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Cholinergics Sara Trovinger PharmD 1 Indications • Cause SLUD: salivation, lacrimation, urination, and defication • Used for contaction of muscles, bronchoconstriction, bradycardia • Frequently used in eye drops to cause contraction of the iris • Examples: Acetylcholine, Bethanechol, Pilocarpine, Carbachol 2 Contraindications • Asthma • GI spasm • Acute heart failure • Hyperthyroidism • Parkinson’s disease • Peptic ulcer disease • Urinary tract obstruction Possible Adverse 2 Effects • Cardiovascular: Bradycardia, flushing, hypotension • Ocular: Clouding, corneal edema • Respiratory: Dyspnea • Diaphoresis Sedatives 3 Indications • Relief of anxiety • Insomnia • Sedation and amnesia before and during medical procedures • Treatment of epilepsy and seizure states • Control of withdrawal states • Muscle relaxation in specific neuromuscular disorders How They 3 Work • Bind to GABAA receptor • GABA is a major inhibitory neurotransmitter • Benzodiazepines potentiate the effect of GABA inhibition, increasing the frequency of chloride ion channel opening • Barbituates appear to increase the duration that these channels are open 3 Examples • Benzodiazepines • Diazepam • Lorazepam • Midazolam • Barbiturates • Pentobarbital • Phenobarbital • Miscellaneous • Chloral hydrate • Hydroxyzine 3 Contraindications • Increased sensitivity seen in patients with: • • • • • • Cardiovascular disease Respiratory disease Hepatic impairment COPD Sleep apnea Elderly • Barbiturates contraindicated: • • • • Acute intermittent porphyria Variegate porphyria Hereditary coproporphyria Systemic porphyria Adverse 3 Events • Drowsiness • Impaired judgment • Diminished motor skills • Respiratory Depression • Dependence • Withdrawal References 1. Drug Classes : Cholenergics. Access Pharmacy [database online]. Available at: http://accesspharmacy.mhmedical.com/drugs.aspx. Accessed August 27, 2014. 2. Drug Monographs: Acetylcholine. Access Pharmacy [database online]. Available at: http://accesspharmacy.mhmedical.com/drugs.aspx?GbosID=13072 8. Accessed September 4, 2014. 3. Trevor, Anthony and Walter Way. Basic and Clinical Pharmacology. McGraw-Hill Companies Inc. 2012. Web. Anticholinergics Trenton Shoda PharmD Candidate Purdue University Indications • Relieve cramps/painful menstruation or spasms of the stomach, intestines, and bladder • In combination w/antacids for treatment of peptic ulcers • Prevent nausea, vomiting, and motion sickness • Surgery and emergency procedures • Runny nose • Asthma • Diarrhea • Excessive saliva production How do they work? • Anticholinergic agents block acetylcholine's action by competitively binding and blocking muscarinic receptors. Contraindications • Elderly • Dementia • Gastrointestinal obstruction • Glaucoma • Ulcerative Colitis • Breastfeeding Possible Side Effects Antiemetics How do they work? • Antihistamines – block H1 receptors centrally and in middle ear • Anticholinergics - blockage of central muscarinic receptors • Benzodiazepines – inhibitory effect on vomiting center and general CNS depression • Corticosteroids – inhibition of prostaglandin activity • Serotonin Antagonists – selective 5-HT3 receptor antagonist peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone Contraindications • Hypersensitivity • Narrow angle glaucoma – Benzodiazepines • Corticosteroids • Glaucoma • Current infection Possible Side Effects • Decrease in appetite • Constipation • Fatigue • Reduced Libido • Lightheadedness • Hypertension Narcotics/ Analgesics How do they work? • NSAIDs & Acetaminophen – inhibition of prostaglandin synthesis • Opioids – react with opioid mu-receptors in the central nervous system Contraindications • NSAIDs • Hypersensivity • <18 yo (aspirin) • Acetaminophen • Active and