🏁 Final Exam

All fifteen sections, 100 questions. Fifteen of them are reproductive drugs; the other eighty-five are everything from the whole semester.

Everything + reproductive · 100 questions · 86 drugs · 32 concepts

Reproductive Introduction to Pharmacology & Her Antibiotics, Antifungals, and Anti Immunomodulators and Antineoplasti Pain, Inflammation, Substance Abus Mental Health Drugs Bone and Skin Disorders Adrenergic and Cholinergic Drugs Endocrine Drugs Blood Thinners, Hematopoietic Agen Cardiovascular Drugs Diuretics, IV Fluids, and Antidote Respiratory Eye and Ear Disorders Gastrointestinal Medications

Reproductive

💉 Betamethasone

Corticosteroid, topical

What it is for

Inflammation/itching corticosteroid-responsive dermatoses on the skin/scalp

How it works

Crosses cell membrane to attach to receptors to decrease inflammation, itching; inhibits multiple inflammatory cytokines

Watch for

INTEG: Burning, folliculitis, pruritus, dermatitis, maceration, erythema MISC: Hyperglycemia, glycosuria, Cushing’s syndrome, HPA axis suppression

Teaching

Topical route:
That betamethasone valerate may be used with occlusive dressings for psoriasis or recalcitrant conditions; not to use dipropionate with occlusive dressings
Avoid use of topical corticosteroids on face
Cream/ointment/lotion:

🔗 Full card in the drug guide

💉 Clomiphene

Ovulation stimulant

What it is for

Female infertility (ovulatory failure)

🔗 Full card in the drug guide

💉 EstrogensHIGH ALERTBLACK BOX

Estrogen, hormone

What it is for

Vasomotor symptoms (menopause), inoperable breast cancer, prostatic cancer, abnormal uterine bleeding, hypogonadism, primary ovarian failure, prevention of osteoporosis, castration, atrophic vaginitis

How it works

Needed for adequate functioning of female reproductive system; affects release of pituitary gonadotropins, inhibits ovulation; adequate calcium use in bone

Watch for

CNS: Dizziness, headache, migraine, depression, seizures, mood disturbances CV: Hypertension, thrombophlebitis, edema, thromboembolism, stroke, pulmonary embolism, MI, chest pain EENT: Contact lens intolerance, increased myopia, astigmatism GI: Nausea, vomiting, diarrhea, anorexia, pancreatitis …

Teaching

To avoid breastfeeding; product is excreted in breast milk
To weigh weekly; to report gain >5 lb

🔗 Full card in the drug guide

💉 Finasteride

Hormone, androgen inhibitor, hair stimulant, 5-α-Reductase inhibitor

What it is for

Symptomatic benign prostatic hyperplasia (Proscar); male-pattern baldness (Propecia)

How it works

Inhibits 5-α-reductase and reduction in DHT; DHT induces androgenic effects by binding to androgen receptors in the cell nuclei of the prostate gland, liver, skin; prevents development of BPH

Watch for

GU: Impotence, decreased libido, decreased volume of ejaculate, sexual dysfunction, gynecomastia INTEG: Rash MISC: Breast tenderness, secondary malignancy, angiedema

Teaching

That volume of ejaculate may be decreased during treatment; that impotence and decreased libido may also occur and may continue after discontinuing treatment
That Propecia results may not occur for 3 mo
That Proscar results may not occur for 6-12 mo
Advise patient to take as directed, not to skip or double doses, up to 12 mo may be required

🔗 Full card in the drug guide

Magnesium sulfate🚨 DANGER

In obstetrics, magnesium sulfate is given IV to PREVENT AND TREAT SEIZURES in preeclampsia and eclampsia. It is also used for fetal neuroprotection in preterm birth under 32 weeks and for short-term tocolysis. It is a CNS depressant and smooth muscle relaxant, and a high-alert drug.

The FIRST sign of toxicity is LOSS OF DEEP TENDON REFLEXES. Check the patellar reflex before each dose and hourly during infusion.
HOLD the infusion and notify the provider for absent DTRs, respirations under 12 to 16 per minute, urine output under 30 mL/hr (magnesium is renally cleared), or a decreased level of consciousness.
ANTIDOTE: CALCIUM GLUCONATE IV. Keep it at the bedside whenever magnesium is infusing.
Therapeutic serum range in preeclampsia is roughly 4 to 7 mEq/L (normal is 1.3 to 2.1). Levels around 10 and above cause respiratory paralysis, then cardiac arrest.
Flushing, warmth, sweating, and lethargy are expected, not toxicity. Monitor the fetal heart rate; the newborn may be hypotonic. Non-obstetric uses: torsades de pointes, severe asthma exacerbation, and hypomagnesemia.

Reflexes, Respirations, urine Output. Lose a reflex, stop the drip and grab calcium gluconate.

💉 MisoprostolBLACK BOX

Gastric mucosa protectant, antiulcer, Prostaglandin E1 analog

What it is for

Prevention of NSAID-induced gastric ulcers, pregnancy termination Black Box Warning: Pregnancy, females

🔗 Full card in the drug guide

💉 OxytocinHIGH ALERTBLACK BOX

Hormone, Oxytocic, uterine-active agent

What it is for

Stimulation, induction of labor; missed or incomplete abortion; postpartum bleeding

How it works

Acts directly on myofibrils, thereby producing uterine contraction; stimulates milk ejection by the breast; vasoactive antidiuretic effect

Watch for

CNS: Seizures, tetanic contractions CV: Hypo/hypertension, dysrhythmias, increased pulse, bradycardia, tachycardia, PVC FETUS: Dysrhythmias, jaundice, hypoxia, intracranial hemorrhage GI: Anorexia, nausea, vomiting, constipation GU: Abruptio placentae …

Teaching

To report increased blood loss, abdominal cramps, fever, foul-smelling lochia, nausea, blurred vision, itching, swelling
That contractions will be similar to menstrual cramps, gradually increasing in intensity
Side effects: italics = common; red = life-threatening
Canada only

🔗 Full card in the drug guide

💉 ProgesteroneBLACK BOX

Hormone, Progestogen, Progesterone derivative

What it is for

Contraception, amenorrhea, premenstrual syndrome, abnormal uterine bleeding, endometrial hyperplasia prevention, assisted reproductive technology (ART) gel

How it works

Inhibits secretion of pituitary gonadotropins, which prevents follicular maturation, ovulation; stimulates growth of mammary tissue; antineoplastic action against endometrial cancer

Watch for

CNS: Dizziness, headache, depression, fatigue, mood swings CV: Hypotension, thrombophlebitis, edema, thromboembolism, stroke, pulmonary embolism, MI EENT: Diplopia, retinal thrombosis GI: Nausea, vomiting, anorexia, cramps, increased weight, cholestatic jaundice, constipation …

Teaching

To report breast lumps, vaginal bleeding, edema, jaundice, dark urine, claycolored stools, dyspnea, headache, blurred vision, abdominal pain, numbness or stiffness in leg …
To avoid gel with other vaginal products; if to be used together, to separate by ≥6 hr; for vaginal route, on proper insertion technique
To report suspected pregnancy
To monitor blood glucose if diabetic

🔗 Full card in the drug guide

💉 Sildenafil

Erectile agent, antihypertensive, pulmonary vasodilator, Phosphodiesterase type-5 inhibito

What it is for

Treatment of erectile dysfunction (Viagra); improvement in exercise ability, pulmonary hypertension (Revatio, LiQrev)

How it works

Enhances the effect of nitric oxide (NO) by inhibiting phosphodiesterase type 5 (PDE5), which is necessary for degrading cGMP in the corpus cavernosum

Watch for

CNS: Headache, flushing, dizziness, transient global amnesia, seizures CV: MI, sudden death, CV collapse, TIAs, ventricular dysrhythmias, CV hemorrhage MISC: Dyspepsia, nasal congestion, UTI, abnormal vision, diarrhea, rash, nonarteritic ischemic optic neuropathy, hearing loss, priapism …

Teaching

That product does not protect against sexually transmitted diseases, including HIV
That product absorption is reduced with a high-fat meal, to take on empty stomach for faster action; to take 30 min to 4 hr before sexual activity; peak is 2 hr
That product should not be used with nitrates or soluble guanylate cyclase stimulators (riociguat) (PAH)
That tabs may be split

🔗 Full card in the drug guide

💉 Tamsulosin

Selective α1-peripheral adrenergic blocker, BPH agent, Sulfamoylphenethylamine derivative

What it is for

Symptoms of benign prostatic hyperplasia (BPH)

How it works

Binds preferentially to α1A- adrenoceptor subtype, which is located mainly in the prostate

Watch for

CNS: Dizziness, headache, asthenia, insomnia CV: Chest pain, orthostatic hypotension EENT: Amblyopia, floppy iris syndrome GI: Nausea, diarrhea, dysgeusia GU: Decreased libido, abnormal ejaculation, priapism INTEG: Rash, pruritus, urticaria MS: Back pain RESP: Rhinitis, pharyngitis …

Teaching

Not to drive or operate machinery for 4 hr after 1st dose or after dosage increase
To continue to take even if feeling better
To advise providers of all products, herbs taken
To make position changes slowly because orthostatic hypotension may occur

🔗 Full card in the drug guide

💉 TerbutalineBLACK BOX

Selective β2-agonist; bronchodilator, Catecholamine

What it is for

Bronchospasm Unlabeled: Premature labor

How it works

Relaxes bronchial smooth muscle by direct action on β2-adrenergic receptors through the accumulation of cAMP at β-adrenergic receptor sites; bronchodilation, diuresis, CNS, cardiac stimulation occur; relaxes uterine smooth muscle

Watch for

CNS: Tremors, anxiety, insomnia, headache, dizziness, stimulation, restlessness CV: Palpitations, tachycardia, hypertension, dysrhythmias, cardiac arrest, QT prolongation GI: Nausea, vomiting META: Hypokalemia, hyperglycemia RESP: Paradoxical bronchospasm …

Teaching

Avoid cough/cold/allergy OTC medications because extra stimulation may occur
About all aspects of product; to avoid smoking, smoke-filled rooms, persons with respiratory infections
To maintain adequate hydration; to allow 15 min between inhalation of product and inhaled product containing steroid
To take on time; if missed, not to make up after 1 hr; to wait until next dose

🔗 Full card in the drug guide

💉 Testosterone

Androgen

What it is for

Breast cancer, metastatic (females); advancing inoperable metastatic (skeletal) mammary cancer who are 1-5 yr postmenopausal; delayed puberty (males)

🔗 Full card in the drug guide

Introduction to Pharmacology & Herbal Supplements

Bioavailability⭐ HIGH YIELD

Bioavailability is the fraction of an administered dose that actually reaches systemic circulation in active form. IV is 100% by definition; oral is lower and more variable because of incomplete absorption plus first-pass metabolism.

Rough order: IV (100%) > IM/subQ > sublingual, inhaled, transdermal > oral > rectal (variable).
Anything that reduces absorption or increases first-pass metabolism reduces bioavailability.
Formulation matters: brand-to-generic switches can matter for narrow-therapeutic-index drugs like levothyroxine, warfarin, and phenytoin.
Food, gastric pH, and other drugs change oral bioavailability; IV has none of those variables.

Bioavailability = how much made it to the party, not how much left the house.

Black cohosh

Black cohosh is taken for MENOPAUSE symptoms: hot flashes, night sweats, irritability, and sleep disturbance, plus PMS and painful periods. Its main contraindications are pregnancy, liver disease, and estrogen-sensitive cancers.

Contraindicated in pregnancy because it may stimulate uterine contractions, and in breastfeeding.
HEPATOTOXICITY is the key safety warning. Teach the patient to report jaundice, dark urine, right upper quadrant pain, nausea, and unusual fatigue. Avoid with other hepatotoxic drugs.
Use cautiously with breast or uterine cancer, hormone therapy, and tamoxifen.
May add to antihypertensives and cause hypotension; may reduce the effect of some statins.
Do not confuse with blue cohosh, which is a different and more toxic plant.

Black cohosh cools the flash but watch the liver.

Echinacea⭐ HIGH YIELD

Echinacea is taken to PREVENT or shorten the common cold and upper respiratory infections by stimulating the immune system. That is exactly why it is CONTRAINDICATED in autoimmune disease and in transplant or immunosuppressed patients.

Avoid in multiple sclerosis, lupus, rheumatoid arthritis, HIV, tuberculosis, and with cyclosporine, tacrolimus, or corticosteroids: it works against the drugs suppressing the immune system.
Cross-allergy with ragweed, daisies, chrysanthemums, and marigolds (Asteraceae family).
Inhibits CYP1A2 and CYP3A4, so it can raise levels of some drugs. Limit continuous use (commonly 8 weeks or less) because of reported hepatotoxicity.
Evidence for actual benefit is weak and inconsistent.
Common effects: GI upset, rash, and a temporary tingling of the tongue.

Echinacea REVS the immune system, so never give it to someone whose immune system we are trying to shut down.

Ginger

Ginger is taken for NAUSEA AND VOMITING (motion sickness, postoperative nausea, and morning sickness of pregnancy) and for osteoarthritis pain. Like the other G-herbs, high doses increase bleeding risk.

It is one of the safer options for pregnancy-related nausea, but doses should stay modest and be cleared with the provider.
Caution with warfarin, aspirin, clopidogrel, and NSAIDs; hold before surgery.
May lower blood glucose and blood pressure, so it is additive with antidiabetics and antihypertensives.
High doses cause heartburn and GI upset. Use caution with gallstones because it increases bile flow.

Ginger for the gut. Still a G-herb, still bleeds.

Pharmacokinetics – absorption, distribution, metabolism, excretion⭐ HIGH YIELD

Pharmacokinetics is what the BODY does to the DRUG, in four steps: Absorption (into the bloodstream), Distribution (blood to tissues), Metabolism (the liver changes it), and Excretion (the kidney removes it). Pharmacodynamics is the reverse: what the drug does to the body.

Only FREE, unbound drug is pharmacologically active.
Liver disease means reduce the dose. Kidney disease means reduce the dose or lengthen the interval.
Half-life, steady state, bioavailability, and the first-pass effect all come out of these four steps.
Two organs run the whole show: the liver metabolizes, the kidney excretes.

Phase	What happens	Main organ or factor	What changes it
Absorption	Drug moves from the site of administration into the blood	Route; the GI tract for oral drugs	Route, food, gastric pH, GI motility, blood flow, first-pass effect
Distribution	Drug travels from blood into tissues and fluids	Circulation and plasma albumin	Cardiac output, protein binding, body fat vs water, blood-brain barrier, placenta
Metabolism	Drug is chemically changed, usually inactivated	LIVER (cytochrome P450)	Liver function, age, genetics, CYP inducers and inhibitors
Excretion	Drug and metabolites leave the body	KIDNEY (also bile, lungs, breast milk)	GFR and renal function, hydration, urine pH, age

ADME: A Drug Must Exit. Absorb, Distribute, Metabolize, Excrete.

