analgesics naplex pg 132. treatment algorithm for pain patient in pain rating scale 0-10 mild pain...

AnalgesicsAnalgesics

NAPLEX

PG 132

Treatment Algorithm for PainTreatment Algorithm for Pain

Patient in painRating Scale 0-10

Mild Pain (0-3)NSAID, aspirin,

APAP

Moderate Pain (4-6)Weak opioid:

codeine, hydrocodone

Severe Pain (7-10)Strong opioid:

morphine, oxycodone,

hydromorphone

Treating Specific Types of Cancer Pain

Treating Specific Types of Cancer Pain

Bone pain NSAIDs, bisphosphonates, corticosteroids, opiates

Visceral pain NSAIDs, opiates

Neuropathic pain TCAs, gabapentin, carbamazepine, corticosteroids

Muscle spasms Benzodiazepines, baclofen

Bone pain NSAIDs, bisphosphonates, corticosteroids, opiates

Visceral pain NSAIDs, opiates

Neuropathic pain TCAs, gabapentin, carbamazepine, corticosteroids

Muscle spasms Benzodiazepines, baclofen

Non Opioid AnalgesicsNon Opioid Analgesics

Drug Dose Interval Renal Adjustment Hepatic Adjustment

Acetaminophen 500-1000 mg

Max: 4 g

4-6 hours GFR: >50 ml/min q4h,

10-50 ml/min q6h,

<10 ml/min q8h

1/2 life is increased,

Can be given safely

Aspirin 500- 1000 mg

Max: 4 g

4-6 hours Avoid Avoid

Celecoxib 100-200 mg

Max: 800 mg

12 hours Avoid Decrease dose by 50 %

Rofecoxib

(off market)

12.5 mg-25 mg

Max: 50 mg

Daily Avoid Avoid

Valdecoxib

(off market)

10-20 mg

Max: 40 mg

Daily Avoid Avoid

PG 134

Non Opioid Analgesics con’tNon Opioid Analgesics con’t

Drug Dose Interval Renal Adjustment Hepatic Adjustment

Ibuprofen 200-800 mg

Max: 3.2 g/day

4-6 hours Use with caution Contraindicated in renal failure

No dose alterations,

Kinetics minimally effected

Naproxen 550 mg initial,

250 subsequent

Max: 1.5g/day

6-8 hours Use with caution Reduce dose 50%

Indomethacin 25 mg

Max: 200mg/day

8-12 hours Use with caution Avoid

Ketoralac 30 mg or 60 mg IM

Max: 5 days of combine treatment (IM & PO)

6 hours Avoid Avoid

Oxicams

Carboxylic Acids

Fenamates

NaphthylalkanoneAcetic Acids

oxaprozinnaproxenibuprofenketoprofenfenoprofenflurbiprofen

Propionic Acids

meclofenamatemefenamic acid

piroxicammeloxicam

sulindacetodolacindomethacintolmetindiclofenacketorolac

nabumetone

GI Sparing Agents

diclofenac/misoprostoldiclofenac/misoprostol

Salicylates

ASA

NonacetylatedSalicylates

salsalatediflunisalcholine

Weak Opioid AnalgesicsWeak Opioid AnalgesicsDrug Dose Interval Renal Adjustment Hepatic Adjustment

Codeine 15-60 mg

Max: 120 mg

4-6 hours CrCl:

10-50 ml/min=75% of dose,

<10 ml/min=50% of dose

A dosage adjustment decrease

Oxycodone w/

-acetaminophen

-aspirin

5 mg

Max: 4 g* 4-6 hours

Be conservative, drug levels increase by 50%

1/3 to 1/2 of usual dose,

Elimination 1/2 life increase by 2.3 hours

Hydrocodone w/

-ibuprofen (7.5/200)

-acetaminophen

(5/500)

-aspirin

(5/500)

1-2 tabs

Max: 5 tabs

1-2 tabs

Max: 4 g*

1-2 tabs

Max: 4 g*

4-6 hours

4-6 hours

4-6 hours

Use cautiously in mild to moderate renal failure, avoid in severe renal failure

Avoid

Tramadol

-acetaminophen

(37.5/325)

