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PHARMACOLO NURS 251 MODULE 1-9 LATEST MATERIAL
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PHARMACOLO NURS 251 module 1
Question 1 A patient recently started taking a new medication; he mentions to his doctor at his next appointment that he has noticed his mouth is dry sin... [Show More] ce starting the medication. He also mentions that this is not a problem, and he has managed it by increasing the amount of water he is drinking. What drug effect best describes the dry mouth this patient is experiencing? Side Effect Adverse Effect Toxic Effect Therapeutic Effect Question 2 Discontinuing drug therapy is always the best course of action whenever a patient experiences a harmful adverse event. True False Question 3 The site within a cell that the drug binds to in order to exert its therapeutic effect is known as: Binding site Receptor Cell wall Agonist Question 4 When a drug binds to a cell exerting its effect leading to a decrease in that cell’s physiologic response that drug is acting as an agonist. True False False. An agonist would cause in increase in that cell’s physiologic response. When the drug decreases a cell’s physiologic response it is called an antagonist. Question 5 Match the following terms to the best definition 1. Duration of Action A. Drug concentration is above MEC and below MTC 2. Onset of Action B. Time from administration to first effect 3. Therapeutic Range C. Length of time the drug produces its effect 1. Duration of Action C This study source was downloaded by 100000852290574 from CourseHero.com on 12-29-2022 16:39:52 GMT -06:00 https://www.coursehero.com/file/78909302/Module-1docx/ 2. Onset of Action B 3. Therapeutic Range A Question 6 Drugs either have a trade name or a generic name. True False False. Drugs have both a trade name and generic name. Question 7 There can be multiple generic names for the same chemical compound. True False False. Chemical compounds have one corresponding generic name, but may be marketed under multiple trade names. Question 8 Select the dosage form that is best described as a flattened tablet that dissolves in the mouth: Tablet Capsule Troche Suppository Question 9 Tablets that are coated with an acid-resistant substance to prevent dissolution in the stomach are called enteric coated. True False Question 10 Suppositories are designed to melt at body temperature. True False [Show Less]
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PHARMACOLO NURS 251 module 2
Module 2 2.1: Introduction Nonprescription medications, perhaps more commonly known as over-the-counter (OTC) medications, are medications that are avai... [Show More] lable without a prescription and are available in most cases without restriction. There are a few medications that do not require a prescription but are kept behind the pharmacy counter and ID is required for purchase. An example of this would be any medication containing the decongestant pseudoephedrine. Pseudoephedrine when combines with other easily obtainable items can be used to make crystal meth. In recent years, many medications that once required a prescription are now available OTC. Common examples of this would be the allergy medication loratadine (Claritin) or the acid blocker esomeprazole (Nexium). It is important to note the degree of oversight varies between OTC medications and other options like dietary and herbal supplements. Starting in 1972, the FDA started an OTC drug review with the goal of ensuring these medications are both safe and effective. In general, there are commonly accepted criteria that would make a medication appropriate for OTC status. Table 2.1 below lists this criterion. The second goal was to establish appropriate labeling standards. During this initial review, many drugs were either found to be ineffective or in some cases even unsafe. The medications determined to be unsafe were removed from the market. Over time, most drugs that were deemed ineffective have also disappeared from the shelves. Table 2.1 Criteria for Over-the-Counter Status Indications for use Consumer must be able to: · Diagnose the condition · Monitor effectiveness Benefits of correct use are greater than the risks Safety Profile Drugs Must have: · Favorable adverse events profile · Limited interactions with other drugs · Low potential for abuse · High Therapeutic Index Practicality for OTC Use Drugs must be: · Easy to use · Easy to monitor It is important to keep in mind that OTC medications are not without their risks, especially for patients that may have other comorbidities (other chronic diseases). Many of the medications available over the counter may cause harm in patients with diseases such as diabetes, hypertension, cardiovascular disease, and glaucoma. It is important to educate patients that have comorbidities to ask a health care professional prior to taking OTC medications, especially if they intend to take the medication continuously. In most cases, OTC medications are simply treating symptoms and are not getting to the cause of the problem. In some cases, the use of OTC medication can prevent someone from seeking the necessary treatment needed for the underlying cause of their symptoms. In other cases, such as the common cold, the symptoms will resolve on their own. The OTC medications do not shorten the length of the cold; they only help ease the patient’s discomfort. For this reason, depending on the patient’s comorbidities, it may be appropriate to recommend against a certain OTC treatment. This study source was downloaded by 100000852290574 from CourseHero.com on 12-29-2022 23:25:24 GMT -06:00 https://www.coursehero.com/file/78909334/Pharmacology-Module-2docx/ Drug Facts Labels As a result of the FDA review of OTC medications, a new requirement was established stating that all OTC medications were to include a ‘Drug Facts’ label with the following information: purpose and uses of the product, specific warnings, side effects, substances or activities to avoid, dosage ingredients, and active ingredients, warning, storage information, and inactive ingredients. Although all consumers should understand the ‘Drug Facts’ label on OTC medications, it is especially important for health care professionals to understand this label. As shown in Figure 2.1 below, the Drug Facts label is a representation of what would be found on a typical OTC medication available today. Figure 2.1 Example of a Drug Facts Label When interpreting a “Drug Facts” label, the most important information is at the top. Active Ingredient and Purpose. Listed together in the first row, these are two pieces of information that quickly tell you what is in the OTC product and what class of drug it is in, which tells you what it could be used to treat. Uses. The recommended uses of the drug are listed out for the consumer. Warnings. As previously mentioned, there are many OTC medications that may not be safe if you have other comorbidities. Essential information is usually included under this section. Additional information within this section may include when to consult a doctor or pharmacist prior to use as well as common side effects that can occur. For instance, there is often a statement regarding if a patient is pregnant or breastfeeding, then they should ask their health care professional prior to use. This is the case even for medications that are rated a pregnancy category A (see Module 1). A warning for keeping medication out of the reach of children is also included in this section. [Show Less]