Physiological changes in the elderly⭐ HIGH YIELD

Older adults have decreased gastric acid and GI motility, decreased total body water with increased body fat, decreased serum albumin, decreased hepatic mass and CYP enzyme activity, and decreased GFR. The net effect is higher drug levels lasting longer, plus increased CNS sensitivity. Start low and go slow.

Increased CNS sensitivity means more sedation, confusion, and falls from benzodiazepines, opioids, and anticholinergics.
Blunted baroreceptor reflex means more orthostatic hypotension; thinner skin changes topical and transdermal absorption.
Pair this with the Beers criteria and polypharmacy: the three geriatric pharmacology topics are always tested together.

Change	Pharmacokinetic effect	Nursing implication
Less gastric acid, slower GI motility	Slower, sometimes altered absorption	Delayed onset; watch for late effects
Less total body water, more fat	Water-soluble drugs more concentrated; fat-soluble drugs stored and prolonged	Lower doses of water-soluble drugs; expect prolonged sedation from diazepam and similar drugs
Lower serum albumin	More free (active) drug	Toxicity at 'normal' doses, especially with warfarin and phenytoin
Smaller liver, less blood flow, reduced CYP activity	Slower metabolism, longer half-life	Reduce doses of hepatically cleared drugs
Reduced GFR and renal blood flow	Accumulation of renally cleared drugs	Use GFR or creatinine clearance, not serum creatinine alone

Less water, less albumin, less liver, less kidney: the same dose hits harder and stays longer.

Routes of administration – How do different routes of administration affect bioavailability?⭐ HIGH YIELD

Bioavailability is the fraction of a dose that reaches systemic circulation. Routes that bypass the GI tract and the liver's first pass have the HIGHEST bioavailability, with IV at 100% by definition. ORAL is the lowest and most variable because of incomplete absorption plus first-pass metabolism.

Same drug, different dose by route: oral morphine is dosed roughly three times the IV dose for the same effect. That gap IS bioavailability.
Food, gastric pH, GI motility, and other drugs change oral bioavailability. IV has none of those variables.
Enteric-coated and extended-release forms deliberately slow absorption, which is why they are never crushed.
Nitroglycerin is given sublingually precisely because oral nitroglycerin is destroyed on first pass.

Route	Bioavailability	Why
IV	100%	Goes directly into the blood: no absorption phase, no first pass
IM / subQ	High, near complete	Absorbed from muscle or fat capillaries; bypasses the liver; rate depends on perfusion
Sublingual / buccal	High	Drains into veins going to the superior vena cava, skipping the portal circulation
Inhaled	High at the target tissue	Huge alveolar surface with direct absorption; minimal systemic exposure with good technique
Transdermal	Moderate but very steady	Slow continuous absorption through skin; bypasses first pass
Rectal	Variable, around 50%	Lower rectal veins bypass the liver, upper rectal veins do not
Oral	Lowest and most variable	Incomplete absorption plus full first-pass hepatic metabolism

The farther a drug travels through the gut and liver, the less of it survives. IV skips the whole trip.

Saw palmetto⭐ HIGH YIELD

Saw palmetto is taken for BENIGN PROSTATIC HYPERPLASIA: urinary frequency, urgency, nocturia, and weak stream. It acts like a weak 5-alpha-reductase inhibitor, reducing conversion of testosterone to DHT.

Contraindicated in pregnancy and in anyone who could become pregnant because of possible harm to a male fetus. Pregnant women should not handle it.
It can LOWER the PSA and mask prostate cancer. Always tell the provider before PSA screening.
Mild antiplatelet effect: caution with warfarin, aspirin, and clopidogrel, and stop before surgery.
May be additive with finasteride, dutasteride, and alpha blockers such as tamsulosin.
Common effects: GI upset, headache, dizziness, and decreased libido.

Saw palmetto saves the stream and saws down the PSA number.

St. John’s wort🚨 DANGER

St John's wort is taken for MILD TO MODERATE DEPRESSION and for anxiety and sleep. It is the most interaction-prone herb on the list: it INDUCES CYP3A4 and P-glycoprotein, which makes other drugs stop working, and it is serotonergic, which causes serotonin syndrome.

Causes PHOTOSENSITIVITY. Teach sunscreen and protective clothing.
Contraindicated in pregnancy and in bipolar disorder, where it can trigger mania. Stop about 5 days before surgery.
Never advise a patient to stop a prescribed antidepressant in order to start it, and taper rather than stopping abruptly.
Always ask about it specifically. Patients do not think of supplements as 'medications.'

Interaction	What happens	Clinical result
Oral contraceptives	Induced metabolism lowers hormone levels	Breakthrough bleeding and UNPLANNED PREGNANCY
Warfarin, digoxin, theophylline, statins, anticonvulsants	Levels drop	Loss of therapeutic effect: clots, arrhythmia, seizures
Cyclosporine, tacrolimus	Levels drop	TRANSPLANT REJECTION
HIV protease inhibitors and NNRTIs	Levels drop	Antiretroviral failure and resistance
SSRIs, SNRIs, TCAs, MAOIs, triptans, tramadol	Additive serotonin	SEROTONIN SYNDROME: agitation, hyperthermia, hyperreflexia, clonus, tachycardia

St John's wort makes everything else WORTHLESS, and stacked with an SSRI it makes serotonin syndrome.

Therapeutic index⭐ HIGH YIELD

Therapeutic index (TI) = TD50 divided by ED50 (the toxic dose in 50% of subjects over the effective dose in 50%). A HIGH/wide TI means a large safety margin; a LOW/narrow TI means toxic and therapeutic doses are close together and the drug needs serum level monitoring.

The therapeutic range or window is the concentration between the minimum effective level and the toxic level.
For narrow-TI drugs also watch renal and hepatic function, drug interactions, and brand-to-generic switches.
Practical example: a digoxin level of 2.5 ng/mL is already toxic while the target is roughly 0.5 to 2 ng/mL.

Narrow (low) therapeutic index	Wide (high) therapeutic index
Small gap between effective and toxic dose	Large gap between effective and toxic dose
Requires serum drug levels, peaks and troughs	Routine level monitoring not needed
Warfarin, digoxin, lithium, phenytoin, theophylline, vancomycin, gentamicin, carbamazepine	Penicillins, most antihistamines, acetaminophen at label dose
Small dose changes or interactions can be dangerous	More forgiving of dose variation

Narrow index = narrow ledge. One step and the patient falls into toxicity.

Antibiotics, Antifungals, and Antivirals

💉 Acyclovir

Antiviral, Purine nucleoside/nucleotide analog

What it is for

Mucocutaneous herpes simplex virus, herpes genitalis (HSV-1, HSV-2), varicella infections, herpes zoster, herpes simplex encephalitis, herpes labialis

How it works

Converted to acyclovir monophosphate by virus-specific thymidine kinase then further converted to acyclovir triphosphate by other cellular enzymes, inhibits viral DNA synthesis

Watch for

CNS: Tremors, confusion, lethargy, hallucinations, seizures, dizziness, headache, encephalopathic changes EENT: Gingival hyperplasia GI: Nausea, vomiting, diarrhea, increased ALT/AST, abdominal pain, colitis GU: Hematuria, acute renal failure …

Teaching

To take as prescribed; if dose is missed, take as soon as remembered up to 1 hr before next dose; do not double dose
That product may be taken orally before infection occurs; product should be taken when itching or pain occurs, usually before eruptions
That sexual partners need to be told that patient has herpes because they can become infected; condoms must be worn to prevent reinfections
Not to touch lesions to avoid spreading infection to new sites, not to use topical products on lesions, spreading may occur

Antidote / reversal: 1

🔗 Full card in the drug guide

💉 Cephalexin

Antiinfective, Cephalosporin (first generation)

What it is for

cefadroxil: gram-negative bacilli: Escherichia coli, Proteus mirabilis, Klebsiella (UTI only); gram-positive organisms: Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus; upper, lower respiratory tract; urinary tract, skin infections …

How it works

Inhibits bacterial cell wall synthesis; renders cell wall osmotically unstable, leads to cell death; lysis mediated by cell wall autolytic enzymes

Watch for

CNS: Headache, dizziness, weakness, paresthesia, fever, chills, confusion, fatigue, hallucinations, seizures (with high doses) GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, Clostridium difficileassociated diarrhea (CDAD) GU: Vaginitis, pruritus, candidiasis HEMA: Thrombocytopenia …

Teaching

To take all medication prescribed for length of time ordered; take missed dose as soon as remembered, unless close to next dose; do not double dose; use calibrated device …
To report vaginal itching; loose, foulsmelling stools; furry tongue occurs; may indicate superinfection
To report immediately rash, flulike symptoms, blisters, stop product
Diarrhea with mucus, blood (may indicate CDAD)

🔗 Full card in the drug guide

💉 Efavirenz

Antiretroviral, Nonnucleoside reverse transcriptase inhibitor (NNRTI)

What it is for

HIV-1 in combination with at least 2 other antivirals

How it works

Binds directly to reverse transcriptase and blocks RNA, DNA polymerase, thus causing a disruption of the enzyme’s site

Watch for

CNS: Fatigue, impaired cognition, insomnia, abnormal dreams, depression, headache, dizziness, anxiety, drowsiness, odd feeling, suicidal thoughts/behaviors GI: Diarrhea, abdominal pain, nausea, vomiting, hepatotoxicity GU: Hematuria, kidney stones HEMA: Neutropenia INTEG: Rash …

Teaching

To take as prescribed; if dose is missed, to take as soon as remembered; not to double dose; to take with water, juice; to take on empty stomach at bedtime; to take at sa …
To make sure health care provider knows all medications, supplements, OTC products taken
To notify health care provider if severe rash occurs; that adverse reactions (rash, dizziness, abnormal dreams, insomnia) lessen after 1 mo, not to stop taking
To avoid hazardous activities if dizziness, drowsiness occur

🔗 Full card in the drug guide

💉 Enfuvirtide

Antiretroviral, Fusion inhibitor

What it is for

Treatment of HIV-1 infection in combination with other antiretrovirals in those who are treatment experienced only Unlabeled: HIV prophylaxis after occupational exposure

How it works

Inhibitor of the fusion of HIV-1 with CD4+ cells

Watch for

CNS: Anxiety, peripheral neuropathy, taste disturbance, Guillain-Barré syndrome, insomnia, depression, fatigue, peripheral neuropathy GI: Nausea, abdominal pain, anorexia, constipation, pancreatitis, dry mouth, weight loss GU: Glomerulonephritis, renal failure HEMA: Thrombocytopenia …

Teaching

That pneumonia may occur; to contact prescriber if cough, fever occur
That hypersensitive reactions may occur; rash, pruritus; to stop product, contact prescriber
That product is not a cure for HIV-1 infection but controls symptoms; HIV-1 can still be transmitted to others; that product is to be used in combination only with other …
How to prepare and give using SUBCUT injection, watch for site reactions, rotate sites; if more information is needed, call 877-438-9366

🔗 Full card in the drug guide

HIV antiretroviral drug classifications⭐ HIGH YIELD

The main antiretroviral classes are NRTIs, NNRTIs, protease inhibitors, integrase strand transfer inhibitors (INSTIs), and entry inhibitors (CCR5 antagonists, fusion inhibitors, attachment inhibitors). Standard therapy combines at least 3 drugs from 2 or more classes, most often 2 NRTIs plus an INSTI.

ADHERENCE is everything. Missed doses breed resistance, so the regimen is never skipped or stopped.
Abacavir requires HLA-B*5701 testing before use because the hypersensitivity reaction can be fatal.
Ritonavir and cobicistat are 'boosters': CYP3A4 inhibitors used to raise other drugs' levels, which means huge interaction potential.
NRTI class effect: lactic acidosis with hepatomegaly and steatosis. Zidovudine causes bone marrow suppression.
St John's wort and rifampin destroy antiretroviral levels and cause treatment failure.

Class	How it works	Examples (suffix clue)
NRTI	A faulty nucleoside terminates the DNA chain built by reverse transcriptase	tenofovir, emtricitabine, abacavir, lamivudine, zidovudine
NNRTI	Binds reverse transcriptase directly and disables it	efavirenz, rilpivirine, doravirine, nevirapine (-virine)
Protease inhibitor	Blocks protease so new virions cannot mature	atazanavir, darunavir, ritonavir (-navir)
INSTI	Blocks integrase so viral DNA cannot insert into host DNA	dolutegravir, raltegravir, bictegravir, cabotegravir (-tegravir)
Entry inhibitors	Block attachment, fusion, or the CCR5 coreceptor so the virus cannot enter the CD4 cell	maraviroc (CCR5), enfuvirtide (fusion), fostemsavir (attachment)

'-navir' navigates protease. '-tegravir' integrates (integrase). '-virine' is an NNRTI.

