🧬 Exam 5
Endocrine drugs, then blood thinners, hematopoietic agents and blood products.
Modules 8–9 · 50 questions · 34 drugs · 17 concepts
Module 8: Endocrine Disorders
What are the signs and symptoms of hypoglycemia?🚨 DANGER
Hypoglycemia is a blood glucose BELOW 70 mg/dL (severe is below 40). Early symptoms are adrenergic: SHAKY, SWEATY, HUNGRY, tachycardic, pale, anxious. As it worsens the brain runs out of fuel: headache, blurred vision, confusion, irritability, combativeness, slurred speech, seizures, unconsciousness.
- The textbook's mild-to-moderate list: shaky or jittery, sweaty, hungry, headache, blurred vision, sleepy or tired, dizzy or light-headed, confused or disoriented, pale, uncoordinated, irritable or nervous, argumentative or combative, changed behavior or personality, trouble concentrating, weak, and fast or irregular heartbeat. SEVERE: unable to eat or drink, seizures or convulsions, unconsciousness.
- ANY sudden change in mood, behavior, or mental status in a diabetic patient means CHECK THE BLOOD GLUCOSE FIRST. That is the textbook's instruction and the exam answer.
- TREATMENT if conscious and able to swallow: 15 grams of rapidly digested carbohydrate (4 oz fruit juice, 4 oz regular soda, 3 to 4 glucose tablets, 1 tablespoon honey), recheck in 15 minutes, repeat if still under 70, then give a protein-plus-carbohydrate snack. The 'rule of 15.'
- If NPO, unconscious, or unable to swallow: DEXTROSE 50% IV push, or GLUCAGON IM or subcutaneous. Never put food or fluid in the mouth of an unresponsive patient. Glucagon peaks in 13 to 20 minutes; give carbohydrate as soon as they can swallow, especially in children.
- Monitor closely for 24 hours after an episode, notify the provider and the oncoming nurse, and look for the cause (missed meal, extra insulin, exercise, alcohol, renal decline).
- BETA BLOCKERS MASK the adrenergic warning signs (tachycardia, tremor, palpitations). DIAPHORESIS still occurs and becomes the key clue. Older adults and patients with long-standing diabetes may have hypoglycemia unawareness.
| Hypoglycemia (under 70) | Hyperglycemia (over 180 to 200) |
|---|
| Sudden onset (minutes) | Gradual onset (hours to days) |
| COLD and CLAMMY, pale, diaphoretic | HOT and DRY, flushed |
| Shaky, tachycardic, anxious, hungry | Thirsty, polyuria, weak, blurred vision |
| Confusion, combativeness, seizure, coma | Lethargy, Kussmaul respirations, fruity breath, coma |
| Treat: 15 g fast carbs, or D50 IV / glucagon IM | Treat: insulin, IV fluids, electrolyte replacement |
COLD and CLAMMY, need some candy. Any weird behavior = check the sugar.
What are the signs and symptoms of hyperglycemia?⭐ HIGH YIELD
Hyperglycemia is a blood glucose above the target range. The classic three P's: POLYURIA (excessive urination), POLYDIPSIA (excessive thirst), and POLYPHAGIA (excessive hunger). Plus fatigue, blurred vision, weight loss, dry flushed skin, poor wound healing, and recurrent infections.
- Onset is GRADUAL, over hours to days, unlike hypoglycemia which comes on in minutes. The skin is HOT AND DRY rather than cold and clammy.
- The mechanism explains the symptoms: glucose spills into the urine and drags water with it (osmotic diuresis), causing polyuria and then dehydration and thirst. Cells cannot use glucose, so the patient is hungry and losing weight while the blood sugar is high.
- Severe/uncontrolled hyperglycemia progresses to DKA (type 1) or HHS (type 2). DKA adds KUSSMAUL respirations (deep, rapid, compensating for metabolic acidosis), FRUITY/acetone breath, nausea, vomiting, abdominal pain, and altered mental status. HHS produces extreme dehydration and profound neurologic changes with glucose often over 600.
- Also seen: dry mouth, headache, difficulty concentrating, yeast and urinary infections, numbness or tingling in the feet, and slow-healing wounds.
- SYMPTOMATIC HYPERGLYCEMIA MUST BE REPORTED TO THE PROVIDER IMMEDIATELY, per the textbook.
- Common triggers in the hospital: infection, stress, corticosteroids, missed insulin doses, IV dextrose or TPN, and illness. Assess glucose MORE FREQUENTLY when a diabetic patient is stressed or infected.
HOT and DRY, sugar HIGH. Three P's: pee, thirst, hunger.
What is the reference range for serum glucose?⭐ HIGH YIELD
Normal blood glucose is tightly maintained between 70 and 110 mg/dL. The ADA gives normal FASTING glucose for a non-diabetic as 80 to 130 mg/dL. HYPOGLYCEMIA is below 70; SEVERE hypoglycemia is below 40. A1C target is generally less than 7%, which corresponds to an average glucose of about 154.
- Memorize the action numbers, not just the range: UNDER 70 = treat for hypoglycemia. UNDER 40 = severe, act immediately.
- Diagnostic thresholds for diabetes: fasting glucose 126 mg/dL or higher, a 2-hour OGTT of 200 or higher, an A1C of 6.5% or higher, or a random glucose of 200 or higher with classic symptoms. Prediabetes: fasting 100 to 125, or A1C 5.7 to 6.4%.
- A1C (glycosylated hemoglobin) reflects average glucose over about 3 MONTHS, so it shows adherence over time and cannot be faked by fasting the morning of the lab. It is checked roughly every 3 to 6 months.
- A1C targets are individualized: under 7% for most, but LESS strict (7.5 to 8%) for older adults, children who cannot recognize hypoglycemia, and anyone with hypoglycemia unawareness, because the risk of a low is worse than the risk of a slightly high average.
- Inpatient targets are looser than outpatient targets, generally 140 to 180 mg/dL for most hospitalized patients, to avoid hypoglycemia.
- The physiology behind the range: above it, insulin is released to move glucose into cells. Below it, glucagon is released to push glucose out of the liver.
| Value | Meaning |
|---|
| 70 to 110 mg/dL | Normal tightly regulated range |
| 80 to 130 mg/dL | ADA normal FASTING range for a non-diabetic |
| Under 70 mg/dL | HYPOGLYCEMIA - treat with 15 g carbohydrate |
| Under 40 mg/dL | SEVERE hypoglycemia - D50 IV or glucagon |
| 126 mg/dL or higher fasting | Diagnostic of diabetes |
| A1C under 7% | General target (average glucose about 154) |
70 is the floor, 110 is the ceiling. Under 70 you feed them; under 40 you inject.
Which antidiabetic medications can cause hypoglycemia?⭐ HIGH YIELD
INSULIN (all types) and the SULFONYLUREAS (glipizide, glyburide, glimepiride) are the two that cause SEVERE hypoglycemia. Meglitinides (repaglinide, nateglinide) also cause it. DPP-4 inhibitors such as SITAGLIPTIN can cause it. METFORMIN by itself does NOT.
- The textbook is explicit: 'All sulfonylurea drugs are capable of producing severe hypoglycemia,' and 'Unlike sulfonylureas, metformin does not produce hypoglycemia.'
- Sulfonylureas work by squeezing insulin out of the beta cells REGARDLESS of the blood sugar, which is exactly why they cause lows. Give them 30 MINUTES BEFORE A MEAL, and hold and call if the patient is not eating.
- Drugs that make sulfonylurea hypoglycemia WORSE: NSAIDs and other highly protein-bound drugs (they displace it), alcohol, beta blockers, and renal impairment.
- The classes that do NOT cause hypoglycemia on their own are metformin, thiazolidinediones (pioglitazone), alpha-glucosidase inhibitors (acarbose), GLP-1 agonists (semaglutide, liraglutide), and SGLT2 inhibitors (empagliflozin). But ANY of them combined with insulin or a sulfonylurea can.
- SPECIAL RULE: if a patient on ACARBOSE becomes hypoglycemic, treat with pure GLUCOSE (glucose tablets or gel), not table sugar or juice, because acarbose blocks the breakdown of sucrose.
- Metformin's danger is different: LACTIC ACIDOSIS, fatal in about half of cases. Contraindicated in renal and hepatic disease, and must be HELD before and after IV iodinated contrast studies. Report chills, low blood pressure, muscle pain, or dyspnea immediately. Hypoglycemia is harder to recognize in older adults and in anyone taking a beta blocker.
| CAUSES hypoglycemia | Does NOT cause it alone |
|---|
| Insulin (every type) | Metformin (biguanide) |
| Sulfonylureas: glipizide, glyburide, glimepiride | Thiazolidinediones: pioglitazone |
| Meglitinides: repaglinide, nateglinide | Alpha-glucosidase inhibitors: acarbose |
| DPP-4 inhibitors: sitagliptin (per the textbook) | GLP-1 agonists: semaglutide, liraglutide |
| SGLT2 inhibitors: empagliflozin, dapagliflozin |
Insulin and the sulfonylureas push insulin out no matter what. Metformin just makes you use your own.