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PHARMACOLO NURS 251 MODULE 3
Module 3 3.1: Introduction to Cardiology Taking a Blood Pressure Blood pressure is the pressure exerted against the walls of blood vessels as blood circ... [Show More] ulates through the body. Blood pressure is measured using an instrument called a sphygmomanometer, perhaps more commonly known as the blood pressure cuff. The pressures associated are measured in units of millimeters of mercury (mm/Hg). The health care provider inflates a blood pressure cuff in order to cut off the blood flow from the brachial artery. As they release the pressure in the cuff, they are listening with a stethoscope, for the first sound, called the Korotkoff sound, meaning there is no longer enough pressure to keep all the blood from flowing. The Korotkoff sound corresponds to a numerical gauge on the sphygmomanometer and is called the systolic value (top number) of the patient’s blood pressure. The provider continues to let air out of the cuff and eventually the sounds disappear, representing that the brachial artery is now completely open. When this occurs, the numerical value on the sphygmomanometer is known as the diastolic value (bottom number) in a patient’s blood pressure. Hypertension is defined as the persistent systolic blood pressure of greater than 150mm/Hg and/or a diastolic blood pressure greater than 90mm/Hg in patients 60 years of age and older. For patients younger than 60 or those with kidney disease or diabetes, it is defined as a systolic reading greater than 140mm/Hg and diastolic greater than 90mmHg. Hypertension is often an asymptomatic disease and is also considered the most common disease state worldwide. Table 3.1 below breaks down different classifications of hypertension. Table 3.1 Classification of Hypertension Classification Blood Pressure (mm/Hg) Normotensive <120/80 Prehypertensive 120-139/80-89 Hypertensive >140/90 Stage 1 140-159/90-99 Stage 2 >160/100 Essential hypertension, also known as primary hypertension, is when the cause of the increased blood pressure is unknown. Secondary hypertension is when a patient’s elevated blood pressure is caused by another disease. Orthostatic hypotension, which is when a patient experiences a sudden drop in blood pressure when they change positions (i.e. when going from a seated position to standing). Physiologic Factors that Determine Blood Pressure Blood Pressure is determined by cardiac output, the amount of blood ejected from the heart’s left ventricle multiplied by the Systemic Vascular Resistance (SVR), the resistance to blood flow. Cardiac output is determined by two factors: heart rate (beats per minute) and stroke volume (volume of blood pumped per minute). SVR is determined by the diameter of the blood vessel as well as the musculature nature of the blood vessel. An increase in any of the above factors: heart rate, stroke volume or SVR will result in a rise in blood pressure. There are also several factors commonly associated with high blood pressure even though they alone do not cause high blood pressure. Associated factors of blood pressure include: sodium intake, maintaining a healthy weight, avoiding smoking, proper exercise, and minimizing stress. If these contributing factors can be carefully regulated, then the blood pressure can be reduced. Figure 3.1 below shows the factors that regulate blood pressure within the body and where certain antihypertensive medications work. Figure 3.1. Normal Regulation of Blood Pressure and corresponding medications. Blue boxes represent align with Cardiac Output. Yellow boxed align with Systemic Vascular Resistance. The kidney’s role will be discussed in more detail later in this module, but it is important to mention that with high blood pressure there is an increased peripheral resistance which in turn decreases the blood supply to the kidney. Peripheral resistance is the resistance generated by the flow of blood through the arteries. When this happens, the kidney releases an enzyme called renin. Ultimately, renin leads to further vasoconstriction, water and sodium retention, and an increase in blood pressure. 3.2: Antihypertensives The goal of antihypertensive therapy is the reduction of cardiovascular and renal morbidity and mortality. According to guidelines, drug therapy should be started in patients over the age of 60 if their blood pressure is greater than 150/90mm/Hg. In younger patients or those with chronic kidney disease or diabetes, it should be started when the blood pressure is greater than 140/90mm/Hg. Fortunately, we are now living in a time where there are many drug therapy options available for patients and often their treatment needs to be individualized to meet their specific needs. There are essentially seven main classes of antihypertensives that can be used or more commonly are used in combination with one another in order to get the patient’s blood pressure to goal. Table 3.2 summarizes the different drug classes available to treat high blood pressure and highlights how they work to reduce blood pressure. Refer to Figure 3.2 to place where in the body each of these major drug classes is exerting their effect. Table 3.2 Antihypertensive Drug Classes and Mechanism of actions. Class Example Mechanism of Action Special Considerations Adrenergic Agents · Centrally acting o Alpha Agonists · Peripherally acting Clonidine- centrally acting alpha agonist Doxazosin- peripheral acting alpha blocker Centrally acting: stimulate alpha2 adrenergic receptors in the brain causing a lack of norepinephrine production. It also reduced the Centrally acting- means their site of action is in the brain. o alpha blockers o beta blockers Metoprolol- beta blocker *Carvedilol and labetalol have both alpha and beta blocking action. (generally classified as Beta Blockers still) activity of renin which is responsible for the production of the potent vasoconstrictor angiotensin II Peripherally acting: Alpha-block norepinephrine’s effect on alpha1 adrenergic receptors. Primarily this dilates arteries and veins reducing SVR and blood pressure. Beta- Block beta receptors causing a reduction in heart rate. They also reduce the secretion of renin. Long term use also reduced SVR. Peripherally acting means their site of action is in the heart and blood vessels. Angiotensin Converting Enzyme Inhibitors (ACE Inhibitors) Lisinopril (Prinivil) Prevent angiotensin I from being converted to