Nursing Pharm Final. Review.

 

Hi if you are a Nursing Student at St. Pauls School of Nursing take some time to go through this detailed Pharm final review It is guaranteed to be very helpful.

 

Antiinflammatory and Antigout Drugs
Inflamation is: – localized protective response stimulated by injury and disease.

  • Signs/Symptoms:
    • pain
    • Fever
    • Loss of function
    • Redness
    • and Swelling

NSAID’s : mild to moderate headaches

    • Pain associated with arthritic disorders such as:
      • rheumatoid arthritis
      • juvenile arthritis
      • ankylosing spondylitis
      • osteoarthritis.
    • Treatment of gout and hyperuricemia
  • Properties of all NSAID’s
    • antipyretict
    • analgesic
    • anti-inflammatory

Salicylates (contain sal in the name) – aspirin.  Can cause GI bleed and ulcers.
Acetic Acid derivatives (contain ac in name)
Cyclooxyhenase-2 inhibitors – Celecoxib
Enolic acid derivatives (contain oxicam in name) – can cause acid ulcers
Propionic acid derivatives (pro in name)

Aspirin – shown to reduce cardiac death after an MI

  • Should be administered at the first sign of MI
  • 81-325mg baby aspirin (low dose)
  • reduced formation of thromboxane A2 (vaso-constricts) a
    substance that normally promotes platelet aggregation

    • high dose – manage pain
    • low – antiplatelet 
    • Thins your blood
  • Contraindication:
    • warfarin
    • heparin
    • conditions that place the patient at risk for bleeding
    • vitamin K deficiency (need this to clot), and peptic ulcers.
    • Adverse Effects
      • heartburn to severe GI bleeding
      • acute renal failure
      • noncadiogenic pulmonary edema
      • increased risk for MI and stroke
      • altered hemostasis
      • hepatotoxicity
      • tinnitus
      • hearing loss.
  • Misoprostol: – protective prostaglandins that help maintain normal integrity of the stomach lining
    • Prevents GI bleed
    • Inhibits gastric secretions and has a cytoprotective component.
    • **can cause spontaneous abortions.
  • NSAID’s and Renal function: precipitate acute or chronic renal function.Renal toxicity can occur in patient with:
    • heart Failure
    • liver dysfunction
    • It’s used as diuretics or angiotensin converting enzymes (ACE) inhibitor

NSAID black box Warning – All NSAID’s except aspirin share a black box warning regarding increased risk for adverse cardiovascular thrombotic events, including fatal MI and Stroke.

    • NSAID’s may counteract the cardioprotective effects of aspirin.

Salicylic acid (aspirin) – headache, neuralgia (joint pain), myalgia, and arthralgia

      • inhibits platelet aggregation at low doses
      • Antithrombotic effect: used in the treatment of MI and other thromboembolic disorders
      • Combination products – aspirin-acetaminophen-caffeine combinations like Excedrin, and acid-antacid combinations.
      • Daily tablet – 81-325 mg is prophylactic therapy for adults who have strong risk for coronary artery disease or cardiovascular accident.
      • Effective after an MI
      • Antipyretic and antirheumatic action

Adverse Effects – salicism, tinnitus, hearing loss, dimness of vision, headache, dizziness, mental confusion, drowsiness, hyperventilation, hypoglycemia or hyperglycemia, tachycardia, and anxiety.

Aspirin: Reye’s Syndrome –neurological deficits that can lead to coma as well as hepatic damage (liver).

                  • Triggered by viral illnesses – salicylate therapy
                  • Survivors of this condition may or may not have permanent neurological damage.

Indomethacin – analgesic, anti-inflammatory, antirheumatic, and antipyretic. 

                  • Uses: RA, OA, acute bursitis or tendonitis, spondylitis, acute gouty arthritis, PDA (patent ductus arthritis), and treatment of preterm labor
                  • Anything with an itis can be treated with these.

Ketorolac – used primarily for its powerful analgesic effects which are comparable to those of narcotic drugs such as morphine.

                  • Indication – short-term use (up to 5 days)
                    • If you pass 5 days it can cause renal impairment. 

Ibuprofen – most commonly used NSAID

Naproxen – somewhat better adverse effect profile than ibuprofen, fewer drug interactions with ACE inhibitors given for hypertension.

Celecoxib – OA, RA, spondylitis, dysmenorrhea

                  • Adverse effects – headache, sinus irritation, diarrhea, lower extremity edema and hypertension
                  • DO NOT use in patients with sulfa allergy

Enolic Acid derivaties – used to treat moderate OA, RA, and gouty arthritis 

NSAID Adverse effects 

                  • GI – dyspepsia, heartburn, epigastric distress, nausea, GI Bleeding, mucosal lesions
                    • Misoprostol can be used to reduce these dangerous effects (warn if pregnant)
                  • Renal – reduction in creatinine clearance (125mL/min), acute tubular necrosis with renal failure.
                  • Cardiovascular – noncardiogenic pulmonary edema

NSAID Interactions – anticoagulants, aspirin, corticosteroids, protein bound drugs, diuretics and ACE inhibitors.

Gout (hyperuricemia) – condition that results from inappropriate uric acid metabolism

                  • Underexcretion of uric acid or overproduction of uric acid.
                  • Big toe pain
                  • ↑ protein diet → gout
                  • #1 choice = Allopurinol

Allopurinol = Xanthine oxidase inhibitor

                  • used to prevent uric acid production
                  • Effects – exfoliative dermatitis, toxic epidermal necrolysis

Probenecid – inhibits the reabsorption of uric acid in the kidneys and thus increases the excretion of uric acid.