💉 Lopinavir

Antiretroviral, Protease inhibitor

What it is for

HIV-1 in combination with or without other antiretrovirals

How it works

Inhibits human immunodeficiency virus (HIV-1) protease and prevents maturation of the infectious virus

Watch for

CNS: Paresthesia, headache, seizures, fever, dizziness, insomnia, asthenia, intracranial bleeding, encephalopathy CV: QT, PR interval prolongation, deep vein thrombosis EENT: Blurred vision, otitis media, tinnitus GI: Diarrhea, buccal mucosa ulceration, abdominal pain, nausea, taste perversion …

Teaching

To take as prescribed; if dose is missed, to take as soon as remembered up to 1 hr before next dose; not to double dose
That product is not a cure for HIV; that opportunistic infections can continue to be acquired
That redistribution of body fat or accumulation of body fat may occur
That others can continue to contract HIV from patient

🔗 Full card in the drug guide

💉 MetronidazoleBLACK BOX

Antiinfective—miscellaneous, Nitroimidazole derivative

What it is for

Intestinal amebiasis, amebic abscess, trichomoniasis, refractory trichomoniasis, bacterial anaerobic infections, giardiasis, septicemia, endocarditis; bone, joint, lower respiratory tract infections; rosacea

How it works

Direct-acting amebicide/trichomonacide binds and disrupts DNA structure, thereby inhibiting bacterial nucleic acid synthesis

Watch for

CNS: Headache, dizziness, confusion, irritability, restlessness, ataxia, depression, fatigue, drowsiness, insomnia, paresthesia, peripheral neuropathy, seizures, incoordination, depression, encephalopathy, aseptic meningitis (IV) CV: Flattening of T waves EENT: Blurred vision, sore throat …

Teaching

That urine may turn dark reddish brown; that product may cause metallic taste; that both are normal
About proper hygiene after bowel movement; handwashing technique
To notify provider about numbness or tingling of extremities
To avoid hazardous activities because dizziness can occur

🔗 Full card in the drug guide

💉 Nystatin

Antifungal, Amphoteric polyene

What it is for

Candida species causing oral, intestinal infections

How it works

Interferes with fungal DNA replication; binds sterols in fungal cell membrane, which increases permeability, leaking of cell nutrients

Watch for

GI: Nausea, vomiting, anorexia, diarrhea, cramps

Teaching

That long-term therapy may be needed to clear infection; to complete entire course of medication
To avoid commercial mouthwashes for mouth infection
To shake susp before measuring each dose, to swish and swallow
To notify prescriber of irritation; product may have to be discontinued

🔗 Full card in the drug guide

💉 Tetracycline

Antiinfective, Tetracycline antibiotic

What it is for

Syphilis, Chlamydia trachomatis, gonorrhea, lymphogranuloma venereum; uncommon gram-positive, gram-negative organisms; rickettsial infections Acinetobacter sp., Actinomyces sp., Bacillus anthracis, Bacteroides sp., Balantidium coli, Bartonella bacilliformis …

How it works

Inhibits protein synthesis and phosphorylation in microorganisms; bacteriostatic Needed for pyruvate metabolism, carbohydrate metabolism

Watch for

CNS: Fever, headache, paresthesia, ICP CV: Pericarditis EENT: Dysphagia, glossitis, decreased calcification, discoloration of deciduous teeth, oral candidiasis, oral ulcers GI: Nausea, abdominal pain, vomiting, diarrhea, anorexia, enterocolitis, hepatotoxicity, flatulence, abdominal cramps …

Teaching

To avoid sun exposure; that sunscreen does not seem to decrease photosensitivity
That all prescribed medication must be taken to prevent superinfection
To avoid milk products, antacids or to separate by 2 hr; to take with full glass of water; to take 1 hr before bedtime to prevent esophageal ulceration
That tooth discoloration may occur, especially in children; not to use in child <8 yr, may cause bone formation abnormalities

🔗 Full card in the drug guide

💉 Vancomycin

Antiinfective—miscellaneous, Tricyclic glycopeptide

What it is for

Actinomyces sp., Bacillus sp., Clostridium difficile, Clostridium sp., Enterococcus faecalis, Enterococcus faecium, Enterococcus sp., Lactobacillus sp., Listeria monocytogenes, Staphylococcus aureus (MRSA), Staphylococcus aureus (MSSA) …

How it works

Inhibits bacterial cell-wall synthesis, damages bacterial plasma membrane and increases osmotic pressure

Watch for

CNS: Headache CV: Hypotension, peripheral edema cardiac arrest, vascular collapse EENT: Ototoxicity, permanent deafness, tinnitus, nystagmus GI: Nausea, CDAD GU: Nephrotoxicity HEMA: Leukopenia, eosinophilia INTEG: Chills, fever, rash, thrombophlebitis at inj site (red man syndrome) …

Teaching

About all aspects of product therapy; about the need to complete entire course of medication to ensure organism death (7-10 days); that culture may be taken after complet …
To report sore throat, fever, fatigue; could indicate superinfection
That product must be taken in equal intervals around the clock to maintain blood levels
That labs will need to be regularly monitored with IV infusion

🔗 Full card in the drug guide

Immunomodulators and Antineoplastic Agents

💉 AzathioprineBLACK BOX

Immunosuppressant, antirheumatic (disease modifying), Purine antimetabolite

What it is for

FDA-labeled: prevention of kidney transplant rejection and severe rheumatoid arthritis. Also widely used off-label in lupus, inflammatory bowel disease and other autoimmune disease — on an exam, answer with the labeled two.

How it works

Turns into a fake purine that gets built into DNA, which stops fast-dividing cells from copying themselves. Lymphocytes are the fastest dividers in an immune response, so the immune system is what gets damped down.

Watch for

HEMA: Bone marrow suppression — leukopenia, thrombocytopenia, anemia. GI: Nausea, vomiting, mouth ulcers, pancreatitis. HEPA: Hepatotoxicity. SYST: Serious infection; long-term lymphoma and skin cancer risk.

Teaching

CBC and liver enzymes get checked regularly — this drug suppresses the marrow, and that is the main thing being watched for.
Any fever, sore throat, cough or wound that will not heal is reported immediately. The immune system is deliberately turned down.
Avoid crowds and anyone who is sick. No live vaccines.
Sunscreen and covered skin, every day. Skin cancer risk is real and long-term.

🔗 Full card in the drug guide

Bone marrow suppression – What are potential causes of this adverse effect? What are the🚨 DANGER

Bone marrow suppression is caused most often by cytotoxic chemotherapy and radiation, but also by immunosuppressants and a long list of ordinary drugs. It presents as neutropenia (infection), anemia (fatigue and pallor), and thrombocytopenia (bruising and bleeding), with the nadir typically 7 to 14 days after chemotherapy.

Antineoplastics: alkylating agents, antimetabolites (methotrexate, 5-FU), anthracyclines, platinum agents, taxanes.
Immunosuppressants: azathioprine, mycophenolate, cyclophosphamide, tacrolimus, cyclosporine, TNF inhibitors.
Non-cancer drugs: chloramphenicol, CLOZAPINE (agranulocytosis, requires mandatory ANC monitoring), methimazole and PTU, carbamazepine, linezolid, ganciclovir, zidovudine, sulfonamides, phenytoin.
Supportive treatment: filgrastim or pegfilgrastim for neutrophils, epoetin or darbepoetin for red cells, romiplostim for platelets, plus transfusions.
Nursing: monitor CBC with differential and ANC, neutropenic and bleeding precautions, no live vaccines, and treat a fever of 100.4 F as an emergency.

Chemo hits the fastest-growing cells: marrow, mouth, hair, and gut. That is why counts crash, mouths ulcerate, hair falls, and stools loosen.

💉 CyclophosphamideHIGH ALERT

Antineoplastic alkylating agent, Nitrogen mustard

What it is for

Hodgkin’s disease, lymphomas, leukemia; cancer of female reproductive tract, breast, multiple myeloma; neuroblastoma; retinoblastoma; Ewing’s sarcoma; nephrotic syndrome

How it works

Alkylates DNA; is responsible for cross-linking DNA strands; activity is not cell-cycle–phase specific

Watch for

CV: Cardiotoxicity (high doses), myocardial fibrosis, hypotension ENDO: SIADH, gonadal suppression GI: Nausea, vomiting, weight loss, anorexia GU: Hemorrhagic cystitis, hematuria HEMA: Thrombocytopenia, leukopenia …

Teaching

To take adequate fluids (3 L/day, adults) to eliminate product
That amenorrhea can occur and may last up to 1 yr after therapy but is reversible after stopping treatment
To report any changes in breathing or coughing
To avoid foods with citric acid, hot temperature, or rough texture; that skin, fingernails may become darker

🔗 Full card in the drug guide

💉 CyclosporineBLACK BOX

Immunosuppressant, antirheumatic (DMARD), Fungus-derived peptide

What it is for

Organ transplants (liver, kidney, heart) to prevent rejection (GVHD), rheumatoid arthritis, psoriasis

How it works

Produces immunosuppression by inhibiting T lymphocytes

Watch for

CNS: Tremors, headache, seizures, progressive multifocal leukoencephalopathy, confusion, migraine, paresthesia GI: Nausea, vomiting, diarrhea, oral candida, gum hyperplasia, hepatotoxicity, pancreatitis GU: Nephrotoxicity INTEG: Rash, acne, hirsutism META: Hyperkalemia, hypomagnesemia …

Teaching

To report fever, chills, sore throat, fatigue since serious infections may occur; tremors, bleeding gums, increased B/P
To take at same time of day, every day; not to skip doses or double dose; not to use with grapefruit juice or receive vaccines; that there are many drug interactions; not …

🔗 Full card in the drug guide

💉 DoxorubicinHIGH ALERTBLACK BOX

Antineoplastic, antibiotic, Anthracycline glycoside

What it is for

Wilms’ tumor; bladder, breast, lung, ovarian, stomach, thyroid cancer; Hodgkin’s/non-Hodgkin’s disease; acute lymphoblastic leukemia; myeloblastic leukemia; neuroblastomas; soft tissue/bone sarcomas

How it works

Inhibits DNA synthesis primarily; replication is decreased by binding to DNA, which causes strand splitting; active throughout entire cell cycle; a vesicant

Watch for

CV: Increased B/P, sinus tachycardia, PVCs, chest pain, bradycardia, extrasystoles, irreversible cardiomyopathy, acute left ventricular failure GI: Nausea, vomiting, anorexia, mucositis, hepatotoxicity GU: Impotence, sterility, amenorrhea, gynecomastia, hyperuricemia …

Teaching

To add 2-3 L of fluids unless contraindicated prior to and for 24-48 hr after to decrease possible hemorrhagic cystitis
To report any complaints, side effects to nurse or prescriber
That hair may be lost during treatment; that wig or hairpiece might make patient feel better; that new hair might be different in color, texture
That continuing follow-up and lab work will be needed

🔗 Full card in the drug guide

💉 Interferon beta

Antiviral, Interferon, Escherichia coli derivative

What it is for

Ambulatory patients with relapsing or remitting MS

How it works

Antiviral, immunoregulatory; action not clearly understood; biologic response-modifying properties mediated through specific receptors on cells, inducing expression of interferoninduced gene products

Watch for

CNS: Headache, fever, pain, chills, mental changes, depression, hypertonia, suicide attempts, seizures CV: Migraine, palpitations, hypertension, tachycardia, peripheral vascular disorders EENT: Conjunctivitis, blurred vision GI: Diarrhea, constipation, vomiting, abdominal pain GU: Dysmenorrhea …

Teaching

With written, detailed information about product
That blurred vision, hearing loss, sweating may occur
That female patients may experience irregular menses, dysmenorrhea or metrorrhagia, breast pain
To use sunscreen to prevent photosensitivity

🔗 Full card in the drug guide

Live vaccines – Which vaccines are examples of live vaccines? When should live vaccines be🚨 DANGER

Live attenuated vaccines include MMR, varicella, the old live zoster vaccine (Zostavax; Shingrix is NOT live), rotavirus, intranasal influenza (LAIV), yellow fever, oral typhoid, BCG, and smallpox. AVOID them in pregnancy, in severely immunocompromised patients, and in anyone on high-dose immunosuppressive therapy.

Severely immunocompromised includes active chemotherapy, hematologic or solid tumors, transplant, congenital immunodeficiency, advanced HIV, and prednisone at 20 mg/day or more (or 2 mg/kg) for 2 weeks or longer.
Pregnancy: avoid live vaccines, and avoid pregnancy for about 4 weeks after MMR or varicella.
If two live vaccines are not given on the same day, separate them by at least 28 days.
Recent immune globulin or blood products blunt the response to live vaccines. Wait the product-specific interval, often 3 to 11 months.
Household contacts of an immunocompromised patient CAN generally receive MMR and varicella. This is a common exam distractor.

Live vaccines and low immune systems do not mix: MMR, Varicella, Rotavirus, Yellow fever, LAIV, BCG, oral Typhoid.

Rhogam⭐ HIGH YIELD

RhoGAM (Rho(D) immune globulin) prevents an Rh-NEGATIVE mother from making antibodies against Rh-POSITIVE fetal blood, protecting future pregnancies from hemolytic disease of the newborn. Standard: 300 mcg IM at 28 weeks gestation, and again within 72 HOURS after delivery of an Rh-positive infant.

Also given after miscarriage, abortion, ectopic pregnancy, amniocentesis or CVS, abdominal trauma, external cephalic version, and any antepartum bleeding.
Only for a mother who is Rh-negative AND not already sensitized (negative indirect Coombs). If she is already sensitized, RhoGAM does not help.
It is given to the MOTHER, never to the infant. Route is IM. A micro-dose (about 50 mcg) is used for early first-trimester loss.
It is a blood product, so verify per policy and document informed consent or refusal.

RhoGAM is for the Rh-negative MOM: 28 weeks, and within 72 hours of birth.

💉 TamoxifenHIGH ALERTBLACK BOX

Antineoplastic, Antiestrogen hormone

What it is for

Advanced breast carcinoma not responsive to other therapy in estrogenreceptor–positive patients (usually postmenopausal), prevention of breast cancer, after breast surgery/radiation for ductal carcinoma in situ Unlabeled: Mastalgia in men …

How it works

Inhibits cell division by binding to cytoplasmic estrogen receptors; resembles normal cell complex but inhibits DNA synthesis and estrogen response of target tissue

Watch for

CNS: Hot flashes, headache, light-headedness, depression, mood changes, stroke CV: Chest pain, stroke, fluid retention, flushing EENT: Blurred vision (high doses) GI: Nausea, vomiting, altered taste GU: Vaginal bleeding, uterine malignancies, altered menses, amenorrhea HEMA: Thrombocytopenia …

Teaching

About risk of stroke and PE: to seek medical attention immediately in case of blurred vision, headache, weakness on one side of the body (stroke signs); or chest pain, fa …
To report any complaints, side effects to prescriber; that use may be 5 yr
To increase fluids to 2 L/day unless contraindicated
To wear sunscreen, protective clothing, sunglasses

🔗 Full card in the drug guide

💉 VincristineHIGH ALERTBLACK BOX

Antineoplastic—miscellaneous, Vinca alkaloid

What it is for

Lymphomas, neuroblastoma, Hodgkin’s disease, acute lymphoblastic and other leukemias, rhabdomyosarcoma, Wilms’ tumor, non-Hodgkin’s lymphoma, malignant glioma, soft-tissue sarcoma …

How it works

Inhibits mitotic activity, arrests cell cycle at metaphase; inhibits RNA synthesis, blocks cellular use of glutamic acid needed for purine synthesis; vesicant

Watch for

CNS: Decreased reflexes, numbness, weakness, motor difficulties, CNS depression, cranial nerve paralysis, seizures, peripheral neuropathy CV: Orthostatic hypotension EENT: Diplopia GI: Nausea, vomiting, anorexia, stomatitis, constipation, paralytic ileus, abdominal pain …

Teaching

To brush teeth bid-tid with soft brush or cotton-tipped applicator for stomatitis; to use unwaxed dental floss
To report change in gait or numbness in extremities; may indicate neuropathy
To report any bleeding, white spots, or ulcerations in mouth to prescriber; to examine mouth daily
To increase bulk, fluids, exercise to prevent constipation

🔗 Full card in the drug guide

Pain, Inflammation, Substance Abuse, and Neurodegenerative Disorders

Alcohol withdrawal treatment options🚨 DANGER

BENZODIAZEPINES are first-line for alcohol withdrawal (lorazepam, chlordiazepoxide, or diazepam), dosed with a symptom-triggered CIWA-Ar protocol, plus THIAMINE given BEFORE any glucose, along with folate, a multivitamin, magnesium, and IV fluids.