angiotensin II. Angiotensin II is a potent vasoconstrictor. It also stimulates the reabsorption of water and sodium into the body. Both of these actions raise blood pressure. Therefore by blocking, blood pressure is reduced. First line Drug of choice for hypertensive patients with Heart Failure and Diabetes due to their cardioprotective effect and protective effects on the kidney. Angiotensin II Receptor Blockers (ARBs) Losartan (Cozzar) Block the binding of Angiotensin II to type 1 Angiotensin II receptors. This blocks vasoconstriction and the secretion of aldosterone. Aldosterone causes sodium and water to be reabsorbed into the body, which can raise BP. Therefore, by blocking, blood pressure is reduced. First line Calcium Channel Blockers Amlodipine (Norvasc) Blocks Calcium from binding to receptors which causes smooth muscles to relax, thereby preventing contraction. First line Diuretics *Thiazide Hydrochlorothiazide Work by decreasing plasma and extracellular fluid volumes- this decreases the preload, which leads to a decrease in cardiac output and total peripheral resistance. First line Vasodilators Hydralazine Directly cause peripheral vasodilation- this results in a reduced SVR. Side Effects Direct Renin Inhibitors Aliskiren (Tekturna) Inhibits renin and decreases the formation of angiotensin I and II. Not recommended for initial treatment [Show Less]
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PHARMACOLO NURS 251 MODULE 4
Module 4 4.1: Introduction to Endocrinology The endocrine system, also referred to as the hormone system, is a series of glands located throughout the bo... [Show More] dy that functions to maintain homeostasis. By modulating the release of chemical messengers (hormones), the endocrine system is able to send signals to regulate organ functions. The endocrine system is unique in that it works through hormones that generally have a longer and slower onset and duration of action. There are actually eight endocrine glands throughout the body including: the pineal, pituitary, thyroid, thymus, adrenal, pancreas, ovary and testis. Each of these glands releases a hormone into the body that is responsible for regulating growth, metabolism, or reproduction. This module will focus on select glands such as the pituitary gland, thyroid gland, and adrenal cortex and the pharmacologic options available when they fail to work properly. Physiology Overview The pituitary gland is sometimes called the “master gland” because it controls many of the other glands within the endocrine system. The pituitary gland is located in the region of the forebrain near the hypothalamus. Hormones released from the pituitary gland work by a negative feedback loop. This means the pituitary gland releases a hormone that signals an endocrine gland to release a subsequent hormone. The presence of this subsequent hormone then signals back to the pituitary gland to stop releasing the original hormone. The pituitary gland has two lobes, the anterior pituitary gland and the posterior pituitary gland. As outlined in Table 4.1, each lobe secretes its own distinct hormones. Table 4.1 Hormones of the Pituitary Gland Anterior Pituitary Gland Posterior Pituitary Gland Adrenocorticotropic Hormone (ACTH) Follicle Stimulating Hormone (FSH) Growth Hormone (GH) Luteinizing Hormone (LH) Prolactin (PH) Thyroid Stimulating Hormone (TSH) Antidiuretic Hormone (ADH) Oxytocin Pathophysiology and Related Drug Therapy Pituitary Generally, medications that affect the pituitary gland are being used as replacements for a hormone deficiency within the body. Examples of medications used to treat a pituitary hormone deficiency include (1) Somatropin (2) Octreotide, (3) Vasopressin and (4) Desmopressin. Somatropin- mimics the effects of growth hormone (GH) by promoting growth within the body. Typically, somatropin is used in children to promote linear growth when they do not produce a sufficient amount of endogenous hormone on their own. Octreotide- inhibits GH release and is structurally similar to the body’s GH release-inhibiting factor or somatostatin. It is useful in the treatment of severe watery diarrhea resulting from slow growing tumors because it reduces the concentration of the protein that causes the diarrhea. Vasopressin- is a potent vasoconstrictor and mimics the actions of the body’s antidiuretic hormone (ADH). It works by increasing water reabsorption in the distal tubule and collecting duct of the nephron (see Module 3). This can reduce water excretion up to 90%. It is also an especially effective vasoconstrictor in higher doses and can be used in emergency situations when blood pressure is dropping dangerously low. Desmopressin- is a synthetic vasopressin. As such, it also mimics ADH and works to increase water reabsorption in the nephron. Additionally, desmopressin shows dose-dependent activity on clotting factors, making it useful in treating certain blood disorders. Thyroid The thyroid gland is located in the neck and is responsible for the regulation of the body’s metabolism through the release of three hormones: Thyroxine (T4), triiodothyronine (T3), and calcitonin. Thyroid Stimulating Hormone (TSH) is the endogenous substance that the pituitary gland secretes to control the release of these thyroid gland hormones. There are two main problems that can occur the thyroid gland: (1) Hypothyroidism and (2) Hyperthyroidism. Hypothyroidism- A common condition characterized by diminished production of the thyroid hormones. Symptoms of this condition include cold intolerance, unintentional weight gain, depression, dry brittle hair and nails, and fatigue. Overall, think of the symptoms as a decrease in the body’s metabolism resulting in an overall slowing. Drug Therapy- The treatment for hypothyroidism is relatively straight forward. It is to provide thyroid hormone replacement to the patient. While there are natural and synthetic options available, the synthetic levothyroxine (synthetic T4) is used in the majority of patients. Essentially, levothyroxine works in the same manner as the endogenous hormones. By taking levothyroxine, the deficiency is corrected. Levothyroxine is the drug of choice in most cases due to its predictable effects and long enough half-life to allow for once daily dosing. However, it can be impacted by food or drugs, so it is recommended to take on an empty stomach 30-60 minutes prior to breakfast. Hyperthyroidism- A condition characterized by excessive production of the thyroid hormones. In contrast to hypothyroidism, hyperthyroidism causes an overall increase in the body’s metabolism. Symptoms of this condition include diarrhea, flushing, increased appetite, muscle weakness, fatigue, palpitations, irritability, nervousness, heat intolerance, and altered menstrual flow. Drug Therapy- Propylthiouracil (PTU) and Methimazole are two anti-thyroid drugs available that work by inhibiting the formation of the thyroid hormones. Two weeks of PTU therapy may be needed prior to symptom improvement. On