Febuxostat – may pose a greater risk of cardiovascular events than Allopurinol 

Colchicine – reduces inflammatory response

                  • Used for short-term management or prevention of gout
                  • Effects – ↓neutrophils, WBC count
                  • Steroids and NSAID can be given for gout

Herbal productsGlucosamine and Chondroitin (replaces lost cartilage)

                  • Used to treat the pain of OA
                  • Drug interactions – enhances effects of warfarin (increases bleed risk), may increase insulin resistance.

Nursing implications

                  • Perform laboratory studies as indicated – cardiac, renal, and liver function studies, complete blood count and platelet count
                  • DO NOT give salicylates to children and teenagers because of risk of Reye’s syndrome
                  • Often better tolerated if taken with food, milk, or antacid to avoid irritation
                  • Explain to patients that therapeutic effects may not be seen for 3 to 4 weeks
                  • Watch for occurrence of unusual bleeding such as in stool.
                  • Back pain

Chapter 47 Biologic response modifying and antirheumatic drugs

                  • Alter the body’s response to diseases such as cancer and autoimmune, inflammatory, and infectious diseases.
                    • Hematopoietic drugs – blood forming (bone marrow)
                    • Immunomodulating drugs 

Immunododulating Drugs – alter a patient’s immune response to malignant tumor cells

                  • Alter the body’s own immune response so that it can destroy various viruses and cancerous cells
                  • Cancer therapy includes – surgery, chemotherapy, radiation
                    • Patient need immune boosting drugs

Biological response-modifying drugs – enhancement or restoration of the host’s immune system defenses against the tumor.

                  • Therapeutic effects – enhancement of hematopoietic function
                  • Regulation or enhancement of immune response, including cytotoxic or cytostatic activity against cancer cells
                  • Inhibition of metastases, prevention of cell division, or inhibition of cell maturation.

Humoral Immunity – B-lymphocytes (b cells) from the humoral immune system

                  • Originate from bone marrow
                  • Antibodies are also known as immunoglobulins
                    • Igm = acute
                    • Igg chronich
                    • Iga = secretions
                    • Ige = hypersensitivity

Cell-mediated immune system – T-lymphocytes (T cells) from the cell-mediated immune system

                  • Originate from bone marrow but mature in the thymus gland
                  • Three types with different functions
                    • Cytotoxic – directly kill their target by causing cell lysis or rupture
                    • T-helper – organizes a response, direct actions of immune system
                      • Twice as many T-helper than T-suppressors
                    • T-suppressor cells – turn immune system off, controls the immune response
                      • Overactive suppressor T cells may be responsible for permitting tumor growth beyond immune system control.

Hematopoietic Drugs – promote the synthesis of various types of major blood components by promoting the growth or differentiation and function of their precursor cells in the bone marrow.

                  • Used to: decrease the duration of chemotherapy-induced anemia, neutropenia, and thrombocytopenia, as well as enable a higher dose of chemo to be given.
                  • Used in bone marrow suppression.
                  • Decrease bone marrow recovery time after bone marrow transplantation or irradiation
                  • Stimulate the cells in the immune system to destroy or inhibit the growth or cancer cells as well as virus-or fungus infected cells.
                  • Decreases the duration of low neutrophil counts, thus reducing the incidence and duration of infections.
                  • Also enhance red blood cell and platelet counts allowing for higher doses of chemo

Adverse effects – fever, muscle aches, bone pain, flushing, thicker blood = hypertension -increases risk for certain cancers.

Erythropoietic drugs – stimulate red blood cell increase (anemia)

                  • Epoetin alfa and darbepoetin alfa (longer duration)

Colony-stimulating factors (end in stim) – increase white blood cell count (neutropenia)

                  • Filgrastim – stimulates WBC known as granulocytes
                    • Administer before patients gets an infection
                  • Pegfilgrastim – longer acting form of filgrastim
                  • Sargramostim – stimulates bone marrow precursor cells to make both granulocytes and phagocytic cells known as monocytes
                    • Indicated to promoting bone marrow recovery after autologous (own marrow) or allogenic (donor marrow) bone marrow transplantation in patients with leukemia and lymphoma.

Platelet-promoting drugs

                  • Oprelvekin – enhances synthesis of platelets
                  • Indication: for the prevention of chemotherapy-induced severe thrombocytopenia and avoidance of the need for platelet transfusions
                    • Stimulates the bone marrow cells, specifically megakaryocytes that eventually give rise to platelets
                    • Look out for clots

Interferons (IFNs) – proteins with three basic properties – antiviral, antitumor, and immunomodulating

                  • Interfere with viral or cancer autoimmune processes. 
                  • Used to treat certain viral infections and cancer
                    • Protect human cells from virus attack
                    • Prevent cancer cells from dividing and replicating
                    • Increases the activity of macrophages, neutrophils, and natural killer cells

Effects on immune system – restore the immune system’s function if it is impaired

                  • Augment the immune system’s ability to function as the body’s defenses.

Indications 

                  • viral infections – genital warts and hepatitis
                  • cancer – chronic myelogenous, leukemia, follicular lymphoma, Kaposi’s sarcoma, and malignant melanoma.
                  • Autoimmune disorders – multiple sclerosis

Adverse Effects – flulike effects (fatigue), dose-limiting adverse effect is fatigue, dizziness, diarrhea, vomiting

Monoclonal Antibodies (end in mab) – treatment of cancer, rheumatoid arthritis, MS, and organ transplants.