Lorazepam is preferred in liver disease and in older adults because it has no active metabolites. Remember the LOT drugs: Lorazepam, Oxazepam, Temazepam.
Thiamine before glucose prevents precipitating Wernicke encephalopathy (confusion, ataxia, ophthalmoplegia), which can progress to irreversible Korsakoff psychosis.
Adjuncts: phenobarbital, propofol or dexmedetomidine in the ICU, beta blockers or clonidine for autonomic symptoms, and haloperidol only for hallucinations after adequate benzodiazepines (it lowers the seizure threshold).
Timeline: tremor and anxiety 6 to 24 hours, seizures 12 to 48 hours, alcoholic hallucinosis 12 to 24 hours, and delirium tremens 48 to 96 hours, which can be fatal.
Long-term maintenance is different: naltrexone, acamprosate, and disulfiram.

Banana bag plus benzos, and ALWAYS thiamine before the sugar.

💉 BaclofenBLACK BOX

Skeletal muscle relaxant, central acting, GABA chlorophenyl derivative

What it is for

Spasticity with spinal cord injury, multiple sclerosis Unlabeled: Neuropathic pain, trigeminal neuralgia

How it works

Inhibits synaptic responses in CNS by stimulating GABAb receptor subtype, which decreases neurotransmitter function; decreases frequency, severity of muscle spasms

Watch for

CNS: Dizziness, weakness, fatigue, drowsiness, headache, disorientation, insomnia, paresthesias, tremors; seizures (IT) CV: Hypotension, bradycardia, flushing, edema EENT: Nasal congestion, blurred vision, tinnitus GI: Nausea, constipation, dry mouth, anorexia, weight gain GU: Urinary frequency …

Antidote / reversal: 1

🔗 Full card in the drug guide

💉 BupropionBLACK BOX

Antidepressant—miscellaneous smoking deterrent, Aminoketone

What it is for

Depression (Wellbutrin), smoking cessation (Zyban); seasonal affective disorder, substance abuse, glaucoma, smoking, cardiac disease, heart failure Unlabeled: ADHD (adult)

How it works

Inhibits reuptake of DOPamine, norepinephrine, serotonin

Watch for

CNS: Headache, agitation, dizziness, akinesia, confusion, seizures, delusions, insomnia, sedation, tremors, suicidal/homicidal ideation, flushing CV: Dysrhythmias, hypertension, palpitations, tachycardia, hypotension, chest pain, chills EENT: Blurred vision, auditory disturbance GI: Nausea …

Teaching

That therapeutic effects may take 2-4 wk; not to increase dose without prescriber’s approval; that treatment for smoking cessation lasts 7-12 wk
To use caution when driving, performing other activities that require alertness; sedation, blurred vision may occur
To avoid alcohol, other CNS depressants; alcohol may increase risk of seizures
Not to chew, crush tablets

Antidote / reversal: 1

🔗 Full card in the drug guide

💉 DiazepamHIGH ALERTBLACK BOX

Antianxiety, anticonvulsant, skeletal muscle relaxant, central acting, Benzodiazepine, lon

What it is for

Anxiety, acute alcohol withdrawal, adjunct for seizure disorders; preoperatively as a relaxant for skeletal muscle relaxation; rectally for acute repetitive seizures

How it works

Potentiates the actions of GABA, especially in the limbic system, reticular formation; enhances presympathetic inhibition, inhibits spinal polysynaptic afferent paths

Watch for

CNS: Dizziness, drowsiness, headache, hangover, slurred speech, paradoxical excitation CV: Hypotension, tachycardia EENT: Blurred vision GI: Constipation, nausea, vomiting, diarrhea, weight gain INTEG: Rash, dermatitis, itching, phlebitis (IV) …

Teaching

That product may be taken with food
That product not to be used for everyday stress or for >4 mo unless directed by prescriber; to take no more than prescribed amount; that product may be habit forming, rev …
To avoid OTC preparations unless approved by prescriber
To avoid driving, activities that require alertness; drowsiness may occur

Antidote / reversal: 1

🔗 Full card in the drug guide

💉 IbuprofenBLACK BOX

NSAID, Propionic acid derivative

What it is for

Inflammatory disorders: Rheumatoid arthritis, osteoarthritis, primary dysmenorrhea, dental pain, musculoskeletal disorders, fever, migraine, patent ductus arteriosus, headache Unlabeled: Ankylosing spondylitis, bone pain, cystic fibrosis, gouty arthritis …

How it works

Inhibits COX-1, COX-2 by blocking arachidonate; analgesic, antiinflammatory, antipyretic

Watch for

CNS: Headache, dizziness, drowsiness, fatigue CV: Tachycardia, peripheral edema, palpitations, dysrhythmias, CV thrombotic events, MI, stroke, HF EENT: Tinnitus, hearing loss, blurred vision GI: Nausea, anorexia, vomiting, diarrhea, jaundice, constipation, flatulence, cramps, dry mouth …

Teaching

To use sunscreen, sunglasses, and protective clothing to prevent photosensitivity, photophobia
To report blurred vision, ringing, roaring in ears (may indicate toxicity); that eye and hearing tests should be done during long-term therapy
To avoid driving, other hazardous activities if dizziness or drowsiness occurs

🔗 Full card in the drug guide

Levodopa/carbidopa⭐ HIGH YIELD

Levodopa is a dopamine precursor that crosses the blood-brain barrier and is converted to dopamine to treat Parkinson's disease. Carbidopa blocks that conversion in the PERIPHERY, so more levodopa reaches the brain and there is far less nausea.

Avoid HIGH-PROTEIN meals with the dose: dietary amino acids compete with levodopa for absorption and blunt the effect.
Harmless but alarming: sweat, saliva, and urine may turn dark red, brown, or black. Warn the patient in advance.
Orthostatic hypotension is common. Rise slowly and use fall precautions.
Long-term: dyskinesias, wearing-off, and the on-off phenomenon (abrupt loss of effect). Doses must be given ON TIME, to the minute.
Do NOT stop abruptly: risk of a neuroleptic malignant-like syndrome. Avoid with MAOIs (hypertensive crisis) and with antipsychotics or metoclopramide, which are dopamine blockers that cancel it out. Report hallucinations, confusion, sudden sleep attacks, and impulse-control behaviors such as gambling, spending, and hypersexuality.

Carbidopa is the bodyguard: it keeps levodopa from being mugged before it reaches the brain.

Opioids – What adverse effects are associated with this class of drugs?🚨 DANGER

The dangerous adverse effect is RESPIRATORY DEPRESSION; the universal one is CONSTIPATION, which never improves with tolerance. Also expect sedation, nausea and vomiting, pruritus, urinary retention, orthostatic hypotension, miosis, and physical dependence and tolerance.

SEDATION PRECEDES RESPIRATORY DEPRESSION. Increasing drowsiness is your early warning, so assess sedation level along with respiratory rate.
Antidote is naloxone. Watch for re-narcotization because naloxone's half-life is shorter than that of most opioids.
Constipation: start a stimulant laxative plus a stool softener at the same time as the opioid. Tolerance to constipation never develops.
Overdose triad: pinpoint pupils, respiratory depression, and decreased level of consciousness or coma.
Highest risk: opioid-naive patients, sleep apnea, older adults, and concurrent benzodiazepines or alcohol (a black-box warning combination). Meperidine is avoided because of a neurotoxic metabolite causing seizures, especially in older adults and renal impairment.

Pinpoint pupils, pinpoint breathing. Sedation comes before respiratory arrest, so catch it there.

Smoking cessation treatment options⭐ HIGH YIELD

Three pharmacologic options: nicotine replacement therapy (patch, gum, lozenge, inhaler, nasal spray), bupropion SR (Zyban), and varenicline (Chantix). Varenicline is generally the most effective, and combining a long-acting patch with a short-acting NRT beats either one alone.

Both pills are started BEFORE the quit date, and the patient keeps smoking during that lead-in period.
Never combine bupropion (Zyban) with bupropion (Wellbutrin): it is the same drug and the seizure risk stacks.
Pair every drug with counseling or behavioral support. The combination roughly doubles quit rates.
Smoking INDUCES CYP1A2, so quitting RAISES levels of clozapine, olanzapine, theophylline, and warfarin. Doses may need to come down.

Option	How it works	Key teaching and cautions
Nicotine replacement (patch, gum, lozenge)	Replaces nicotine without the tar and carcinogens, blunting withdrawal	Do NOT smoke while wearing a patch. Chew-and-park the gum; no acidic drinks 15 min before or during. Remove the patch at night if vivid dreams or insomnia occur.
Bupropion SR	Dopamine and norepinephrine reuptake inhibitor that reduces craving	Start 1 to 2 weeks BEFORE the quit date. Contraindicated with seizure disorder, eating disorders, MAOIs, and abrupt alcohol or benzodiazepine withdrawal.
Varenicline	Partial nicotinic receptor agonist: eases withdrawal and blocks the reward of smoking	Start 1 week before the quit date. Take with food and a full glass of water because nausea is the top side effect. Report mood changes and vivid dreams.

Both pills start BEFORE the quit date. Only the patch starts on it.

💉 Sumatriptan

Antimigraine agent, 5-HT1B/D receptor agonist, abortive agent, triptan

What it is for

Acute treatment of migraine with/without aura and cluster headache

How it works

Binds selectively to the vascular 5-HT1B/D receptor subtype; exerts antimigraine effect; causes vasoconstriction in cranial arteries

Watch for

CNS: Tingling, hot sensation, burning, feeling of pressure, tightness, numbness, dizziness, sedation, headache, anxiety, fatigue, cold sensation CV: Flushing, MI, hypo-/hypertension EENT: Throat, mouth, nasal discomfort …

Teaching

To report chest pain, tightness; sudden, severe abdominal pain; swelling of eyelids, face, lips; skin rash to prescriber immediately
To notify prescriber if pregnancy is planned or suspected; to use contraception while taking product
Risk of medication overuse: do not use for abortive headache treatments more than 10 days/mo (ergotamines, triptans, opioids, or combinations)
Nasal spray: to use 1 spray in 1 nostril; may repeat if headache returns; not to repeat if pain continues after 1st dose

🔗 Full card in the drug guide

💉 Varenicline

Smoking cessation agent, Nicotine receptor agonist

What it is for

Adjunct to psychosocial interventions for tobacco cessation (smoking); dry eye disease (Tyrvaya)

How it works

Partial agonist for nicotine receptors; partially activates receptors to help curb cravings; occupies receptors to prevent nicotine binding

Watch for

CNS: Headache, agitation, dizziness, insomnia, abnormal dreams, fatigue, malaise, behavioral changes, depression, homicidal ideation, suicidal ideation, amnesia, hallucinations, hostility, mania, psychosis, tremors, seizures, stroke CV: Dysrhythmias, MI EENT: Blurred vision GI: Nausea, vomiting …

Teaching

To set a date to quit smoking and to initiate treatment 1 wk before that date
That treatment for smoking cessation lasts 12 wk and that another 12 wk may be required
To use caution when driving, performing other activities requiring alertness; blurred vision may occur
How to titrate product

🔗 Full card in the drug guide

Mental Health Drugs

💉 CarbamazepineBLACK BOX

Anticonvulsant, Iminostilbene derivative

What it is for

Tonic-clonic, complex-partial, mixed seizures; trigeminal neuralgia; bipolar disorder

How it works

Exact mechanism unknown; appears to decrease polysynaptic responses and block posttetanic potentiation

Watch for

CNS: Drowsiness, dizziness, fatigue, headache, suicidal thoughts/behaviors CV: Hypertension, AV block, hypotension EENT: Dry mouth, blurred vision, diplopia, nystagmus ENDO: SIADH (geriatric patients) GI: Nausea, anorexia, increased hepatic enzymes, pancreatitis, hepatotoxicity GU: Retention …

Teaching

To carry emergency ID stating patient’s name, products taken, condition, prescriber’s name, and phone number
To avoid driving, other activities that require alertness usually for the first 3 days of treatment; dizziness, drowsiness may occur
Not to discontinue medication quickly after long-term use; seizures may occur
To immediately report chills, rash, light-colored stools, dark urine, yellowing of skin and eyes, abdominal pain, sore throat, mouth ulcers, bruising, blurred vision, diz …

🔗 Full card in the drug guide

💉 ClozapineBLACK BOX

Antipsychotic, Tricyclic dibenzodiazepine derivative

What it is for

Management of psychotic symptoms for schizophrenic patients for whom other antipsychotics have failed; recurrent suicidal behavior

How it works

Interferes with DOPamine receptor binding with lack of EPS; also acts as an adrenergic, cholinergic, histaminergic, serotonergic antagonist

Watch for

CNS: Neuroleptic malignant syndrome, sedation, dizziness, headache, seizures, insomnia, dystonia CV: Tachycardia, hypo/hypertension, orthostatic hypotension, mitral valve incompetence, myocarditis, ventricular dysrrthmias EENT: Blurred vision GI: Drooling or excessive salivation, constipation …

Teaching

About symptoms of agranulocytosis and need for blood tests weekly for 6 mo, then q2wk; to report flulike symptoms
That orthostatic hypotension often occurs; to rise gradually from sitting or lying position; to avoid hot tubs, hot showers, tub baths; hypotension may occur
To avoid abrupt withdrawal of this product because EPS may result; that product should be withdrawn over 1-2 wk
To avoid OTC preparations (cough, hay fever, cold) unless approved by prescriber because serious product interactions may occur; to avoid use with alcohol or CNS depressa …

Antidote / reversal: 1

🔗 Full card in the drug guide

Extrapyramidal symptoms – What are the signs/symptoms? What causes this adverse effect?⭐ HIGH YIELD

Extrapyramidal symptoms are drug-induced movement disorders caused by DOPAMINE (D2) BLOCKADE in the nigrostriatal pathway. The classic causes are first-generation antipsychotics (haloperidol, fluphenazine) and also metoclopramide, prochlorperazine, and promethazine.

Second-generation (atypical) antipsychotics cause much less EPS, but not zero, especially risperidone at higher doses.
Anticholinergics treat dystonia and pseudoparkinsonism but can WORSEN tardive dyskinesia.
Screen with the AIMS (Abnormal Involuntary Movement Scale) at baseline and regularly.
Do not confuse with neuroleptic malignant syndrome: fever, lead-pipe rigidity, altered mental status, autonomic instability, and elevated CPK. That is an emergency treated with dantrolene and bromocriptine.

Type	Onset	Signs	Treatment
Acute dystonia	Hours to about 5 days	Sustained muscle spasm: torticollis, jaw and tongue spasm, oculogyric crisis, laryngospasm	IM or IV benztropine or diphenhydramine. EMERGENCY if the airway is involved.
Akathisia	Days to weeks	Inner restlessness, inability to sit still, pacing, hand-wringing	Propranolol, a benzodiazepine, or reduce the dose
Pseudoparkinsonism	Weeks to about 1 month	Bradykinesia, cogwheel rigidity, resting tremor, shuffling gait, masklike face	Benztropine or trihexyphenidyl, or amantadine; reduce the dose
Tardive dyskinesia	Months to years	Involuntary lip smacking, tongue thrusting, chewing, grimacing, writhing limb movements	Often IRREVERSIBLE. Stop or switch the drug; valbenazine or deutetrabenazine

Dystonia = stuck. Akathisia = can't sit. Parkinsonism = slow. Tardive = tongue. In that order over time.