the other hand, Methimazole, is rarely used clinically. It is also important to note that is some cases where drug therapy is ineffective, or the patient is unable to tolerate treatment, surgical resection of the thyroid gland is often performed. Such a patient would be then considered to have hypothyroidism and would need thyroid hormone replacement for the rest of their life. Adrenal Glands The adrenal glands are located on the upper surface of each kidney. Although there are two parts of the adrenal glands, the adrenal medulla (the inner part) and the adrenal cortex (the outer part), the focus will be on the adrenal cortex in this section. The hormones released by the adrenal cortex are generally referred to as corticosteroids or just steroids. Importantly, there are two distinct types of corticosteroids: (1) glucocorticoids and (2) mineralocorticoids, Glucocorticoids are critical to the body’s overall function and work to stimulate the production of glucose (gluconeogenesis) and the breakdown of proteins (catabolism). When the body undergoes any type of stress including trauma or surgery, the need for glucose increases. For tissues to be able to repair glucose is a necessary component. Two specific glucocorticoid hormones exist and can be released in the form of either cortisol or cortisone. When there is a deficiency in glucocorticoids, a person is said to have Addison’s disease. Conversely, when a person is producing excess glucocorticoids, the patient is said to have Cushing’s disease. Mineralocorticoids, such as the hormone aldosterone, are also released by the adrenal cortex. Aldosterone is critical to the regulation of sodium and potassium as well as water in the extracellular fluid. The regulatory effects of aldosterone, therefore, plays a role in blood pressure. The renin angiotensin system (Module 3) is a major regulator of aldosterone secretion as is the adrenocorticotropic hormone (ACTH), although to a lesser degree. [Show Less]
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PHARMACOLO NURS 251 MODULU 5
Module 5 5.1: Introduction to Pulmonology The main function of the respiratory system is two-fold: (1) to deliver oxygen to the cells of the body and (2)... [Show More] remove carbon dioxide from the body. This is accomplished through the combination of the upper respiratory tract working in communication with the lower respiratory tract. A diagram of the anatomy of the respiratory tract is shown in Figure 5.1. The upper respiratory tract (URT) is outside the chest cavity and includes the nose, and nasopharynx (down to the larynx). The lower respiratory tract (LRT) includes the organs within the chest including the trachea, bronchial tree, and lungs. When a person breathes in air, oxygen diffuses across the alveoli (microscopic sacs) in the lungs where it is exchanged for carbon dioxide. The diffused oxygen is then taken to the rest of the body through the circulatory system. Figure 5.1 Anatomy of the Respiratory Tract. Above is a diagram of the anatomy of the respiratory tract broken down between the Upper Respiratory Tract (URT) and the Lower Respiratory Tract (LRT). There are several common diseases that affect the airways and this exchange of gas, the most common of which are asthma and chronic obstructive pulmonary disease (COPD). Asthma is the general term for recurrent and reversible shortness of breath resulting from the narrowing of the bronchi and bronchioles. COPD consists of both emphysema and chronic bronchitis. Emphysema is a disease process involving inflammation of the alveoli. Chronic Bronchitis is characterized by chronic inflammation or irritation on the lower respiratory tract, specifically the bronchi. The primary drugs used in the treatment of both asthma and COPD include bronchodilators and a variety of antiinflammatory and antiallergic agents. Pathophysiology All three of these diseases have one primary similarity in that they all involve obstruction of airflow through the airways. Chemical Mediators are defined as a substance released from mast cells and white blood cells during inflammation and allergic reactions. As such, chemical mediators are responsible for most of the symptoms and complications associated with asthma and COPD. The only chemical mediator with a known involvement where drug therapy has been shown to This study source was downloaded by 100000852290574 from CourseHero.com on 12-29-2022 23:48:13 GMT -06:00 https://www.coursehero.com/file/78909088/Pharmacology-Module-5docx/ HEALTH help patient symptoms is leukotrienes. Leukotrienes are potent bronchoconstrictors with a long duration of action. They stimulate receptors responsible for bronchoconstriction, edema and other inflammatory actions. There is a class of drugs called leukotriene inhibitors that inhibit these actions and have an important role in treating asthma specifically. Asthma The narrowing of the bronchioles can be caused by bronchospasm, inflammation, edema and the production of mucus. This ultimately obstructs airflow meaning that the carbon dioxide cannot get out and the oxygen cannot get in. There are different types of asthma. Some asthma is caused by outside factors such as allergens; this is often referred to as allergic asthma. Conversely, intrinsic asthma is caused by unknown factors. In some cases, certain factors have precipitated the asthma attack such as respiratory infections, stress, or cold weather. It is not fully understood why some people seem to be predisposed to asthma attacks. Emphysema Emphysema occurs when the air spaces within the bronchioles enlarge as a result of the destruction of the alveolar walls. As the alveolar walls are destroyed, there is less surface area available for oxygen and carbon dioxide exchange. The cause of this appears to be enzymes that are released in response to inflammation. These enzymes are increased by air pollution, tobacco smoke, and other irritants to the respiratory tract. Hyperinflation is the result of the air spaces being enlarged. These patients have difficulty expelling air from the lungs. This results in a reduction in gas exchange and the feeling of shortness of breath. Emphysema causes irreversible lung damage over time. Chronic Bronchitis Chronic irritation, usually from cigarette smoke or other environmental pollutants, can lead to chronic bronchitis. The irritants cause mucus secretions to increase and thicken which can then begin to interfere with gas exchange within the lungs. These patients often present with a chronic cough, difficulty breathing, and increased respiratory infections. Drug therapy can provide relief, but it cannot reverse the damage. Drug Therapy Historically, the treatment of both asthma and COPD has centered around bronchodilation. Recently, there has been a shift in focus to the anti-inflammatory component of treatment. Treatment still includes bronchodilators, so we will cover both types of treatment since they are often used in combination. Table 5.1 provides a summary of the most common treatment options used in asthma and COPD management. [Show Less]
