TOP 200 Midterm

affects 23.6 million americans

25%

-hypoglycemia
-sensitivity @ injection site

1- increase insulin secretion
2- reduce glucose production

*least expensive drug class

-Hypoglycemia
-weight gain

1- Glyburide (Micronase, Glynase, Diabeta)
2- Glimepiride (Amaryl)
3- Glipizide (Glucotrol, Glucotrol XL)

1- make muscle & adipose cells more insulin sensitive (leads to dec. in insulin resistance)
2- Supress glucose production

*take 6 weeks for maximum effect
*improve HDL & triglycerides
*(LDL remains constant)

-weight gain
-edema
-hypoglycemia when taken with inulin

CI in patients with abnormal liver function or CHF

1- Pioglitazone (Actos)
2- Rosiglitazone (Avandia)

1- decrease glucose production
2-sensitize cells to insulin ("increase insulin mediated peripheral glucose uptake")

Diarrhea
abdominal discomfort
lactic acidosis (if improperly prescribed)

Metformin (Glucophage, Glucophage XR)
Glucovance (Glyburide + Metformin)

1- stimulate insulin production (rapidly in the presence of glucose & for a short duration)

Hypoglycemia
weight gain

Repaglinide (Prandin)

1- slow absorption of glucose from the gut ("block enzymes that digest glucose in the small intestine, delaying its uptake)

*take w/ food!

flatulence
abdominal discomfort

Acarbose (Precose)
Miglitol (Glyset)

1- stimulates insulin production
2- decrease glucose production

-decrease fasting blood glucose 10-15mg/dL
-decrease A1C 0.5-.6%
-decrease post-prandial glucose 50mg/dL

GI side effects

Januvia (Sitgliptin)

1- increase insulin production (incretin is a hormone in the gut that acts on the pancreas)

*SC injection
*increases beta cell growth & replication

CHF & Myocardial ischemia

Exenatide (Byetta)

100-125mg/dL

70-100mg/dL

<or equal to 6.5%
(amount in blood in a 2-3month time period)

thirst
HA
difficulty concentrating
blurred vision
frequent urination
fatigue
weight loss

hot/sweaty
shaky
dizzy
HA
pale skin

-A1C <6.5%
-FPG >or equal to 126mg/dL
-2h plasma glucose >or equal to 200mg/dL
-in a patient with hyperglycemia, >or equal to 200mg/dL

low-->glucagon released from alpha pancreatic cells-->liver releases glucose into the blood

high-->insulin released from pancreatic beta cells-->fat cells take glucose in from blood

Insulin Aspart (Novolog)
Insulin Glulisine (Apidra)
Insulin Lispro (Humalog)
10-30 minutes for onset
peak effect on blood sugar= 30min-3hours
duration of action= 3-5hours

Insulin regular (Humulin R, Novolin R)
30-60min for onset
peak effect on blood sugar= 2-5hours
duration of action=up to 8 hours

Insulin NPH (Humulin N, Novolin N)
1-2 hours for onset
peak effect on blood sugar=4-12 hours
duration of action=16-24 hours

insulin glargine (Lantus)
insulin detemir (Levemir)
1-5 hours for onset
no clear peak
duration= up to 24 hours

for children >6months
temp <102.5 =5mg/kg/DOSE
>102.5=10mg/kg/DOSE
-every 6-8 hours
MAX=40mg/kg/DAY

gastric mucosa
kidneys
platelets
*inhibition can cause renal insufficiency & hyperkalemia

inc. in CV disorder

100-102

103-105

>106

no, it crosses the placenta and enters fetal circulation
-especially in the 3rd trimester
-promotes premature closing of the ductus arteriosus

in children <12
10-15mg/kg/DOSE q4h prn
MAX=5 doses (2.6g) in 24 hours

325-650mg q4h or 1000mg 3-4x/day
MAX=4g/DAY

Class: NSAID

Indications: inflammatory disease, rheumatoid disorders, mild to moderate pain, fever

Adverse effects: indigestion, abdominal pain, constipation

Pt. Education: take with food or milk & avoid aspirin

Class: nonselective NSAID

Indications: inflammatory disease, rheumatoid disorders, mild to moderate pain, fever

adverse effects: indigestion, abdominal pain, constipation

Pt. Education: take with food or milk & avoid aspirin

class: Analgesic & NSAID

Indications: mild to moderate pain, inflammation, fever, prevention of MI, inhibits prostaglandin synthesis

adverse effects: bleeding, fatigue, rash, abdominal pain
*Salicylism w/ toxic dose (vomitting, vertigo, tinnitus)