💉 LithiumBLACK BOX

Mood stabilizer, Alkali metal ion salt

What it is for

Bipolar disorders (manic phase), prevention of bipolar manicdepressive psychosis

How it works

May alter sodium, potassium ion transport across cell membrane in nerve, muscle cells; may balance biogenic amines of norepinephrine, serotonin in CNS areas involved in emotional responses

Watch for

CNS: Headache, drowsiness, dizziness, tremors, twitching, ataxia, seizure, slurred speech, restlessness, confusion, stupor, memory loss, clonic movements, fatigue CV: Hypotension, ECG changes, dysrhythmias, circulatory collapse, edema, Brugada syndrome, QT prolongation EENT: Tinnitus …

Teaching

About the symptoms of minor toxicity: vomiting, diarrhea, poor coordination, fine motor tremors, weakness, lassitude; major toxicity: coarse tremors, severe thirst, tinni …
To monitor urine specific gravity, emphasize need for follow-up care to determine lithium levels; to monitor lithium levels to ensure effective levels and treatment
Not to operate machinery until lithium levels are stable
To use emergency ID with diagnosis, product used

Antidote / reversal: 1

🔗 Full card in the drug guide

💉 MethylphenidateBLACK BOX

Cerebral stimulant, Piperidine derivative

What it is for

Attention deficit disorder (ADD), attention-deficit/hyperactivity disorder (ADHD); narcolepsy (except Concerta, Metadate CD, Ritalin LA)

How it works

Increases release of norepinephrine, DOPamine in cerebral cortex to reticular activating system; exact action not known

Watch for

CNS: Hyperactivity, insomnia, restlessness, talkativeness, dizziness, drowsiness, toxic psychosis, headache, akathisia, dyskinesia, masking or worsening of Tourette’s syndrome, seizures, hallucinations, malignant neuroleptic syndrome, aggression …

Teaching

To decrease caffeine consumption (coffee, tea, cola, chocolate); may increase irritability, stimulation; not to use guarana, yerba maté, cola nut
To avoid OTC preparations unless approved by prescriber
To always use dosing dispenser provided for oral suspension dose
To taper off product over several weeks because depression, increased sleeping, lethargy will occur

🔗 Full card in the drug guide

💉 PhenelzineBLACK BOX

Antidepressant, Monoamine oxidase inhibitor (MAOI)

What it is for

Depression that has not responded to other antidepressants; described on the label as atypical, nonendogenous or neurotic depression. It is a later-line drug, not a first choice.

How it works

Blocks monoamine oxidase — the enzyme that breaks down serotonin, norepinephrine and dopamine — IRREVERSIBLY and non-selectively. It destroys the enzyme rather than just occupying it, so the body has to build new enzyme before normal breakdown resumes.

Watch for

CNS: Dizziness, drowsiness, insomnia, tremor, hyperreflexia, toxic delirium. CV: Orthostatic hypotension in ordinary use — and a dangerous pressure SPIKE in hypertensive crisis. Edema. GI: Nausea, constipation, weight gain. GU: Sexual dysfunction, urinary retention.

Teaching

TYRAMINE IS THE ONE TO KNOW. Aged cheese, cured or smoked meat, pickled herring, liver, yogurt, meat or yeast extracts, sauerkraut, soy sauce, draft and craft beer, red wine, and any protein food that has been left out or stored badly. Tyramine plus an MAOI causes a hypertensive crisis.
Non-alcoholic beer and wine are NOT a safe substitute — the label restricts those too.
The food and drug rules continue for TWO FULL WEEKS after the last dose. The enzyme was destroyed, not merely blocked, and the body has to rebuild it.
Hypertensive crisis: a sudden OCCIPITAL headache that may spread forward, stiff or sore neck, palpitations, sweating, nausea and vomiting, dilated pupils, light sensitivity, chest pain. The pulse may be FAST OR SLOW — do not rule it out because the heart rate is low. Emergency.

Antidote / reversal: 1

🔗 Full card in the drug guide

💉 PhenytoinBLACK BOX

Anticonvulsant; antidysrhythmic (IB), Hydantoin

What it is for

Generalized tonic-clonic seizures; status epilepticus; nonepileptic seizures associated with Reye’s syndrome or after head trauma; complex partial seizures Unlabeled: Digoxin toxicity; seizures, prophylaxis in head trauma, subarachnoid hemorrhage

How it works

Inhibits spread of seizure activity in motor cortex by altering ion transport; increases AV conduction

Watch for

CNS: Dizziness, insomnia, paresthesias, depression, suicidal tendencies, aggression, headache, confusion, slurred speech, peripheral neuropathy CV: Hypotension, ventricular fibrillation, bradycardia, cardiac arrest EENT: Nystagmus, diplopia, blurred vision ENDO: Diabetes insipidus GI: Nausea …

Teaching

That, if diabetic, blood glucose should be monitored
That urine may turn pink
Not to discontinue product abruptly because seizures may occur
Oral hygiene: about the proper brushing of teeth using a soft toothbrush, flossing to prevent gingival hyperplasia; about the need to see dentist frequently

🔗 Full card in the drug guide

Bone and Skin Disorders

💉 Alendronate

Bone-resorption inhibitor, Bisphosphonate

What it is for

Treatment and prevention of osteoporosis in postmenopausal women, treatment of osteoporosis in men, Paget’s disease, treatment of corticosteroidinduced osteoporosis in postmenopausal women not receiving estrogen and in men who are on continuing corticosteroid …

How it works

Decreases rate of bone resorption and may directly block dissolution of hydroxyapatite crystals of bone; inhibits osteoclast activity

Watch for

RESP: Asthma exacerbation CV: Atrial fibrillation INTEG: Rash, photosensitivity CNS: Headache GI: Abdominal pain, constipation, nausea, vomiting, esophageal ulceration, acid reflux, dyspepsia, esophageal perforation, diarrhea, esophageal cancer META: Hypophosphatemia, hypocalcemia MS: Bone pain …

Teaching

To remain upright for 30 min after dose to prevent esophageal irritation; if dose is missed, skip dose, do not double doses or take later in day; to take in am before foo …
To take calcium, vitamin D if instructed by health care provider
To use sunscreen, protective clothing to prevent photosensitivity
To avoid smoking, alcohol intake, which increase osteoporosis

🔗 Full card in the drug guide

💉 Colchicine

Antigout agent, Alkaloid

What it is for

Gout, gouty arthritis (prevention, treatment); to arrest the progression of neurologic disability in those with MS, Mediterranean fever Unlabeled: Bechet syndrome with arthritis, cutaneous lesions or mucocutaneous ulcers …

How it works

Inhibits microtubule formation of lactic acid in leukocytes, which decreases phagocytosis and inflammation in joints

Watch for

GI: Nausea, vomiting, anorexia, cramps HEMA: Agranulocytosis, thrombocytopenia, aplastic anemia, pancytopenia MISC: Alopecia, peripheral neuritis

Teaching

To avoid alcohol, OTC preparations that contain alcohol
To report any pain, redness, hard areas, usually in legs; rash, sore throat, fever, bleeding, bruising, weakness, numbness, tingling, nausea, vomiting, abdominal pain, mu …
To avoid grapefruit and juice, may increase colchicine level
About the importance of complying with medical regimen (diet, weight loss, product therapy); about the possibility of bone marrow depression occurring; not to double or s …

Antidote / reversal: 1

🔗 Full card in the drug guide

Gout – What are the treatment options for acute gout treatment and gout prophylaxis?⭐ HIGH YIELD

ACUTE gout: NSAIDs (indomethacin, naproxen), colchicine, or corticosteroids (oral, IV, or injected into the joint). PROPHYLAXIS: urate-lowering therapy with allopurinol or febuxostat (xanthine oxidase inhibitors) or probenecid (uricosuric), plus low-dose colchicine or an NSAID as cover for the first 3 to 6 months.

Allopurinol plus azathioprine or 6-mercaptopurine causes severe marrow toxicity: allopurinol blocks their breakdown.
Any new rash on allopurinol must be reported: it can progress to Stevens-Johnson syndrome.
Starting urate-lowering therapy can PRECIPITATE a flare, which is exactly why colchicine or NSAID cover is added.
Avoid aspirin, thiazides, and loop diuretics when possible; they raise uric acid.
Diet teaching: 2 to 3 L of fluid daily, limit organ meats, shellfish, and red meat, limit alcohol especially beer, and limit high-fructose drinks.

Acute treatment	Prophylaxis
NSAIDs: indomethacin, naproxen	Allopurinol: first-line, blocks uric acid production
Colchicine: start within 24 to 36 hours; causes nausea, vomiting, diarrhea	Febuxostat: alternative xanthine oxidase inhibitor with a cardiovascular boxed warning
Corticosteroids: prednisone, or intra-articular injection	Probenecid: uricosuric, increases renal excretion; needs 2 to 3 L fluid daily
Rest and elevate the joint; ice; avoid weight on it	Target serum uric acid under 6 mg/dL
Do NOT start allopurinol during a flare	Do NOT stop allopurinol during a flare if already taking it

Allopurinol PREVENTS, colchicine and NSAIDs RELIEVE. Never start the preventer mid-attack.

💉 Hydroxychloroquine

Antimalarial, antirheumatic (DMARDs), 4-Aminoquinoline derivative

What it is for

Malaria caused by susceptible strains of Plasmodium vivax, P. malariae, P. ovale, P. falciparum (some strains); SLE, rheumatoid arthritis Unlabeled: Lupus nephritis, polymorphous-light eruptions

How it works

Impairs complement-dependent antigen–antibody reactions

Watch for

CNS: Headache, fatigue, irritability, seizures, bad dreams, dizziness, confusion, psychosis, anxiety, suicidal ideation CV: HF, torsades de pointes, QT prolongation, asystole with syncope EENT: Blurred vision, corneal changes, tinnitus, vertigo, nystagmus, corneal deposits GI: Nausea, vomiting …

Teaching

To use sunglasses in bright sunlight to decrease photophobia; to wear protective clothing (photosensitivity)
That urine may turn rust or brown; that skin may become blue-black
To report hearing, visual problems, fever, fatigue, bruising, bleeding, which may indicate blood dyscrasias
RA: To report to provider if there is no change in condition, may need several months for results

Antidote / reversal: 1

🔗 Full card in the drug guide

💉 IsotretinoinBLACK BOX

Antiacne agent, retinoid

What it is for

Severe recalcitrant nodulocystic acne

🔗 Full card in the drug guide

💉 Mupirocin

Topical antiinfective

What it is for

Impetigo, skin lesions (Staphylococcus aureus/Streptococcus pyogenes)

How it works

Antibacterial activity results from inhibition of protein synthesis; bacteriostatic at low concentration, bactericidal at high concentration

Watch for

CNS: Headache GI: Taste change, nausea INTEG: Burning, rash, pruritus

Teaching

Topical route
Not to use skin products near the eyes, nose, or mouth
To wash hands before and after use and to wash affected area and gently pat dry
Cream/ointment: to apply a thin film to the cleansed affected area; to cover treated areas with gauze dressing if desired

🔗 Full card in the drug guide

Adrenergic and Cholinergic Drugs

Adrenergic receptors – What are the effects on body tissues from stimulation of alpha-1, alpha-⭐ HIGH YIELD

Alpha-1: vasoconstriction (raises BP), pupil dilation, bladder neck and prostate contraction (urinary retention). Alpha-2: presynaptic feedback, so stimulating it DECREASES sympathetic outflow (lowers BP and HR, sedation). Beta-1: the HEART, increased rate, contractility, conduction, and renin release. Beta-2: the LUNGS and smooth muscle, bronchodilation, vasodilation, uterine relaxation, raised glucose. Beta-3: bladder relaxation and lipolysis.

Alpha-2 is the confusing one because it is a BRAKE. Agonists like clonidine LOWER blood pressure.
Beta-2 agonists cause predictable side effects: tremor, tachycardia from spillover, nervousness, and HYPOKALEMIA as potassium shifts into cells.
Non-selective beta blockers hit beta-2 and cause bronchospasm, which is why they are avoided in asthma.

Receptor	Location	Effect when stimulated	Drug example
Alpha-1	Vascular smooth muscle, iris, bladder neck and prostate	Vasoconstriction and higher BP, pupil dilation, urinary retention	Phenylephrine (agonist); tamsulosin, prazosin (blockers)
Alpha-2	Presynaptic nerve terminals and CNS	Less norepinephrine released: lower BP and HR, sedation, dry mouth	Clonidine, brimonidine, dexmedetomidine
Beta-1	HEART (you have 1 heart)	Increased rate, contractility, conduction, and renin	Dobutamine (agonist); metoprolol (blocker)
Beta-2	LUNGS (you have 2 lungs), skeletal muscle vessels, uterus, liver	Bronchodilation, vasodilation, uterine relaxation, higher glucose	Albuterol, terbutaline (agonists); propranolol blocks it
Beta-3	Bladder detrusor and fat cells	Bladder relaxation for storage, lipolysis	Mirabegron

You have ONE heart (beta-1) and TWO lungs (beta-2). Alpha-1 squeezes; alpha-2 eases.