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PHARMACOLO NURS 251 MODULE 6
Module 6 6.1: Introduction to Infectious Diseases Infectious diseases are caused by pathogenic (disease-causing) organisms such as bacteria, fungi, and p... [Show More] arasites as well as by viruses. Bacteria are defined as single-celled microorganisms. They can be found virtually everywhere and can either be harmless or very dangerous. This module will focus on the role of antibiotics to eliminate the pathogenic effects brought on by bacteria within a human host. Antibiotics are drugs that have the ability to destroy or interfere with the development of a living organism, typically bacteria. Bacteria Bacteria can be classified as either Gram-positive or Gram-negative. This classification refers to how they respond to the Gram stain procedure. Gram-positive bacteria stain purple, and Gram-negative stain pink. Interestingly, the results of a Gram stain actually play a significant role in selecting an appropriate antibiotic therapy. Due to differences in the composition of the cell membrane, some drugs cannot effectively penetrate the membrane which is often required to elicit the desired effects. Generally, Gram-negative bacterial infections are harder to treat because Gram-negative bacteria have a more complex cell wall structure. Another way bacteria are classified is by whether they are an aerobe or anaerobe. An aerobe is defined as a bacterium that grows in the presence of air or requires oxygen for growth. An anaerobe is defined as a bacterium that does not require oxygen in order to grow. Anaerobes, for instance, are most commonly found in the GI tract. Although there are many different kinds of bacteria and strategies for classifying them, this goes beyond the scope of this introductory module. Instead, it is important to understand generally that bacteria do not simply cause a single disease: rather, multiple disorders are possible depending on where in the body the bacteria accumulate. For example, the bacteria streptococcus pyogenes is the specific bacteria responsible for the common throat infection known as strep throat. This bacterium is spread through airborne droplets when someone with the bacteria coughs or sneezes. It can also be spread by sharing food or drinks. When the bacteria spread through the air or even food, the throat is one of the first contact points in the body, which makes strep throat a common result. However, if it happened to be transferred via contact with a contaminated surface and the person had an open sore, the very same bacteria could cause an entirely different infection, in this case, a skin infection. There are also common infections associated with certain bacteria based on where they are found naturally or how the pathogen is acquired. Take for instance, the bacteria E.coli. Although typically found within the intestines of a healthy individual, when someone becomes exposed to a pathogenic strain of E.coli, often via contaminated food, it often presents as diarrhea because of where the bacteria naturally end up by way of the digestive tract. One last factor is related to where the person contracts the infection—different types of bacteria are found in the environmental community compared to a healthcare setting. Generally, healthcare-associated infections are much more difficult to treat because the microorganisms have been exposed to strong antibiotics in the past; therefore, they are resistant to many treatments. Healthcare-associated infections are defined as an infection acquired during the course of receiving treatment for another condition in a health care institution. Examples of common Gram-positive bacteria and Gram-negative bacteria can be found in Table 5.1 below. This study source was downloaded by 100000852290574 from CourseHero.com on 12-30-2022 00:04:14 GMT -06:00 https://www.coursehero.com/file/78909152/Pharmacology-Module-6docx/ Important terminology to be familiar with regarding antibiotics and bacteria: Antibiotic spectrum- bacteria that are susceptible to the antibacterial actions of a particular drug. Broad Spectrum is defined as an antibiotic that is effective against a wide variety of both Gram-positive and Gramnegative bacteria. Bacteria Resistance is defined as the ability of some bacteria to resist the actions of antibiotics. MRSA stands for methicillin-resistance Staphylococcus aureus. Methicillin is a penicillin-related antibiotic that was previously effective against resistant staph infections. However, over time, an even more drug-resistant strain developed and was termed MRSA. MRSA infections have become a major problem because none of the penicillin-class drugs are effective against it. In fact, only a few antibiotics, such as Vancomycin, have demonstrated effectiveness. 6.2: Antibiotics Similar to other types of medications, antibiotics are classified into broad categories or classes. These classifications are most often based on their chemical structure; however, these classes vary in more ways than just their chemical structure. Distinguishing characteristics include antibacterial spectrum, mechanism of action, potency, toxicity, and pharmacokinetic properties. Antibiotics are different than most other drugs in that their targeted site of action is not a part of the body but is actually the foreign bacteria that is causing an infection. The ultimate goal of the drug treatment is to kill or destroy the bacteria causing harm. There are four common mechanisms of action associated with antibiotics: 1. Interference with bacterial cell wall synthesis. This causes the formation of defective cell walls within the bacteria that are unstable and easily broken down. This generally causes the bacteria cell to rupture and ultimately die. 2. Interference with protein synthesis. Without the ability to make proteins, the bacteria can no longer function. 3. Interference with replication of DNA and RNA. DNA and RNA replication are how bacteria cells multiply. If they are not able to multiply, then the infection cannot survive. 4. Antimetabolite action that disrupts important metabolic reactions within the bacterial cell. By inhibiting important metabolic activities, the bacteria are no longer able to grow and function properly. Antibiotics are either considered bactericidal or bacteriostatic. Bactericidal antibiotics work by killing the bacteria. [Show Less]
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PHARMACOLO NURS 251 MODULE 7