What is the onset of action, peak effect, duration of action, and administration schedule for each type of insulin?⭐ HIGH YIELD
Learn it by class. RAPID: onset 15-30 min, peak 1-3 h, lasts 3-5 h, give within 15 minutes before a meal or right after. SHORT/regular: onset 30 min, peak 3 h, lasts 8 h, give 30 minutes before a meal. INTERMEDIATE/NPH: onset 1-2 h, peak 6 h, lasts up to 24 h, once or twice daily. LONG-ACTING: onset 3-4 h, NO PEAK, lasts over 24 h, once daily.
- THE PEAK IS WHEN HYPOGLYCEMIA HAPPENS. If you know when the insulin peaks, you know when to assess and when the food has to be there.
- REGULAR insulin is the only one given IV, and it is the insulin used in DKA drips. NPH is the only CLOUDY insulin; roll or invert it gently to resuspend, never shake.
- MIXING NPH AND REGULAR: air into NPH (cloudy) first, air into regular (clear), then draw REGULAR FIRST. Clear before cloudy. 'RN' - Regular before NPH. Long-acting insulins are NEVER mixed with anything.
- Sites: outer upper arm, abdomen (below the costal margin to the iliac crest and more than 2 inches from the umbilicus), anterior thighs, or buttocks. Rotate WITHIN one region to prevent lipodystrophy. Abdomen absorbs fastest.
- Insulin is a HIGH-ALERT medication: independent double check, insulin syringes or pens only, never abbreviate 'units' as U, and after injecting with a pen COUNT TO FIVE before withdrawing the needle.
- Storage: unopened vials in the refrigerator until the expiration date; opened vials labeled with the open date and refrigerated 28 to 42 days depending on the product. Used pens at room temperature away from heat and light for 10 to 28 days. Never freeze; never use discolored or clumped insulin. Inhaled insulin (Afrezza) is rapid-acting but is CONTRAINDICATED in asthma and COPD; boxed warning for acute bronchospasm.
| Type | Onset | Peak | Duration | Administration schedule |
|---|
| Rapid-acting: lispro (Humalog), aspart (Novolog), inhaled (Afrezza) | 15-30 min | 1-3 h | 3-5 h | Within 15 minutes BEFORE a meal or immediately after |
| Short-acting: regular (Humulin R, Novolin R) | 30 min | 3 h | 8 h | 30 minutes before a meal; the ONLY insulin given IV |
| Intermediate: NPH (Humulin N, Novolin N) | 1-2 h | 6 h (range 2.8-13 h) | Up to 24 h | Once or twice daily; subQ only; roll to resuspend (cloudy) |
| Combination intermediate/rapid: Humalog Mix 75/25, Novolog Mix 70/30 | 15-30 min | 1-5 h | 11-22 h | Twice daily, 15 min before a meal or right after; subQ only |
| Combination intermediate/short: Humulin 70/30, Novolin 70/30 | 30-90 min | 1.5-6.5 h | 18-24 h | Twice daily, 30-45 min before a meal; do not mix with other insulin |
| Long-acting: glargine (Lantus), detemir (Levemir) | 3-4 h | NO PEAK | Over 24 h | Once daily (sometimes split); subQ only; NEVER mix |
Clear before cloudy, RN: Regular then NPH. No peak, no mixing, for the long-acting.
💉 DesmopressinBLACK BOX
Pituitary hormone, Synthetic antidiuretic hormone
What it is for
Hemophilia A, von Willebrand’s disease type 1, nonnephrogenic diabetes insipidus, symptoms of polyuria/polydipsia caused by pituitary dysfunction, nocturnal enuresis, nocturia Unlabeled: Uremic bleeding
How it works
Promotes reabsorption of water by action on renal tubular epithelium; causes smooth muscle constriction, increase in plasma factor VIII levels, which increases platelet aggregation, thereby resulting in vasopressor effect …
Watch for
CNS: Drowsiness, headache, lethargy, flushing, seizures CV: Increased B/P, palpitations, tachycardia EENT: Nasal irritation, congestion, rhinitis GI: Nausea, heartburn, cramps GU: Vulval pain META: Hyponatremia, hyponatremiainduced seizures SYST: Anaphylaxis (IV)
Teaching
- About the proper technique for nasal instillation: to insert tube into nostril to instill product, clear nasal passage before use
- To avoid OTC products (cough, hay fever) because these preparations may contain EPINEPHrine, decrease product response; not to use with alcohol because adverse reactions …
- To wear emergency ID specifying therapy
- That if dose is missed, to take when remembered up to 1 hr prior to next dose; not to double dose; to avoid fluids from 1 hr to up to 8 hr after PO dose
🔗 Full card in the drug guide
💉 Fludrocortisone
Corticosteroid, synthetic, Mineralocorticoid
What it is for
Adrenal insufficiency, salt-losing adrenogenital syndrome, Addison’s disease
🔗 Full card in the drug guide
💉 Hydrocortisone
Corticosteroid, Short-acting glucocorticoid
What it is for
Severe inflammation, adrenal insufficiency, ulcerative colitis, collagen disorders, asthma, COPD, SLE, Stevens-Johnson syndrome, ulcerative colitis, TB Unlabeled: Carpal tunnel syndrome, Churg-Strauss syndrome, COVID-19, endophthalmitis …
How it works
Decreases inflammation by suppression of migration of polymorphonuclear leukocytes, fibroblasts, reversal of increased capillary permeability, and lysosomal stabilization
Watch for
CNS: Depression, flushing, sweating, psychosis, headache, mood changes, pseudotumor cerebri, euphoria, insomnia, seizures CV: Hypertension, edema EENT: Increased intraocular pressure, blurred vision, cataracts, glaucoma GI: Diarrhea, nausea, abdominal distention, GI hemorrhage, pancreatitis …
Teaching
- That emergency ID as corticosteroid user should be carried
- To immediately report abdominal pain, black tarry stools because GI bleeding/perforation can occur; if received by epidural route, to report immediately a change in visio …
- To notify prescriber if therapeutic response decreases; that dosage adjustment may be needed; about signs of infection
- Not to discontinue abruptly because adrenal crisis can result; that product should be tapered
🔗 Full card in the drug guide
💉 LevothyroxineBLACK BOX
Thyroid hormone, Levoisomer of thyroxine
What it is for
Hypothyroidism, myxedema coma, thyroid hormone replacement, thyrotoxicosis, congenital hypothyroidism, some types of thyroid cancer, pituitary TSH suppression
How it works
Increases metabolic rate; controls protein synthesis; increases cardiac output, renal blood flow, O2 consumption, body temperature, blood volume, growth, development at cellular level via action on thyroid hormone receptors
Watch for
CNS: Anxiety, insomnia, tremors, headache, thyroid storm, excitability CV: Tachycardia, palpitations, angina, dysrhythmias, hypertension, cardiac arrest GI: Nausea, diarrhea, increased or decreased appetite, cramps MISC: Menstrual irregularities, weight loss, sweating, heat intolerance, fever …
Teaching
- That hair loss will occur in child, is temporary; that hypothyroid child will show almost immediate behavior/personality change
- To report excitability, irritability, anxiety, which indicate overdose
- Not to switch brands unless approved by prescriber; to protect from light, moisture
🔗 Full card in the drug guide
💉 Methimazole
Thyroid hormone antagonist (antithyroid), Thioamide
What it is for
Hyperthyroidism
How it works
Inhibits synthesis of thyroid hormones by decreasing iodine use in manufacture of thyroglobulin and iodothyronine; does not affect circulatory T4, T3
Watch for
CNS: Drowsiness, headache, vertigo, fever, paresthesias, neuritis ENDO: Enlarged thyroid GI: Nausea, diarrhea, vomiting, jaundice, hepatitis, loss of taste GU: Nephritis HEMA: Agranulocytosis, leukopenia, thrombocytopenia, hypothrombinemia, lymphadenopathy, bleeding, vasculitis INTEG: Rash …
Teaching
- To take pulse daily
- To report redness, swelling, sore throat, mouth lesions, fever, which indicate blood dyscrasias
- To keep graph of weight, pulse, mood
- To avoid OTC products, seafood that contain iodine, other iodine products
🔗 Full card in the drug guide
💉 Octreotide
Growth hormone, antidiarrheal, Synthetic analog of somatostatin
What it is for
SandoSTATIN: acromegaly, improves symptoms of carcinoid tumors, vasoactive intestinal peptide tumors (VIPomas); LAR Depot: long-term maintenance of acromegaly, carcinoid tumors, VIPomas Unlabeled: GI fistula, variceal bleeding, diarrheal conditions …
How it works
A potent growth hormone similar to somatostatin
Watch for
CNS: Headache, dizziness, fatigue, weakness, depression, anxiety, tremors, seizure, paranoia CV: Sinus bradycardia, conduction abnormalities, dysrhythmias, chest pain, SOB, thrombophlebitis, ischemia, HF, hypertension, palpitations, QT prolongation ENDO: Hypo/hyperglycemia, ketosis, hypothyroidism …
Teaching
- That regular assessments are required; that diabetics need to monitor blood glucose
- To use as prescribed, not to miss, double doses; if a dose is missed, take when remembered unless close to next dose
- About SUBCUT inj if patient or other persons will be giving inj, provide instructions for use
- That product may cause dizziness, drowsiness, weakness; to avoid hazardous activities if these occur; to report abdominal pain immediately
🔗 Full card in the drug guide
💉 PropylthiouracilBLACK BOX
Antithyroid agent, Thioamide
What it is for
Hyperthyroidism and Graves disease, particularly in the first trimester of pregnancy and in thyroid storm.