                  • Specifically target cancer cells and have minimal effects on healthy cells
                  • Fewer adverse effects than traditional antineoplastic medications

Interleukins – beneficial antitumor action (end in leukin or contain kin)

                  • IL-2 is produced by activated T cells in response to macrophage – processed antigens and secreted IL-1
                  • Aldesleukin – bind to receptor sites on T-cells, which stimulate the T cells to multiply
                    • Treatment of metastatic renal cell carcinoma and metastatic melanoma 
                    • Off table use: includes HIV infection and AIDS and non-Hodgkin’s lymphoma
                  • Lymphokine-activated killer cells: recognize and destroy only cancer cells and ignore normal cells

Adverse effects – capillary leak syndrome

                  • Capillaries lose the ability to retain vital colloids in the blood’ these substances are leaked into the surrounding tissues
                    • Results in massive fluid retention
                      • Respiratory distress, HF, MI, and dysrhythmias 

Anakinra – severe rheumatoid arthritis 

Rheumatoid arthritis – autoimmune disorder causing inflammation and tissue damage in joints

                  • Treatment consists of nonsteroidal anti-inflammatory drugs and DMARD’s
                  • Any age can get it and it can affect any joint
                  • Symmetrical (bilateral)

Disease modifying drugs – inhibit the movement of various cells into an inflamed, damaged area, such as a joint

                  • Slows onset of action of several weeks verses minutes to hours for NSAID’s
                  • Also, referred to as slow-acting antirheumatic drugs

Osteoarthritis – wear/tear (elderly) 

Nonbiologic disease-modifying 

                  • Methotrexate – first line (RH)/chemo drug
                  • Hydroxychloroquine – antimalarial
                  • Sulfasalazine – check for sulfur allergy

Etanercept – used to treat RA and psoriasis

                  • Patients much be screened for latex allergy
                  • Onset: 1 to 2 weeks

Contraindication in the presence of active infections

                  • Reactivation of hepatitis and TB have been reported.

Abatacept – used to treat RA

                  • Caution if the patient has a history of recurrent infections or COPD
                  • Patients must be up to date on immunizations before starting therapy
                  • May increase risk for infections associated with live vaccines
                  • May decrease response to vaccines

Contraindication – COPD, any airway issue

Nursing implication

                  • Assesses for allergies, specifically allergies to egg proteins, IgG (chronic) or neomycin
                  • Assess for infection
                  • Teach patients to report signs of infections immediately: sore throat, diarrhea, vomiting, fever of 100.5 or higher

Chapter 48 Immunosuppressant Drugs

Two types of immunity:

                  1. Humoral immunity (work sin the blood stream), which is medicated by B lymphocytes
                  2. Cellular immunity, which is medicated by T lymphocytes

Immunosuppressant’s block the action of the T-cells

                  • Used to prevent rejection of transplanted organs
                  • Used for: rheumatoid arthritis, systemic lupus erythematosus, crohn’s disease, MS, myasthenia gravis, and psoriasis.
                  • Muromonab-CD3, (reverses rejection) mycophenolate, and tacrolimus (reverses rejection) are indicated for both prevention of rejection and treatment of organ rejection.

Transplants – rejection is the primary concern; occurs from an immune response targeted against the transplanted organ

                  • Transplanted patients are on immunosuppressant therapy for the duration of their lifetime.

Major classes used to prevent organ rejection:

                  • Glucocorticoids – inhibit all the stages of T-cell activation and are used for induction, maintenance immunosuppression, and acute rejection.
                  • Calcineurin inhibitors – inhibit the phosphate required for interleukin 2 production 
                  • Antimetabolites – inhibit cell proliferation = knocks out what we need for DNA to replicate.
                  • Biologics – inhibit cytotoxic T killer cell function

Azathioprine – prophylaxis of organ rejection concurrently with other immunosuppressant drugs, such as cyclosporine and corticosteroids.

                  • Bone marrow suppression – need complete blood count before treatment
                    • Red/white blood count and platelets (140,000 – 150,000)

Adverse Effects – lymphoma, increased cancer, increased bleed risk (anemia), and thrombocytopenia

Basiliximab***monoclonal antibodies = prevent rejection of transplanted kidney’s

                  • Multidrug immunosuppressive regimen that includes cyclosporine and corticosteroids
                  • Allergy-like reaction known as cytokine release syndrome – pre-treat with corticosteroid
                    • Monitor every 15 minutes for allergy reaction

Black-box warning – potential for lymphoproliferative disorders and opportunistic infections and severe hypersensitivity reactions including anaphylaxis. 

Cyclosporine – prevention of organ rejection

                  • *** loves to stick to any nonglass surface (mix only in glass)

Adverse effects – assess kidney (urine output, creatinine level (0.6-1.2), bun, posterior flank pain), gingival hyperplasia (watch oral hygiene/candidiasis)

Interactions – St. John’s Wart → induces metabolism – destroys cyclosporine and achalasia → immune stimulant.

Black-box warning – renal impairment, increased risk of serious and fatal infections, liver injury, seizures, encephalopathy, and skin cancer.

Glatiramer Acetate – works by blocking T-cell autoimmune activity against myelin protein, which reduces the frequency of the neuromuscular exacerbations associated with MS

                  • unique for MS

Fingolimod – only oral drug for relapsing forms of MS

Adverse effects – headache, hepatotoxicity, black pain, macular edema, decreases heart function, hypertension

Muromonab-CD3 – reversal and prevention of graft rejection

                  • indicated for the prevention of organ rejection as well as the treatment of organ rejection.
                  • Black-box warning – increased risk for congenital malformations and spontaneous abortions when used during pregnancy.

Side effects – hypertension, tachycardia, hyperglycemia, and hyperlipidemia

                  • Assess blood sugar, lipid levels and blood pressure.

