NUR 2407Pharm Study Guide Exam 2 Week 4 – Chapter 37-39, 32- 33, Exams of Nursing

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Week 4 – Chapter 37-39, 32- Chapter 37: Antineoplastic Agents

- Cancer - Cancer (malignant, neoplastic) cells are characterized by unregulated growth, lack of differentiation and spread (metastasis) to other places in the body. - Anticancer Therapy: - Chemotherapy is the use of chemicals to kill cancer cells by inhibiting or preventing cell reproduction. Classes of Chemotherapy Drugs:

• Alkylating Agents
• Antimetabolites
• Antitumor Agents
• Mitotic Inhibitors
• Hormonal Agents - Antimetabolites Folic Acid Antagonist
• Methotrexate (Trexall) – Used to treat cancer, rheumatoid arthritis, psoriasis. INDUCES MISCARRIAGES in patients with ectopic pregnancy. ⇨ General side effects: Bone suppression leading to leukopenia, thrombocytopenia, and anemia. Can cause stomatitis, vomiting, alopecia, and hepatic/renal dysfunction. **Patients should report any signs of bleeding and have platelet levels checked.
• Alkylating Drugs** Nitrogen Mustard
• Cyclophosphamide (Cytoxan) is used to treat Hodgkin’s disease and many other types of cancer. - This drug can cause hemorrhagic cystitis as result of severe bladder inflammation
• This drug should be taken with copious amounts of water and early in the day, so it does not accumulate in the bladder. Chapter 38: Targeted Therapies to treat cancer Targeted Therapy:

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• Drugs or other substances that block the growth and spread of cancer by interfering with specific molecules in tumor growth and progression.
• Cancers that do not have sufficient quantities of the specific molecular target will not respond to targeted therapy. Chapter 39: Biological Response Modifiers Colony Stimulating Factors: - Erythropoietin (Epoetin Alpha) stimulates red blood cell production, and increases the risk of death when a patient’s hemoglobin is >

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Chapter 32: Anti-TB, Antifungal, Peptides, Metronidazole Tuberculosis is caused by a bacterium call mycobacterium tuberculosis. The bacteria usually attack the lungs, but TB bacteria can attack any part of the body, such as the kidney, spin, and brain. If not treated properly, TB disease can be fatal.

- TB is one of the world’s top health challenges: More than 2 billion people, equal to a QUARTER of the world’s population are infected with TB.

• Each year there is 9 million new cases and 1.5 million deaths
• Each day there is 24,000 new cases, 4000 deaths and 8,000 missed. Latent TB Infection – TB bacteria can live in the body without making you sick. This is called Latent TB Infection. In most people who breathe in TB bacteria and become infected, the body is able to fight the bacteria to stop them from growing. People with this condition do no not feel sick and do not have any symptoms. People with this condition are not infectious and cannot spread TB bacteria to others. TB Disease – TB bacteria becomes active if the immune system can’t stop them from growing. When TB bacteria are active, multiplying in your body, this is called TB disease. People with TB disease are sick. They may also be able to spread the bacteria to people they spend time with every day. - Mycobacterium have a thick, way cell wall. It is very tough! Main Symptoms of Pulmonary Tuberculosis:
• Appetite Loss
• Fatigue
• Chest Pain
• Coughing up blood
• Productive, prolonged cough
• Night sweats, pallor **Anti- Tuberculars
• TB Treatment
• To prevent drug resistance – Multidrug Therapy (The golden standard of treatment)**
• Drugs: Isoniazid, Rifampin, Ethambutol, and Pyrazinamide******* Rifampin
• Antimycobacterial
• Must be taken daily for several months with no break. **- Can stain body fluids orange.
• Can cause hepatotoxicity**
• Take on empty stomach or absorption reduced by >30%***
• First discovered in soil from the French Riviera

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Isoniazid

• Antimycobacterial - BLACK BOX WARNING: Hepatoxicity
• Drug to Drug Interactions: Acetaminophen due to increased risk of liver damage***
• Drug of choice for pregnant women with TB
• Treats Latent and Active TB - Can cause peripheral neuropathy in patients with vitamin B6 deficiencies
• First tested in the Navajo community Many Farms, AZ

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Ethambutol

- Can cause vision problems, including optic neuritis and red green color blindness.