50-100 mg

Max: 400mg

2 tabs

Max: 8 tabs

4-6 hours

4-6 hours

CrCl < 30 ml/min increase dosing interval to q12h with a max of 200 mg per day

Cirrhosis 50 mg q12h

Avoid

Weak Opioid Analgesics con’tWeak Opioid Analgesics con’tDrug Dose Interval Renal Adjustment Hepatic Adjustment

Propoxyphene

-acetaminophen

-aspirin

1-2 tabs

Max: 4 g*

1-2 tabs

4 hours

4 hours

Don’t give in severe renal failure, use cautiously in mild and moderate renal failure

Avoid

Strong Opioid AnalgesicsStrong Opioid AnalgesicsDrug Dose Interval Renal Adjustment Hepatic

Adjustment

Meperidine

- Binds opiate receptors

50 - 150 mgMetabolite accumulation (normeperidine) Anxiety, agitation, tremor &/or seizures

3-4 hours GFR

>50 ml/min No adjustment

10-50 ml/min 75% of dose

<10 ml/min 50% of dose

Decrease dose, 1/2 life is increased

Morphine (gold standard)

-immediate release

-IV, IM, SQ,

continuous infusion

-epidural

-intrathecal

-rectal

10-30 mg

2.5-20 mg

0.8 to 10 mg/hr

Max: 80 mg/hr

5mg bolus, redose 1 hr 1 to 2 mg

Max: 10 mg/24 hr

0.2 to 1 mg

10-20 mg

Titrate to response

2-6 hours

No repeat dose

4 hours

GFR

>50 ml/min No adjustment



(morphine-6-glucuronide) accumulates in renal failure

1/2 life prolonged increase interval by 1.5 to 2 times

Strong Opioid Analgesics con’tStrong Opioid Analgesics con’tDrug Dose Interval Renal Adjustment Hepatic Adjustment

Hydromorphone

-PO, IM, IV, SQ

-rectal

1-4 mg

3 mg

4-6 hours

6-8 hours

Decrease dose

Oxycodone

- percocet (APAP)

- percodan (ASA)

5 mg

May titrate to response – no maximum dose

6 hours – Be conservative, drug levels increase by 50%

1/3 to 1/2 of usual dose,

Elimination 1/2 life increase by 2.3 hours

Methadone

-PO, IM, SQ

-IV

2.5-10 mg

Max:1000 mg

0.1mg/kg

3-8 hours

4 hrs x 3 doses then 6-12 hours

GFR

>50ml/min q6h

10-50 ml/min q8h

<10 ml/min q12h

CrCl

<10 ml/min 50-75% dose

No Change in dose mild to moderate disease,

Avoid in severe liver disease

Strong Opioid Analgesics con’tStrong Opioid Analgesics con’tDrug Dose Interval Renal Adjustment Hepatic Adjustment

Fentanyl

-transdermal

-transmucosal-Parenteral

Initial 25 mcg/hr

Initial 200 mcg

72 hours

30 min

CrCl



Unaffected by cirrhosis, effected by hepatic blood flow

Remind patients that heat can increase fentanyl absorption. Remind patients that heat can increase fentanyl absorption. Warn against extended exposure of the patch to heating pads, Warn against extended exposure of the patch to heating pads, hot tubs, sunbathing, high fever, etc.hot tubs, sunbathing, high fever, etc.

Opioid Equianalgesic DosingOpioid Equianalgesic DosingDrug Oral (mg) Parenteral (mg)

Morphine 30 10

Hydromorphone 7.5 1.5

Oxycodone 20-30 10-15

Methadone 10-20 acute?

2-4 chronic

10 acute?

2-4 chronic

Levorphanol 4 acute

1 chronic

2 acute

1 chronic

Fentanyl x 0.1-0.2

Oxymorphone x 1

Meperidine 300 75

Morphine Analogs---table 2-28, pg.132

General propertiesGeneral properties

CNS depressionCNS depression

Respiratory depressionRespiratory depression

Reduce propulsive activity of the gut Reduce propulsive activity of the gut

Urinary retentionUrinary retention

Toxicity causes pinpoint pupilsToxicity causes pinpoint pupils

No maximum doseNo maximum dose

Meperidine Analogs---See Table 2-28, pg.132Meperidine Analogs---See Table 2-28, pg.132

General properties

Good analgesic (parenteral)

Less CNS depression or constipation than opiates

Spasmolytic action - may be useful for pain related to uterus, GI, bronchi, etc.