Immunosuppressant’s cannot be used if patient has an active serious infection, liver disease, or live vaccines (MMR, oral polio, small pox, BCG, yellow fever, and varicella)

Nursing implications

                  • Perform a thorough assessment: renal, liver, cardio function, CNS, respiratory
                  • CBC
                  • Monitor WBC count throughout therapy; if the count drops below normal range, contact the prescriber.
                  • Oral immunosuppressant’s should be taken with food to minimize GI upset
                  • Oral forms are used when possible to decrease the risk for infection that may occur with parenteral injections
                  • Grapefruit juice interacts with these medications
                  • Oral antifungal drugs are usually given with these drugs to prevent oral candidiasis
                  • Assess the oral cavity often for white patches on the tongue, mucous membranes, and oral pharynx 
                  • Mix oral cyclosporine solutions in glass
                  • Inform patients that lifelong therapy with immunosuppressant’s is indicated with organ transplantation
                  • Patients taking immunosuppressant’s should avoid crowds and people with colds or other infections
                  • Immediately report fever, sore throat, chills, joint pain, fatigue, or other signs of infection.

Chapter 45 Chemotherapy – Antineoplastic Drugs

Cancerous cells do not have:

                  • Growth control mechanism
                  • Positive physiologic function – no purpose

Cancer:

                  • Primary lesion – original site of growth 
                  • Metastasis – uncontrolled cell growth
                    • Secondary lesion in a new and remote part of the body
                  • Neoplasm (new tissue) – new growth (tumor)
                  • Tumor – benign which doesn’t metastasize or malignant (cancer)

Carcinogenesis 

                  • Hereditary – breast, testicular, skin
                  • Chemicals – cigarette smoke and asbestos 
                  • Radiation – gamma rays and ultra violet rays
                  • Viruses – HPV, Hep C, HIV, and epstinebar virus

Cancer: tissues of origin

                  • Carcinomas – epithelial tissue (GI, respiratory tract, skin)
                  • Sarcomas – connective tissue (cartilage, muscle, and bone marrow)
                  • Lymphomas (spleen) and leukemia (WBC)

Paraneoplastic syndromes – various groups of symptoms that cannot be directly attributed to the spread of a cancerous tumor

                  • May be the first sign of malignancy
                    • Cachexia (wasting away), fatigue, fever, weight loss

Cell growth cycle

                  • G0 – resting phase
                  • G1 – duplicate everything in the cell EXCEPT DNA
                  • S – synthesis phase = duplicate DNA
                    • Nutritional factors – FOLATE (B9), B12, cyanocobalamin 
                  • G2 – proof read DNA
                  • M – mitosis phase (cell reproduction) = nuclear division

Cancer Treatment

                  • Surgery (cut it out), radiation (shrink it), and chemotherapy
                    • Immune modulating drugs
                    • **asymmetry, border irregularity, color, diameter > 5cm, and evolving.

Malignant neoplasm – technical term for cancer

Antineoplastic drugs (end in ase) – drugs used to treat cancer

                  • Also, called cancer drugs, anticancer drugs, cytotoxic chemotherapy, or just chemo.

Chemotherapy – pharmacologic treatment of cancer

                  • Cell-cycle-nonspecific (CCNS) – cytotoxic during any cell cycle stage
                  • Cell-cycle-specific (CCS) – cytotoxic during a specific cell cycle stage
                    • Some drugs have characteristics of both

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Chemotherapy drugs have a narrow therapeutic index

                  • Combination of drugs is usually more effective than a single-drug therapy (helps with drug resistance)
                  • All drugs cause adverse effects
                  • Kills rapidly dividing normal cells → hair follicles, GI tract cells (vomiting, nausea, diarrhea), bone marrow cells (RBC = anemia → pale, WBC = leukopenia ↑ sickness, and platelets = easily bruise)
                    • Platelets – 150,000 – 400,000 less than 150,000 = bleed risk (thrombocytopenia)

Immune system can manage 1000-million cancer cells 

                  • Billion cells – initiate surgery or chemotherapy
                  • Trillion cells – stage 4 cancer

Alopecia – hair loss

Emetic potential – vomiting

Myelosuppression – bone marrow suppression/depression

*Nadir – lowest level of WBC

Extravasation – leaking out into the vessel

                  • Coolness – leave line in but stop the infusion, try to aspirate it and give the antidote.

Antimetabolites – work primarily in the S phase of the cell cycle, when DNA synthesis is most active

                  • Block the following:

Folate (folic acid) antagonist – trex in the name

                  • Interferes with the use of folic acid
                  • As a result, DNA is not produced and the cell dies

Purine antagonist – Mercaptopurine

                  • Interrupts metabolic pathways of purine nucleotides
                  • Results in interruption of DNA and RNA synthesis
                  • Tumor lysis syndrome – burst tumor
                    • Adverse effects
                      • Increased potassium – Hyperkalemia (normal value 3.5-5)
                      • Hyperphospatemia (normal value 2.5-4.5)
                      • Hyperuricemia 
                      • Hypocalcemia (normal value 8-10)

Pyrimidine antagonist – fluorouracil (5-FU) and cytarbine (ara-C)

                  • Interrupts metabolic pathways of pyrimidine bases
                  • Results in interruption of DNA and RNA synthesis

Antimetabolite indication – used in combination with other drugs to treat various types of cancer, such as solid tumors and some hematologic cancers

                  • Acute (pediatrics) and chronic (elderly) lymphocytic leukemia
                  • Leukemia
                  • Colon, rectal, breast, stomach, lung, pancreatic cancers
                  • Oral and topical forms may be used for low-dose maintenance and palliative cancer therapy
                  • Methotrexate – used to treat severe cases of psoriasis and rheumatoid arthritis 
                  • Patient is in pain, depressed, needs opioids, antibiotics, and antinausea