How it works
Blocks the enzyme that builds thyroid hormone, and — unlike methimazole — also blocks the conversion of T4 to the more active T3 out in the tissues. It does nothing to hormone already stored, so the effect takes weeks.
Watch for
HEMA: Agranulocytosis (the dangerous one), leukopenia, thrombocytopenia. GI: Nausea, loss of taste. HEPA: Severe liver injury and failure. INTEG: Rash, itching. MS: Joint pain. ENDO: Hypothyroidism if overtreated.
Teaching
- A sore throat, fever or mouth ulcer is not a minor complaint on this drug — it is agranulocytosis until proven otherwise. Stop and call the same day.
- Report yellow skin or eyes, dark urine, pale stools or right upper abdominal pain (liver injury).
- Preferred over methimazole in the first trimester of pregnancy. It is also often chosen in thyroid storm because it blocks T4-to-T3 conversion — but note that thyroid storm is NOT part of the boxed warning, so do not say it if asked what the boxed warning states.
- Methimazole is usually preferred otherwise.
🔗 Full card in the drug guide
Somatotropin
Somatotropin is recombinant human GROWTH HORMONE, given SUBCUTANEOUSLY to replace deficient GH. Used for growth hormone deficiency in children and adults, Turner syndrome, Prader-Willi syndrome, chronic kidney disease, small-for-gestational-age children who fail to catch up, and idiopathic short stature.
- Give it at BEDTIME, subcutaneously, to mimic the body's natural nighttime GH surge. Rotate injection sites to prevent lipoatrophy. It must be given BEFORE the epiphyseal growth plates close, or it cannot increase height.
- Monitor: height and weight at regular intervals (the whole point of therapy), BLOOD GLUCOSE (GH is a counter-regulatory hormone and causes insulin resistance and hyperglycemia), THYROID function (it can unmask hypothyroidism, which then blocks growth), and IGF-1 levels.
- Report: persistent severe headache, vision changes, nausea and vomiting (intracranial hypertension), a limp or hip and knee pain (slipped capital femoral epiphysis), and new-onset scoliosis progression.
- CONTRAINDICATED in closed epiphyses, ACTIVE MALIGNANCY, acute critical illness (post-surgery, trauma, respiratory failure - it increases mortality), proliferative diabetic retinopathy, and in Prader-Willi patients who are severely obese or have severe respiratory impairment or untreated sleep apnea, where deaths have occurred.
- Common effects: injection-site reactions, fluid retention and edema, arthralgias and myalgias, carpal tunnel syndrome, and gynecomastia.
- Store in the refrigerator, do not freeze or shake, and check the reconstitution instructions for the specific brand. Therapy is long-term and expensive; adherence and psychosocial support matter. The opposite drugs, for excess GH (acromegaly), are octreotide, lanreotide, and pegvisomant.
Growth hormone at BEDTIME, before the plates close. Watch the sugar and the thyroid.
💉 AcarboseHIGH ALERT
Oral antidiabetic
What it is for
Type 2 diabetes mellitus, alone or in combination with a sulfonylurea, metformin, insulin
🔗 Full card in the drug guide
💉 CanagliflozinBLACK BOX
Oral antidiabetic, Sodium-glucose cotransporter 2 (SGLT2) inhibitor
What it is for
Type 2 diabetes mellitus, with diet and exercise; may use in combination; to reduce CV events in type 2 diabetes mellitus with CV disease
How it works
Blocks glucose reabsorption by the kidney, increases glucose excretion, lowers blood glucose concentrations by inhibiting proximal renal tubular sodium glucose transporter 2 (SGLT2)
Watch for
CV: Hypotension, orthostatic hypotension GI: Pancreatitis, nausea, vomiting dehydration GU: Cystitis, candidiasis, urinary frequency, polydipsia, polyuria, renal impairment, UTI, genital fungal infections INTEG: Photosensitivity, rash, pruritus META: Hypercholesterolemia, lipidemia, hypoglycemia …
Teaching
- The symptoms of hypo/hyperglycemia, what to do about each
- That medication must be taken as prescribed; explain consequences of discontinuing abruptly; that insulin may need to be used for stress, including trauma, fever, surgery …
- To avoid OTC medications and herbal supplements unless discussed with health care professional
- That diabetes is a lifelong illness; that the diet and exercise regimen must be followed; that this product is not a cure
🔗 Full card in the drug guide
💉 Glucagon
Antihypoglycemic
What it is for
Hypoglycemia, used to temporarily inhibit movement of GI tract as a diagnostic test
🔗 Full card in the drug guide
💉 Glyburide/glipizideHIGH ALERT
Antidiabetic, Sulfonylurea (2nd generation)
What it is for
Type 2 diabetes mellitus
How it works
Causes functioning β-cells in pancreas to release insulin, thereby leading to a drop in blood glucose levels
Watch for
CNS: Headache, weakness, paresthesia ENDO: Hypoglycemia GI: Nausea, hepatotoxicity, cholestatic jaundice, vomiting, diarrhea, weight gain HEMA: Leukopenia, thrombocytopenia, agranulocytosis, aplastic anemia (rare) INTEG: Rash, pruritus, photosensitivity, erythema MISC: Angiedema …
Teaching
- To check for symptoms of cholestatic jaundice: dark urine, pruritus, jaundiced sclera; if these occur, notify prescriber
- To use a blood glucose meter for testing while taking this product
- About the symptoms of hypo/hyperglycemia, what to do about each
- That product must be continued on a daily basis; about consequences of discontinuing product abruptly; that in times of stress, infection, surgery, trauma, a higher dose …
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Insulin glargine/detemirHIGH ALERT
Antidiabetic, Long-acting insulin analog
What it is for
Basal insulin coverage in type 1 and type 2 diabetes.
How it works
Engineered to be barely soluble at body pH, so it forms a small depot under the skin and trickles out steadily. The result is a flat level with essentially no peak — background insulin, covering what the liver puts out between meals and overnight.
Watch for
ENDO: Hypoglycemia, weight gain. INTEG: Injection site pain, lipodystrophy.
Teaching
- Clear, but never mix it in a syringe with any other insulin — mixing ruins the flat release. It gets its own syringe and its own site.
- Essentially peakless, given once daily at about the same time each day. Because there is no peak, it is not the insulin you use to cover a meal or to correct a high.
- Subcutaneous only. Not IV, not in a pump.
- It still causes hypoglycemia — usually overnight or when a meal is skipped.
