself) safe is to be prudent and deliberate in your decision- making process. Cost, availability, current practice guidelines, medication interactions including interactions with food, side effects, need for monitoring, how drug is metabolized (hepatic or renal), special populations (pregnancy, nursing, older adults)

6. Be familiar with pharmacokinetic and pharmacodynamic changes of older adults and how that would translate to baseline information needed to pre- scribe: Pharmacokinetic is the study of drug absorption, distribution, metabolism,

4 / 14 and excretion in the body. The ability of older adults to metabolize drugs is commonly decreased. Drug dosages may need to be reduced to prevent drug toxicity.

7. Beer's criteria: Guidelines for prescribing medications to patients 65 & older. Drugs on the list should be avoided in patients over 65 expect when the benefits significantly outweigh the risks. The Beers Criteria includes five lists that describe certain medications and situations and include: potentially inappropriate medication (PIM) us in older adults, PIM use in older adults due to medication- disease or medication-syndrome interactions that may exacerbate the disease or syndrome, medications to be used cautiously in older adults, clinically significant drug interac- tions that should be avoided in older adults, medications to be avoided or dosage decreased in the presence of impaired kidney function in older adults.
8. Why is Beer's criteria important ?: It provides a list of medications that are potentially harmful in elderly. List that identifies drugs with a high likelihood of caus- ing adverse effects in older adults. Beers Criteria are recommendations; ultimately prescribers must determine whether a medication is appropriate for use or not. These guidelines are not intended to limit the use of medications or

5 / 14 apply to all older adults. Safe and judicious prescribing is crucial in the older adult to optimize pharmacotherapy.

9. Impacts/outcomes of polypharmacy: Polypharmacy greatly increases the risk for interactions. Drug interactions with mild side effects to life-threatening conse- quences. Elderly is at a higher risk of polypharmacy due to taking five or more medications daily.
10. CYP450: metabolic pathway, involved in metabolism of drugs in the liver. Me- tabolism can be inhibited or induced by drugs and once this happens drug- drug interaction can occur.
11. What are the CYP450 inhibitors ?: Liver enzymes. It's not just a single molec- ular entity but rather a group of 12 closely related enzyme families. Examples: Valproate, Isoniazid, Sulfonamides, Amiodarone, Chloramphenicol, Ke- toconazole, Grapefruit juice, Quinidine What do they do? Slows down metabolism of medications. Inhibitors are medications that inhibit activity of one or more of the CYP450 enzymes. Medications that inhibit an enzyme can potentially slow that enzymes activity required for

6 / 14 metabolism of other medications, thereby increasing the levels of medications dependent on that particular enzyme for biotransformation. This inhibition prolongs the pharmacalogi- cal effects, which may result in toxicity. Factors that affect the inhibition include the dose and the capacity to bind to the enzyme

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12. What do they cause if not used correctly (CYP450)?(aka:What would the patient experience?): Toxicity. drug build up
13. Examples of CYP450 inducers ?: barbiturates, St Johns wart, carbamazepine, rifampin, alcohol, phenytoin, griseofulvin, phenobarbital, sulfonylureas
14. What do CYP450 inducers do ?: Increase medication metabolism. Inducers are xenobiotics that elevate the CYP450 enzyme activity by increasing the enzyme synthesis. This action leads to additional sites available for biotrans- formation. The increased number of sites enhances the medication metabolism, decreasing the concentration of the "parent drug" while increasing the metabolite production. The half-life of the inducing drug may cause a delay before enzyme activity increases. A decease in concentration of a medication metabolized by CYP2C9 (responsible for 10% of drug metabolism) usually occurs within 24 hours after the administration of the medication.
15. What happens when someone has a poor metabolism phenotype ?: Slow or increase absorption, slow the metabolism, keep drug in body longer and increase toxicity. Poor metabolisms affect a high or low therapeutic index: increase drug toxicity, Ex: Plavix: Clots and increase platelets.
16. What does the U.S. Food and Drug Administration regulate when it comes to