• Ok to take while breast feeding
• Antimycobacterial Pyrazinamide
• Give in first months of combo therapy to reduce the total length of treatment (by months)****** **- Can cause arthralgia (joint pain), peripheral neuropathy, and hepatoxicity *****

- Drug Resistance TB

• TB drug resistance is a major public health problem that threatens progress made in TB care and control worldwide. This improper use is a result of a number of actions including, administration of improper treatment regimens and failure to ensure that patients complete the whole course of treatment.
• Extensively drug-resistant TB. MDR TB is caused by an organism that is resistant to at least isoniazid and rifampin, the two most potent TB drugs.
• “Totally Drug-Resistant” tuberculosis: a WHO consultation on the diagnostic definition and treatment options. - TB Vaccine - The Bacille Calmette-Guerin (BCG) vaccine has existed for 80 years and is one of the most widely used of all currect vaccines, reading >80% of neonates and infants in countries where it is part of the national childhood immunization programmer. BCG vaccine has a documented protective effect against meningitis and disseminated TB in children.
• The World Health Organization recommends that in countries with a high rate of TB burden all infants should receive one dose of BCG attenuated live vaccine, as soon as possible after birth. **Antifungal Drugs
• Fungal Infections**
• Can be topical or systematic
• Can be opportunistic or non-opportunistic
• Can be mild to life-threatening
• Can be caused by antibiotic or steroid use - In the mouth, it is called Thrush* Nystatin (Myostatin) -** Antifungal Drug - Action: Binds to fungal cell membranes, causing cell contents to leak out = death - Use: Topical treatment of fungal infections. Not absorbed in the GI system, so safe to give orally.
• Elizabeth Lee Hazen and Rachel Fuller Brown discovered nystatin

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- Swish and Swallow!! Fluconazole (Diflucan) - Antifungal Drug - Used to treat candida infections and cryptocoal meningitis - Pregnancy Category C, give with caution Peptide Antibiotics Bacitracin

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- Effective against gram positive and some gram-negative bacteria - Available OTC as ointment for application to the skin - Peptide Antibiotic Metronidazole Metronidazole (Flagyl) - Impairs DNA function of susceptible bacteria - Used primarily to treat organism of the GI tract and to treat bacterial vaginosis**** - To prevent a disulfiram reaction patients must avoid alcohol and all alcohol containing products during treatment and for 48 hours after treatment. Disulfiram Reaction

• facial flushing - severe headache
• abdomen cramping - slurred speech
• tachycardia - palpitations
• hypotension - dyspnea
• sweating - nausea
• vomiting *****Most common with metronidazole & cephalosporin antibiotics** **Chapter 33: Antivirals, Antimalarial, Anthelmintic
• Viruses -** Obligate intracellular infectious agents that must reside within a living host cell to replicate. - Uses their own DNA and RNA to generate new viruses within the host cell Common human viruses
• Influenza
• Herpes
• Varicella Zoster (Chicken Pox & Shingles)
• Epstein-Barr (Mononucleosis)
• Hepatitis B
• Human Papilloma Virus (causes cervical cancer) - Influenza
• Osteltamivir (Tamiflu) – Shortens the course of flu symptoms by 2-3 days only if given within 48hrs of onset of symptoms.
• Children and teenagers with the flu may be at a higher risk for seizures, confusion, or abnormal behavior early during their illness
• An ounce of prevention (VACCINE) is better than a pound of cure (there is none)
• Influenza viruses mutate quickly and often

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- The potential for a major pandemic is a constant threat

• It is estimated that in the 1918-1919 influenza pandemic; the global death toll was 30-50 million people. - Herpes - Acyclovir (Zovirax) is effective against the herpes virus! ⇨ Life threatening adverse reactions: neuropathy, seizures, nephrotoxicity (large doses), thrombocytopenia, leukopenia. ⇨ Comes in an oral medication, cream, and injection - Zika Virus

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- Zika virus is a mosquito born single stranded RNA virus related to dengue virus - Zika Virus infections have been confirmed in infants with microcephaly. - Because there is neither a vaccine nor prophylactic medications available to prevent Zika, virus infection, the CDC recommends that all pregnant women consider postposing travel to areas where Zika Virus Transmission is ongoing.