Adverse effects – hair loss, nausea, vomiting, myelosuppression, neurologic, cardio, pulmonary, hepatobiliary, GI, genitourinary, dermatologic, ocular, otic, and metabolic toxicity, tumor lysis syndrome, and palmar-plantar dysesthesia 

Mitotic Inhibitors – natural products obtained from the periwinkle plant

                  • Mechanism of action = M phase
                  • Paclitaxel – treats breast cancer

Indications – often used in combination therapy

                  • Used to treat a variety of solid tumors and some hematologic malignancies
                    • Testicular, small cell lung, breast, ovarian, non-small cell lung cancer
                    • Kaposi sarcoma
                    • Acute leukemia

Adverse Effects – hair loss, nausea, vomiting, myelosuppression, liver, kidney, lung toxicities, convulsions, extravasation

Alkaloid Topoisomerase II Inhibitors (G2 phase)

                  • Used to treat small cell lung cancer and testicular cancer.

Topoisomerase 1 inhibitor – used primarily to treat ovarian and colorectal cancer

                  • Inhibits proper DNA function in the S phase
                  • Topotecan and irinotecan (nasty cholinergic diarrhea)

Adverse effects – topotecan – BMS and Irinotecan – causes more severe adverse effects 

Antineoplastic enzymes (end in ase) – treatment of acute lymphocytic leukemia

Adverse effects – impaired pancreatic function which can lead to hyperglycemia and severe or fatal pancreatitis, dermatologic, hepatic, genitourinary, neurologic, musculoskeletal, GI, and cardiovascular effects

Nursing implications

                  • Assess baseline blood count before administering antineoplastic drugs
                  • Monitor for complications – hair loss, bone marrow components, GI mucous membranes, poor appetite, stomatitis
                  • Implement measures to monitor for and prevent infection in patients with neutropenia or leukopenia
                  • Implement measures to monitor for and prevent bleeding in patients with thrombocytopenia
                  • Keep in mind anemia may result in severe fatigue
                  • Monitor for stomatitis, anticipate nausea and vomiting
                  • Antiemetics often work better if given 30-60 minutes before chemotherapy is started
                  • Women of childbearing age need to use a nondrug form of contraception

Chapter 46 Antineoplastic drugs part 2

Cell cycle-nonspecific (CCNS) antineoplastic drugs

Alkylating drugs – work by preventing cancer cells from reproducing

                  • Cisplatin, Cyclophosphamide, Mechlorethamine

Indication – used in combination with other drugs to treat various cancer, such as ovarian cancer, brain tumors, lymphomas, leukemia’s, breast and bladder cancer.

Adverse effects – nausea, vomiting, myelosuppression, alopecia, nephrotoxicity (hydration can prevent nephrotoxicity), peripheral neuropathy, ototoxicity, and extravasation causes tissue damage.

                  • Discontinue drug to prevent further damage, but keep line in.

Cytotoxic antibiotics (End in cin) – natural substances produced by the mold Streptomyces

                  • ***Bleomycin (pulmonary toxicity), Daunorubicin (heart failure), and Doxorubincin (left ventricular failure)
                  • Bone marrow suppression: common toxicity
                  • Active in all phases of the cell cycle, act by interaction (screws up the helix of DNA)

Indications – used to treat a variety of solid tumors and some hematologic malignancies

                  • Leukemia, ovarian, breast, bone cancer
                  • Squamous cell carcinomas
                  • AID’s related Kaposi’s sarcoma

Adverse effects – all produce bone marrow suppression EXCEPT for Bleomycin → pulmonary fibrosis, hair loss, heart failure, acute left ventricular failure.

                  • Pulmonary symptoms – shortness of breath, dyspnea, low breath rate
                  • Liver, kidney, and cardiovascular toxicity
                  • Cardiomyopathy is associated with large amounts of doxorubicin
                    • ANTIDOTE = Dexrazoxane – can decrease the incidence of devastating toxicity.

Bevacizumab – blocks blood supply to the growing tumor

                  • Used to treat: metastatic colon cancer, rectal cancer in combination with 5-fluorouracil, non-small cell lung cancer, and malignant glioblastoma.
                  • Adverse effects – nephrotoxicity

Hydroxyurea – used to treat squamous cell carcinoma and some leukemia’s

                  • Adverse effects – edema, headache, rash, hyperuricemia (gout), dysuria, nephrotoxicity, pulmonary fibrosis.  Inhibits ribonucleotide reductase and messes with DNA 

Imatinib – used to treat chronic myeloid leukemia (20-40 years old)

Octreotide – management of cancer-related condition called carcinoid crisis

                  • Treats VIPomas 

Hormone Drugs – used to treat a variety of neoplasms in men and women

                  • Breast cancer and ovarian cancer in women
                  • Prostate and testicular cancer in men

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Extravasation – leaking of an antineoplastic drug into surrounding tissue during IV administration.

                  • Can cause permanent damage to nerves, tendons, muscles and loss of limb.
                  • If suspected, stop the infusion immediately and contact the prescriber but leave the IV catheter in place
                    • Aspirate any residual drug or blood from the catheter
                    • Consult guidelines or pharmacists regarding antidotes, application of hot or cold packs or sterile occlusive dressing, and elevation and rest of the affected limb.