8 / 14 medications ?: Regulates what the pharmacies can sell, requires special alerts and management guidelines, for drugs that cause serious adverse effects. Ensuring pharmaceutical companies thoroughly test new products for efficacy and safety with an aim towards minimizing side effects. They approve or disapprove drugs

17. Reasons for medication non-adherence: 1. patient feels not needed
18. affordability
19. side effects
20. forgetfulness
21. lack of info
22. lack of disease concern
23. poor social support
24. low reaction satisfaction
25. poor physician relationship
26. What are black box warnings ?: Concise summaries of adverse effects of concern in a box surrounded by a thick black line.
27. Why are black box warnings issued ?: - Neonate and infant drug absorption

• Purpose is to alert the provider to potentially severe side effects and ways to prevent or reduce harm. Provides a concise summary of the adverse effects of concerns.

9 / 14 The FDA requires a boxed warning on drugs with serious or life- threatening risks.

21. Be familiar with general development and when absorption would reach adult levels: The drug-metabolizing of infants is limited. The liver does not develop

10 / 14 its full capacity to metabolize drugs until approximately 1 year after birth. During the time before hepatic maturation, infants are especially sensitive to drugs, and care must be taken to avoid injury.

22. Examples of pure opioid agonists: - agonist is a drug that binds to the receptor, producing a similar response to the intended chemical and receptor
23. How would you know when to refer someone to a pain specialist for pain management? Prescription Drug Monitoring Program (PDMP) What is it? Why is it important ?: are secure, online, state-based databases that contain information about controlled substance prescriptions written by clinicians and dispensed by pharmacists within a state or jurisdiction PDMPs store patient-specific prescription information in a central repository. The information in accordance with state or jurisdictional laws.

11 / 14 PDMPs are valuable tools that facilitate safer opioid prescribing, inform clinical practice, and improve patient safety.

24. Schedule I Drugs: Opioids, Acetylmethadol, Heroin, Normethadone,mari- juana, any otherso Schedule II Drugs: Opioids, Alfentanil, Codeine, Fentanyl, Hydrocodone, Methamphetamine, Barbiturates, Cocaineo Schedule III Drugs: Opi- oids, Buprenorphine, Paregoric,Cannabinoids,Dronabinol (THC), Stimulants, Testosterone, Ketamineo Schedule IV Drugs:Opioids,Benzodiazepines,Alprazolam, Chlordiazepoxide, Clonazepam, Lorazepam, Midazolamo Schedule V Drugs: Opioids, Diphenoxylate plus atropine, Pregabalin:
25. Know how what type of evidence prescribers should use to make treatment recommendations: Cost, guidelines, availability, interactions, side effects, allergies hepatic and renal function, need for monitoring, special populations
26. **Schedule II drugs

• rules and prescribing examples:** Opioids, Alfentanil, Codeine, Fentanyl, Hydrocodone, Methamphetamine, Barbiturates, Cocaine

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• All prescriptions for Alternatively, prescribers may submit prescriptions using an electronic prescribing procedure. Oral prescriptions may be called in but only in emergencies, and a written prescription must follow within 72 hours. Prescriptions for schedule II drugs cannot be refilled. However, a DEA rule allows a prescriber to write multiple prescriptions

13 / 14 on the same day—for the same patient and same drug.

27. Behaviors that predict controlled substance abuse: Illegal drug use; pre- scription drug use for nonmedical reasons. History of substance use disorder or overdose. Mental health conditions (eg, depression, anxiety). Sleep-disordered breathing. Concurrent benzodiazepine use.
28. When should naloxone be prescribed for a patient ?: - Providers should con- sider offering naloxone to patients when the following factors that increase risk for an opioid overdose are present

• history of nonfatal OD
• hx of substance abuse disorder
• higher opioid dosages (>50 MME/day)
• Concurrent benzo use
• high risk of returning to a dose to which tolerance is no longer expected, such as when a pt is released from jail

29. US Drug Enforcement Administration description of the scheduled drugs Treatment of Chronic Pain

14 / 14 Example: How should something like OA be treated ?: Education: weight loss, exercise, NSAIDS, steroid injections OA; yoga, heat, compassion, relationship-building

30. Risk factors for opioid use disorder: - Risk Evaluation and Mitigation Strategy (REMS)-reinforces safe medication use. Goal of REMS is to ensure that medication is used according to FDA approved prescribing.