💉 AtropineHIGH ALERT

Antidysrhythmic, anticholinergic parasympatholytic, antimuscarinic, Belladonna alkaloid

What it is for

Bradycardia <40-50 bpm, bradydysrhythmia, reversal of anticholinesterase agents, insecticide poisoning, blocking cardiac vagal reflexes, decreasing secretions before surgery, antispasmodic with GU, biliary surgery, bronchodilator …

How it works

Blocks acetylcholine at parasympathetic neuroeffector sites; increases cardiac output, heart rate by blocking vagal stimulation in heart; dries secretions by blocking vagus

Watch for

CNS: Headache, dizziness, involuntary movement, confusion, flushing, drowsiness CV: Tachycardia, bradycardia EENT: Blurred vision, photophobia, dry eyes GI: Dry mouth, constipation RESP: Tachypnea, pulmonary edema GU: Retention, hesitancy, impotence INTEG: Flushing, decreased sweating

Teaching

To report blurred vision, chest pain, allergic reactions, constipation, urinary retention; to use sunglasses to protect the eyes
Not to perform strenuous activity in high temperatures; heat stroke may result
To take as prescribed; not to skip or double doses
Not to operate machinery if drowsiness occurs

Antidote / reversal: 1

🔗 Full card in the drug guide

💉 Bethanechol

Urinary tract stimulant, cholinergic, Synthetic choline ester

What it is for

Urinary retention (postoperative, postpartum), neurogenic atony of bladder with retention Unlabeled: Ileus, GERD, anticholinergic syndrome

How it works

Stimulates muscarinic ACH receptors directly; mimics effects of parasympathetic nervous system stimulation; stimulates gastric motility, micturition; increases lower esophageal sphincter pressure

Watch for

CNS: Dizziness, headache, malaise CV: Hypotension, bradycardia, reflex tachycardia, cardiac arrest, circulatory collapse EENT: Miosis, increased salivation, lacrimation, blurred vision GI: Nausea, bloody diarrhea, belching, vomiting, cramps, fecal incontinence GU: Urgency INTEG: Rash, urticaria …

Teaching

To take product exactly as prescribed; 1 hr before meals or 2 hr after meals to avoid nausea
To make position changes slowly; orthostatic hypotension may occur
To avoid driving, hazardous activities until effects are known

🔗 Full card in the drug guide

💉 EpinephrineHIGH ALERT

Bronchodilator nonselective adrenergic agonist, vasopressor, Catecholamine

What it is for

Acute asthmatic attacks, hemostasis, bronchospasm, anaphylaxis, allergic reactions, cardiac arrest, adjunct in anesthesia, shock

How it works

β1- and β2-agonist causing increased levels of cAMP, thereby producing bronchodilation, cardiac, and CNS stimulation; high doses cause vasoconstriction via alpha-receptors; low doses can cause vasodilation via β2-vascular receptors

Watch for

CNS: Tremors, anxiety, insomnia, headache, dizziness, confusion, hallucinations, weakness, drowsiness CV: Palpitations, tachycardia, hypertension, dysrhythmias, increased T wave GI: Anorexia, nausea, vomiting MISC: Sweating, dry eyes RESP: Dyspnea …

Teaching

About the reason for product administration
Inhalation: to rinse mouth after use to prevent dryness after inhalation, not to spray near eyes, teach correct use
To take exactly as prescribed. If on scheduled regimen, take missed dose as soon as remembered. Space remaining doses evenly. Do not double doses. To contact prescriber i …
To consult prescriber prior to taking any OTC, Rx medications, supplements or herbals

🔗 Full card in the drug guide

Malignant hyperthermia – What are the risk factors for developing this condition?🚨 DANGER

The core risk factor is a GENETIC predisposition, autosomal dominant, usually an RYR1 ryanodine receptor mutation (also CACNA1S), combined with exposure to a trigger: volatile inhaled anesthetics or succinylcholine.

A personal or FAMILY history of malignant hyperthermia, or of an unexplained anesthesia death or high fever during surgery, is the biggest red flag. Ask about it at every preoperative assessment.
Associated muscle disorders raise risk: central core disease, multiminicore disease, King-Denborough syndrome, and some muscular dystrophies.
More often reported in males, children, and young adults, but it can happen at any age.
PRIOR UNEVENTFUL ANESTHESIA DOES NOT RULE IT OUT. Many patients have had safe anesthesia before their first episode.
Susceptibility is confirmed by caffeine-halothane contracture testing or genetic testing. Susceptible patients get a trigger-free anesthetic: propofol, ketamine, opioids, nitrous oxide, or regional anesthesia.

Genes plus gas (or sux) equals crisis. Always ask about family reactions to anesthesia.

💉 NorepinephrineHIGH ALERT

Vasopressor, α/ β-agonist

What it is for

Acute hypotension, shock

How it works

Causes increased contractility and heart rate by acting on β-receptors in heart; also acts on α-receptors, thereby causing vasoconstriction in blood vessels; B/P is elevated, coronary blood flow improves, and cardiac output increases

Watch for

CNS: Headache, anxiety, dizziness, insomnia, restlessness, tremor, cerebral hemorrhage CV: Palpitations, tachycardia, hypertension, ectopic beats, angina GI: Nausea, vomiting GU: Decreased urine output INTEG: Necrosis, tissue sloughing with extravasation, gangrene RESP: Dyspnea SYST: Anaphylaxis

Teaching

About the reason for product administration; to report dyspnea, dizziness, chest pain

🔗 Full card in the drug guide

💉 Oxybutynin

Anticholinergic, urinary antispasmodic, Synthetic tertiary amine

What it is for

Antispasmodic for neurogenic bladder, overactive bladder in females (OTC)

How it works

Relaxes smooth muscles in urinary tract by inhibiting acetylcholine at postganglionic sites

Watch for

CNS: Anxiety, restlessness, dizziness, somnolence, insomnia, nervousness, seizures, headache, drowsiness, confusion CV: Palpitations, sinus tachycardia, hypertension, peripheral edema, QT prolongation EENT: Blurred vision, dry eyes, increased intraocular tension, dry mouth, dry throat GI: Nausea …

Teaching

To avoid hazardous activities because dizziness, blurred vision may occur
To avoid OTC medications with alcohol, other CNS depressants
To avoid hot weather, strenuous activity because product decreases perspiration
About the correct application of each product form

🔗 Full card in the drug guide

💉 SuccinylcholineHIGH ALERTBLACK BOX

Neuromuscular blocker (depolarizing, ultra short)

What it is for

Facilitation of endotracheal intubation, skeletal muscle relaxation during orthopedic manipulations

How it works

Inhibits transmission of nerve impulses by binding with cholinergic receptor sites, thus antagonizing action of acetylcholine; causes release of histamine

Watch for

CV: Bradycardia, tachycardia; increased, decreased B/P; sinus arrest, dysrhythmias, edema EENT: Increased secretions, intraocular pressure HEMA: Myoglobulinemia INTEG: Rash, flushing, pruritus, urticaria MS: Weakness, muscle pain, fasciculations, prolonged relaxation, myalgia …

Teaching

Reason for product, expected results

🔗 Full card in the drug guide

Sympathetic response – What are the effects of sympathetic stimulation on different body⭐ HIGH YIELD

Sympathetic (fight or flight) stimulation shifts blood and energy toward survival: heart rate and contractility UP, blood pressure UP, bronchioles DILATE, pupils DILATE, blood glucose UP, and everything non-essential (digestion, urination, salivation) slows DOWN.

Neurotransmitters: sympathetic uses norepinephrine and epinephrine at adrenergic receptors; parasympathetic uses acetylcholine at muscarinic receptors.
Adrenergic drugs mimic this response; beta blockers and alpha blockers oppose it.
Anticholinergics look sympathetic because they remove the parasympathetic brake: dry mouth, tachycardia, dilated pupils, urinary retention.

Body system	Sympathetic (fight or flight)	Parasympathetic (rest and digest)
Heart	Increased rate, contractility, and conduction	Decreased rate and conduction
Blood vessels	Vasoconstriction in skin and gut, higher BP	Little direct effect
Lungs	Bronchodilation, increased respiratory rate	Bronchoconstriction, increased secretions
Eyes	Pupils DILATE (mydriasis), far vision	Pupils CONSTRICT (miosis), near vision
GI tract	Decreased motility and secretions, sphincters contract	Increased motility and secretions, sphincters relax
Bladder	Detrusor relaxes, sphincter contracts: retention	Detrusor contracts: urination
Skin and glands	Sweating, cool clammy skin, piloerection, dry mouth	Salivation and tearing
Metabolism	Glycogenolysis raises glucose, lipolysis	Storage and digestion

Running from a bear you do not need to pee, poop, or digest, but you do need to see, breathe, and pump.

Endocrine Drugs

💉 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, leading to drop in blood glucose levels; may improve insulin binding to insulin receptors or increase the number of insulin receptors with prolonged administration …

Watch for

CNS: Headache, weakness, dizziness, drowsiness, tinnitus, fatigue, vertigo ENDO: Hypoglycemia GI: Hepatotoxicity, cholestatic jaundice, nausea, vomiting, diarrhea, heartburn, weight gain HEMA: Leukopenia, thrombocytopenia, agranulocytosis, aplastic anemia; increased AST, ALT, alk phos …

Teaching

Not to drink alcohol; about disulfiram reaction (nausea, headache, cramps, flushing, hypoglycemia)
To report bleeding, bruising, weight gain, edema, SOB, weakness, sore throat, swelling in ankles, rash
To check for symptoms of cholestatic jaundice: dark urine, pruritus, yellow sclera; prescriber should be notified
About symptoms of hypo/hyperglycemia, what to do about each; to have glucagon emergency kit available; to carry sugar packets

Antidote / reversal: 1

🔗 Full card in the drug guide

💉 InsulinHIGH ALERT

Antidiabetic, Intermediate-acting human insulin

What it is for

Type 1 and type 2 diabetes, usually twice daily, often paired with a short-acting insulin at meals.

How it works

Regular insulin bound to protamine so it dissolves slowly out of the injection site. Same action as any insulin once absorbed — it just arrives over hours instead of minutes, which is what gives basal-ish coverage.

Watch for

ENDO: Hypoglycemia (classically in the afternoon or overnight, at the peak), weight gain. INTEG: Lipodystrophy, injection site reaction.

Teaching

The cloudy one. Roll it gently between the palms to mix — do not shake, shaking makes foam and breaks up the suspension.
Subcutaneous only. NPH must never go IV.
Onset roughly one to two hours, peak around four to twelve. Plan a snack near the peak, and know that an overnight dose puts the peak in the middle of the night.
When mixing with regular: air into NPH first, then air into regular, then draw regular up first. Clear before cloudy.

Antidote / reversal: 1

🔗 Full card in the drug guide

Onset, peak, & duration of action for each insulin type⭐ HIGH YIELD

Learn them by class: rapid-acting starts in about 15 minutes, short-acting (regular) in 30 to 60 minutes, intermediate (NPH) in 1 to 2 hours with a broad 4 to 12 hour peak, and long-acting in 1 to 2 hours with essentially NO peak. The PEAK is when hypoglycemia is most likely.

Rapid-acting insulin is given 15 minutes before the meal or immediately after: the food must be present or on the tray.
REGULAR is the only insulin given IV, and it is the one used in DKA drips.
Long-acting insulins are clear but must NEVER be mixed with any other insulin in the same syringe.
Mixing NPH and regular: inject air into the NPH vial, air into the regular vial, then draw REGULAR FIRST. Clear before cloudy.
Know when your patient's insulin peaks, because that is when to expect and assess for hypoglycemia.

Type	Onset	Peak	Duration
Rapid-acting (lispro, aspart, glulisine)	10 to 15 min	30 min to 1.5 h	3 to 5 h
Short-acting / Regular	30 min to 1 h	2 to 3 h	5 to 8 h
Intermediate (NPH)	1 to 2 h	4 to 12 h	12 to 18 h (up to 24)
Long-acting (glargine, detemir)	1 to 2 h	No true peak	About 24 h
Ultra-long-acting (degludec)	1 to 4 h	No peak	Over 24 h (up to 42 h)

Clear before cloudy. RN: Regular, then NPH.

Examples of different insulin types⭐ HIGH YIELD

Rapid: lispro (Humalog), aspart (NovoLog), glulisine (Apidra). Short/Regular: Humulin R, Novolin R. Intermediate: NPH (Humulin N, Novolin N). Long: glargine (Lantus, Basaglar, Toujeo), detemir (Levemir). Ultra-long: degludec (Tresiba). Premixed: 70/30 and 75/25.

NPH is the ONLY cloudy insulin. Roll it gently between the palms, never shake it.
Store unopened vials in the refrigerator; in-use vials can stay at room temperature (commonly about 28 days). Never freeze, and never use discolored or clumped insulin.
Rotate injection sites within one anatomic area to prevent lipohypertrophy. The abdomen absorbs fastest.
Insulin is a HIGH-ALERT drug: independent double check, insulin syringes or pens only (never a tuberculin syringe), and never abbreviate 'units' as U.

Category	Generic	Brand
Rapid-acting	insulin lispro, aspart, glulisine	Humalog, NovoLog, Apidra
Short-acting (Regular)	regular insulin	Humulin R, Novolin R
Intermediate	NPH (isophane)	Humulin N, Novolin N
Long-acting	insulin glargine, insulin detemir	Lantus, Basaglar, Toujeo; Levemir
Ultra-long-acting	insulin degludec	Tresiba
Premixed	70% NPH / 30% regular; 75% lispro protamine / 25% lispro	Humulin 70/30, Humalog Mix 75/25

Only NPH is cloudy. Only Regular goes IV. Only long-acting is never mixed.

💉 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

💉 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

💉 Prednisone

Corticosteroid, Intermediate-acting glucocorticoid

What it is for

Severe inflammation, neoplasms, multiple sclerosis, collagen disorders, dermatologic disorders, pulmonary fibrosis, asthma

How it works

Decreases inflammation by increasing capillary permeability and lysosomal stabilization, minimal mineralocorticoid activity

Watch for

CNS: Depression, flushing, sweating, headache, mood changes CV: Hypertension, thrombophlebitis, embolism, tachycardia, fluid retention EENT: Fungal infections, increased intraocular pressure, blurred vision GI: Diarrhea, nausea, abdominal distention, GI hemorrhage, increased appetite …

Teaching

That emergency ID as corticosteroid user should be carried; provide information about product being taken and condition
To notify prescriber if therapeutic response decreases; that dosage adjustment may be needed
To avoid vaccinations
Not to discontinue abruptly; adrenal crisis can result

🔗 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

Blood Thinners, Hematopoietic Agents, and Blood Products

💉 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

💉 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

💉 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

💉 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

💉 WarfarinHIGH 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

Cardiovascular Drugs

💉 Atorvastatin

Antilipidemic, HMG-CoA reductase inhibitor (statin)

What it is for

As adjunct for primary hypercholesterolemia (types Ia, Ib), elevated triglyceride levels, prevention of CV disease by reduction of heart risk in those with mildly elevated cholesterol, heterozygous familial hypercholesterolemia in pediatric patients …

How it works

Inhibits HMG-CoA reductase enzyme, which reduces cholesterol synthesis; high doses lead to plaque regression

Watch for

CNS: Headache, asthenia, insomnia EENT: Lens opacities GI: Abdominal cramps, constipation, diarrhea, flatus, heartburn, dyspepsia, liver dysfunction, pancreatitis, nausea, increased serum transaminase GU: Impotence, UTI INTEG: Rash MISC: Hypersensitivity …

Teaching

That compliance is needed for positive results to occur, not to skip or double doses
That blood work and eye exam will be necessary during treatment
To report blurred vision, severe GI symptoms, headache, muscle pain, and weakness; to avoid alcohol
That previously prescribed regimen will continue: low-cholesterol diet, exercise program, smoking cessation

🔗 Full card in the drug guide

💉 Cholestyramine

Antilipemic, Bile acid sequestrant

What it is for

Primary hypercholesterolemia (esp. type IIa/IIb hyperlipoproteinemia), pruritus associated with biliary obstruction

🔗 Full card in the drug guide

💉 DigoxinHIGH ALERT

Cardiac glycoside, inotropic, antidysrhythmic, Digoxin preparation

What it is for

Heart failure, atrial fibrillation/flutter, paroxysmal supraventricular tachycardia (PSVT) treatment/prophylaxis