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Insulin lispro
Antidiabetic, pancreatic hormone, Modified structures of endogenous human insulin
What it is for
Type 1 diabetes mellitus, type 2 diabetes mellitus, gestational diabetes; insulin lispro may be used in combination with sulfonylureas in children >3 yr
How it works
Decreases blood glucose; by transport of glucose into cells and the conversion of glucose to glycogen, indirectly increases blood pyruvate and lactate, decreases phosphate and potassium …
Watch for
EENT: Blurred vision, dry mouth INTEG: Flushing, rash, urticaria, warmth, lipodystrophy, lipohypertrophy, swelling, redness META: Hypoglycemia, rebound hyperglycemia (Somogyi effect 12-72 hr or longer) MISC: Peripheral edema SYST: Anaphylaxis
Teaching
- That blurred vision occurs; not to change corrective lenses until vision is stabilized after 1-2 mo
- To keep insulin, equipment available at all times; to carry a glucagon kit, candy, or oral glucose preparation to treat hypoglycemia
- That product does not cure diabetes but controls symptoms
- To carry emergency ID as diabetic
🔗 Full card in the drug guide
💉 MetforminHIGH ALERTBLACK BOX
Antidiabetic, oral, Biguanide
What it is for
Type 2 diabetes mellitus
How it works
Inhibits hepatic glucose production and increases sensitivity of peripheral tissue to insulin
Watch for
ENDO: Lactic acidosis, hypoglycemia GI: Nausea, vomiting, diarrhea, heartburn, anorexia, metallic taste
🔗 Full card in the drug guide
💉 RepaglinideHIGH ALERT
Antidiabetic, Meglitinide
What it is for
Type 2 diabetes mellitus
How it works
Causes functioning β-cells in pancreas to release insulin, thereby leading to a drop in blood glucose levels; closes ATP-dependent potassium channels in the β-cell membrane; this leads to the opening of calcium channels …
Watch for
CNS: Headache, weakness, paresthesia CV: Angina EENT: Tinnitus, sinusitis ENDO: Hypoglycemia GI: Nausea, vomiting, diarrhea, constipation, dyspepsia, pancreatitis INTEG: Rash, allergic reactions MISC: Chest pain, UTI, allergy MS: Back pains, arthralgia RESP: URI, sinusitis, rhinitis, bronchitis
Antidote / reversal: 1
🔗 Full card in the drug guide
Module 9: Cardiovascular Drugs Part 1
What “cardiac rules” should be followed when administering an antihypertensive medication?🚨 DANGER
Check the BLOOD PRESSURE and APICAL HEART RATE before every dose, and HOLD and notify the provider if they are below the ordered parameters (commonly hold a beta blocker for an apical rate under 60, or systolic BP under 90 to 100). Never stop an antihypertensive abruptly. Teach orthostatic precautions.
- Take an APICAL pulse for a FULL MINUTE, not a radial pulse for 15 seconds. The textbook's rule: assess the apical pulse before metoprolol; if under 60, withhold the drug and call the provider immediately unless other parameters are provided.
- If BP or HR is below parameters, HOLD the dose and notify the provider. Do not give it and then chart it.
- REBOUND HYPERTENSION: abrupt discontinuation of a beta blocker or clonidine causes rebound tachycardia, hypertension, angina, and MI. Teach the patient never to run out and never to stop on their own.
- ORTHOSTATIC HYPOTENSION: change positions slowly, dangle the legs before standing, get up slowly from bed, and use fall precautions. Especially the first dose and after any dose increase.
- Timing considerations: give diuretics in the MORNING so the patient is not up all night, and avoid giving a diuretic right before a diagnostic test or procedure. Take doses at the SAME TIME each day.
- Teach the patient to monitor BP at home and to keep a log, to weigh daily and report a gain over 2 to 3 pounds in a day or new ankle edema, to avoid alcohol and CNS depressants, and to avoid OTC decongestants and NSAIDs. Class-specific: ACE inhibitors and ARBs cause hyperkalemia and require avoiding salt substitutes and high-potassium foods; ACE inhibitors cause a dry cough and angiedema. Extended-release formulations are NEVER crushed. Beta blockers mask hypoglycemia in diabetics.
Apical pulse for a full minute, hold under 60, never stop cold, and stand up slowly.
Define the terms inotrope, chronotrope, and dromotrope.⭐ HIGH YIELD
INOTROPE affects the FORCE of contraction (contractility). CHRONOTROPE affects the RATE (heart rate, via the SA node). DROMOTROPE affects the CONDUCTION VELOCITY through the AV node. Positive means increases, negative means decreases.
- Memory hook: inO for FORCE (think 'contract'), chrono for TIME/rate (chronometer = clock), dromo for the ROAD the impulse travels (dromos is Greek for 'running course') = conduction.
- DIGOXIN is the classic combination: POSITIVE inotrope (stronger squeeze) with NEGATIVE chronotropic and dromotropic effects (slower rate, slower AV conduction). That is why it treats both heart failure and atrial fibrillation.
- Beta blockers and non-dihydropyridine calcium channel blockers (diltiazem, verapamil) are negative on all three: less force, slower rate, slower conduction. That combination is why they are avoided together and why they can worsen acute decompensated heart failure and cause heart block.
- Clinical translation: a positive inotrope raises cardiac output and blood pressure in cardiogenic shock; a negative chronotrope and dromotrope controls the ventricular rate in atrial fibrillation and SVT.
- Cardiac output = heart rate x stroke volume. Chronotropes change the heart rate side; inotropes change the stroke volume side. A drug that slows the rate too far will drop cardiac output even if contractility is fine.
| Term | What it changes | Positive examples | Negative examples |
|---|
| Inotrope | FORCE of contraction | digoxin, dobutamine, dopamine, epinephrine, milrinone, norepinephrine | beta blockers, diltiazem, verapamil, flecainide |
| Chronotrope | RATE (SA node) | atropine, epinephrine, dopamine, isoproterenol, dobutamine | beta blockers, diltiazem, verapamil, digoxin, amiodarone, adenosine, ivabradine |
| Dromotrope | CONDUCTION through the AV node | epinephrine, atropine | digoxin, diltiazem, verapamil, beta blockers, adenosine, amiodarone |
InO = FOrce. ChrOnO = clOck (rate). DrOmO = the rOad (conduction).
Describe the first dose phenomenon.🚨 DANGER
First-dose phenomenon is severe ORTHOSTATIC HYPOTENSION, dizziness, and sometimes SYNCOPE occurring 30 to 90 minutes after the FIRST dose of an ALPHA-1 BLOCKER (prazosin, terazosin, doxazosin, tamsulosin). It also occurs after a dose increase or after restarting the drug.
- PREVENTION: give the first dose AT BEDTIME, start with the LOWEST dose, and titrate slowly. Tell the patient to take it when they can lie down and not drive.
- The textbook's version: assess and monitor blood pressure, especially after the first dose, because tamsulosin may cause orthostatic hypotension, and advise the patient to change positions slowly.
- Mechanism: blocking alpha-1 receptors on vascular smooth muscle removes vasoconstrictor tone. On the first dose the baroreceptor reflex has not yet adapted, so blood pools in the legs when the patient stands.
- Nursing: fall precautions, assist with the first ambulation, take orthostatic vital signs (lying, sitting, standing), and teach dangling the legs before standing.
- It resolves with continued therapy as the body compensates, usually within days. But it returns if doses are missed for several days and the drug is restarted at full dose.
- Higher risk with concurrent diuretics, other antihypertensives, PDE-5 inhibitors (sildenafil - separate by at least 4 hours), volume depletion, and in older adults. These drugs treat both hypertension and BPH. Tamsulosin is the most uroselective, so it drops blood pressure the least, but it still causes it.
First alpha blocker dose: bedtime, lowest dose, and do not let them get up fast.
What are the first line pharmacological treatment options of hypertension for patients in⭐ HIGH YIELD
For most adults, first-line is one of four: THIAZIDE diuretic, ACE INHIBITOR, ARB, or CALCIUM CHANNEL BLOCKER. The choice is driven by comorbidity: ACE inhibitor or ARB for diabetes with albuminuria and for CKD; thiazide or CCB for Black adults; labetalol, nifedipine, or methyldopa in PREGNANCY; beta blocker plus ACE inhibitor after MI.
- BLACK ADULTS without CKD or heart failure: start with a THIAZIDE or a CALCIUM CHANNEL BLOCKER. ACE inhibitors and ARBs are less effective as monotherapy in this population and carry a higher rate of angiedema.
- DIABETES: any of the four classes works, but an ACE INHIBITOR OR ARB is preferred when there is albuminuria, because it protects the kidney. Remember beta blockers MASK hypoglycemia.
- CHRONIC KIDNEY DISEASE: ACE INHIBITOR or ARB, for renal protection. Never use both together. Monitor creatinine and potassium after starting; a creatinine rise up to about 30% is expected.
- PREGNANCY: ACE inhibitors and ARBs are ABSOLUTELY CONTRAINDICATED (fetal renal failure and death). Use LABETALOL, NIFEDIPINE, or METHYLDOPA. Magnesium sulfate is for seizure prophylaxis in preeclampsia, not for blood pressure.
- HEART FAILURE with reduced EF: ACE inhibitor/ARB/ARNI PLUS a beta blocker (carvedilol, metoprolol succinate, bisoprolol) PLUS an aldosterone antagonist PLUS an SGLT2 inhibitor. Avoid non-dihydropyridine CCBs.