severe hepatic disease • Hepatic impairment • Hypersensitivity • Opioids • Respiratory depression • Hypersensitivity • Hypercarbia Possible Side Effects • Hypotension • Constipation, Nausea, Vomiting • Dizziness, Lightheadedness, Sedation • Increased risk of bleeding References • Norco. DrugPoints Summary. Micromedex 2.0. Truven Health Analytics, Inc. Greenwood Village, CO. Available at: http://www.micromedexsolutions.com. Accessed September 5, 2014. Laxatives Claire McClain 2015 PharmD Candidate Purdue College of Pharmacy Indications • Encourage bowel movements to relieve constipation • Bowel evacuation before gastrointestinal procedures How do they work? • Bulk laxatives: stimulate peristalsis by causing the retention of fluid and an increase in mass of fecal material (psyllium, polycarbophil) • Stimulant laxatives: increase muscle contractions to move the stool along by directly stimulating nerve endings (bisacodyl, senna) • Osmotic laxatives: draw water into the intestine from surrounding tissues resulting in a bulky soft stool to stimulate peristalsis ( saline laxatives, Lactulose, sorbitol) • Stool softeners: help to mix liquids in the stool and prevent hard, dry stools(docusate) • Lubricant laxatives: coat the stool and intestinal track to keep water in the stool (mineral oil) Contraindications • Patients with signs of appendicitis or inflamed bowel • Not intended for patients who miss only a day or two of bowel movements • Patients with a documented allergic reaction to any of these medications • Children under 6 years of age unless prescribed by a doctor • Avoid saline laxatives in patients with reduced kidney function Possible adverse effects • Increased blood sugar in diabetic patients • Exacerbation of heart disease or high blood pressure • Mineral oil can increase a patient’s risk of pneumonia • Diarrhea, bloating, cramping, belching • Difficulty swallowing (lump in throat) • Overuse of some laxatives has caused damage to the nerves, muscles, and tissues of the intestines and bowel. Corticosteroids Indications • Anti-inflammatory agent • Immunosuppressant • Used in active ulcerative colitis and Crohn's disease How do they work? • Closely resemble cortisol, a hormone produced by the adrenal glands • Reduce the production of inflammatory chemicals • Reduce the activity of the immune system by altering the function of white blood cells • Induce remission in patients with inflammatory bowel disease • Examples include: prednisone, prednisolone, methylprednisolone, belcometasone Contraindications • Acute infections uncontrolled by antimicrobial therapy • Patients with active tuberculosis • Caution in patients with heart failure, recent myocardial infarction, diabetes, or hypertension • Caution in septic shock patients Possible Adverse Effects • Mood swings, irritability • Weight gain, increased appetite • Increased risk of infection • Puffy face, water retention • Increased blood sugar • Increased blood pressure • Easy bruising • Slower wound healing • Osteoporosis (long term) Possible Adverse Effects • CUSHINGOID • C – Cataracts U – Ulcers S – Striae, Skin thinning H – Hypertension, Hirsutism I – Immunosuppression, Infections N – Necrosis of femoral heads G – Glucose elevation O – Osteoporosis, Obesity I – Impaired wound healing D – Depression/mood changes Sclerosants5 Indication • Acute endoscopic hemostasis • Elective obliteration of bleeding esophageal varices • Can be used alone or in combo with ligation for the treatment of bleeding esophageal or junctional varices • Not indicated for primary prophylactic treatments of varices that have not bled How do they work? • Tissue irritants that cause vascular thrombosis and endothelial damage • Leads to endofibrosis and vascular obliteration when injected into adjacent blood vessels • Most are fatty-acid derivatives (sodium morrhuate, ethanolamine oleate) ,synthetic chemicals (sodium tetradecyl sulfate, polidocanol), or alcohols (ethanol) • Dispensed with a sclerotherapy needle passed through the working channel of an endoscope Possible adverse effects • • • • • • • • Chest pain Mucosal ulceration Bleeding Esophageal strictures and fistulas Pleural effusions Sepsis/bactermia Pneumonia Hypoxia * Complications may occur in as many as 25% of patients Contraindications • Patients with cirrhosis and patients who are immunocompromised are at a greater risk for bacteremia • Caution in patients with: • • • • • Mechanical prosthetic devices History of endocarditis Vascular grafts Surgical systemic-pulmonary shunts Ascites References 1. Laxatives. DrugPoints Summary. Micromedex 2.0. Truven Health Analytics, Inc. Greenwood Village, CO. Available at: http://www.micromedexsolutions.com. Accessed August 27, 2014. 2. Cleavland Clinic. Drugs and Supplements. Available at: http://my.clevelandclinic.org/drugs/corticosteroids/hic_corticosteroids.aspx. Accessed August 27,2014. 3. Mayo Clinic. Prednisone and other corticosteroids. Available at: http://www.mayoclinic.org/steroids/art20045692?pg=2. Accessed August 27,2014. 4. Corticosteroids.DrugPoints Summary. Micromedex 2.0. Truven Health Analytics, Inc. Greenwood Village, CO. Available at: http://www.micromedexsolutions.com. Accessed August 27, 2014. 5. Croffie J, Somogyi L, Chuttani R, et al. Sclerosing agents for use in GI endoscopy. Gastrointest Endosc 2007;66:1-6. doi:10.1016/j.gie.2007.02.014. Antacids Alice (Siyue) Li 2015 PharmD Candidate Purdue College of Pharmacy Indications • Relieve heartburn, sour stomach, or acid indigestion • Some contain simethicone, which may relieve the symptoms of excess gas How do they work? • Neutralizing excess stomach acid • Simethicone lower the surface tension of gas bubbles Contraindications • Aluminum-containing antacids • Hypersensitivity • Caution in HF, renal failure, edema, recent GI bleed • Magnesium-containing antacids • Hypersensitivity • Extreme caution in myasthenia gravis or other neuromuscular disease, renal impairment • Calcium-containing antacids • Hypersensitivity • Caution in renal impairment, hx of kidney stones, hypoparathyroid disease, achlorhydria • Sodium bicarbonate-containing antacids • Alkalosis, hypernatremia, severe pulmonary edema, hypocalcemia, unknown abdominal pain Possible Adverse Effects • Aluminum-containing antacids • Constipation, discoloration of feces (white speckles), fecal impaction, N/V, stomach cramps • Magnesium-containing antacids • Diarrhea, N/V, dizziness, fatigue, electrolyte disturbances • Calcium-containing antacids • Constipation, bloating, gas, hypercalcemia, headache, acid rebound, N/V anorexia, electrolyte disturbance • Milk-alkali syndrome with very high, chronic dosing +/- renal failure • Sodium bicarbonate-containing antacids • • • • Belching, flatulence, gastric distension, tetany, Metabolic alkalosis, hypernatremia, hypocalcaemia Milk-alkali syndrome especially with renal dysfunction CHF exacerbation, edema, cerebral hemorrhage, Antispasmodics Belladonna alkaloids, Donatal (hyoscyamine, atropine, scopolamine, phenobarbitol), Librax (clidinium, chlordiazepoxide) Indications • Adjunct in treatment of irritable bowel syndrome, acute enterocolitis, duodenal ulcer How do they work? • Anticholinergic agents inhibit the muscarinic actions of acetylcholine at the postganglionic parasympathetic neuroeffector sites, including smooth muscle, secretory glands, and CNS sites. Contraindications • Donatal • Narrow angel glaucoma, GI/GU obstruction, myasthesia gravis, paralytic ileus, intestinal atony; unstable cardiovascular status in acute hemorrhage; severe ulcerative colitis (especially complicated