How it works

Inhibits the sodium-potassium ATPase pump, which makes more calcium available for contractile proteins, thereby resulting in increased cardiac output (positive inotropic effect); increases force of contractions …

Watch for

CNS: Headache, drowsiness, apathy, confusion, disorientation, fatigue, depression, hallucinations CV: Dysrhythmias, hypotension, bradycardia, AV block EENT: Blurred vision, yellow-green halos, photophobia, diplopia GI: Nausea, vomiting, anorexia, abdominal pain, diarrhea

Teaching

Not to stop product abruptly; about all aspects of product; to take exactly as ordered; how to monitor heart rate
To avoid OTC medications, herbal remedies because many adverse product interactions may occur; not to take antacid within 2 hr of this product
To notify prescriber of loss of appetite, lower stomach pain, diarrhea, weakness, drowsiness, headache, blurred or yellow vision, rash, depression, toxicity
About the toxic symptoms of this product; when to notify prescriber

Antidote / reversal: 1

🔗 Full card in the drug guide

💉 DiltiazemHIGH ALERT

Calcium channel blocker, antiarrhythmic class IV, antihypertensive, Benzothiazepine

What it is for

PO angina pectoris due to coronary artery spasm, hypertension, improvement in exercise tolerance (chronic stable angina), IV atrial fibrillation, flutter, paroxysmal supraventricular tachycardia

How it works

Inhibits calcium ion influx across cell membrane during cardiac depolarization; produces relaxation of coronary vascular smooth muscle, dilates coronary arteries, slows SA/AV node conduction times, dilates peripheral arteries

Watch for

CNS: Tremor, paresthesia CV: Dysrhythmia, edema, HF, bradycardia, hypotension, palpitations GI: Nausea, vomiting, diarrhea, constipation GU: Nocturia, polyuria, sexual dysfunction, dysuria INTEG: Rash, flushing, photosensitivity, burning, pruritus, Stevens-Johnson syndrome, sweating RESP: Rhinitis …

Teaching

How to take pulse, B/P before taking product; that a record or graph should be kept
To avoid hazardous activities until stabilized on product, dizziness is no longer a problem
To limit caffeine consumption; to avoid grapefruit juice
To discuss OTC, Rx, herbals, supplements with provider

Antidote / reversal: 1

🔗 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

💉 Nitroglycerin

Antianginal, Nitrate, vasodilator

What it is for

Acute angina and prevention of angina; acute coronary syndrome and MI; heart failure with pulmonary congestion; hypertension during surgery.

How it works

Turns into nitric oxide in the vessel wall, which relaxes smooth muscle. Veins dilate first, so less blood comes back to the heart — preload drops and the heart has less work to do. At higher levels arteries dilate too, and it opens the coronary arteries directly.

Watch for

CNS: Headache (very common, expected, and a sign it is working), dizziness, fainting. CV: Hypotension, reflex tachycardia, flushing. GI: Nausea, vomiting. INTEG: Contact dermatitis under a patch. MISC: Tolerance with continuous use.

Teaching

Sit or lie down before taking it — it drops blood pressure and people faint standing up.
Sublingual tablet: one dose, then call 911 if the pain is not gone in five minutes, then up to two more doses five minutes apart while help is coming. Newer teaching calls EMS after the first dose.
A tingling or burning under the tongue and a headache mean the tablet is still potent. No headache at all can mean the supply has gone stale.
Store sublingual tablets in the original glass bottle, tightly capped, away from heat and light, and honor the expiration date. Older nursing teaching says replace six months after opening.

🔗 Full card in the drug guide

💉 RamiprilBLACK BOX

Antihypertensive, Angiotensin-converting enzyme (ACE) inhibitor

What it is for

Hypertension, alone or in combination with thiazide diuretics; HF (post-MI), reduction in risk for MI, stroke, death from CV disorders

How it works

Selectively suppresses reninangiotensin-aldosterone system; inhibits ACE, prevents conversion of angiotensin I to angiotensin II; results in dilation of arterial, venous vessels

Watch for

CNS: Headache, dizziness, anxiety, insomnia, paresthesia, fatigue, depression, malaise, vertigo, syncope CV: Hypotension, chest pain, palpitations, angina, syncope, dysrhythmia, heart failure, MI GI: Nausea, constipation, vomiting, anorexia, diarrhea, abdominal pain GU: Proteinuria, increased BUN …

Teaching

Not to discontinue product abruptly; to comply with dosage schedule, even if feeling better
Not to use OTC products (cough, cold, allergy), herbals, supplements unless directed by prescriber; not to use salt substitutes containing potassium without consulting pr …
To rise slowly to sitting or standing position to minimize orthostatic hypotension
To notify prescriber of mouth sores, sore throat, fever, swelling of hands or feet, irregular heartbeat, chest pain

Antidote / reversal: 1

🔗 Full card in the drug guide

Diuretics, IV Fluids, and Antidotes

💉 Furosemide

Loop diuretic, Sulfonamide derivative

What it is for

Pulmonary edema; edema with HF, hepatic disease, nephrotic syndrome, ascites, hypertension

How it works

Inhibits reabsorption of sodium and chloride at proximal and distal tubule and in the loop of Henle

Watch for

CNS: Headache, fatigue, weakness, vertigo, paresthesias CV: Orthostatic hypotension, chest pain, ECG changes, circulatory collapse EENT: Loss of hearing, ear pain, tinnitus, blurred vision ELECT: Hypokalemia, hypochloremic alkalosis, hypomagnesemia, hyperuricemia, hypocalcemia, hyponatremia …

Teaching

To discuss the need for a highpotassium diet or potassium replacement with prescriber
To rise slowly from lying or sitting position because orthostatic hypotension may occur; teach fall prevention strategies
To recognize adverse reactions that may occur: muscle cramps, weakness, nausea, dizziness; teach diabetic patients to monitor blood glucose carefully; blood glucose level …
About the entire treatment regimen, including exercise, diet, stress relief for hypertension

Antidote / reversal: 1

🔗 Full card in the drug guide

💉 Hydrochlorothiazide

Thiazide diuretic, antihypertensive, Sulfonamide derivative

What it is for

Edema, hypertension, diuresis, HF; idiopathic lower extremity edema therapy Unlabeled: Diabetes insipidus, hypercalciuria, nephrolithiasis, premenstrual syndrome, renal calculus

How it works

Acts on distal tubule and ascending limb of loop of Henle by increasing excretion of water, sodium, chloride, potassium

Watch for

CNS: Drowsiness, paresthesia, depression, headache, dizziness, fatigue, weakness, fever CV: Irregular pulse, orthostatic hypotension, palpitations, volume depletion, allergic myocarditis EENT: Blurred vision ELECT: Hypokalemia, hypercalcemia, hyponatremia, hypochloremia, hypomagnesemia GI: Nausea …

Teaching

To rise slowly from lying or sitting position to prevent postural hypotension
To notify prescriber of muscle weakness, cramps, nausea, dizziness; hypokalemia is common; rash
That product may be taken with food or milk
To use sunscreen for photosensitivity

Antidote / reversal: 1

🔗 Full card in the drug guide

💉 MannitolBLACK BOX

Diuretic, osmotic; GU irrigant, Hexahydric alcohol

What it is for

Edema; promotion of systemic diuresis in cerebral edema; decrease in intraocular/intracranial pressure; improved renal function in acute renal failure, chemical poisoning, urinary bladder irrigation, kidney transplant

How it works

Acts by increasing osmolarity of glomerular filtrate, which inhibits reabsorption of water and electrolytes and increases urinary output

Watch for

CNS: Dizziness, headache, confusion CV: Edema, thrombophlebitis, hypo/hypertension, tachycardia, angina-like chest pains, fever, chills, HF, circulatory overload ELECT: Fluid, electrolyte imbalances, electrolyte loss, dehydration, hypo/hyperkalemia GI: Nausea, vomiting …

Teaching

To rise slowly from lying or sitting position
About the reason for, method of treatment
To report signs of electrolyte imbalance, confusion, pain at injection site, hearing loss, blurred vision

Antidote / reversal: 1

🔗 Full card in the drug guide

💉 Potassium chlorideHIGH ALERT

Electrolyte, mineral replacement, Potassium

What it is for

Prevention and treatment of hypokalemia

How it works

Needed for the adequate transmission of nerve impulses and cardiac contraction, renal function, intracellular ion maintenance

Watch for

CNS: Confusion CV: Bradycardia, cardiac depression, dysrhythmias, arrest; peaking T waves, lowered R, depressed RST, prolonged P-R interval, widened QRS complex GI: Nausea, vomiting, cramps, pain, diarrhea, ulceration of small bowel GU: Oliguria INTEG: Cold extremities, rash

Teaching

To add potassium-rich foods to diet: bananas, orange juice, avocados, whole grains, broccoli, carrots, prunes, cocoa after product is discontinued
To avoid OTC products: antacids, salt substitutes, analgesics, vitamin preparations unless specifically directed by prescriber; to avoid licorice in large amounts because …
To report hyperkalemia symptoms (lethargy, confusion, diarrhea, nausea, vomiting, fainting, decreased output) or continued hypokalemia symptoms (fatigue, weakness, polyur …
To dissolve powder or tablet completely in ≥120 mL water or juice

🔗 Full card in the drug guide

💉 Sodium bicarbonate

Alkalinizer, NaHCO3

What it is for

Acidosis (metabolic), cardiac arrest, alkalinization (systemic/urinary), antacid, salicylate poisoning Amyotrophic lateral sclerosis (ALS)

How it works

Orally neutralizes gastric acid, which forms water, NaCl, CO2; increases plasma bicarbonate, which buffers H+ ion concentration; reverses acidosis IV

Watch for

CNS: Irritability, headache, confusion, stimulation, tremors, twitching, hyperreflexia, tetany, weakness, seizures of alkalosis CV: Irregular pulse, cardiac arrest, water retention, edema, weight gain GI: Flatulence, belching, distention META: Metabolic alkalosis MS: Muscular twitching, tetany …

Teaching

Not to take antacid with milk because milk-alkali syndrome may result; not to use antacid for >2 wk
To notify prescriber if indigestion accompanied by chest pain; trouble breathing; diarrhea; dark, tarry stools; vomit that looks like coffee grounds; swelling of feet/ank …
About sodium-restricted diet; to avoid use of baking soda for indigestion
sodium phenylbutyrate/taurursodiol (Rx)

🔗 Full card in the drug guide

💉 SpironolactoneBLACK BOX

Potassium-sparing diuretic, Aldosterone antagonist

What it is for

Edema of HF, hypertension, diuretic-induced hypokalemia, primary hyperaldosteronism (diagnosis, shortterm treatment, long-term treatment), edema of nephrotic syndrome, cirrhosis of liver with ascites

How it works

Competes with aldosterone at receptor sites in distal tubule, thereby resulting in the excretion of sodium chloride and water and the retention of potassium and phosphate

Watch for

CNS: Headache, confusion, drowsiness, lethargy, ataxia ELECT: Hyperchloremic metabolic acidosis, hyperkalemia, hyponatremia ENDO: Impotence, gynecomastia, irregular menses, amenorrhea, postmenopausal bleeding, hirsutism, deepening voice, breast pain GI: Diarrhea, cramps, bleeding, gastritis …

Teaching

To avoid foods with high potassium content: oranges, bananas, salt substitutes, dried apricots, dates; to avoid potassium salt substitutes
That drowsiness, ataxia, mental confusion may occur; to observe caution when driving
To notify prescriber of cramps, diarrhea, lethargy, thirst, headache, skin rash, menstrual abnormalities, deepening voice, breast enlargement
To take in am to prevent sleeplessness

Antidote / reversal: 1

🔗 Full card in the drug guide

Respiratory

💉 Acetylcysteine

Mucolytic; antidote—acetaminophen, Amino acid l-cysteine

What it is for

Acetaminophen toxicity; bronchitis; cystic fibrosis; COPD; atelectasis

How it works

Decreases viscosity of secretions by breaking disulfide links of mucoproteins; serves as a substrate in place of glutathione, which is necessary to inactivate toxic metabolites with acetaminophen overdose

Watch for

CNS: Dizziness, drowsiness, fever, chills CV: Edema, flushing tachycardia EENT: Rhinorrhea, pharyngitis GI: Nausea, stomatitis, vomiting, anorexia INTEG: Urticaria, rash, clamminess, pruritus RESP: Bronchospasm, chest tightness, cough, dyspnea MISC: Anaphylaxis, angiedema, unpleasant odor

Teaching

That foul odor and smell may be unpleasant
To clear airway for inhalation
To report vomiting because dose may need to be repeated
Provide adequate hydration

🔗 Full card in the drug guide

💉 Albuterol

Bronchodilator, Adrenergic β2-agonist, sympathomimetic, bronchodilator

What it is for

Prevention of exercise-induced asthma, acute bronchospasm, bronchitis, emphysema, bronchiectasis, or other reversible airway obstruction Unlabeled: Hyperkalemia in dialysis patients, COPD, emphysema

How it works

Causes bronchodilation by action on β2 (pulmonary) receptors by increasing levels of cAMP

Watch for

CNS: Tremors, anxiety, insomnia, headache, stimulation, restlessness CV: Angina, hypo/hypertension, dysrhythmias, chest pain EENT: Dry nose, irritation of nose and throat GI: Nausea, vomiting MISC: Hyperglycemia RESP: Paradoxical bronchospasm

Teaching

To use exactly as prescribed; to take missed dose when remembered, alter dosing schedule; not to use OTC medications; that excess stimulation may occur, to use this produ …
About use of inhaler: review package insert with patient; use demonstration, return demonstration; shake, prime before first use and when not used for >2 wk; release 4 te …
To avoid getting aerosol in eyes (blurring of vision may result) or use near flames or sources of heat
Do not wash inhaler, wipe with dry cloth, to discard product when counter changes to red

🔗 Full card in the drug guide

Antihistamines – Compare 1st and 2nd generation antihistamines⭐ HIGH YIELD

First-generation antihistamines cross the blood-brain barrier, so they cause SEDATION plus ANTICHOLINERGIC effects. Second-generation agents barely cross, so they are non-sedating or minimally sedating with almost no anticholinergic effect and once-daily dosing.

Neither generation treats anaphylaxis. Epinephrine does; antihistamines are adjuncts.
Teach: no alcohol or other CNS depressants and no driving with first-generation agents.
Avoid first-generation drugs in narrow-angle glaucoma, BPH, and dementia.
Fexofenadine absorption drops with fruit juice; take it with water.