- POST-MI and angina: BETA BLOCKER plus ACE inhibitor. OLDER ADULTS: thiazide or CCB, started low because of orthostatic hypotension and fall risk. ASTHMA/COPD: avoid non-selective beta blockers; use a cardioselective one if a beta blocker is required. GOUT: avoid thiazides, which raise uric acid. BPH: an alpha blocker treats both. General approach: lifestyle changes for everyone (sodium restriction, DASH diet, weight loss, exercise, limit alcohol, stop smoking), and start TWO agents when the BP is more than 20/10 above goal.
| Population | First-line choice | Avoid |
|---|
| General adult population | Thiazide, ACE inhibitor, ARB, or CCB | - |
| Black adults (no CKD or HF) | THIAZIDE or CALCIUM CHANNEL BLOCKER | ACE inhibitor/ARB as monotherapy (less effective, more angiedema) |
| Diabetes with albuminuria | ACE INHIBITOR or ARB | Beta blockers mask hypoglycemia |
| Chronic kidney disease | ACE INHIBITOR or ARB | Never combine ACE inhibitor + ARB; watch K+ and creatinine |
| PREGNANCY | LABETALOL, NIFEDIPINE, METHYLDOPA | ACE inhibitors and ARBs are CONTRAINDICATED |
| Heart failure (reduced EF) | ACE inhibitor/ARB/ARNI + beta blocker + MRA + SGLT2 inhibitor | Diltiazem, verapamil |
| Post-MI / stable angina | Beta blocker + ACE inhibitor | - |
| Older adults | Thiazide or CCB, low and slow | Watch orthostasis and falls |
| Asthma / COPD | Any non-beta-blocker; cardioselective if needed | Non-selective beta blockers (propranolol) |
The A-B-C-D menu: ACE/ARB, Beta blocker, CCB, Diuretic. The comorbidity picks the letter. Never ACE or ARB in pregnancy.
Which beta-blockers are non-selective?⭐ HIGH YIELD
NON-SELECTIVE beta blockers block BOTH beta-1 (heart) and beta-2 (lungs and vessels): PROPRANOLOL, NADOLOL, SOTALOL, TIMOLOL, PINDOLOL, plus LABETALOL and CARVEDILOL (which also block alpha-1). Because they hit beta-2, they cause BRONCHOCONSTRICTION and are avoided in asthma and COPD.
- CARDIOSELECTIVE (beta-1 only) alternatives: metoprolol, atenolol, bisoprolol, esmolol, nebivolol, acebutolol. Memory trick: generic names starting with A through M tend to be beta-1 selective; N through Z tend to be non-selective.
- Selectivity is DOSE-DEPENDENT. The textbook notes that metoprolol primarily blocks beta-1, but at HIGHER DOSES it also blocks beta-2 in the lungs and causes bronchoconstriction. There is no such thing as a fully safe beta blocker in severe asthma.
- Beta-2 blockade also blunts glycogenolysis, so non-selective agents both MASK hypoglycemia symptoms and PROLONG recovery from a low. That is the worst combination in an insulin-treated diabetic.
- Labetalol and carvedilol add ALPHA-1 blockade, so they cause more orthostatic hypotension. Carvedilol is one of the three beta blockers proven in heart failure (with metoprolol succinate and bisoprolol). Labetalol is a first-line antihypertensive in pregnancy.
- Sotalol also has class III antiarrhythmic (potassium channel) properties and prolongs the QT interval; it requires inpatient initiation with ECG monitoring. Timolol eye drops for glaucoma are systemically absorbed and can cause bradycardia and bronchospasm.
- For every beta blocker: apical pulse for a full minute, hold for HR under 60 or per parameters, never stop abruptly, and teach the patient about fatigue, dizziness, sexual dysfunction, depression, and vivid dreams.
| NON-selective (beta-1 AND beta-2) | Cardioselective (beta-1 only) |
|---|
| propranolol | metoprolol |
| nadolol | atenolol |
| sotalol (also class III, prolongs QT) | bisoprolol |
| timolol (also glaucoma drops) | esmolol (IV, ultra-short) |
| pindolol | nebivolol |
| labetalol and carvedilol (also block alpha-1) | acebutolol |
| AVOID in asthma and COPD | Safer in lung disease, but not risk-free at high dose |
A through M = beta-1 seleMtive. N through Z = No selectivity, No asthma.
What are the reversal agents for heparin and warfarin?🚨 DANGER
HEPARIN is reversed by PROTAMINE SULFATE, given by slow IV infusion. WARFARIN is reversed by VITAMIN K (phytonadione); for urgent reversal add FRESH FROZEN PLASMA or 4-factor prothrombin complex concentrate.
- Monitoring goes with the antidote: heparin is monitored by aPTT (therapeutic is 1.5 to 2 times the control) and warfarin by PT/INR (therapeutic 2.0 to 3.5 depending on the indication).
- Protamine works within about 5 minutes. Give it SLOWLY - rapid infusion causes hypotension, bradycardia, flushing, and anaphylaxis. Highest anaphylaxis risk in patients with fish allergy, prior protamine exposure, or a vasectomy.
- Protamine only PARTIALLY reverses low-molecular-weight heparin (enoxaparin), about 60%, and does not reverse fondaparinux at all.
- Vitamin K is SLOW: hours to days for full effect, because the liver has to synthesize new clotting factors. That is why FFP or PCC is added when the patient is actively bleeding and you need reversal NOW.
- Vitamin K route matters: oral or IV. IV must be given slowly and diluted because of anaphylaxis risk. Avoid IM in an anticoagulated patient because of hematoma.
- Teach warfarin patients to keep vitamin K intake CONSISTENT (green leafy vegetables) rather than avoiding it entirely, and to report bleeding, bruising, dark stools, or blood in urine. Warfarin's boxed warning is major or fatal bleeding. Newer anticoagulants have their own agents: IDARUCIZUMAB (Praxbind) for dabigatran, and ANDEXANET ALFA (Andexxa) for apixaban and rivaroxaban. Activated charcoal is used for a recent oral overdose.
| Anticoagulant | Lab monitored | Reversal agent |
|---|
| Heparin (unfractionated) | aPTT (1.5 to 2x control) | PROTAMINE SULFATE, slow IV |
| Enoxaparin (LMWH) | Usually none; anti-Xa if needed | Protamine (partial, about 60%) |
| Warfarin | PT / INR (2.0 to 3.5) | VITAMIN K (phytonadione); FFP or 4-factor PCC if urgent |
| Dabigatran | None routinely | Idarucizumab (Praxbind) |
| Apixaban, rivaroxaban | None routinely | Andexanet alfa (Andexxa) |
| Alteplase (tPA) | - | No true antidote: cryoprecipitate, FFP, aminocaproic acid |
PROtamine for the PRO-drug of bleeding, heParin. Vitamin K for the K-oumadin.