Combination with hydroxyzine or promethazine permits 25–50% dosage reduction

Principal drugs

Meperidine (Demerol)---accumulates in renal disease, metabolite can cause siezures

Diphenoxylate + atropine (Lomotil) – C-V

- antidiarrhea- subtherapeutic dose of atropine to prevent abuse

PG 133

Drugs for MigraineDrugs for Migraine

Headache TypesHeadache Types

- - Tension, Cluster, MigraineTension, Cluster, Migraine

- Migraine is unilateral, pulsating, throbbing, with - Migraine is unilateral, pulsating, throbbing, with or w/o aura, or w/o aura,

nausea, photophobia, sonophobia nausea, photophobia, sonophobia

TreatmentsTreatments – – Prophylactic and AbortiveProphylactic and Abortive

AbortiveAbortiveAspirin - analgesic, antipyretic, anti-inflammatory, anti-plateletAspirin - analgesic, antipyretic, anti-inflammatory, anti-platelet

Acetaminophen—analgesic, antipyreticAcetaminophen—analgesic, antipyretic

NSAIDs - analgesic, antipyretic, anti-inflammatory (See Table pg. NSAIDs - analgesic, antipyretic, anti-inflammatory (See Table pg. 133)133)

• • Mechanism of actionMechanism of action

• • Common adverse effects: GI toxicity, hypersensitivity, renal effectsCommon adverse effects: GI toxicity, hypersensitivity, renal effects

Contraindications to the use of Imitrex include which of the following:

I. uncontrolled HTNII. use of and MAOI within the past 2

weeksIII. ischemic heart disease

a. I onlyb. III onlyc. I and II onlyd. II and III onlye. I, II, and III

Contraindications to the use of Imitrex include which of the following:

I. uncontrolled HTNII. use of and MAOI within the past 2

weeksIII. ischemic heart disease


PG 132

Drugs for Migraine

Abortive - (cont.)Abortive - (cont.)Dihydroergotamine (Migranal)Dihydroergotamine (Migranal)nasal spray; dose may be repeated nasal spray; dose may be repeated after 15 min – after 15 min – MOA – blocks alpha adrenergic causing vasoconstritionMOA – blocks alpha adrenergic causing vasoconstrition

5-HT15-HT1DD Receptor Agonists Receptor Agonistsavoid in patients with cardiovascular avoid in patients with cardiovascular diseasedisease

• • Almotriptan (Axert)Almotriptan (Axert)

• • Eletriptan (Relpax) – tablets; newest agent on the market – another “me-too”Eletriptan (Relpax) – tablets; newest agent on the market – another “me-too”

• Frovatriptan (Frova) – tablets; longest half life among agents

• • Naratriptan (Amerge) - tablets Naratriptan (Amerge) - tablets

• • Rizatriptan (Maxalt) - tablets; also Maxalt MLT Rizatriptan (Maxalt) - tablets; also Maxalt MLT (oral disintegrating tab)(oral disintegrating tab)

•• Sumatriptan (Imitrex) - Sumatriptan (Imitrex) - injection, tablet, nasal sprayinjection, tablet, nasal spray

• • Zolmitriptan (Zomig) - tablets; also Zomig ZMT (oral disintegrating tab)Zolmitriptan (Zomig) - tablets; also Zomig ZMT (oral disintegrating tab)

PG 133

Drugs for Migraine

Prophylactic Therapy

- Given to patients with >2-3 HA/month, severe HA, ineffective

treatment

Drugs of Choice:

- propranolol (Inderal) – use if patient also has HTN

- amitriptyline (Elavil) – concomitant depression

- valproate (Depakote) - concomitant seizures

Other agents:

- verapamil, topiramate

PathophysiologyPathophysiology

ComplicationsComplications

Source: www.arava.com

Rheumatoid ArthritisRheumatoid Arthritis Corticosteroids – early, acute, not long-term