Feature	1st generation	2nd generation
Examples	Diphenhydramine, chlorpheniramine, hydroxyzine, promethazine	Loratadine, cetirizine, fexofenadine, levocetirizine
Blood-brain barrier	Crosses readily	Poorly crosses
Sedation	Marked; also paradoxical excitation in children and older adults	Minimal (cetirizine is the most sedating of the group)
Anticholinergic effects	Dry mouth, blurred vision, urinary retention, constipation, confusion	Few to none
Dosing	Every 4 to 6 hours	Usually once daily
Older adults	On the Beers list, avoid	Preferred; adjust for renal function
Other uses	Motion sickness, vertigo, nausea, sleep aid, acute allergic reaction	Allergic rhinitis and urticaria only

1st gen puts you to sleep AND dries you out. 2nd gen just treats the allergy.

Asthma – What are the treatment options for an acute asthma exacerbation?🚨 DANGER

SABA first: inhaled albuterol by nebulizer or MDI with spacer, repeated, often with ipratropium added. Give SYSTEMIC CORTICOSTEROIDS early (oral prednisone or IV methylprednisolone) and oxygen to keep SpO2 at 90 to 92% or higher. For severe or refractory attacks add IV magnesium sulfate, continuous nebulized albuterol, subcutaneous epinephrine or terbutaline, and prepare for intubation.

The standard emergency pattern: albuterol 2.5 to 5 mg nebulized every 20 minutes for 3 doses, then reassess.
Steroids take 4 to 6 hours to work, which is exactly why they are started EARLY rather than last.
Do NOT use long-acting beta agonists (salmeterol), cromolyn, or montelukast for an acute attack. Those are controllers.
Ominous signs: a SILENT CHEST (no wheeze because no air is moving), inability to speak in full sentences, accessory muscle use, altered mental status, and exhaustion.
A rising or 'normalizing' PaCO2 in a struggling asthmatic means impending respiratory failure, not improvement. Sit the patient upright, keep them calm, and monitor peak flow and pulse oximetry continuously.

Oxygen, albuterol, steroids. And a silent chest is the loudest warning you will get.

Beclomethasone inhaler⭐ HIGH YIELD

Beclomethasone is an INHALED CORTICOSTEROID: a long-term CONTROLLER that reduces airway inflammation in asthma. It is NOT a rescue inhaler and does nothing for an acute attack.

RINSE THE MOUTH and spit after every use to prevent oral thrush (candidiasis) and hoarseness.
Use a SPACER with the MDI to improve lung delivery and reduce drug deposited in the mouth and throat.
If a rescue inhaler is also due, give the BRONCHODILATOR FIRST, wait a few minutes, then the steroid: open the airway before delivering the anti-inflammatory.
Takes 1 to 2 weeks of consistent daily use to reach full effect. Do not stop when feeling well.
Long-term or high dose: monitor growth in children, easy bruising, cataracts and glaucoma, and adrenal suppression at very high doses. Also available as a nasal spray for allergic rhinitis.

Steroid inhaler: RINSE and SPIT, or you grow a white carpet in your mouth.

💉 Diphenhydramine

Antihistamine (first generation, nonselective), Ethanolamine derivative, H1-receptor antag

What it is for

Allergy symptoms, rhinitis, motion sickness, antiparkinsonism, nighttime sedation, infant colic, nonproductive cough, insomnia in children

How it works

Acts on blood vessels, GI, respiratory system by competing with histamine for H1-receptor site; decreases allergic response by blocking histamine

Watch for

CNS: Dizziness, drowsiness, confusion, headache, seizures CV: Hypotension, palpitations EENT: Blurred vision, tinnitus, nasal stuffiness GI: Nausea, anorexia, diarrhea GU: Retention, dysuria, frequency HEMA: Thrombocytopenia, agranulocytosis, hemolytic anemia INTEG: Photosensitivity …

Teaching

About all aspects of product use; to notify prescriber of confusion, sedation, hypotension
To avoid driving, other hazardous activity if drowsiness occurs
That photosensitivity may occur, use sunscreen, protective clothing
To avoid concurrent use of alcohol, other CNS depressants

🔗 Full card in the drug guide

💉 Fexofenadine

Antihistamine—2nd generation, Piperidine, peripherally selective

What it is for

Rhinitis, allergy symptoms, chronic idiopathic urticaria

🔗 Full card in the drug guide

💉 PhenylephrineHIGH ALERT

Vasopressor, nasal decongestant, mydriatic, Alpha-1 adrenergic agonist

What it is for

Clinically important hypotension from vasodilation, especially under anesthesia (IV); nasal congestion (spray); pupil dilation for eye exams (ophthalmic); hemorrhoids (topical). The oral form is sold for congestion but FDA has proposed removing it as ineffective.

How it works

An alpha-1 agonist with minimal to no beta activity. It squeezes blood vessels; it does not directly drive the heart. Pressure rises because the vessels tighten, and the vagus answers that rise by SLOWING the heart.

Watch for

CV: Reflex BRADYCARDIA, hypertension, reduced cardiac output, reduced blood flow to kidney and gut, arrhythmias. CNS: Headache, restlessness, tremor, insomnia. EENT: Rebound congestion after more than three days of spray;

Teaching

Pure enough alpha-1 that the exam point is simple: vessels constrict, pressure goes UP, and the heart rate reflexively goes DOWN. Reflex bradycardia is the classic answer.
IV it is a high-alert vasopressor and a vesicant. Watch the site continuously. If it infiltrates: stop the infusion, leave the catheter in to aspirate, then infiltrate the area with about 5 to 10 mg of phentolamine in 10 mL of saline, within 12 hours.
The ORAL form does not work. FDA proposed removing oral phenylephrine in November 2024 because first-pass metabolism destroys it before it reaches the nose. It is still on shelves because the order is not final. The NASAL SPRAY does work.
Do not confuse it with pseudoephedrine. Pseudoephedrine is the effective one, kept behind the pharmacy counter; phenylephrine sits out on the open shelf.

Antidote / reversal: 1

🔗 Full card in the drug guide

Eye and Ear Disorders

💉 Ciprofloxacin/dexamethasoneBLACK BOX

Antiinfective—broad spectrum, Fluoroquinolone

What it is for

Infection caused by susceptible Escherichia coli, Enterobacter cloacae, Proteus mirabilis, Klebsiella pneumoniae, Proteus vulgaris, Citrobacter freundii, Serratia marcescens, Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermidis …

How it works

Interferes with conversion of intermediate DNA fragments into high-molecular-weight DNA in bacteria; DNA gyrase inhibitor

Watch for

CNS: Headache, dizziness, fatigue, insomnia, depression, restlessness, seizures, suicidal ideation, pseudotumor cerebri, confusion, hallucinations GI: Nausea, diarrhea, increased ALT/AST, flatulence, vomiting, abdominal pain, pancreatitis, hepatotoxicity, CDAD GU: Vaginitis INTEG: Rash, pruritus …

Teaching

Not to take any products that contain magnesium, calcium (such as antacids), iron, aluminum with this product or 2 hr before, 6 hr after product; to drink fluids to preve …

🔗 Full card in the drug guide

Eye drop administration⭐ HIGH YIELD

Wash hands, verify the drug and which eye (OD right, OS left, OU both), tilt the head back, pull the LOWER LID down to form a pocket, instill the drop into the conjunctival sac without touching the eye or lashes, have the patient close the eye gently, then press the inner canthus for 30 to 60 seconds.

Punctal occlusion (pressing the inner corner) blocks the tear duct and prevents systemic absorption. This matters most with timolol and other beta blocker drops, which can cause bradycardia and bronchospasm.
Rest the dominant hand on the patient's forehead to stabilize it, and have the patient look up and away from the tip.
Wait 5 MINUTES between different eye drops. Give drops before ointments. Remove contact lenses first and wait about 15 minutes to reinsert.
Never touch the dropper to the eye, lashes, or any surface, and recap immediately; contamination causes serious eye infections.
Blot excess with a tissue from the inner to the outer canthus, and never share eye drops between patients.

Lower lid pocket, never the cornea, then press the inner corner.

💉 Latanoprost

Antiglaucoma agent, Rho kinase inhibitor/prostaglandin F2 alpha analogue

What it is for

Reduction of elevated intraocular pressure (IOP) in open-angle glaucoma or ocular hypertension

🔗 Full card in the drug guide

Otitis externa treatment options⭐ HIGH YIELD

Topical antibiotic drops are first-line for otitis externa (swimmer's ear), usually combined with a corticosteroid: ofloxacin otic, ciprofloxacin with dexamethasone (Ciprodex), or neomycin/polymyxin B/hydrocortisone. Add analgesics. Oral antibiotics are reserved for infection spreading beyond the canal or for high-risk patients such as diabetics and the immunocompromised.

If the tympanic membrane is PERFORATED, tubes are in place, or you cannot visualize the membrane, use only a FLUOROQUINOLONE drop. Neomycin and other aminoglycosides are OTOTOXIC if they reach the middle ear.
If the canal is swollen shut, an ear WICK is inserted so the drops reach the whole canal.
Fungal otitis externa (otomycosis) requires an antifungal such as clotrimazole or acidifying acetic acid drops, not an antibiotic.
Teaching: keep the ear DRY, no swimming for 7 to 10 days, no cotton swabs, no earbuds, dry ears after showering. Prophylactic acetic acid/isopropyl alcohol drops help frequent swimmers. Warm the drops to room temperature, lie with the ear up for 3 to 5 minutes, and finish the full course even after pain resolves.
Malignant (necrotizing) otitis externa in a diabetic or immunocompromised patient, with severe pain and granulation tissue in the canal, is an emergency needing IV antipseudomonal therapy.

Perforated eardrum? Fluoroquinolone only. Neomycin is ototoxic on the wrong side of the drum.

Gastrointestinal Medications

💉 MetoclopramideBLACK BOX

Cholinergic, antiemetic, GI stimulant, Central dopamine receptor antagonist

What it is for

Prevention of nausea, vomiting induced by chemotherapy, radiation, delayed gastric emptying, gastresophageal reflux

How it works

Enhances response to acetylcholine of tissue in upper GI tract, which causes the contraction of gastric muscle; relaxes pyloric, duodenal segments; increases peristalsis without stimulating secretions …

Watch for

CNS: Sedation, fatigue, restlessness, headache, sleeplessness, dystonia, dizziness, drowsiness, suicidal ideation, seizures, EPS, neuroleptic malignant syndrome; tardive dyskinesia (>3 mo, high doses) CV: Hypotension, supraventricular tachycardia GI: Dry mouth, constipation, nausea, anorexia …

Teaching

To avoid driving, other hazardous activities until stabilized on product
To avoid alcohol, other CNS depressants that will enhance sedating properties of this product

🔗 Full card in the drug guide

💉 Omeprazole

Antiulcer, proton pump inhibitor, Benzimidazole

What it is for

Gastresophageal reflux disease (GERD), severe erosive esophagitis, poorly responsive systemic GERD, pathologic hypersecretory conditions (Zollinger-Ellison syndrome, systemic mastocytosis, multiple endocrine adenomas) …

How it works

Suppresses gastric secretion by inhibiting hydrogen/potassium ATPase enzyme system in gastric parietal cells; characterized as gastric acid pump inhibitor because it blocks the final step of acid production

Watch for

CNS: Headache, dizziness, asthenia GI: Diarrhea, abdominal pain, vomiting, nausea, constipation, flatulence, acid regurgitation, abdominal swelling, anorexia, irritable colon, esophageal candidiasis, dry mouth, hepatic failure, Clostridium difficile–associated diarrhea (CDAD) INTEG: Rash, dry skin …

Teaching

To report severe diarrhea; black, tarry stools; abdominal cramps/pain; or continuing headache; product may have to be discontinued
That if diabetic, hypoglycemia may occur
To avoid hazardous activities because dizziness may occur
To avoid alcohol, salicylates, NSAIDs; may cause GI irritation

🔗 Full card in the drug guide

💉 Ondansetron

Antiemetic, 5-HT3 antagonist

What it is for

Prevention of nausea, vomiting associated with cancer chemotherapy, radiotherapy; prevention of postoperative nausea, vomiting

How it works

Prevents nausea, vomiting by blocking serotonin peripherally, centrally, and in the small intestine

Watch for

CNS: Headache, dizziness, drowsiness, fatigue GI: Diarrhea, constipation, abdominal pain, dry mouth MISC: Rash, bronchospasm (rare), musculoskeletal pain, wound problems, shivering, fever, hypoxia, urinary retention

Teaching

To report diarrhea, constipation, rash, changes in respirations, discomfort at insertion site, serotonin symptoms, EPS symptoms
That headache requiring analgesic is common
Drink with whole glass of water (PO)
Oral disintegrating tabs: remove strip from pouch, place on tongue, and allow to dissolve; drink water

🔗 Full card in the drug guide

💉 Orlistat

Weight-control agent, Lipase inhibitor

What it is for

Obesity management

🔗 Full card in the drug guide

Peptic ulcer disease triple therapy⭐ HIGH YIELD

Classic H. pylori TRIPLE therapy is a PPI plus CLARITHROMYCIN plus AMOXICILLIN (substitute metronidazole if penicillin-allergic) for 14 days. Because of rising clarithromycin resistance, current US guidelines now favor BISMUTH QUADRUPLE therapy first-line: PPI plus bismuth plus tetracycline plus metronidazole for 14 days.

ADHERENCE is everything. The full course must be finished or resistance develops and the ulcer returns.
Teach expected effects so the patient does not quit: bismuth turns the STOOL AND TONGUE BLACK (harmless, not GI bleeding), and metronidazole causes a metallic taste and a DISULFIRAM-LIKE REACTION with alcohol. No alcohol during treatment and for 3 days after.
Clarithromycin: QT prolongation and many CYP3A4 interactions with statins and warfarin. Tetracycline: photosensitivity, avoid dairy and antacids, and avoid in pregnancy and children under 8.
Confirm eradication at least 4 weeks after treatment with a urea breath test or stool antigen. Hold the PPI 1 to 2 weeks and antibiotics 4 weeks before testing or you get a false negative.
Also address the other ulcer causes: NSAIDs, aspirin, smoking, and alcohol.

Regimen	Components	Duration
Triple therapy (the classic one exams ask about)	PPI + clarithromycin + amoxicillin (metronidazole if penicillin-allergic)	14 days
Bismuth quadruple (now guideline-preferred)	PPI + bismuth subsalicylate/subcitrate + tetracycline + metronidazole	14 days

Bismuth turns the tongue and stool BLACK: reassure, do not panic. Metronidazole plus alcohol equals misery.

💉 Sucralfate

Protectant, antiulcer, Aluminum hydroxide, sulfated sucrose

What it is for

Duodenal ulcer, oral mucositis, stomatitis after radiation of head and neck

How it works

Forms a complex that adheres to ulcer site, adsorbs pepsin

Teaching

To take on empty stomach
To take full course of therapy; not to use for >8 wk; to avoid smoking
To avoid antacids, milk, alkaline water within 1 hr of this product
To increase fluids, bulk, exercise to lessen constipation

🔗 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.

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