Nursing implications

                  • Assess baseline blood counts before administrating antineoplastic drugs
                  • Alkylating drugs
                    • Monitor for expected effects of bone marrow suppression
                    • Hydration is important to prevent nephrotoxicity
                    • Report ringing or roaring in the ears – possible ototoxicity
                    • Report tingling, numbness, or pain in the extremities
                  • Cytotoxic antibiotics
                    • Expect bone marrow suppression
                    • Monitor pulmonary status because pulmonary fibrosis may occur
                    • Monitor for nephrotoxicity and liver toxicity
                    • Monitor cardiovascular status
                    • Daunorubicin may turn the urine a reddish color
                  • Cytoprotective drugs may be used to reduce toxicities
                    • IV amifostine to reduce renal toxicity associated with cisplatin
                    • IV or oral allopurinol to reduce hyperuricemia 

Chapter 34 Women’s health drugs

                  • Female sex steroid hormones – estrogen and progestin
                  • Pituitary gonadotropin hormones – follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
                    • They both promote development of primary (ovaries, uterus) and secondary (breast, widening pelvis) sex characteristic.

Estrogen

                  • Estradiol (steroids) – principle and most active = give lowest dose
                  • Synthesized from cholesterol in ovarian follicles
                    • Adverse effects – hypertension and sodium retention

Nonsteroidal – Diethylstilbestrol (DES) = teratogenic, can have daughters with increased cancer risk.

Estrogen (est in their names) – responsible for the development and maintenance of female reproductive system as well as secondary sex characteristics.

Indication – treatment or prevention of disorders that result from estrogen deficiency

                  • Smallest dosage of estrogen that relieves the symptoms or prevents the condition is used.
                  • Atrophic vaginitis (maintain endometrium), vasomotor spasms of menopause (hot flashes), osteoporosis (bone protective), and palliative care for breast cancer (contraindicated for stage 1 and 2).

Contraindications – any estrogen dependent cancer (breast, ovarian, and endometrium), undiagnosed abnormal vaginal bleeding, pregnancy, **active thromboembolic disorder.

Adverse effects – thrombolytic events (most serious), nausea, hypertension, thrombophlebitis, edema, photosensitivity, and **chloasma (pigmentation on sun exposed skin (face)), amenorrhea, tender breasts, fluid retention, headaches.

Interactions – decreases the activity of oral anticoagulants (warfarin = increased clots), decreased effect of rifampin (anti TB), St. John’s wort, tricyclic antidepressants, smoking, **high protein bound

Initiate hormone replacement therapy (HRT) around the time of menopause to treat menopause-related symptoms

                  • When HRT is discontinued after several years of use, assess bone mineral density and begin treatment if indicated.

Progestins – treatment of functional uterine bleeding caused by: hormone imbalance, fibroids, and uterine cancer, amenorrhea.

                  • Adjunctive and palliative treatment of some cancers and endometriosis.

Indications – alone or in combination with estrogen to prevent conception, prevention of threatened miscarriage, and alleviation of premenstrual syndrome symptoms.

Contraindications – similar to estrogen, clot risk, damages liver.

Adverse effects – liver dysfunctions (cholestatic jaundice) → check ALT, bilirubin, AST, and Right upper quadrant pain, thrombophlebitis, thromboembolic disorders such as pulmonary embolism, spotting, edema, weight gain.

Medroxyprogesterone – inhibits the secretions of pituitary gonadotropins which prevent follicular maturation and ovulation, stimulates the growth of mammary tissue.

                  • Used to treat: uterine bleeding, secondary amenorrhea, endometrial cancer, and renal cancer and can be used as a contraceptive.

Contraceptive Drugs – medications used to prevent pregnancy, treatment of endometriosis and hypermenorrhea and production of cyclic withdrawal bleeding 

                  • Triphasic form most closely duplicated the normal hormonal levels of the female cycle
                  • Most contain estrogen-progestin combinations.
                    • Long-acting injectable form of medroxyprogesterone
                    • Transdermal contraceptive patch
                    • Intravaginal contraceptive ring
                    • Implanted rods.

Mechanism of action – prevent ovulation by inhibiting the release of gonadotropins and increasing uterine mucus viscosity.

                  • Decreases perm movement and fertilization of the ovum
                  • Possible inhibition of implantation of fertilized egg.

Drug effects – improve menstrual cycle regularity, decrease blood loss during menstruation

Adverse effects – hypertension, thromboembolism, possible pulmonary embolism, MI, Stroke, pregnancy symptoms

Contraindications – pregnancy, known high risk for or history of thromboembolic events such as MI, venous thrombosis, PE, or stroke.

Interactions – drugs that decrease effectiveness of oral contraceptive drugs

                  • Barbiturates, isoniazid (INH), rifampin, tetracycline’s ↓ estrogen 
                  • Beta blockers, warfarin, tricyclic antidepressants, hypnotics, anticonvulsants, theophylline, and antidiabetic drugs.

Osteoporosis – low bone mass, increased risk of fractures, primarily affects women post menopause

                  • Risk factors – European or Asian descent, slender, smoking, alcohol consumption, low-calcium diet, sedentary lifestyle and family history.
                  • Calcium supplements and vitamin D may be recommended for women at high risk for osteoporosis.

Bisphosphonates (end in dronate) – decrease osteoclasts and increase osteoblasts

                  • Inhibiting osteoclasts indirectly enhances bone mineral density
                  • Reverse lost bone mass and reduce facture risk.
                  • Must stand or sit for 30 minutes after taking medication

Contraindication – hypocalcemia, esophageal dysfunction, and inability to sit or stand upright for at least 30 minutes after taking the medication.

Adverse effects – risk of esophageal burns if medication lodges in esophagus before reaching the stomach, risk for osteoporosis.

Alendronate – oral bisphosphonate – inhibits or reverses osteoclast-mediated bone resorption 

                  • Prevention and treatment of osteoporosis in men and postmenopausal women, as well as, glucocorticoid induced osteoporosis in men and for the treatment of paget disease in women.