- also NSAIDs / COX-2 Inhibitors

Disease Modifying Antirheumatic Drugs (DMARDs) – Disease Modifying Antirheumatic Drugs (DMARDs) – liver, hemeliver, hemeAuranofin (Ridaura) Auranofin (Ridaura) Aurothioglucose (Solganol)Aurothioglucose (Solganol)Azathioprine (Imuran)Azathioprine (Imuran)Cyclophosphamide (Cytoxan) Cyclophosphamide (Cytoxan) Cyclosporine (Neoral, Sandimmune) Cyclosporine (Neoral, Sandimmune) Gold sodium thiomalate (Myochrysine) Gold sodium thiomalate (Myochrysine) Hydroxychloroquine (Plaquenil)Hydroxychloroquine (Plaquenil) – retinal toxicity – Q 6 months – retinal toxicity – Q 6 monthsMethotrexate (Rheumatrex)Methotrexate (Rheumatrex)Leflunomide (Arava)---Preg Cat X, long half-life, hepatotoxicLeflunomide (Arava)---Preg Cat X, long half-life, hepatotoxic Penicillamine (Cuprimine, Depen)Penicillamine (Cuprimine, Depen)Sulfasalazine (Azulfindine) – orange-yellow urineSulfasalazine (Azulfindine) – orange-yellow urine

Corticosteroids – early, acute, not long-term - also NSAIDs / COX-2 Inhibitors

Disease Modifying Antirheumatic Drugs (DMARDs) – Disease Modifying Antirheumatic Drugs (DMARDs) – liver, hemeliver, heme

Auranofin (Ridaura) Auranofin (Ridaura) Aurothioglucose (Solganol)Aurothioglucose (Solganol)Azathioprine (Imuran)Azathioprine (Imuran)Cyclophosphamide (Cytoxan) Cyclophosphamide (Cytoxan) Cyclosporine (Neoral, Sandimmune) Cyclosporine (Neoral, Sandimmune) Gold sodium thiomalate (Myochrysine) Gold sodium thiomalate (Myochrysine) Hydroxychloroquine (Plaquenil)Hydroxychloroquine (Plaquenil) – retinal toxicity – Q 6 months – retinal toxicity – Q 6 monthsMethotrexate (Rheumatrex)Methotrexate (Rheumatrex)Leflunomide (Arava)---Preg Cat X, long half-life, hepatotoxicLeflunomide (Arava)---Preg Cat X, long half-life, hepatotoxic Penicillamine (Cuprimine, Depen)Penicillamine (Cuprimine, Depen)Sulfasalazine (Azulfindine) – orange-yellow urineSulfasalazine (Azulfindine) – orange-yellow urine

PG 134

GoldGold

Biologic Response ModifiersBiologic Response Modifiers

Etanercept (Enbrel) – avoid with live vaccine Etanercept (Enbrel) – avoid with live vaccine (soluble receptor TNF (soluble receptor TNF inhibitor)inhibitor)Anakinra (Kineret) – monitor for pulmonary problems Anakinra (Kineret) – monitor for pulmonary problems (IL-1 receptor (IL-1 receptor antagonist)antagonist)Infliximab (Remicade) – monitor for infection Infliximab (Remicade) – monitor for infection (monoclonal antibody (monoclonal antibody for TNF)for TNF)Adalimumab (Humira) – monitor for infection Adalimumab (Humira) – monitor for infection (monoclonal antibody (monoclonal antibody for TNF receptor)for TNF receptor)

Abatacept (Orencia®) – monitor for infection (Inhibits T-Cell (T-lymphocytes activation by binding to CD80 and CD86 on antigen presenting cells)

Osteoarthritis (OA)Osteoarthritis (OA)- acetaminophen & NSAIDs- acetaminophen & NSAIDs- surgery – knee/hip replacement- surgery – knee/hip replacement- glucosamine/chondrotin – NIH study (GAIT)- glucosamine/chondrotin – NIH study (GAIT)