Module 7 7.1: Introduction to Gastroenterology The organs of the upper gastrointestinal tract (mouth, pharynx, esophagus, stomach, and duodenum) work in ... [Show More] conjunction to first digest food and then absorb the nutrients obtained from the digested food. Both the stomach and the upper part of the small intestines (duodenum) release hormones and enzymes that help in this process. When food enters the body, the stomach is triggered to begin releasing gastric juices such as hydrochloric acid (HCl) and an enzyme called pepsin. HCl is released by parietal cells located in the stomach. Due to its acidic nature, HCl aids in the breakdown of food entering the stomach. Pepsin is the primary digestive enzyme found in the stomach. Pepsin is responsible for the catabolism (breaking down) of proteins into polypeptides. There are three major stimulators that affect the release of gastric juices: Acetylcholine (ACh), gastrin, and histamine. First, the ingestion of food stimulates ACh to bind to its target receptors, stimulating the release of pepsin, gastrin, histamine, and HCl from chief cells, G cells, enterochromaffin like (ECL) cells, and parietal cells respectively. Gastrin then binds to its target receptors on ECL and parietal cells which stimulates the release of more histamine and more HCl. The histamine then binds to the H2 receptors on the parietal cells which, in turn, increases the amount of HCl or gastric acid released. Figure 7.1 Stimulation of Gastric Juices. The figure above depicts the different cells involved in the release of the different gastric juices. The process is started by ACH being released when food is ingested. The release of the initial gastrin and histamine go on to stimulate the release of more histamine and HCL. Peptic Ulcers and Gastrointestinal Esophageal Reflux Disease (GERD) Peptic ulcers are defined as open sores in the mucous membranes of the mucosal lining of the stomach or duodenum. Pathophysiology: The cause of peptic ulcers is not always the same. The majority of GI ulcers are caused by the bacterium Helicobacter Pylori (H. Pylori). The bacterium is believed to enter the body through contaminated food or water. Reacting to the bacteria, an inflammatory response is initiated, which is often associated with an increase in stomach acid secretions. The long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) is also closely related to the incidence of peptic ulcers. NSAIDs block prostaglandins which play a role in inhibiting gastric acid secretion. In both cases, the resulting increase in stomach acid secretions places a strain on the inner lining of the stomach until an ulcer (break or tear) appears. Symptoms of a peptic ulcer include pain, nausea, and loss of appetite. The pain is typically described as a dull, gnawing, burning sensation similar to heartburn. Interestingly, if the ulcer is in the duodenum, food often relieves the pain, whereas if the ulcer is in the stomach, food often worsens the pain. GERD stands for gastrointestinal esophageal reflux disease and is characterized primarily by the presence of heartburn. Heartburn (acid indigestion) is defined as a painful burning feeling behind the sternum that occurs when stomach acid backs up into the esophagus. Pathophysiology of GERD involves the lower esophageal sphincter (LES) or valve at the bottom of the esophagus going into the stomach. This valve loosens such that the gastric acid is able to go back up (reflux) into the esophagus. Symptoms of GERD go beyond occasional heartburn. In GERD, heartburn is part of an ongoing problem, often occurring after meals and upon lying down. In severe cases, there can even be blood loss from chronic injury to the esophagus. Treatment Overview Peptic Ulcers If the patient has a peptic ulcer that is caused by H. Pylori, they will need to be treated with antibiotics. It is generally recommended to use at least two antibiotics in combination with bismuth salts (Pepto-Bismol or Kaopectate), a regimen referred to as “triple therapy.” When a proton pump inhibitor (PPI) is added to the regimen it is then referred to as “quadruple therapy.” PPIs will be discussed further below. The recommended antibiotics to treat H. pylori include amoxicillin, tetracycline, metronidazole, and clarithromycin. The purpose of the Pepto-Bismol is that bismuth is thought to disrupt the bacterial cell wall and prevent further binding to the mucosa. Treatment typically lasts for 8 weeks leading to the eradication of the bacteria. If the ulcer was not caused by H. Pylori, treatment does not involve antibiotics but rather anti-secretory drugs. Antisecretory drugs are defined as drugs that inhibit the secretion of digestive enzymes, hormones, or acids. Such drugs include H2 receptor antagonists, prostaglandins, and proton pump inhibitors. Treatment should last 4-8 weeks. Prostaglandins are only useful in the treatment or prevention of NSAID-induced ulcers. Prostaglandins inhibit histamine which counteracts the NSAIDs inhibition of prostaglandin synthesis. There is only one synthetic prostaglandin available, misoprostol. It is limited in its use, primarily being used for patients at high risk of developing an ulcer that must be on an NSAID for a limited time. Misoprostol has not been shown to be effective at preventing ulcers in patients on chronic NSAID therapy. Misoprostol is also known to cause uterine contractions and is, therefore, contraindicated in pregnancy due to the risk of miscarriage. GERD Depending on the severity of the disease, the recommended treatment may differ. In mild-moderate GERD, the H2 antagonists are a great option. They have a longer duration of action than alternatives such as an OTC antacid and provide good relief. However, in severe GERD or in cases where there is ulcerative damage, PPIs are considered first line therapy. Lifestyle modifications are a critical part of the management of peptic ulcers and GERD. Recommendations include smoking cessation, avoiding caffeine and alcohol, as well as reducing stress. If possible, NSAIDs should be avoided. If the patient is overweight, weight loss can help. If the patient has symptoms at night, it is recommended to elevate their bed. Drug Therapy H2 receptor antagonists were introduced in Module 2. We will go into more detail in this module. Mechanism of action: Work by competitively inhibiting the interaction of histamine with H2 receptors within the GI mucosa. This blockade significantly reduces the secretion of acid and pepsin from the stomach. Uses: Recommended for the short-term use (up to 8 weeks) of benign gastric ulcers and duodenal ulcers, GERD, stress ulcers and gastric irritation in patients that need to remain on NSAIDs. Adverse Events: Headache or constipation. Cimetidine specifically has been associated with reversible CNS effects such as confusion and disorientation, usually in critically ill patients. Drug Interactions: Cimetidine has been reported to increase the drug levels of many medications by altering metabolism. Select examples include calcium channel blockers, beta blockers, sulfonylureas, and theophylline. Famotidine and nizatidine have no effect on the metabolic pathway and are therefore preferred. They do not appear to interact with food and therefore can be taken at mealtime. Example Drugs: Cimetidine, ranitidine, famotidine, and nizatidine PPIs are superior in their effectiveness in acid reduction and ulcer healing compared