💉 AliskirenBLACK BOX
Antihypertensive, Direct renin inhibitor
What it is for
Hypertension, alone or in combination with other antihypertensives Black Box Warning: Pregnancy
How it works
Renin inhibitor that acts on the renin-angiotensin system (RAS)
Watch for
CV: Orthostatic hypotension, hypotension CNS: Headache, dizziness, seizures GI: Diarrhea GU: Renal stones, increased uric acid INTEG: Rash META: Hyperkalemia MISC: Angiedema, cough
Teaching
- About the importance of complying with dosage schedule even if feeling better; that if dose is missed, take as soon as possible; that if it is almost time for the next do …
- How to take B/P and normal reading for age group
- Not to use OTC products including herbs, supplements unless approved by prescriber
- To report to prescriber immediately: dizziness, faintness, chest pain, palpitations, uneven or rapid heartbeat, headache, severe diarrhea, swelling of tongue or lips, tro …
🔗 Full card in the drug guide
💉 ClonidineBLACK BOX
Antihypertensive, Central alpha-adrenergic agonist
What it is for
Mild to moderate hypertension, used alone or in combination; severe pain in cancer patients (epidural), attention-deficit/hyperactivity disorder (ADHD)
How it works
Inhibits sympathetic vasomotor center in CNS, which reduces impulses in sympathetic nervous system; B/P, pulse rate, cardiac output are decreased …
Watch for
CNS: Drowsiness, nightmares, anxiety, depression, hallucinations, syncope, dizziness CV: Orthostatic hypotension, HF, ECG abnormalities, sinus tachycardia EENT: Taste change, dry eyes ENDO: Hyperglycemia GI: Nausea, vomiting, constipation, dry mouth GU: Impotence, urinary retention …
Teaching
- To avoid hazardous activities and driving until response is known, product may cause drowsiness
- To notify all health care providers of medication use
- Not to discontinue product abruptly or withdrawal symptoms may occur: anxiety, increased B/P, headache, insomnia, increased pulse, tremors, nausea, sweating; to comply wi …
- Not to use OTC (cough, cold, or allergy), alcohol, or CNS depressant products unless directed by prescriber
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 Eplerenone
Antihypertensive, Aldosterone antagonist
What it is for
Hypertension, alone or in combination with other antihypertensives, HF (reduced ejection fraction after MI)
How it works
Binds to mineralocorticoid receptor and blocks the binding of aldosterone
Watch for
CNS: Headache, dizziness, fatigue GI: Increased GGT, diarrhea, abdominal pain, increased ALT GU: Gynecomastia META: Hyperkalemia, hypercholesteremia, hypertriglyceridemia MISC: Flulike symptoms
Teaching
- Not to discontinue product abruptly
- Not to use OTC products (cough, cold, allergy) unless directed by prescriber; not to use salt substitutes containing potassium without consulting prescriber
- To comply with dosage schedule, even if feeling better
- That product may cause dizziness, fainting, light headedness; may occur during first few days of therapy, avoid hazardous activities
🔗 Full card in the drug guide
💉 Hydralazine
Antihypertensive, directacting peripheral vasodilator, Phthalazine
What it is for
Essential hypertension; hypertensive emergency/urgency Unlabeled: HF, eclampsia
How it works
Vasodilates arteriolar smooth muscle by direct relaxation; reduction in blood pressure with reflex increases in heart rate, stroke volume, cardiac output
Watch for
CNS: Headache, dizziness, drowsiness, peripheral neuritis CV: Palpitations, tachycardia, angina, orthostatic hypotension, shock GI: Nausea, vomiting, anorexia, diarrhea, hepatotoxicity EENT: Nasal congestion RESP: Dyspnea HEMA: Agranulocytosis GU: Urinary retention INTEG: Rash, pruritus …
Teaching
- To take with food to increase bioavailability (PO)
- To avoid OTC, herbals, supplements unless directed by prescriber
- To notify prescriber if chest pain, severe fatigue, fever, muscle or joint pain, rash, sore throat; tingling, pain in hands, feet, pyridoxine can be used
- To rise slowly to prevent orthostatic hypotension
🔗 Full card in the drug guide
💉 MetoprololHIGH ALERTBLACK BOX
Antihypertensive, antianginal, β1-Blocker
What it is for
Mild to moderate hypertension, acute MI to reduce cardiovascular mortality, angina pectoris, NYHA class II, III heart failure, cardiomyopathy
How it works
Lowers B/P by β-blocking effects; reduces elevated renin plasma levels; blocks β2-adrenergic receptors in bronchial, vascular smooth muscle only at high doses; negative chronotropic effect
Watch for
CNS: Insomnia, dizziness, mental changes, hallucinations, depression, anxiety, headaches, nightmares, confusion, fatigue, weakness CV: Hypotension, bradycardia, HF, palpitations, dysrhythmias, cardiac arrest, AV block, pulmonary/peripheral edema, chest pain EENT: Blurred vision GI: Nausea …
Teaching
- To take immediately after meals; to take medication at bedtime to prevent effect of orthostatic hypotension
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 PropranololHIGH ALERTBLACK BOX
Antihypertensive, antianginal, antidysrhythmic (class II), β-Adrenergic blocker
What it is for
Chronic stable angina pectoris, hypertension, supraventricular dysrhythmias, migraine prophylaxis, pheochromocytoma, cyanotic spells related to hypertrophic subaortic stenosis, essential tremor, acute MI, vascular headache prophylaxis Unlabeled: Anxiety …
How it works
Nonselective β-blocker with negative inotropic, chronotropic, dromotropic properties
Watch for
CNS: Depression, hallucinations, dizziness, fatigue, lethargy, paresthesias, bizarre dreams, disorientation CV: Bradycardia, hypotension, HF, palpitations, AV block, peripheral vascular insufficiency, vasodilation, cold extremities, pulmonary edema, dysrhythmias EENT: Sore throat, laryngospasm …
Teaching
- Not to discontinue abruptly; may precipitate life-threatening dysrhythmias, exacerbation of angina, MI; to take product at same time each day, either with or without food …
- To avoid OTC products unless approved by prescriber; to avoid alcohol
- To avoid hazardous activities if dizzy
- About the importance of compliance with complete medical regimen; to monitor blood glucose, may mask symptoms of hypoglycemia
🔗 Full card in the drug guide
💉 NitroprussideHIGH ALERTBLACK BOX
Antihypertensive, vasodilator
What it is for
Hypertensive crisis/urgency/induction; to decrease bleeding by creating hypotension during surgery; acute HF
How it works
Directly relaxes arteriolar, venous smooth muscle, thereby resulting in reduction in cardiac preload and afterload
Watch for
CNS: Dizziness, headache, agitation, twitching, decreased reflexes, restlessness CV: Bradycardia, ECG changes, tachycardia, hypotension GI: Nausea, vomiting, abdominal pain INTEG: Pain, irritation at inj site, sweating MISC: Cyanide, thiocyanate toxicity, flushing, hypothyroidism
Teaching
- To report headache, dizziness, loss of hearing, blurred vision, dyspnea, faintness, pain at IV site
- About the reason for giving product and expected results
🔗 Full card in the drug guide
💉 Prazosin/doxazosin
Antihypertensive, α1-Adrenergic blocker, peripheral
What it is for
Hypertension, benign prostatic hypertrophy to decrease urine outflow obstruction
How it works
Blocks α-mediated vasoconstriction of adrenergic receptors, thereby inducing peripheral vasodilation
Watch for
CNS: Dizziness, headache, drowsiness, anxiety, depression, vertigo, weakness, fatigue, syncope CV: Palpitations, orthostatic hypotension, tachycardia, edema, rebound hypertension EENT: Blurred vision, epistaxis, tinnitus, dry mouth, red sclera GI: Nausea, vomiting, diarrhea, constipation …
Teaching
- That fainting occasionally occurs after 1st dose; to take 1st dose at bedtime; not to drive or operate machinery for 4 hr after 1st dose; that full effect may take 4-6 wk
- To change positions slowly to prevent orthostatic hypotension
- To avoid OTC medications, alcohol unless approved by prescriber; not to crush, chew caps
- Not to discontinue abruptly
🔗 Full card in the drug guide
💉 Albumin
Plasma volume expander
What it is for
Restores plasma volume after burns, hyperbilirubinemia, shock, hypoproteinemia, prevention of cerebral edema, cardiopulmonary bypass procedures, ARDS, nephrotic syndrome
🔗 Full card in the drug guide
Apheresed granulocytes🚨 DANGER
Apheresed granulocytes are a blood product: neutrophils collected from a single donor by apheresis and transfused to a patient with SEVERE NEUTROPENIA and a documented bacterial or fungal infection that is NOT responding to antimicrobials. It is a rescue therapy, not a routine transfusion.
- They must be transfused AS SOON AS POSSIBLE, ideally within 6 hours and no later than 24 hours after collection, because granulocytes have an extremely short shelf life and do not store.
- They must be ABO/Rh compatible and CROSSMATCHED (the product contains many red cells), and they must be IRRADIATED to prevent transfusion-associated graft-versus-host disease. Do NOT use a leukocyte-reduction filter - that would remove the entire therapeutic product.
- Reaction rate is HIGH: expect fever, chills, and rigors. Premedication is common. Monitor closely for PULMONARY reactions - dyspnea, hypoxia, and infiltrates (TRALI-like pictures) - and stop the infusion for respiratory compromise.
- DO NOT INFUSE CONCURRENTLY WITH AMPHOTERICIN B. Separate the two by several hours because of the risk of severe pulmonary reactions.
- Use CMV-negative or leukoreduced-equivalent products for CMV-seronegative at-risk recipients per policy.
- Its use has declined because filgrastim (G-CSF) and better antifungals work better in most patients. Nursing role is standard transfusion protocol plus very close respiratory monitoring.
Borrowed neutrophils for a patient with none. Fresh, irradiated, no leukocyte filter, and never with amphotericin.
Erythropoietin🚨 DANGER
Erythropoietin (epoetin alfa, Procrit/Epogen; darbepoetin alfa, Aranesp) is an erythropoiesis-stimulating agent that tells the bone marrow to make RED BLOOD CELLS. Used for anemia of CHRONIC KIDNEY DISEASE, chemotherapy-induced anemia, and zidovudine-related anemia, to reduce the need for transfusion.
- BOXED WARNING: ESAs increase the risk of DEATH, MYOCARDIAL INFARCTION, STROKE, VENOUS THROMBOEMBOLISM, and thrombosis of vascular access, and they shorten survival and hasten tumor progression in some cancers.
- THE TARGET IS DELIBERATELY LOW. Use the lowest dose needed to avoid transfusion. In CKD, do not start unless hemoglobin is under 10 g/dL, and reduce or hold the dose if hemoglobin exceeds 11 g/dL or rises more than 1 g/dL in 2 weeks. Chasing a normal hemoglobin is what kills people.