by toxic megacolon); hiatal hernia associated with reflux esophagitis; acute intermittent porphyria; restlessness and/or excitement caused by phenobarbital • Librax • Hypersensitivity, glaucoma, prostatic hyperplasia, benign bladder neck obstruction • Anticholinergic agents – avoid in geriatric patients • Caution in patients with impaired renal/liver function, impaired gag reflex, depression, hx of drug abuse and respiratory disease Possible Adverse Effects http://media-cache-ec0.pinimg.com/236x/42/61/9d/42619d447565cbd965164810fd615763.jpg Antibiotics Indications • Intra-abdominal infection • • • • • • • Bacterial cause of diarrhea Bacterial gastroenteritis Bowel perforation Diverticulitis Cholecystitis Peptic ulcer caused by Helicobactor pylori Clostridium difficile Colitis How do they work? • Eradicate or suppress bacterial growth by interfering with production or functioning of essential bacterial components Common Antibiotics Used for GI • Common initial empiric board spectrum antiobiotics used for intra-abdominal infection • Meropenem, ertapenem, imipenem, pip/tazo, amp/sulbactam, Levofloxacin, ciprofloxacin, metronidazole, ceftriaxone, cefuroxime, cefazolin, etc. • Clostridium difficile infection • Oral Metronidazole, Oral Vancomycin • Peptic ulcer caused by Helicobactor pylori • Clarithromycin plus amoxicillin/metronidazole if allergic • De-escalate therapy to target particular bacteria based on culture and sensitivity results to decrease resistance Contraindications • Hypersensitivity • Anaphylaxis to penicillin • Do not try cephalosporin • Itching, rash or hive to penicillin • May still consider cephalosporin Possible Adverse Effects • • • • • Diarrhea Nausea and vomiting Thrush C. diff Antibiotic resistance Reference • Antispasmodics gastrointestinal, librax, donatol, sodium bicarb, calcium bicarb, magniesium hydroxide, aluminun hydroxide. LexiDrugs. Lexicomp. Wolters Kluwer Health, Inc. Hudson, OH. Available at: http://online.lexi.com. Accessed September 4, 2014. • Antacid, simethicone. DrugPoints Summary. Micromedex 2.0. Truven Health Analytics, Inc. Greenwood Village, CO. Available at: http://www.micromedexsolutions.com. Accessed September 4, 2014. • Solomkin JS, mazuski JE, et al. Diagnosis and mangement of Complicated Intra-abdominal Infection in Adults and Children: Guildline by the Surgical Infection society and the Infectious Diseases Society of America. IDSA guidelines, CID 2010:50 (15 Jan); 133-164. Anti-Ulcers Andy Campbell 2015 PharmD Candidate Purdue College of Pharmacy Ulcers • Stress ulcer prophylaxis • Active peptic ulcers: • Gastric • Esophageal • Duodenal Drug Subclasses • Antacids • Neutralize the stomach acid. • H2- antagonists/blockers • Block H2 receptors in parietal cells • No effect on gastrin • Proton pump inhibitors (PPIs) • Irreversible inhibition of the H+, K+, ATPase Adverse Effects • Antacids • Diarrhea and Constipation • H2-antagonists • Headache, fatigue, dizziness • PPIs • Headache, dizziness, Vitamin B12 deficiency Contraindications • Hx of hypersensitivity • Generally safe Antiflatulents Gas and Bloating • Type of diet • Fatty foods • Carbonated beverages • Foods high in carbohydrates • GI infection, blockage, or disease • Celiac disease, lactose inolerance, or IBS • Stress and anxiety Drugs Commonly Used • Simethicone • Anti-foaming mechanism • Beano • Contains alpha galactosidase • Lactaid, Dairy-Ease, etc. • Contains lactase Adverse Effects • Mild diarrhea • Nausea/Vomiting • Regurgitation Contraindications • Hx of hypersensitivity • Known or suspected intestinal perforation or obstruction Anti-Diarrheals Diarrhea • Antibiotic-associated diarrhea • Viral or bacterial infection • Lactose intolerance • GI disorder • • • • Crohn’s disease Ulcerative colitis Celiacs disease Irritable bowel