to H2 receptor antagonists. Mechanism of action: The exchange of hydrogen and potassium via the ATPase exchange is essential to the production of HCl. PPIs work by inhibiting this exchange, therefore, preventing the formation of acid. Uses: First line along with antibiotics to treat H. Pylori related ulcers, benign gastric ulcers, active duodenal ulcers, and GERD. They promote better healing over H2 blockers and therefore are the drug of choice for healing ulcers. Adverse Events: Headache, abdominal pain, diarrhea, nausea, and constipation. New concerns have arisen that longterm use could lead to the development of osteoporosis. Overprescription of PPIs could lead to an increase in GI infections because of the reduction of normal acid-mediated microbial protection. Drug Interactions: Omeprazole can increase levels of warfarin and some seizure medications (diazepam, phenytoin). It can also affect the absorption of drugs that require an acidic environment such as iron. Omeprazole has also been shown to decrease the antiplatelet effects of clopidogrel. Lansoprazole, pantoprazole, and rabeprazole have no clinically relevant drug interactions. Example Drugs: Omeprazole, esomeprazole, lansoprazole, dexlansoprazole, pantoprazole, and rabeprazole. See Table 7.1 below for a summary chart of the H2 receptor antagonists and the PPIs. [Show Less]
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PHARMACOLO NURS 251 MODULE 9
Module 9 9.1: Introduction to Specialty Medications In general, specialty medications are high cost medications used for treating complex disease states. ... [Show More] They can be challenging to both manufacture and administer, and they often require significant patient education and close monitoring to ensure their safe and appropriate use. Although specialty medications were once a very small piece of the pharmaceutical industry, there has been a significant change over the last 20 years and especially within the last decade. Specialty medications are now the fastest growing segment of the pharmaceutical industry. Common characteristics associated with specialty medications are listed in Table 9.1. Table 9.1 Specialty Medication Characteristics High Cost Potential for limited or exclusive availability for distribution Complex treatment regimen that require ongoing Treat rare diseases monitoring and patient education Special handling, storage, or delivery requirements Treat diseases known to have long term or severe side effects or increased fatality Biologically derived and available in injection, infusion, or Payers may define what they consider to be a specialty oral form medication for reimbursement and contracting purposes. With the increase in specialty medications over the last two decades, a whole new approach to dispensing these medications emerged called specialty pharmacies. Generally, specialty medications are not available at typical community pharmacies, so patients must obtain them through specialty pharmacies. There are many reasons for this: some practical, some financial, and some clinical. Traditional retail pharmacy is not designed to handle these complex, costly medications. First, the high cost alone, in many cases, would prohibit retail pharmacies from stocking the medication. Second, the often-busy nature of a retail pharmacy does not align itself well with being able to appropriately manage and support the needs of patients with complex disease states. For these reasons, the first specialty pharmacies began in the early 2000s. Specialty pharmacies are typically required, through their contract with health insurance companies, to meet unique requirements that are not part of their contracts with retail pharmacies. Examples of these requirements are listing in Table 9.2. Table 9.2 Examples of Specialty Pharmacy Services Coordinating care and facilitating the drug access Case management- disease state management Facilitating mail order delivery logistics Product device training when applicable Working with health insurance to determine coverage Data management of technical and clinical patient care and help coordinate any requirements of the insurance services. company Investigating patient assistance programs for patients Call center development without insurance or lack of coverage Patient Experience A patient receiving a prescription for a specialty medication should be aware that the process for getting the medication is going to look different than the normal retail pharmacy experience. However, the system is designed so that the patient has the best chance of successfully obtaining and using the medication safely and appropriately. The prescription would first be sent to the specialty pharmacy. The specialty pharmacy then takes responsibility for making sure the patient gets the medication, understands the risks and benefits, is able to afford it, able to take it appropriately, and will HEALTH follow through with any necessary monitoring. The patient may be connected with a case manager that will call them on a monthly basis to make sure there are no issues with the medications, check to see if they had any required monitoring completed, provide any necessary education, and/or answer patient questions. Patient follow-up often happens every month prior to sending out the next months’ worth of medications in order to minimize waste, ensure safety, and assess for efficacy. As specialty pharmacies are generally not local to the patient they are caring for, care and coordination are often provided telephonically. The process is centralized, and the medications are shipped to the patient’s house or, in some cases, to the facility that will be administering the medications. Brief Overview of Common Disease States Treated with Specialty Medications Common disease states managed by specialty pharmacies include (1) oncology, (2) multiple sclerosis, (3) rheumatoid arthritis, (4) Crohn’s disease, (5) hepatitis C, and (6) HIV/AIDs. This module with introduce some of the most commonly used specialty medications that most health care professionals would come into contact with, regardless of their specialty. Many of these conditions represent an entire specialty in medicine and are very complex. Therefore, for the purposes of this module, these conditions will be introduced briefly. Oncology is the study and treatment of cancer. Cancer is a disease process that involves the development and proliferation of abnormal calls. Cancer cells are marked by both a structural change and a loss of function from the original healthy cell. They are often characterized by multiplying at a faster than normal rate. As this collection of abnormal cells, called a tumor, grows it can become life threatening as it deprives normal body cells of the nutrients they need to function. Multiple Sclerosis (MS) is an often unpredictable, disabling disease of the central nervous system. It disrupts the flow of information both within the brain as well as between the brain and the body. Damage