- In cancer, use ONLY for chemotherapy-induced anemia, only when the planned chemotherapy is palliative rather than curative, and STOP after the chemotherapy course ends.
- MONITOR: hemoglobin at least weekly at first, BLOOD PRESSURE (hypertension is very common and seizures can occur), and IRON STUDIES. Iron deficiency is the most common reason an ESA 'fails' - the marrow cannot build cells without iron, so transferrin saturation and ferritin must be adequate.
- Route is subcutaneous or IV. Do NOT shake the vial (it denatures the protein). Rotate subcutaneous sites.
- Teach the patient to report chest pain, shortness of breath, one-sided weakness or slurred speech, calf pain or swelling, severe headache, or a seizure. Report a missed dialysis access clot promptly. Filgrastim (WBCs) and romiplostim/oprelvekin (platelets) are the parallel growth factors for the other two cell lines.
EPO builds red cells but builds clots too. Keep hemoglobin UNDER 11 and give them iron.
💉 FilgrastimHIGH ALERT
Biologic modifier, Granulocyte colony-stimulating factor
What it is for
To decrease infection in patients receiving antineoplastics that are myelosuppressive; to increase WBC in patients with product-induced neutropenia …
How it works
Stimulates proliferation and differentiation of neutrophils
Watch for
CNS: Fever, headache GI: Nausea, vomiting, diarrhea, mucositis, anorexia, splenic rupture HEMA: Thrombocytopenia, excessive leukocytosis INTEG: Alopecia, exacerbation of skin conditions, urticaria, cutaneous vasculitis, allergic reactions MS: Osteoporosis, skeletal pain OTHER: Chest pain …
Teaching
- About the technique for self-administration: dose, side effects, disposal of containers and needles; provide instruction sheet
- That bone pain is common
🔗 Full card in the drug guide
Fresh frozen plasma⭐ HIGH YIELD
Fresh frozen plasma is the liquid portion of blood containing ALL the clotting factors, fibrinogen, albumin, and immunoglobulins. It is given to replace clotting factors in active bleeding: urgent warfarin reversal, DIC, massive transfusion, liver failure with bleeding, and plasma exchange for TTP.
- It must be ABO COMPATIBLE (the reverse of red cell compatibility rules - AB plasma is the universal plasma donor, O plasma is the universal recipient). Rh matching is not required.
- Once thawed it must be transfused within 24 hours. A unit is about 200 to 250 mL and is usually infused over 30 to 60 minutes; like all blood products it must be completed WITHIN 4 HOURS of leaving the blood bank.
- FFP does NOT carry red cells or platelets and does not raise hemoglobin. It is not a volume expander and should not be used just to fill the tank - crystalloid or albumin is used for that.
- Standard transfusion nursing applies: two-nurse verification of patient and product, large-bore access with normal saline as the only compatible solution, a filtered blood administration set, baseline vitals, stay with the patient for the first 15 minutes at a slow rate, and recheck vitals per policy.
- Reactions to watch for: allergic and anaphylactic reactions (plasma proteins make these more common with FFP than with red cells), TRALI (transfusion-related acute lung injury - hypoxia and pulmonary infiltrates within 6 hours), TACO (circulatory overload), and febrile reactions. STOP the transfusion, keep the line open with normal saline, and notify the provider and blood bank.
- Evaluate the effect with PT/INR, aPTT, and fibrinogen. For isolated low fibrinogen, cryoprecipitate is the better product. For warfarin reversal specifically, vitamin K plus 4-factor PCC is now preferred over FFP when available.
FFP = all the clotting factors, no cells. ABO compatible, thawed and used within 24 hours, in within 4.
Oprelvekin🚨 DANGER
Oprelvekin (Neumega) is recombinant INTERLEUKIN-11, a thrombopoietic growth factor that stimulates the bone marrow to produce PLATELETS. It is given subcutaneously to prevent severe thrombocytopenia and reduce the need for platelet transfusions after myelosuppressive chemotherapy.
- BOXED WARNING: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS. Permanently discontinue it in any patient who has an anaphylactic reaction.
- The signature adverse effect is FLUID RETENTION: peripheral edema, dyspnea on exertion, pleural effusion, weight gain, and worsening of pre-existing heart failure. Monitor daily weights, intake and output, lung sounds, and edema. Use with caution in heart failure and in anyone on diuretics.
- It causes a DILUTIONAL ANEMIA from plasma volume expansion - the hemoglobin falls without any actual red cell loss. Do not misread this as bleeding.
- Also causes ATRIAL ARRHYTHMIAS (especially atrial fibrillation and flutter), tachycardia, palpitations, conjunctival injection/redness of the eye, headache, dizziness, and blurred vision. Report palpitations or an irregular pulse.
- Timing: started 6 to 24 hours AFTER the chemotherapy dose is completed and continued until the platelet count recovers, then stopped at least 2 days before the next chemotherapy cycle. Monitor CBC with platelet count regularly.
- It is a growth factor, not a platelet transfusion. It takes days to work, so it PREVENTS thrombocytopenia rather than treating an acute bleed. Practical note: this product was withdrawn from the US market and is not in common clinical use, but it is still tested as the interleukin-11 platelet growth factor. Romiplostim and eltrombopag are the agents used today.
OPRELvekin = platelets (think 'PLatelets'). IL-11 for the 11 letters. Fluid retention and atrial fib are the price.
Packed red blood cells🚨 DANGER
Packed red blood cells are red cells with most of the plasma removed, transfused to treat SYMPTOMATIC ANEMIA or acute blood loss by increasing oxygen-carrying capacity. One unit raises hemoglobin by about 1 g/dL and hematocrit by about 3%.
- TWO-NURSE VERIFICATION at the bedside before starting: patient identifiers, blood type and Rh, unit number, product type, and expiration. This is the single highest-risk moment in transfusion nursing, because an ABO mismatch causes fatal acute hemolysis.
- ONLY 0.9% NORMAL SALINE may hang with blood. Lactated Ringer's contains calcium and will clot the line; dextrose solutions cause hemolysis. Use a Y-type blood administration set with an in-line FILTER and large-bore access (18 to 20 gauge in adults).
- STAY WITH THE PATIENT FOR THE FIRST 15 MINUTES and run it slowly, because most severe reactions appear in that window. Take vital signs at baseline, at 15 minutes, and per policy thereafter, and at completion.
- COMPLETE THE INFUSION WITHIN 4 HOURS of removing it from the blood bank (usually over 2 to 4 hours per unit), because of bacterial growth risk. Blood must never be stored in a unit refrigerator.
- REACTIONS: STOP THE TRANSFUSION IMMEDIATELY, disconnect the tubing at the hub, keep the line open with normal saline using NEW tubing, take vital signs, notify the provider and the blood bank, and send the unit and tubing back with a post-transfusion specimen. Acute hemolytic: fever, chills, flank or back pain, dark urine, hypotension, sense of doom. Febrile non-hemolytic: fever and chills alone. Allergic: hives and itching. TACO: dyspnea, crackles, hypertension, jugular distention.
- Typical trigger is hemoglobin under 7 g/dL (under 8 in cardiac disease or active symptoms). Transfuse ONE unit at a time and reassess. Verify consent and check for prior reactions. Special products: leukoreduced (fewer febrile reactions and less CMV risk), irradiated (prevents graft-versus-host disease in immunocompromised recipients), and washed (for repeated severe allergic reactions or IgA deficiency).
One unit, one gram. Normal saline only. Two nurses, first 15 minutes at the bedside, done in 4 hours.