Biologic Response ModifiersBiologic Response Modifiers

Etanercept (Enbrel) – avoid with live vaccine Etanercept (Enbrel) – avoid with live vaccine (soluble receptor TNF (soluble receptor TNF inhibitor)inhibitor)Anakinra (Kineret) – monitor for pulmonary problems Anakinra (Kineret) – monitor for pulmonary problems (IL-1 receptor (IL-1 receptor antagonist)antagonist)Infliximab (Remicade) – monitor for infection Infliximab (Remicade) – monitor for infection (monoclonal antibody (monoclonal antibody for TNF)for TNF)Adalimumab (Humira) – monitor for infection Adalimumab (Humira) – monitor for infection (monoclonal antibody (monoclonal antibody for TNF receptor)for TNF receptor)

Abatacept (Orencia®) – monitor for infection (Inhibits T-Cell (T-lymphocytes activation by binding to CD80 and CD86 on antigen presenting cells)

Osteoarthritis (OA)Osteoarthritis (OA)- acetaminophen & NSAIDs- acetaminophen & NSAIDs- surgery – knee/hip replacement- surgery – knee/hip replacement- glucosamine/chondrotin – NIH study (GAIT)- glucosamine/chondrotin – NIH study (GAIT)

PG 134

Joint Distribution: RA Compared to OARheumatoid Arthritis Osteoarthritis

SLE (systemic lupus erythematosus) occurs more frequently in:

a. male African Americans

b. Asians

c. post-menopausal women

d. people of Mediterranean origin

e. young women

SLE (systemic lupus erythematosus) occurs more frequently in:

a. male African Americans

b. Asians

c. post-menopausal women

d. people of Mediterranean origin

e. young women

Patients who are life time smokers have the greatest risk of leg pain associated with? a. hypokalemia

b. rhabdomylosisc. intermittent claudicationd. dopamine deficiency e. myocardial infarction

Patients who are life time smokers have the greatest risk of leg pain associated with? a. hypokalemia

b. rhabdomylosisc. intermittent claudicationd. dopamine deficiency e. myocardial infarction

Patients who are life time smokers have the greatest risk of leg pain associated with? a. hypokalemia (cramps)

b. rhabdomylosis (statins)c. intermittent claudication (PVD)d. dopamine deficiency (RLS)e. myocardial infarction

Patients who are life time smokers have the greatest risk of leg pain associated with? a. hypokalemia (cramps)

b. rhabdomylosis (statins)c. intermittent claudication (PVD)d. dopamine deficiency (RLS)e. myocardial infarction

Trigeminal neuralgia is treated by the use of:

a. aspirin

b. carbamazepine

c. dipyridamole

d. methylprednisolone

e. thiamine

Trigeminal neuralgia is treated by the use of:

a. aspirin

b. carbamazepine

c. dipyridamole

d. methylprednisolone

e. thiamine

When dispensing a prescription for Robitussin AC, the pharmacist should attach label(s) indicating:

I. May cause drowsinessII. Shake well before usingIII. Finish all of this medication


When dispensing a prescription for Robitussin AC, the pharmacist should attach label(s) indicating:

I. May cause drowsinessII. Shake well before usingIII. Finish all of this medication


Which of the following is/are appropriate warning(s) for the use of Duragesic transdermal system patches?

I. Do not cut patches before applyingII. Not intended for use in children under

the age of 12III. Replace patch every day unless pain is

under control a. I onlyb. III onlyc. I and II onlyd. II and III onlye. I, II, and III

Which of the following is/are appropriate warning(s) for the use of Duragesic transdermal system patches?

I. Do not cut patches before applyingII. Not intended for use in children under

the age of 12III. Replace patch every day unless pain is

under control a. I onlyb. III onlyc. I and II onlyd. II and III onlye. I, II, and III

The upper daily dosing regimen for naproxen is NOT more than:

a. 0.5 g

b. 1 g

c. 1.5 g

d. 2.5 g

e. 4 g


a. 0.5 g

b. 1 g

c. 1.5 g

d. 2.5 g

e. 4 g


a. 0.5 g

b. 1 g (mefenamic)

c. 1.5 g (naproxen)

d. 2.5 g

e. 4 g (acetaminophen)

Ibuprofen (3.2g) Indomethacin (200mg)


a. 0.5 g

b. 1 g (mefenamic)

c. 1.5 g (naproxen)

d. 2.5 g

e. 4 g (acetaminophen)