Selective estrogen receptor modifiers (SERMs) (contain fen) – stimulates estrogen on bone only which increases bone density, antiestrogen everywhere else.

Contraindication – who are or may become pregnant, venous thromboembolic disorder (DVT, PE, and retinal vein thrombosis)

Adverse effects – hot flashes, leg cramps, teratogenic, leukopenia 

Hormones – treat breast cancer

                  • Calcitonin – directly inhibits osteoclastic bone resorption
                    • Contraindication – salmon allergy
                    • Adverse effects – flushing face
                  • Teriparatide – only drug that stimulates bone formation for patients with high risk or fractures and used as a last resort drug.
                  • Adverse effects – chest pain, hypercalcemia, arthralgia
                  • Denosumab – prevents bone resorption
                    • Given sub q once every 6 months with daily calcium and vitamin D = can increase infection risk.
                    • Contraindication – hypocalcemia, renal impairment or failure, and infection

Raloxifene – prevention of postmenopausal osteoporosis 

                  • Adverse effects – hot flashes

Fertility drugs – includes in vitro fertilization and medication therapy (ovulation stimulation)

Clomiphene – blocks estrogen receptors in the uterus and brain resulting in a false signal of low estrogen

                  • Increases production of gonadotropin-releasing hormone, FSH, and LH.
                  • Maturation of ovarian follicles in stimulated, leading to ovulation and increased chance or conception.

Menotropins – standardized mixture of FSH and LH

                  • Stimulates development of ovarian follicles, leading to ovulation
                  • **May also be given to men to stimulate spermatogenesis
                  • treats both male and female patients 

Chorionic gonadotropin – causes rupture and ovulation of mature ovarian follicles and maintenance of corpus luteum

                  • used to stimulate ovulation.

Indications – used primarily to induce ovulation in anovulatory patients

Adverse effects – tachycardia, hypovolemia, DVT, urticarial, ovarian hyperstimulation, multiple pregnancy, blurred vision, diplopia, photosensitivity, and breast pain.

Uterine Stimulants – medication used to alter uterine contractions

                  • promote labor, prevent the start of progression of labor and postpartum use to reduce the risk of postpartum hemorrhage

Oxytocin – promotes labor and ↑ uterine contractions

                  • used to induce labor at or near full-term gestation and to enhance labor when contractions are weak and ineffective
                    • prevent or control postpartum uterine bleeding
                    • complete an incomplete abortion (after miscarriage)
                    • promote milk ejection during lactation.

Prostaglandins (contain prost in their name) – cause potent contractions of myometrium

                  • used to induce labor by softening the cervix and enhancing uterine muscle tone.
                  • Misoprostol – coats stomach lining to protect it, can cause abortion pre-term

Ergot alkaloids – increases force and frequency of uterine contractions

                  • Used after delivery of the infant and placenta to prevent postpartum uterine atony and hemorrhage
                  • Methylergonovine

Progesterone antagonistMifepristone – stimulates uterine contractions to induce abortions preterm

                  • Given with a prostaglandin drug for elective abortions

Adverse effects – hypotension or hypertension, headache, leg cramps, swelling, fever, chills.

Uterine relaxants – Tocolytics – used to stop labor that begins before term to prevent premature birth generally used after the 20th week of gestation.

                  • Nonpharmacological measures – bed rest, sedation, hydration

Indomethacin – nonsteroidal anti-inflammatory agent – decreases contractions 

Nifedipine – calcium channel blocker

                  • Used if ineffective and labor proceeding

Terbutaline – beta adrenergic agonist

                  • Relaxes the uterus and bronchodilation
                  • Increase b/p and hyperglycemia

Mg Sulfate – antidote for calcium toxicity

                  • Can cause diarrhea.

When indomethacin and nifedipine are ineffective and delivery is proceeding, corticosteroids (betamethasone or dexamethasone) are administered to the mother to promote lung maturity in the fetus between 24 to 34 weeks of gestation.

Herbal products – soy – relief of menopausal symptoms and osteoporosis prevention 

                  • Estrasorb, applied as a lotion
                    • Strains the skin for 8 hours

Nursing Implications

                  • Before giving any uterine stimulants, assess the mother’s vital signs and fetal heart beat
                  • Uterine relaxants are used when premature labor occurs between 20th and 37th weeks or gestation
                  • For bisphosphonates, ensure that patients have no esophageal abnormalities and can remain upright or in a sitting position for 30 minutes after the dose.
                  • Estrogen and progestin – take smallest dose needed
                    • Give intramuscular dose deep in a large muscle masses and rotate sites.
                    • Give oral doses with meals
                    • Teach patients about correct self-administration and what to do if missed dose.
                    • Increased susceptibility to sunburn may occur
                  • Take fertility drugs as ordered
                  • SERMs – instruct patient that the medication will need to be discontinued 72 hours before and during any prolonged immobility. 

Chapter 35 Men’s health drugs

Testosterone – maintenance of primary and secondary male sex characteristics.

                  • Development of bone and muscle tissue
                  • Inhibition of protein catabolism
                  • Retention of various electrolytes (Na)
                  • Stimulates the production of blood cells

Androgen – long-term forms can last from 2 to 3 days to 2 to 4 weeks

                  • Oral forms have a high first pass effect
                  • Methyltestosterone and fluoxymesterone
                  • Transdermal forms
                    • Testoderm – scrotal skin
                    • Androderm – never scrotal

Anabolic steroids – synthesis of tissue and increasing tissue formation

                  • Schedule II drug 0 great potential for misuse by athletes.
                  • Serious consequences – sterility, cardiovascular diseases and liver cancer, hepatic pelliosis

Indications – adjunctive therapy to promote weight gain after extension surgery, trauma, chronic diseases, anemia, hereditary angioedema, and metastatic breast cancer.