Pt. Education: CI in bleeding disorders (coumadin) & children <16 (Reyes syndrome)

class: NSAID analgesic

Indications: relief of symptoms of osteo, rheumatoid, and juvenile rheumatoid arthritis

adverse effects: edema, HA, dizziness

Pt. Education: take with food or milk & avoid aspirin

class: NSAID

indications: relief of osteo and rheumatoid arthritis

adverse effects: nausea, indigestion, constipation

Pt. education: take with food or milk & avoid aspirin

class: NSAID

indicaitons: treatment of osteo & rheumatoid arthritis, pain management

adverse effects: nausea, indigestion, constipation

Pt. Counsel: take with food or milk and avoid aspirin

class: NSAID

indications: relief of osteo and rheumatoid arthritis

adverse effects: abdominal pain, constipation, nausea

Pt. education: take with food or milk & avoid aspirin

class: NSAID

indications: relief of osteo and rheumatoid arthritis

adverse effects: abdominal pain, constipation, nausea

Pt education: take with food or milk and avoid aspirin

class: COX II inhibitor/NSAID

indications: relief of osteo and rheumatoid arthritis

adverse effects: GI irritation, HA

NO

class: analgesic

indications: relief of mild to moderate pain & fever

adverse effects: rash, anemia

Pt. education: very weak COX I and II inhibitor *ETHANOL inc. risk of acetaminophen induced hepatotoxicity

allergic rhinitis
allergic conjunctivitis
allergic dermatological conditions
urticaria
angioedema
pruritus
anaphylactic rxns
N/V
sedation

they cross the BBB causing CNS effects

Meclizine (Antivert)
Hydroxyzine (Atarax-Hcl Vistaril-pamoate)
Promethazine (Phenergan)
Benadryl (diphenhydramine)

Fexofenadine (Allegra)
Desloratadine (Clarinex)

Mucolytics
Expectorants
Suppressants
Decongestants
Antihistamines
Pain relievers

drowsiness, dry mouth

HA
drowsiness
throat irritation

HA
nausea
fatigue

Expectorant

dizziness
HA
stomach pain
vomitting

1/2008 not used in children <2
10/2008 patients <4 years of age should not be used unless under guidance of a health care professional

class: antihistamine 1st gen.

indications: relief of allergic symptoms

adverse effects: drowsiness, dizziness, dry mouth, fatigue, diarrhea

Pt. Education: enters breast milk, watch out for allergic rxn

class: Aniemetic, Antihistamine, sedative

indications: allergic rxn, sedative, motion sickness, post op pain

adverse effects: drowsiness, dizziness, dry mouth

Pt. Education: refrigerate suppositories, *onset=15-30 min, not for children <2

5mg/kg/DAY *divided into doses q6-8h

tab, syrup, suppository, injection

class: antitussive

indications: relief of cough

adverse effects: drowsiness, constipation

Pt. education: shake well, avoid alcohol, not for children <6 or asthmatics

class: antitussive

indications: relief of cough

adverse effects: HA, constipation, nausea

**life threatening rxns in pt.s allergic to tetracaine & procaine

Pt. education: do not crush, chew or dissolve, not for children <10

Flexeril (Cyclobenzaprine)
Soma (Carisoprodol)
Skelaxin (Metaxalone)
Zanaflex (Tizanidine)
Robaxin (Methocarbamol)

sleepiness
lack of coordination
acting silly

Aricept (Donezepil)
Exelon
Razadyne

MOA:enhance memory and mood by increasing acetylcholine levels

nausea
diarrhea
insomnia

Namenda (Memantine)

dizziness
HA
confusion

MOA; inhibit excitatory glutamate NON competitvely leading to cell death

cluster & migraine

tension

neck disorder

eye strain

sinusitis

NSAIDS
Triptans
BP meds
Antidepressants
Muscle Relaxers

indication: 1st line for migraine and cluster HA

MOA: bind to serotonin receptors (5-HT-1B and 5-HT-1D) inhibiting pro-inflammatory neuropeptide release

Imitrex
Maxalt
Amerge
Zomig
Axert

Ca-->stimulates gastrins release stmulating acid production
Mg-->diarrhea
Al-->constipation or toxic (bone demineralization)
alginic acid (Gaviscon)-->floats on the top of gastric contents as a protective barrier

neutralize acid in the stomach by reacting with hydrochloric acid to form H2O + salt
*do not decrease acid production

bind to H2 receptors on parietal cells, preventing histamine induced activation
*do not heal inflammation
*12 weeks 60% symptomatic improvement

block secretion of acid into the stomach by acid secreting parietal cells
*esophagus heals
*83% symptom reduction

anticholinergics, nitrates, benzodiazepines, narcotics, aspirin

Phenergan (Promethazine)
Zofran (Ondansetron)

MOA: H1 antagonist, anticholinergic

Administration: PO, IV, PR
(IV-->extravasation)