• Women trying to become pregnant should consult with their healthcare provider before traveling to these areas. **Pregnant Women with Any Lab Evidence of Zika Virus Infection******
• US States and DC: 195
• US Territories: 146 **Anthelmintic Drugs
• Helminths** - Parasitic worms that fee on host tissue - Most common location is the intestine - Other sites include the lymphatic system, blood vessels, liver, and brain - Includes: Flukes, round worms, hook worms, and pin worms. ⇨ Can be acquired by poor handwashing, lack of access to clean drinking water, or eating undercooked pork. - Anthelmintic Drugs - Can cause GI distress, neurologic problems, or liver disease - Cysticercosis: Cysts on the brain caused by larval tapeworms**. ***** - Malaria - Caused by the protozoan parasites Plasmodium, carried by infected mosquitoes. - Once the human is infected with the parasite, it passes through two phases: - Tissue phase – No symptoms - Erythrocytic Phase – Invasion of RBCs, causing symptoms of chills, fever, and sweating.
• Over one million people die from malaria each year, mostly children under five years of age, with 90% of malaria cases occurring in Sub-Saharan Africa Antimalarial Drugs
• Chloroquine – Serious Adverse Reactions: ECG changes, hypotension, psychosis, seizures.
• Scientists engineer mosquito with malaria-blocking genes: Scientists 'edit' mosquito DNA to resist malaria, with hopes to breed with species in wild, block disease transmission
• EU regulator greenlights world's first malaria vaccine: Mosquirix is only about 30 percent

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effective, but EMA recommendation is likely to accelerate approval

• New malaria drug could be introduced in 2016: Joshua Blumenfeld, the managing director of Malaria No More, discusses the new medicine and its prospect **Week 5: Chap 35 & 36, 49 & 50 Chapter 35: HIV & AIDs related Drugs
• HIV & AIDs**

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- HIV is an RNA retrovirus. Retroviruses have an enzyme, called reverse transcriptase, that gives them the unique property of transcribing their RNA into DNA after entering a cell. The retroviral DNA can then integrate into the DNA of the host cell, to be expressed there. - HIV destroys CD4+ T helper lymphocyte cells, resulting in immune deficiencies, which can become fatal. - HIV Treatment: Combination Antiretroviral Therapy (ART) - Attaining viral suppression of HIV necessitates involves the use of at least two, preferably three, active drugs from two or more drug classes. - ART involves taking a combination of HIV medicines (called an HIV regimen) every day, EXACTLY as prescribed. - Zidovudine (AZT, Retrovir) – Nucleoside Reverse Transcriptase Inhibitor - Tenofovir (Viread) – Nucleoside Reverse Transcriptase Inhibitor - Efavirenz (Sustiva) – Nucleoside Reverse Transcriptase Inhibitor - Atazanavir (Reyatza) – Protease Inhibitor - HIV Lab Testing - Lab tests used to determine when to initiate medication therapy and to monitor efficacy of therapy and indications for changing therapy:

• CD4 T-Cell count
• HIV RNA quantitative assay (Viral Load)
• HIV Resistance Testing - Here is what your T-cell count can tell you: - More than 500 cells/mm^3 = Your immune system is NORMAL - 200-500 cells/mm^3 = Your immune system is WEAKEND - Less than 200 cells/mm^3 = Your immune system is VERY WEAK. You are at high risk for getting an opportunistic infection - an infection that develops only when the immune system is weak. 1 **Chapter 36: Vaccines
• Active Immunity
• Acquired Immunity:** Occurs as part of the human immune response which is activated when a pathogen invades the body. The body recognizes this pathogen as foreign, and begins the production of antibodies. - The next time the body encounters the same pathogen, it recognizes it and mounts a target response. - Immunization can provoke acquired immunity - Artificial active immunity is a type of protection developed against illnesses that produce such serious side effects that total avoidance of the disease is most desirable (a vaccination)