syndrome Drugs used • Loperamide • Anticholinergics • Lomotil • Diphenoxylate and atropine Adverse Reactions • Hyperglycemia • Abdominal pain, N/V, xerostomia • Dizziness, somnolence • Fatigue Contraindications • Loperamide • • • • • Hx of hypersensitivity Abdominal pain w/o diarrhea Dysentery, not as primary therapy Infants <24 months Pseudomembranous colitis, not as primary therapy • Lomotil • Pseudomembranous colitis • Obstructive jaundice References • Mayo Clinic. Bloating, belching and intestinal gas: How to avoid them. Available at: http://www.mayoclinic.org/diseases-conditions/gas-and-gas-pains/in-depth/gas-and-gaspains/art-20044739. Accessed September 5, 2014. • Lomotil. DrugPoints Summary. Micromedex 2.0. Truven Health Analytics, Inc. Greenwood Village, CO. Available at: http://www.micromedexsolutions.com. Accessed September 5, 2014. IV Administration Risks Sara Trovinger, PharmD 1 Needlesticks • Approximately 385,000 needlesticks and other sharps-related injuries occur yearly to hospital-based healthcare personnel • Primarily associated with transmission of: • • • • Hepatitis B Hepatitis C HIV More than 20 other pathogens Medication 2 Spills • Not only risk to patient and nurse, but also risk for anyone cleaning up the spill or disposing of materials • Many medication spills involve intravenous (IV) tubing leaking on the floor, the patient, or on patient linens • Most dangerous if the medication is classified as a hazardous drug due to having one of the following traits: • • • • • Carcinogenicity Teratogenicity Reproductive Toxicity Organ Toxicity at Low Doses Genotoxicity Latex 3 Allergies • Affects less than 1% of Americans • Allergy to proteins in the sap of the Brazilian rubber tree • Can be aggregated by touching or breathing the protein • Reactions range from localized rash to anaphylactic shock • Can be found in many medical devices such as syringes, IV tubing, and bandages • Not all brands contain latex, always check packaging prior to using Latex Allergies – 3 cont. • People with frequent contact with latex products are more likely to develop a reaction • Affects up to 12% of health care professionals • Ways to reduce your risk of developing a latex allergy • Use powder-free gloves with reduced protein content • Use nitrile gloves • Do not used creams or lotions while wearing gloves (may cause glove deterioration) • Wash hands with mild soap and dry after removing gloves Complications of IV Therapy • Phlebitis • Infection • Thrombus • Infiltration or Extravastion Indications for IV Medication • Patient can not take medication via another route (PO, Rectal, Topical, etc.) • Medication only comes via IV route or is not absorbed via other routes • Fast onset is needed due to emergent procedure IV 4 Sedation • Refer to previous slides on IV sedation • Anterograde amnesia • Dose-related • Allows patient to cooperate with procedure, however have no recall of events • Medications from home can interact with procedure medications • Suggest using some sort of drug interaction checking software to check for interactions if unsure • Micromedex • Epocrates References 1. Sharps Safety for Healthcare Settings. Centers for Disease Control and Prevention Website. http://www.cdc.gov/sharpssafety/ July 27, 2010. Accessed July 23, 2014. 2. Hazardous Spills: The Safe Handling of Hazardous Drugs. Pennsylvania Patient Safety Advisory Website. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Sep 5(3)/Pages/96.aspx September 5, 2008. Accessed July 24, 2014. 3. Latex Allergy – Information for Health Professionals. New York State Department of Health Website. http://www.health.ny.gov/publications/1453/ July, 2014. Accessed July 29, 2014. 4. Trevor, Anthony and Walter Way. Basic and Clinical Pharmacology. McGraw-Hill Companies Inc. 2012. Web.