• Requires drug manufacturers to add recs about naloxone The patient requests refills before the prescription runs out The patient fails to disclose pertinent information, such as current opioid prescriptions The patient makes unreasonable excuses for losing medications The patient may show physical signs of opioid withdrawal, such as anxiety, nausea, vomiting, or abdominal pain. If any of the above signs are noticed during a patient exam, you may need to assess your patient for OUD.

31. Methadone: black box warning benefits of use in opioid use disorder: prolongs the QT interval and hence may

15 / 14 pose a risk for potentially fatal dysrhythmia. Torsades de pointes has developed in patients taking 65 to 400 mg/day. To reduce risk, methadone should be used with great caution—if at all—in patients with existing QT prolongation or a family history

16 / 14 of long QT syndrome and in those taking other QT- prolonging drugs. In addition, methadone causes severe respiratory depression that can be potentially fatal.

32. Buprenorphine and naloxone benefits of using this combination: - Buprenorphine is an opioid partial agonist. The partial agonist effect relieves withdrawal symptoms resulting from cessation of opioids.

• Buprenorphine should be started at 6-12 hours after the last dose of heroin or immediate release opioids and longer after ER. At least 36 hours after the last dose of methadone
• providers must have board certification in addiction medication and complete special training to qualify for the federal waiver to prescribe Buprenorphine NALOXONE; is an opioid antagonist. Is added with Buprenorphine to make the product less likely to be abused by injection. The naloxone component will have no effect if taken in tablet form. If injected then naloxone will precipitate withdrawal.

33. **Treatment of chronic pain Use of pregabalin

• sedation, dizziness, and ataxia are more linked to pregabalin**

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- GI bleeding may be caused by COX- 2 inhibitors and and NSAIDs: - Use of pregabalin

• sedation, dizziness, and ataxia are more linked to pregabalin
• treats neuropathic pain Tricyclics (TCAs) and SNRIs treats neuropathies pain
• contraindicated in severe cardiac disease, particularly conduction issues
• anticholinergic effects

34. **Order HTN meds are typically prescribed

• Best for someone with diabetes
• Best approach or drug to use during pregnancy or someone wishing to become pregnant:**

35. - Therapeutic action of drug classification used:
36. Ethnic groups impacted by certain drug classifications:
37. Prescribing considerations when carbamazepine is prescribed with war- farin:
38. **Beta blockers:

• Their use with nitroglycerin and tachycardia**

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**- know examples

• risk of stopping them abruptly
• what happens when given to someone with asthma ?:**

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39. Know the outcome of having a poor metabolism phenotype: slowed metab- olism of a prodrug into an active drug, leading to accumulation go prodrug
40. Know the role of the government when it comes to rx drugs: Although the federal government controls drug regulation, However, several organizations have appealed for changes that would place scope of practice and prescriptive authority under federal regulation in an effort to expand prescriptive authority and the scope of practice of advanced practice providers.
41. Fentanyl: Products containing fentanyl can cause fatal respiratory depression. Many of these products are only available through restricted distribution programs secondary to misuse and abuse
42. Methadone: prolongs the QT interval and hence may pose a risk for potentially fatal dysrhythmia. Torsades de pointes has developed in patients taking 65 to 400 mg/day. To reduce risk, methadone should be used with great caution—if at all—in patients with existing QT prolongation or a family history of long QT syndrome and in those taking other QT- prolonging drugs. In addition, methadone causes severe respiratory depression that can be potentially fatal.
43. Which of the following is NOT a potential harm/risk of pregabalin? Select the best answer.: GI bleeding