Ibuprofen (3.2g) Indomethacin (200mg)

Which of the following ingredients is are present in Percodan but not in Percocet:

I. AspirinII. AcetaminophenIII. Oxycodone


Which of the following ingredients is are present in Percodan but not in Percocet:

I. AspirinII. AcetaminophenIII. Oxycodone


Drugs for the Treatment of Asthma


NAPLEX

PG 142

Symptoms Nighttime Symptoms

Lung Function

Step 1Mild

Intermittent

Symptoms ≤ 2 times a week Asymptomatic and normal PEF between exacerbations Exacerbations brief (from a few hours to a few days); intensity may vary

≤ 2 times a month FEV1/PEF ≥ 80% predicated PEF variability < 20%

Step 2Mild

Persistent

Symptoms > 2 times a week but < 1 time a day Exacerbations may affect activity

> 2 times a month FEV1/PEF ≥ 80% predicated PEF variability < 20-30%

Step 3ModeratePersistent

Daily symptoms Daily use of inhaled short-acting beta-2 agonist Exacerbations affect activity Exacerbations ≥ 2 times a week; may last day

> 1 time a week FEV1/PEF > 60 - < 80% predicated PEF variability > 30%

Step 4Severe

Persistent

Continual Symptoms Limited Physical Activity Frequent Exacerbations

Frequent FEV1/PEF ≤ 60% predicated PEF variability > 30%

Classification

PG 142

Drugs for the Treatment of AsthmaDrugs for the Treatment of Asthma

phosphodiesterasephosphodiesterase

Adenyl cyclaseAdenyl cyclase cyclic AMP (bronchodilation) cyclic AMP (bronchodilation) eliminationelimination

SympathomimeticsSympathomimetics

Increase formation of cyclic AMPIncrease formation of cyclic AMP

NonselectiveNonselective

• • EphedrineEphedrine

• • Epinephrine (Adrenalin, Medihaler-Epi, Bronkaid, Primatene, Epinephrine (Adrenalin, Medihaler-Epi, Bronkaid, Primatene, etc.)etc.)

• • Ethylnorepinephrine (Bronkephrine)Ethylnorepinephrine (Bronkephrine)

PG 143


Selective Short-Acting Beta-2 Agonists. Selective Short-Acting Beta-2 Agonists. Provide Provide quick relief; may cause tachycardia, tremor, etc.quick relief; may cause tachycardia, tremor, etc.

• • Albuterol (Proventil, Ventolin, Airet, Albuterol (Proventil, Ventolin, Airet, Volmax) Volmax) 0.5hr peak, 4 0.5hr peak, 4 hours durationhours duration

• • Albuterol - oral sustained-release productAlbuterol - oral sustained-release product

• • Pirbuterol (Maxair) – Pirbuterol (Maxair) – Autoinhaler – longer duration 6 Autoinhaler – longer duration 6 hrs (tertiary butyl hrs (tertiary butyl group) group)

• • Levalbuterol (Xopenex) – Levalbuterol (Xopenex) – active isomer of albuterol, active isomer of albuterol, neb., less cardiac neb., less cardiac side effects side effects

• • Metaproterenol (Alupent, Metaprel) – Metaproterenol (Alupent, Metaprel) – delayed delayed onset (1 hour) & onset (1 hour) & prolonged prolonged effect (4 hour)effect (4 hour)

• • Terbutaline (Brethine, Bricanyl) – Terbutaline (Brethine, Bricanyl) – delayed onset delayed onset 1 hour & prolonged duration (6hr) – no-inhalation in U.S. & (management 1 hour & prolonged duration (6hr) – no-inhalation in U.S. & (management of pretermed labor)of pretermed labor)

• • isoproterenol (Isuprel, Medihaler-Iso) – isoproterenol (Isuprel, Medihaler-Iso) – beta-1 & beta-2 activitybeta-1 & beta-2 activity

Drugs for the Treatment of Asthma (cont.)

Long-Acting Beta-2 Agonists. Long-Acting Beta-2 Agonists. For long-term symptom control; For long-term symptom control; frequently used with frequently used with inhalational corticosteroids; may cause inhalational corticosteroids; may cause tachycardia, tremor,tachycardia, tremor, etc.; for prophylaxis only. etc.; for prophylaxis only.