MOA: 5-HT3 (serotonin) antagonist

Administration: PO, IV
*in chemo

2/3 of the world are infected and asymptomatic

Increase LES pressure and strengthen contractions (peristalsis) *does not heal inflammation
Reglan (metoclopramide)

GERD
N/V
gastroparesis (damage to the nervous system resulting in dec. ability of the stomach to empty its contents)

common: weakness, somnolence

serious: tardive dyskinesia & neurological malignant syndrome

ALL OTC
Zantac (Ranitidine) -in children <1
Pepcid (Famotidine)
Tagamet (Cimetidine) -many drug interactions
Axid (Nizatidine)

Pepcid (Famotidine)
Tagamet (Cimetidine)
Axid (Nizatidine)

Prilosec (Omeprazole)
Prevacid (Lansoprazole-only 15mg)
Zegerid (Omeprazole +Na bicarbonate)

Prilosec (Omeprazole)
Nexium (Esomeprazole)
Prevacid (Lansoprazole)
Dexilant (Dexlansoprazole) -previously kapidex
Protonix (Pantoprazole)
Aciphex (Raberprazole)
Zegerid (Omeprazole + Na bicarbonate)

Prilosec (omeprazole)
Nexium (esomeprazole)
Prevacid (lansoprazole)

Dexilant (Dexlansoprazole)
Protonix (pantoprazole) EC
Aciphex (Raberprazole) EC
Zegerid (omeprazole + Na bicarbonate)

back pain
cough
constipation

HA
diarrhea
constipation

diarrhea
abdominal pain
nausea

diarrhea
HA
flatulence

HA

HA
dizziness
constipation

HA
dizziness
constipation

drowsiness
rash
N/V

1) Clarithromycin triple therapy x14days
clarithromycin, PPI, amoxicillin or metronidazole

2)Bismuth Quadruple Therapy x10-14 days
bismuth, PPI or H2 antagonist, metronidazole, tetracycline

MOA: inhibit osteoclasts so reducing bone turnover

Adverse effects: heartburn, indigestion, jaw bone pain

take first thing in the am
w/ full glass of water
do not eat/drink for 30min prior or after
remain sitting or standing for 30min

MOA: estrogen agonist in bone (antagonist in breast tissue)

adverse effects: hot flashes, night sweats, leg cramps, blood clots

breast cancer
osteoporosis
HRT

Raloxifene (Evista)
Calcitonin (miacalcin)

hot flashes, nigth sweats, leg cramps, blood clots, weight gain

Denosumab (Prolia)
MOA: blocks osteoclast activation leading to decreased resorption *in postmenopausal women

adverse effects: stomach upset, muscle pain, infection

Premarin (conjugated estrogens) -pregnant mare urine
adverse effects: rash, acne, alopecia

indications: most effective therapy for relief of moderate to severe vasomotor symptoms

adverse effects: vaginal bleeding, venous thromboembolism, stroke

unopposed estrogen treatment can increase risk of endometrial cancer
-taken with opposing progesterone

regulate menstrual cycle
treat acne
prevent pregnancy

upset stomach, cramping, bloating, gingivitis, weight gain or loss, acne, intermittent bleeding/spotting, painful or missed periods, vomiting, diarrhea, constipation, inc. or dec. appetite, discolored skin, unusual hair growth, menstrual flow change, breast tenderness enlargement or discharge, swelling itching redness burning or irritation of the vagina, white discharge

CV disease or risk (DVT, pulmonary embolism, stroke, MI)

PCOS treatment
endometriosis treatment
dysmenorrhea treatment
dec. ovarian cancer risk 40%
dec. endometrial cancer risk 50%
inc. breast size

estrogenic-ethinyl estradoil

progestational-norgestimate, drospirenone, norelgestrmin, norethindrone

-polycycstic ovarian syndrome
a hormone imbalance leading to overproduction of follicles each month by ovaries without producing an egg *usually temporary and comes with insulin resistance

leads to: infertility, irregular or no period, depression, weight gain, acne, abnormal hair growth

-endometrial tissue grows outside of the uterus causing pelvic pain and infertility
-5.5 million women in north america

700mg Ca & 600 IU Vit. D

1000mg Ca & 600 IU Vit. D

1300mg Ca & 600 IU Vit. D

1000mg Ca & 600 IU Vit. D

1200mg Ca & 800-1000 IU Vit. D

Boniva (Ibandronate) -also given PO

Reclast (Zoledronic acid)

Fosamax (Alendronate)
Actonel (Risedronate
Boniva (Ibandronate)