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44. Alan Sayed has neuropathic pain. What nonopioid medications should be considered for his treatment? Select all that apply.: A)Tricyclic antidepressants (TCAs) B)Topical lidocaine C)Serotonin and norepinephrine reuptake inhibitors (SNRIs) D)Gabapentin Answer: ABCD
45. Diuretics: Action Contradictions to thiazide diuretics o Monitoring needs: - Thiazide diuretics are the preferred agent for treating stage 1 hypertension

• Preferred in African American with HTN
• All diuretics decrease blood volume, venous pressure, and preload
• thiazide diuretics block the sodium-chloride channel in the kidney, decreasing the cross of sodium over the luminal membrane, which in turn decreases the action of the sodium-potassium pump and sodium and water passage to the renal interstitium

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• monitor K and electrolytes
• DO NOT GIVE IF SULFA ALLERGY
• can also be used to manage osteopenia or osteoporosis Examples: HCTZ, Hygroton, Lozol

22 / 14 Side effects: hyperglycemia, hyperuricemia (can precipitate gout), hyperlipidemia, hypokalemia, hyponatremia, hypomangesium

46. **Heart failure:

• What to prescribe in response to fibrotic changes?
• effects of cardiac glycosides:** - Digoxin belongs to a class of drugs known as cardiac glycosides, agents best known for their positive inotropic actions—that is, their ability to increase myocardial contractile force. By increasing contractile force, digoxin can increase cardiac output. In addition, it can alter the electrical activity of the heart and can favorably affect neurohormonal systems. Unfortunately, although digoxin can reduce symptoms of HF, it does not prolong life. Used widely in the past, digoxin is considered a second-line agent today.

47. Quinidine and digoxin What happens when they are combined ?:
48. Atherosclerotic Cardiovascular Disease (ASCVD) Risk Score What is it? When is it used ?:
49. Statin drugs-- at what age are they preferred ?:
50. Exetimibe (Zetia) what is it?

23 / 14 When is it used ?:

51. **Pharmacological option to minimize side effects

• In other words, how would you treat high cholesterol if someone was con- cerned about or experiencing side effects from other medications? Which drug classification would be a good choice ?:**

52. **Angina:

• therapeutic action of organic nitrates
• contraindication for ranolazine:** - prevention of MI and death
• antiplatelet drugs, cholesterol-lowering drugs, angiotensin-converting enzyme in- hibitors
• Reduction of cardiac ischemia and the associated pain-- nitrates, beta blockers, CCB, ranolazine
• CCBs and ACEI most expensive
• BB mid-range
• Nitrates cheapest

53. **Most appropriate treatment approach for OA

• pharmacological and non-pharm:**

54. gout

24 / 14 o Complicationsofuntreatedgouto Treatmentofacuteflarewithcolchicine Patient education Adverse effects

25 / 14 o Long-term use of allopurinol What condition can be developed?o Drug interactions with allopurinolo What should be co-administered with febuxostat ?: - Gout is a recurrent inflammatory disorder characterized by hyperuricemia (high blood levels of uric acid) and episodes of severe joint pain, typically in the large toe. Hyperuricemia

• Drugs are used in two ways in patients with gout. First, they are given short term to relieve symptoms of an acute gouty attack. Second, they are given long term to lower blood levels of uric acid. In patients with infrequent flareups (less than three per year), treatment of symp- toms may be all that is needed. Nonsteroidal antiinflammatory drugs (NSAIDs) are considered first-line agents for relieving the pain of an acute gouty attack. Glucocorticoids are an acceptable option. In the past, colchicine was considered a drug of choice for acute gout—even though it has a poor risk/benefit ratio. Today, colchicine is generally reserved for patients who are unresponsive to or intolerant of safer agents. In patients with chronic gout, tophaceous gout, or frequent gouty attacks (three or more per year), drugs for hyperuricemia are indicated. Three types of drugs may