• • Formoterol (Foradil) – DPI - capsuleFormoterol (Foradil) – DPI - capsule

• • Salmeterol (Serevent) – DPI – DiskusSalmeterol (Serevent) – DPI – Diskus

NOT SUITABLE AS A RESCUE INHALER!!!!!!!!!!!!!!NOT SUITABLE AS A RESCUE INHALER!!!!!!!!!!!!!!

PG 142

PG 142


XanthinesXanthinesPhosphodiesterase inhibitors; generally for prophylaxis; adverse Phosphodiesterase inhibitors; generally for prophylaxis; adverse effects similar to caffeineeffects similar to caffeine

• • Theophylline (Slo-Phyllin, Theolair, Theo-Dur)----Think Theophylline (Slo-Phyllin, Theolair, Theo-Dur)----Think drug interactions, serum levels 10-20, arryhthimogenic at high drug interactions, serum levels 10-20, arryhthimogenic at high levelslevels

• • Dyphylline (Lufyllin)Dyphylline (Lufyllin)theophylline derivativetheophylline derivative

• • Aminophylline (Somophyllin-CRT)Aminophylline (Somophyllin-CRT)anhydrous contains anhydrous contains 86% 86%

- 300mg theo (PO) = 380mg Amino (IV)- 300mg theo (PO) = 380mg Amino (IV)

theophylline, dihydrate 79%theophylline, dihydrate 79%

• • Oxtriphylline (Choledyl)Oxtriphylline (Choledyl)contains 64% theophyllinecontains 64% theophylline

Leukotriene receptor drugsLeukotriene receptor drugsFor prophylaxis; may reduce need for beta-2 agonistFor prophylaxis; may reduce need for beta-2 agonist

• • Zafirlukast (Accolate)Zafirlukast (Accolate)leukotriene receptor antagonistleukotriene receptor antagonist

• • Montelukast Sodium (Singulair)Montelukast Sodium (Singulair) leukotriene receptor leukotriene receptor antagonistantagonist

• • Zileuton (Zyflo)Zileuton (Zyflo)inhibits leukotriene formation (5-inhibits leukotriene formation (5-lipoxygenase inhibitor); lipoxygenase inhibitor);

monitor hepatic function, think DIs---potent inhibitormonitor hepatic function, think DIs---potent inhibitor

Zyflo CR will be given BID instead of QID. But patients will still need liver function tests every month for the first 3 months...then every 2 to 3 months for the rest of the first year. – 2007

Omalizumab. Save the monoclonal antibody, Xolair, for patients with severe asthma and allergies...who are not responding adequately to high-dose inhaled steroids and long-acting beta-agonists.

New NIH guidelines will improve asthma treatment. You'll see renewed emphasis on controlling symptoms...patient education...and avoiding allergens.

Zyflo CR will be given BID instead of QID. But patients will still need liver function tests every month for the first 3 months...then every 2 to 3 months for the rest of the first year. – 2007

Omalizumab. Save the monoclonal antibody, Xolair, for patients with severe asthma and allergies...who are not responding adequately to high-dose inhaled steroids and long-acting beta-agonists.

New NIH guidelines will improve asthma treatment. You'll see renewed emphasis on controlling symptoms...patient education...and avoiding allergens.

PG 142


CorticosteroidsCorticosteroids

Inhalational; reduce inflammation and bronchial reactivity; may Inhalational; reduce inflammation and bronchial reactivity; may cause oral candidiasis, cough, and other steroid effects (with cause oral candidiasis, cough, and other steroid effects (with prolonged use). Prophylaxis only.prolonged use). Prophylaxis only.