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- Vaccination involves administration of a small amount of antigen, which although capable of initiating an immune response, does not typically produce disease. - Passive immunity occurs when antibodies against a specific antigen are in a person's body, but the person did not actively generate these antibodies. **- Live attenuated (weakened) Vaccines

• Contraindications: *****
• currently ill
• egg or flu vaccine allergy
• under 2 or over 49 yrs
• immune suppression or live with someone who is
• pregnant

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• had or has Guillain Barre Syndrome
• age 2-17 and taking aspirin - Ex. Flu Vaccine Nasal Spray
• Vaccines
• Attenuated (Live):**
• BCG (Tuberculosis)
• MMR (Measles, mumps, rubella)
• Varicella (Chicken Pox) - Not Live (Inactivated):
• Hep B (Hepatitis B)
• Tetanus Toxoid ******Varicella (Varivax)** – For varicella prophylaxis, outbreak control of local epidemics of wild-type virus in susceptible persons following varicella exposure. Adverse Reactions: anaphylaxis, thrombocytopenia, encephalitis, Stevens-Johnson syndrome. **Chapter 49 & 50: Eye, Ear, and Dermatologic Medications Chapter 49: Eye and Ear Medications
• Drugs for Disorders of the Eye -** Diagnostic Stains **- Topical Anesthetics*****
• Anti-infective
• Anti-inflammatories
• Decongestants
• Lubricants
• Immunosuppressant
• Anti-glaucoma Agents - Topical Anesthetics
• Not for self-administration
• Given only under strict medical supervision***
• Numbing of the eye could lead to serious injury of the eye by trauma, without the patient being aware of it.

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**- Disorders of the Eye: Glaucoma***** - Optic nerve damage occurs as a result of increased intraocular pressure (IOP), due to a build-up of the fluid, aqueous humor. - Aqueous humor normally drains through the trabecular meshwork of the eye.

• Open Angle Glaucoma = Trabecular network becomes gradually clogged
• Narrow Angle Glaucoma = The iris bows and blocks the trabecular meshwork, narrowing the angle where the fluid normally exits the eye (often requires surgery) - Glaucoma Treatment 1. Prostaglandin Analogues

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2. Beta-Adrenergic Blockers 3. Cholinergic Agents 4. Alpha Adrenergic Agonists 5. Alpha Adrenergic Agonists 6. Carbonic Anhydrase Inhibitors 7. Osmotic - Latanoprost (Xalatan) – Know this drug and its side effects!!

• Prostaglandin Analogue*
• Decreases IOP by increasing outflow*
• Side Effects: Permeant darkening of the iris**
• Increase in length, number, darkness, and thickness of eyelashes**
• Adverse Effects: Up to 4% of patients report respiratory problems** **- Disorders of the Ear:
• Acute Otitis Media**
• Most common in children
• Risk factors: under 2, day care, not immunized, exposure to tobacco smoke and air pollution - First choice treatment: **Amoxicillin (PO)
• Acute Otitis Externa (Swimmers Ear)**
• Infection of the external auditory canal, occurring when moisture is present with a break in the skin allowing bacterial or fungal infiltration.
• Treatment: topical (drops) - Drugs for Disorders of the Ear:
• Oral Antihistamines
• diphenhydramine
• Oral Decongestants
• phenylephrine
• pseudoephedrine ****Agency for Healthcare Research and Quality: “Outcomes showed NO BENEFIT for use of these medications…evidence of increased side effects and harms with use of these medications.” (Diphenhydramine, Phenylephrine, and Pseudoephedrine) - Cerumen Impaction - Cerumenolytics
• Topical agents used to soften ear wax
• Usually mineral oil with hydrogen peroxide (patients can use mineral oil alone - Irrigation
• Body temperature water gently flushed into the ear canal
• Can use 3% hydrogen peroxide 1:1 with water or vinegar 1:1 with water