Fosamax (Alendronate)
Actonel (Risdronate)
Reclast (Zoledronic acid)

concerns: avoid in renal insufficiency

adverse effects: abdominal pain, constipation, diarrhea

(combo tab w/ Vit. D available

concerns: avoid in renal insufficiency

adverse effects: back & abdominal pain, HTN

special concerns: must not eat, and remain upright for 60mins after dose (to avoid fever), avoid in renal insufficiency, APAP given at the time of IV treatment

adverse effects: dyspepsia, diarrhea, bronchitis

concerns: avoid in renal insufficiency, APAP given with IV treatment

concerns: anti-mineral corticoid activity, avoid in renal/adrenal insufficiency

adverse effects: N/V, abdominal cramps

adverse effects: abdominal cramps, acne, anorexia

concerns: inserted every 3 weeks on day 1 of cycle, use back up if removed >3hours

adverse effects: migraine, HA, breast tenderness enlargement or secretion

adverse effects: abdominal cramps, acne, anorexia

menstrual frequency varies, must discuss when menses will begin

-contains 60% more estrogen
-replace patch weekly
-not recommended in patients >90kg

nausea, breast tenderness, increased BP, HA, melasma

early or mid-cycle breakthrough bleeding, increased spotting, hypomenorrhea

breast tenderness, HA, fatigue, mood changes

increased appetite, weight gain, acne, oily skin, hirutism-excessive hairyness, increased LDL, decreased LDL

Doxazosin ( cardura)
Prazosin (minipress)
Terazosin (Hytrin)
Alfuzosin (uroxatral)
Silodosin (Rapaflo)
Tamsulosin (Flomax)

yes combination has been shown to increase urine flow rate

adverse effects: orthostatic hypotension, dizziness, weakness, dec. libido, insomnia, rhinitis, abormal ejaculation, intraoperative floppy iris syndrome

pt education: administer 30mins prior to the same meal daily

Dutasteride (Avodart)
Finasteride (Proscar)

indications: treat symptomatic BPH

adverse effects: erectile dysfunction, dec. libido, inc. breast size/tenderness, rash

pt. counsel: pregnant females should not handle broken or crushed tablets (category X) & it is transfered in semen

alpha 1 blockers
5 alpha reductase inhibitors
muscarinic blockers

arousal-->Ach release (from pelvic nerve)-->NO release (from cavernosal nerve)-->smooth muscle relaxation-->inc. arterial flow & dec. venous outflow-->penile rigidity

endothelial damage leads to decreased NO production

normal pathway: cGMP buildup-->smooth muscle relaxation-->inc. inflow of blood

PDE5 inhibitors inhibit cGMP

HA, flushing, dyspepsia, rhinitis, impaired color discrimination, dizziness, hypotension, CV affects, sudden hearing loss

CI: with nitrates (hypotension) and grapefruit juice (inc. concentration)

classification: Selective alpha 2 adrenergic blocker that produces a vasodilatory resposne

adverse effects: dizziness, anxiety, flushing, HA, hypertension, tachycardia, tremor

Alprostadil (Caverject)

2-30minutes

Oxybuytnin (Ditropan or XR, Oxytrol patch, gelnique 10% gel)

Tolterodine (Detrol/Detrol LA)
Fesoterodine (Toviaz)
Solifenacin (Vesicare)
Trospium (Sanctura/Sanctura XR)
Darfenacin (Enablex)

their M3 (bladder muscarinic) selectivty

to decrease urge and decrease urination
-response isnt immediate

-antimuscarinic
-IR increases the adverse effects of dry mouth, constipation, nausea, blurred vision
-dec. adverse effects w/ the gel

-antimuscarinic/UI w/ increased selectivity for bladder receptors
-dec. urge & dec. urination

-antimuscarinic
-efficacy >tolterodine

-selective antimuscarinic (M3>M2)
-non-inferior to tolterodine

-nonselective antimuscarinic
-dec. frequency, urge, and increase volume voided

-highly selective antimuscarinic (90x) M3>M1
-dose dependent dec. in incontinence episodes
-increase bladder capacity
-expensive

MOA: competitive muscarinic receptor antagonist--dec. bladder contractions, detrusor pressure, and incomplete voiding

adverse effects: dry mouth, HA, constipation, blurred vision, dizziness

administration: once daily (ER/XR), twice daily (IR)
*reductions in renal/hepatic insufficiency

Pt. education: may take weeks to months for full efficacy
-leads to adherence issues

administration: without food, 30-60min before intercourse, no more that once daily

duration: up to 4 hours

administration: take without food 30-60min before intercourse no more than once daily

duration: up to 4 hours

administration: WITH OR WITHOUT food 30min before intercourse no more than once daily

duration: 24-36 HOURS

special concerns: avoid high fat foods and nitrates, caution w/ alpha blockers and some antibiotics/antifungals

adverse effects: HA, flushing, dyspepsia

high fat foods inc tmax (time to max [ ]), avoid w/ nitrates, caution with alpha blockers, antibiotics & antifungals

concerns: TMAX-2hours
avoid with nitrates and caution with alpha blockers, antibiotics, and antifungals

adverse effects: HA, dyspepsia, back pain