Mechanism of action – stimulate normal growth and development of male sex organs, muscle mass, and enhancement or erythropoiesis (increase red blood cells)

Danazol – treatment of hereditary angioedema, and in women, endometriosis and fibrocystic breast disease

Androgen Inhibitors (end in astride)– 5-alpha reductase inhibitors – teratogenic, benign prostatic hyperplasia treatment

Finasteride – inhibition of 5-alpha reductase prevents the thinning of hair caused by increased levels of DHT

                  • Male pattern baldness
                  • Teratogenic in pregnant women
                    • Used in women of any age (pregnant or not) is not recommended,
                    • Women need to wear gloves when handling finasteride.

Alpha1 – adrenergic blockers (peripheral vascular system, sphincters, and muscles) End in osin – used for symptomatic relief of obstruction caused by BPH

                  • Tamsulosin – BPH
                  • Terazosin – BPH and hypertension 
                  • Vasodilation, dilates urinary sphincter, orthostatic hypertension, take drug while in seated position.
                  • These drugs have clinical effects of prostate shrinkage immediately.

Androgen Receptor blockers (end in tamide) – used in treatment of prostate cancer

Gonadotropin-releasing hormone analogs (end in relin) – used to treat prostate cancer

                  • Inhibits the secretion of pituitary gonadotropin, decrease testosterone production

Erectile dysfunction Drugs (End in afil) – phosphodiesterse (PDE) inhibitors ae used in the treatment of erectile dysfunction.

                  • Sildenafil (Viagra) – first oral drug treatment of ED
                    • Causes relaxation of smooth muscle in the corpora cavemosa of the penis and permits the inflow of blood.
                    • Can produce hypotension (no alcohol, beta blockers, and nitrates)
                  • Tadalafil – similar to sildenafil but longer duration of action
                    • Can be used to treat pulmonary hypertension 

Men’s health drug indications – replacement therapy

Contraindications – sildenafil, vardenafil, tadalafil, and avanafil: contraindicated in men with major cardiovascular disorders especially if they used nitrate medications

                  • Use of finasteride is contraindicated in women and children

Adverse effects – peliosis of the liver, hepatic neoplasm, cholestatic hepatitis, jaundice, abnormal liver function.

                  • Priapism – abnormally prolonged penile erection (4-6 hours)
                    • Medical emergency that warrants medical attention
                  • PDE inhibitors can cause unexplained visual loss
                  • Finasteride – loss of libido, loss of erection, ejaculatory dysfunction, gynecomastia, and severe myopathy

Interactions – androgens when used with oral anticoagulants (warfarin) can significantly increase or decrease anticoagulant activity

                  • Androgens with cyclosporine increases the risk of cyclosporine toxicity
                  • Alpha blockers: addictive hypotension when given with other drugs that lower blood pleasure
                  • Effects of tamsulosin may be increased when it is taken with azole antifungal drugs, erythromycin and clarithromycin, cardiac drugs, such as propranolol and verapamil and protease inhibitors.

Herbal products: Saw palmetto

                  • Used for BPH and alopecia
                  • Adverse effects – GI upset, headache, back pain, dysuria

Nursing implications

                  • Check baseline vital signs, weight, height, and serum electrolyte levels, and sodium levels
                  • Assess renal and liver function
                  • Assess PSA level and perform digital rectal examination before beginning any drug for treatment of prostate disease
                  • Follow exact instruction for sublingual, buccal, and oral forms
                  • Pregnant women should not touch crushed or broken hormone drugs
                  • Educate patients on proper administration techniques for each drug 

Chapter 54 Anemia Drugs

Underlying cause of anemia are red blood cell maturation defects as well as a result of intrinsic and extrinsic factors.

Epoetin Alfa – used for treatment of anemia associated with end stage renal disease, chemotherapy induced anemia, and anemia associated with zidovudine.

                  • Most patients receiving eopetin alfa need to also receive an oral or IV iron preparation

Contraindications – uncontrolled hypertension, Hg levels are above 10g/dl for cancer patients and 11g/d; for renal patients, head and neck cancer, risk of thrombosis.

Adverse effects – hypertension, fever, arthralgia, pruritis, rash, pain at injection site

Darbepoetin – longer lasting form of epoetin alfa

Iron (have iron in name) – oxygen carrier in hemoglobin

                  • Stored in liver, spleen, and bone marrow
                  • Antidote – Deferoxaine
                  • Deferiprone is used for iron overload
                    • Toxicity – maintain airway, control shock and dehydration 
                  • PO – remain upright for 30 minutes
                  • IV – laydown (recumbent) for 30 minutes

Dietary sources – meats and veggies

                  • Dietary iron must be converted by gastric juices before it can be absorbed.
                  • Some food with iron absorption – veal, orange juice, fish, ascorbic acid
                    • Impair iron absorption = eggs

Adverse effects – most common cause of pediatric poisoning deaths, causes black tarry stool,

Liquid oral preparation strain teeth

Iron dextran (IV) – may cause anaphylactic shock, including major orthostatic hypertension

Ferric gluconate – repletion of total body iron content in patients with iron-deficiency anemia who are undergoing hemodialysis.

Folic acid (b12) – deficiency can cause nerve dysfunction

                  • Malabsorption syndromes are most common cause
                  • May mask symptoms of pernicious anemia, which requires treatment other than folic acid.  Untreated can cause neurologic damage

Cyanocobalamin (vitamin B12) – used to treat pernicious anemia and other megaloblastic anemias

                  • Administer orally or intranasal to treat vitamin b12 deficiency 
                  • Usually administered by deep intramuscular injection

 

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