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Chapter 50: Drugs for Dermatologic Disorders

- Acne Vulgaris - Nonpharmalogic - diet, stress reduction, gentle cleansing - Topical - Keratolytic: benzoyl peroxide, salicylic acid, resorcinol, tretinoin - Systemic - oral antibiotics

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- Isotretinoin (Annesteem, Accutane) - For treatment of severe cystic acne - Decrease sebum formation, anti-inflammatory, antikeratinizing - Pregnancy Category X (Teratogenic)****** - Requires registry of patient, provider, pharmacist and wholesaler for use of medication, on iPLEDGE registry.** - Psoriasis - Characterized by erythematous papules and plagues covered with silvery scales - Epidermal cell growth and epidermal turnover are accelerated to approximately 5x normal expected growth - Usually has periods of remission and exacerbation* - Topical Medications

• Keratolytic
• Glucocorticoids
• Coal tar derivatives - Systemic Medications
• Methotrexate (anticancer drug, can decrease cell growth)
• UV light therapy
• Biologic Agents - Sunscreens
• Chemical Screens: Absorb UV radiation. Most absorb UVB, less than half absorb UVA. - Avobenzone absorbs UVA & UVB - Sunscreens protect against sunburn, premature aging of the skin, photosensitive to select drugs, but DO NOT protect against MELANOMA or **Basal Cell Carcinoma
• Burns -** Minor burns should be treated with a cool water compress. - Minor burns can be treated with a cool water compress - Partial & Full thickness burns require more intense treatment - Silver Sulfadiazine (SSD) – Antibacterial, Topical, Used for cutaneous burns, Steven-Johnson Syndrome. - Works on cell wall to produce bactericidal effects - 1% or less of the silver is absorbed - Up to 10% of the sulfadiazine is absorbed - DO NOT use of the FACE or HANDs , tattooing (permanent staining) may occur**

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Week 6: Chap 29 & 30, 31 & 34 Chapter 29: Penicillin’s and Cephalosporins

- Bacteria - Single celled organisms lacking a true nucleus or nuclear membrane - Can be classified by shape or ability of cell wall to hold gram stain - Produce toxins that cause host cell lysis - Antibacterial Drugs/ Antibiotics - Bacteriostatic- Slows the bacteria

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• Bactericidal-Kills the bacteria*** - 5 Mechanisms of Action (antibiotics):

1. Inhibition of bacterial cell wall synthesis
2. Alteration of membrane permeability
3. Inhibition of protein synthesis
4. Inhibition of the synthesis of RNA & DNA
5. Interference with metabolism within the cell

• Alexander Fleming- the first to notice mold spores interfering with bacterial cultures. Leading to antibiotic development.
• It’s not just the Drug!
• Antibiotics & Your Immune system work together to subdue the invading micro- organism. **- Antibiotic Resistance
• Antibiotics are powerless against this new superbug: E.Coli**
• Researchers in China have discovered a strain of E. Coli bacteria resistant to all known antibiotics - Narrow Spectrum Antibiotics:
• Primarily effective against one type of organism
• More effective against the organism it is fighting than a broad-spectrum antibiotic - Broad Spectrum Antibiotics
• Can be effective against gram negative and gram positive organisms
• Often used when the organism causing the infection has not been identified. Ex. Sepsis. **- Adverse Reactions to Antibiotics

1. Allergy or Hypersensitivity**

• Mild to fatal (anaphylaxis) – Itching and hives to angioedema 2. Superinfection
• A secondary infection that occurs when the normal microbial flora of the body is disturbed
• Often Fungal
• More common with broad spectrum antibiotics
• Ex. C.diff 3. Organ Toxicity - Hepatoxic

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- Nephrotoxic - Ototoxic - Anaphylaxis**** - A serious allergic reaction and should be treated as a medical emergency. It can occur within minutes of exposure, or take several hours. - Sign of Anaphylaxis : - Anxiety, Confusion - Lightheadedness, Loss of consciousness - Headache - Swelling of the lips, tongue, and/or throat