💉 AlteplaseHIGH ALERT
Thrombolytic enzyme, Tissue plasminogen activator (TPA)
What it is for
Lysis of obstructing thrombi associated with acute MI, ischemic conditions that require thrombolysis (i.e., PE, unclotting arteriovenous shunts, acute ischemic CVA) …
How it works
Produces fibrin conversion of plasminogen to plasmin; able to bind to fibrin, convert plasminogen in thrombus to plasmin, which leads to local fibrinolysis, limited systemic proteolysis
Watch for
INTEG: Urticaria, rash SYST: GI, GU, intracranial, retroperitoneal bleeding, anaphylaxis, fever
Teaching
- The purpose and expected results of the treatment; to report adverse reactions, bleeding
🔗 Full card in the drug guide
💉 AspirinHIGH ALERTBLACK BOX
Opiate analgesic, Semisynthetic derivative
What it is for
Moderate to severe pain Unlabeled: Postherpetic neuralgic (cont rel)
How it works
Inhibits ascending pain pathways in CNS, increases pain threshold, alters pain perception
Watch for
CNS: Drowsiness, dizziness, confusion, headache, sedation, euphoria, fatigue, abnormal dreams/thoughts, hallucinations CV: Palpitations, bradycardia, change in B/P EENT: Tinnitus, blurred vision, miosis, diplopia GI: Nausea, vomiting, anorexia, constipation, cramps, gastritis, dyspepsia …
Teaching
- To report any symptoms of CNS changes, allergic reactions
- That physical dependency may result from extended use
- That withdrawal symptoms may occur after long-term use: nausea, vomiting, cramps, fever, faintness, anorexia
- To avoid CNS depressants, alcohol
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 ClopidogrelHIGH ALERTBLACK BOX
Platelet aggregation inhibitor, Thienopyridine derivative
What it is for
Reducing the risk of stroke, MI, vascular death, peripheral arterial disease in high-risk patients, acute coronary syndrome, transient ischemic attack (TIA), unstable angina
How it works
Inhibits ADP-induced platelet aggregation
Watch for
CNS: Headache, dizziness, depression CV: Edema, hypertension, chest pain GI: Diarrhea, constipation, GI discomfort HEMA: Bleeding (major/minor from any site), neutropenia, aplastic anemia, agranulocytosis, thrombotic thrombocytopenic purpura INTEG: Rash, pruritus, anaphylaxis MISC: Fatigue …
Teaching
- That blood work will be necessary during treatment (CBC, LFTs)
- To report any unusual bruising, bleeding to prescriber; that it may take longer to stop bleeding
- To take without regard to food
- To tell all health care providers that clopidogrel is being used; may be held for 5 days before surgery, restart as soon as possible
🔗 Full card in the drug guide
💉 DabigatranBLACK BOX
Anticoagulant, Direct thrombin inhibitor
What it is for
Stroke/systemic embolism prophylaxis with nonvalvular atrial fibrillation, DVT, pulmonary embolism in hip replacement
How it works
Direct thrombin inhibitor that inhibits both free and clot-bound thrombin; prevents thrombin-induced platelet aggregation and thrombus formation by preventing conversion of fibrinogen to fibrin
Watch for
GI: Abdominal pain, dyspepsia, esophagitis, gastritis, diarrhea HEMA: Bleeding (any site) SYST: Anaphylaxis (rare), angiedema
Teaching
- About the purpose and expected results; to take at same time of day; not to skip or double doses; if dose is missed, to take as soon as remembered if on the same day; do …
- To take without regard to food; to swallow capsule whole, not to open; to take with a full glass of water, mix pellets/granules with 2 tsp of soft foods, do not mix with …
- To notify all providers that this product is being used; to check with prescriber about when to discontinue
- Bleeding: to report any bleeding or bruising, including blood in stool, emesis, urine; nosebleeds
🔗 Full card in the drug guide
💉 Enoxaparin (How is this medication administered?)HIGH ALERTBLACK BOX
Anticoagulant, antithrombotic, Low-molecular-weight heparin (LMWH)
What it is for
Prevention of DVT (inpatient or outpatient), PE (inpatient) in hip and knee replacement, abdominal surgery at risk for thrombosis; unstable angina, acute MI, coronary artery thrombosis
How it works
Binds to antithrombin III inactivating factors Xa/IIa, thereby resulting in a higher ratio of anti–factor Xa to IIa
Watch for
CNS: Fever, confusion, dizziness, headache GI: Nausea, vomiting, constipation HEMA: Hemorrhage from any site, hypochromic anemia, thrombocytopenia, bleeding INTEG: Ecchymosis, injection site hematoma, alopecia, pruritus, rash META: Hyperkalemia in renal failure MS: Osteoporosis SYST: Edema …
Teaching
- Black Box Warning: Spinal anesthesia: to report numbness, weakness in lower extremities
- To use soft-bristle toothbrush to avoid bleeding gums; to use electric razor
- To report any signs of bleeding: gums, under skin, urine, stools; do not rub injection site, easy bruising
- To report dizziness, rash, breathing changes
🔗 Full card in the drug guide
💉 FondaparinuxHIGH ALERTBLACK BOX
Anticoagulant, antithrombotic, Synthetic, selective factor Xa inhibitor
What it is for
Prevention/treatment of deep venous thrombosis, PE in hip and knee replacement, hip fracture or abdominal surgery Unlabeled: Acute MI NSTEMI/STEMI, PCI, unstable angina
How it works
Inhibits factor Xa, binds ATIII; neutralization of factor Xa interrupts blood coagulation and thrombin formation
Watch for
CNS: Confusion, headache, dizziness, insomnia HEMA: Anemia, hematoma, thrombocytopenia, major bleeding (intracranial, cerebral, retroperitoneal hemorrhage), postoperative hemorrhage, heparin-induced thrombocytopenia INTEG: Increased wound drainage, bullous eruption, local reaction—rash, pruritus …
Teaching
- To use soft-bristle toothbrush to avoid bleeding gums; to use electric razor
- To report any signs of bleeding: gums, under skin, urine, stools
- To avoid OTC products containing aspirin, NSAIDs
- Method for SUBCUT injection if needed
🔗 Full card in the drug guide
💉 HeparinHIGH ALERT
Anticoagulant, antithrombotic, Unfractionated heparin
What it is for
Prevention and treatment of DVT and pulmonary embolism; acute coronary syndrome and MI; atrial fibrillation with embolism; keeping lines, dialysis circuits and cardiopulmonary bypass from clotting; disseminated intravascular coagulation.
How it works
Boosts the body’s own antithrombin III many times over. The heparin–antithrombin complex then shuts down thrombin (IIa) and factor Xa, so fibrin cannot form. It does not dissolve a clot that is already there — it stops it from growing while the body breaks it down.
Watch for
HEMA: Bleeding from any site, heparin-induced thrombocytopenia (HIT), anemia. INTEG: Injection-site bruising, hematoma, rarely skin necrosis. MS: Osteoporosis with long-term use. SYST: Hypersensitivity, chills, fever. META: Hyperkalemia (it suppresses aldosterone).
Teaching
- Monitored with aPTT, kept roughly one and a half to two and a half times the control value — not INR. INR belongs to warfarin.
- The antidote is protamine sulfate. Know that pairing cold.
- A platelet count that drops by about half, especially on day 5 to 10, is heparin-induced thrombocytopenia. Stop the heparin and call — HIT causes clotting, not bleeding, and it is dangerous.
- Report bleeding gums, nosebleeds, blood in urine or stool, bruising, or a headache that will not quit.
Antidote / reversal: 1
🔗 Full card in the drug guide
💉 RivaroxabanHIGH ALERTBLACK BOX
Anticoagulant, Factor Xa inhibitor
What it is for
For deep venous thrombosis (DVT) prophylaxis/treatment, pulmonary embolism (PE), in patients undergoing knee or hip replacement surgery; for stroke prophylaxis and systemic embolism prophylaxis in patients with nonvalvular atrial fibrillation
How it works
A novel oral anticoagulant that selectively and potently inhibits coagulation factor Xa
Watch for
GI: Increased hepatic enzymes, hyperbilirubinemia, jaundice, nausea, cholestasis, cytolytic hepatitis HEMA: Bleeding, intracranial bleeding, epidural hematoma, GI bleeding, retinal hemorrhage, adrenal bleeding, retroperitoneal hemorrhage, cerebral hemorrhage, subdural hematoma, epidural hematoma …
Teaching
- To report if pregnancy is planned or suspected; not to breastfeed
🔗 Full card in the drug guide
💉 Warfarin (How long does it take for warfarin to reach a therapeutic effect?)HIGH ALERTBLACK BOX
Anticoagulant, vitamin K antagonist, Coumarin derivative
What it is for
Antiphospholipid antibody syndrome, arterial thromboembolism prophylaxis, DVT, MI prophylaxis, after MI, stroke prophylaxis, thrombosis prophylaxis, pulmonary embolism
How it works
Interferes with blood clotting by indirect means; depresses hepatic synthesis of vit K–dependent coagulation factors (II, VII, IX, X)
Watch for
GI: Nausea, cramps GU: Hematuria, calciphylaxis HEMA: Hemorrhage, agranulocytosis, leukopenia, eosinophilia, anemia, ecchymosis, petechiae INTEG: Rash, dermal necrosis MISC: Fever MS: Bone fractures
Teaching
- To avoid OTC preparations that may cause serious product interactions unless directed by prescriber; to avoid alcohol, herbs, supplements
- To carry emergency ID identifying product taken
- About the importance of compliance with exams and doses
🔗 Full card in the drug guide
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Where this came from. Drug cards are pulled from your own drug guide, which was fact-checked against FDA labeling. The concept answers were written for this guide from your course textbook,
Pharmacology (WTCS, 2e), so they should match your lectures. Check anything that contradicts what your instructor said — they write the exam.