to the myelin coating around the nerve fibers in the CNS causes the nerve signals to be disrupted. This damage ultimately leads to the symptoms of MS that can vary between individuals with the disease. Some of the more common symptoms include fatigue, difficulty walking, numbness or tingling, stiffness in the limbs, weakness, vision problems, cognitive changes, pain, depression, and emotional changes. Rheumatoid Arthritis (RA) is a chronic autoimmune disorder that causes inflammation and tissue damage in the joints. It is a very painful and (often) disabling disease. The common symptoms of RA include pain, stiffness, and reduced range of motion. Generally, the treatment would not start with a specialty medication. The initial medications fall under the class disease modifying antirheumatic drug (DMARD). However, these are not always effective or in some instances, patients may no longer respond as they once did. In either case, a patient would be then switched to one of the specialty medications reviewed below. Crohn’s Disease is an inflammatory bowel disease caused by inflammation in the digestive tract which can lead to symptoms such as abdominal pain, severe diarrhea, fatigue, weight loss, and malnutrition. The inflammation can spread deep into the layers of the affected bowel tissues making the symptoms extremely painful and often hard to control. Hepatitis C is a viral infection that causes liver inflammation which can sometimes lead to serious liver damage. The virus is spread through infected blood. There are often no symptoms associated with chronic hepatitis C until the virus damages the liver significantly enough. Symptoms of hepatitis C then include bleeding and bruising easily, fatigue, poor appetite, dark urine, swelling, weight loss, and confusion. Interestingly, acute hepatitis C often goes undiagnosed because of the lack of or self-limiting nature of the symptoms. Additionally, some people that contract hepatitis C never go on to develop chronic hepatitis C because their body is able to clear the virus on its own. However, those that do progress to chronic hepatitis C, will likely develop liver failure and need a liver transplant should they live long enough if the disease is left untreated. Recent treatments have made the possibility of a cure very likely with only three months of treatment. HIV/AIDS is a notorious virus with incredible advancements in treatment over the last 30 years. HIV stands for human immunodeficiency virus and is the causative agent of acquired immunodeficiency syndrome (AIDS). The virus is spread through sexual contact, perinatally from an infected mother, or by injection into the blood. The typical course of the infection is characterized by an acute clinical illness that varies in presentation followed by a longer clinical latency. People may go years without any symptoms. However, during this asymptomatic time, the virus is working in the body to destroy the immune system, specifically the CD4 Cells (T-cells). With the destruction of immune cells, the person is eventually no longer able to fight off pathogens (disease causing agents), a state referred to as being immunocompromised. When a pathogen is able to take advantage of the lowered immunity, it is called an opportunistic infection. At this point, the patient is generally considered to have AIDS. HIV/AIDS cannot be cured, but it can be controlled with antiretroviral therapy (ART). 9.2: Introduction to Immunomodulating Drugs Over the last twenty years, medical technology has developed a new group of drugs that affect the immune system. Many of these drugs are synthesized through recombinant DNA technology, which is the process of joining DNA molecules from two different sources and inserting them into a host organism which then generates specific products for human use. These drugs are often referred to as biologics and are almost always considered specialty medications. They are in a large part responsible for the growth of the specialty pharmacy industry. Such drugs work by altering the body’s response to diseases such as cancer, autoimmune, inflammatory and infectious diseases. Biologics can work either by enhancing or restricting the patient’s natural immune response. To better understand how such medications work within the body, we will briefly cover the physiology of the immune system. Immune Response Overview One of the main functions of the immune system is to identify substances as being either foreign or of self. When bacteria or viruses enter the body, the immune system should recognize both as foreign and initiate an immune response to eliminate it from the body. More specifically, there is humoral immunity and cell-mediated immunity. Humoral immunity is defined as the immune response mediated by B-cells and the production of antibodies targeted against specific antigens. B-cells are leukocytes that develop into plasma cells and then produce antibodies that bind to and inactivate antigens. Antibodies are molecules that have the ability to bind to and inactivate antigen molecules through the formation of an antigen-antibody complex. Cell-mediated immunity which works in collaboration with humoral immunity, is the immune response mediated by Tcells. T-cells (T lymphocytes) are not involved in the production of antibodies but instead act through either direct cellto-cell contact or through the production of cytokines. Cytokines are a generic term for non-antibody proteins released by specific cell populations (activated T-cells) upon contact with antigens. They act as intercellular mediators of an immune response. Of note, there are various subtypes of T-cells: (1) helper, (2) suppressor and (3) cytotoxic. T helper cells are cells that promote the direct actions of numerous other cells associated with the immune system. T suppressor cells regulate and limit the immune response, balancing the effect of T helper cells. Cytotoxic T cells (natural killer cells) are differentiated T-cells that can recognize foreign antigens being presented on the surface of another cell. Once recognized, the cytotoxic T-cell then attacks and destroys the particular target cell. The main types of biologics covered in this module are classified as immunomodulating drugs. Immunomodulating drugs are defined as a subclass of biologics that specifically or nonspecifically enhance or reduce the immune response. The subclasses of immunomodulating drugs include (1) interferons, (2) monoclonal antibodies, (3) interleukin receptor antagonists and agonists and (4) other miscellaneous drugs. Since these drugs alter a patient’s immune response, they are often used in cancer treatments because they are able to specifically target the cancer cells while leaving healthy cells alone. They are also commonly used to treat autoimmune and inflammatory conditions by interfering with a patient’s overactive immune response in diseases like rheumatoid arthritis [Show Less]
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