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- Runny nose ****Think -** Low blood pressure, fast or slow heart rate Airway -** Flushing of the skin, hives, and/or itchiness - Vomiting, diarrhea, and/or abdominal cramping - Cough, wheezing, shortness of breath - Hoarseness, pain when swallowing *Anyone with symptoms of anaphylaxis should seek medical attention immediately! Areas most commonly affected in anaphylaxis:

• Skin, in 80-90% of cases
• Respiratory, 70%
• Gastrointestinal, 30-45%
• Cardiovascular, 10-45%
• Central Nervous System, 10-15% **- Penicillins
• Amoxicillin*** -** Broad Spectrum - Primarily used to treat respiratory tract infections, Otis media, and sinusitis - Contraindicated with penicillin allergy - Give with caution in cephalosporin allergy **- Other Penicillins include Penicillin, Ampicillin, and Bicillin
• Beta Lactamase Inhibitor
• Beta Lactamase:** An enzyme produced by some bacteria that make them resistant to Penicillins. - Amoxicillin/ Clavulanic acid (Augmentin)
• Combines
• Broad Spectrum antibiotic
• Beta Lactamase Inhibitor
• Resulting in extended antimicrobial effect **- Cephalosporins
• Ceftriaxone (Rocephin)**
• Cephalexin (Keflex)
• Active against gram positive and negative bacteria
• Resistant to beta lactamase
• Give with caution to patients with penicillin allergy, and monitor for signs of an allergic reaction

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• Cross allergy may not be as common as once thought
• A fungus discovered near a sewer outlet in Mediterranean seawater at Sardinia.
• **REMEMBER: Potential Disulfiram Reaction when mixed with alcohol! Chapter 30: Macrolides, Tetracyclines, Aminoglycosides, and Fluoroquinolones
• Macroslides – Antimicrobials
• Erythromycin
• Frequently prescribed if a patient has a hypersensitivity to Penicillins** -** Allergic Reactions are rare

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- Hepatotoxicity can occur, especially when combined with other hepatotoxic drugs like acetaminophen

• Excreted primarily in the bile by the liver, making it a good choice for patients with renal impairment.** - Azithromycin
• Treats respiratory tract, sinus, GI tract, skin, and soft tissue infections, as well as impetigo and sexually transmitted infections (STIs)
• Life Threatening Adverse Reactions: Hepatotoxicity, anaphylaxis, Steven Johnson syndrome. **- Glycopeptide Antibiotics – Antimicrobials
• Vancomycin**
• Used against drug resistant staphylococcus aureus
• Ototoxicity can lead to permanent hearing loss by damaging CN VII***
• Too rapid administration can lead to Red Man Syndrome***
• Peak and trough levels must be checked to ensure safety and efficacy (metabolism and elimination). **- Tetracyclines - Antimicrobials
• Tetracycline***
• Take on an empty stomach as milk or antacid products can prevent absorption.
• Can stain teeth of fetus or young children**
• Can decrease effectiveness of oral contraceptives**
• Can result in photosensitivity reactions - Doxycycline
• Take with food to enhance absorption, but AVOID milk containing products
• Contraindicated in pregnancy
• Diarrhea, Nausea, and vomiting are common side effects **- Aminoglycoside Antibiotics
• Gentamicin**
• Used to treat serious infections
• Can cause nephrotoxicity and ototoxicity*
• Assess hearing, balance, and urine output while on therapy **- Fluoroquinolone Antibiotics
• Levofloxacin (Levaquin)**
• Primarily used to treat respiratory infections, such as community acquired pneumonia, chronic bronchitis, acute sinusitis. Can also treat UTI and uncomplicated skin infections. - Ciprofloxacin (Cipro)

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• Broad spectrum antibiotic
• Treats UTI, lower respiratory infections, skin, soft tissue, and bone infections
• Used to treat anthrax**
• Administer on an empty stomach. Products with magnesium, aluminum, iron, or zinc should be ingested 4 hours before or 2 hours after Cipro.
• Do not take with antacids! ** Fluoroquinolones can cause tendon rupture, especially if taken in combination with steroids Chapter 31: Sulfonamides

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