•• Beclomethasone dipropionate (Beclovent, Vanceril)Beclomethasone dipropionate (Beclovent, Vanceril)

• • Triamcinolone acetonide (Azmacort)Triamcinolone acetonide (Azmacort)

• • Flunisolide (Aerobid)Flunisolide (Aerobid)

• • Fluticasone propionate (Flovent)Fluticasone propionate (Flovent)

• • Mometasone (Asmanex Twisthaler)Mometasone (Asmanex Twisthaler)

• • Budesonide (Pulmicort) (Pulmicort Respules – only neb Budesonide (Pulmicort) (Pulmicort Respules – only neb ICS)ICS)

AnticholinergicsAnticholinergics

Ipratropium bromide (Atrovent); bronchodilator. Reduces Ipratropium bromide (Atrovent); bronchodilator. Reduces secretions; alternative to beta-2 agonists; anticholinergic secretions; alternative to beta-2 agonists; anticholinergic adverse effectsadverse effects

- combivent – albuterol and ipratropium- combivent – albuterol and ipratropium

Tiotropium (Spiriva)----long acting, dry powder capsule for Tiotropium (Spiriva)----long acting, dry powder capsule for inhalationinhalation

PG 143


Mast cell stabilizersMast cell stabilizers

Anti-inflammatory; very safe; for prophylaxis onlyAnti-inflammatory; very safe; for prophylaxis only

• • Cromolyn sodium (Intal, Nasalcrom)Cromolyn sodium (Intal, Nasalcrom)

• • Nedocromil sodium (Tilade)Nedocromil sodium (Tilade)

Combination productsCombination products

Ipratropium bromide/albuterol sulfate (Combivent)Ipratropium bromide/albuterol sulfate (Combivent)

Salmeterol xinafoate/fluticasone propionate (Advair Salmeterol xinafoate/fluticasone propionate (Advair Diskus)Diskus)

SymbicortSymbicort contains the corticosteroid budesonide ( contains the corticosteroid budesonide (PulmicortPulmicort)...plus the )...plus the long-acting beta-agonist formoterol (long-acting beta-agonist formoterol (ForadilForadil). - 2007 - 2 puffs BID ). - 2007 - 2 puffs BID

Side effects of oral corticosteroids include all of the following except:

a. hyperglycemia

b. nervousness

c. fluid retention

d. HPA axis suppression

e. thrombocytopenia

Side effects of oral corticosteroids include all of the following except:

a. hyperglycemia

b. nervousness

c. fluid retention

d. HPA axis suppression

e. thrombocytopenia

Patients exhibiting Cushing syndrome should avoid products containing:

a. corticosteriods

b. iodine

c. sulfas

d. penicillins

e. salicylates

Patients exhibiting Cushing syndrome should avoid products containing:

a. corticosteriods

b. iodine

c. sulfas

d. penicillins

e. salicylates

Which of the following drugs is/are administered by dry powder inhalation?

I. Ipratropium (atrovent of combivent)II. Pirbuterol (MaxAir Turboinhaler)III. Salmeterol (Diskus)


Which of the following drugs is/are administered by dry powder inhalation?



Which of the following drug(s) is/are administered by dry powder inhalation?



Which of the following drug(s) is/are administered by dry powder inhalation?



All of the following drugs are available as aerosol units EXCEPT:

a. Spiriva

b. Azmacort

c. Rhinocort

d. Beconase

e. Combivent

All of the following drugs are available as aerosol units EXCEPT:

a. Spiriva

b. Azmacort

c. Rhinocort

d. Beconase

e. Combivent

Drugs Used to Treat Glaucoma

Drugs Used to Treat Glaucoma

NAPLEX

PG 136

Causes of GlaucomaCauses of Glaucoma

• • Wide or open angle – most common, malfunction of trabecular Wide or open angle – most common, malfunction of trabecular meshworkmeshwork

• • Narrow angle or closed angle – Narrow angle or closed angle – obstruction of the outflowobstruction of the outflow of of aqueous humor through the trabecular meshwork.aqueous humor through the trabecular meshwork.

An instrument used to measure intraocular pressure is a(n):

a. gonioscope

b. otoscope

c. ophthalmoscope

d. tonometer

e. barometer


a. gonioscope

b. otoscope

c. ophthalmoscope

d. tonometer

e. barometer


a. gonioscope (lens to study angle of eye)

b. otoscope (instrument to examine the drum membrane of the ear)

c. ophthalmoscope (device to study interior of eye)

d. tonometer (device to measure intraocular pressure)

e. barometer (device to measure the atmospheric pressure)


a. gonioscope (lens to study angle of eye)

b. otoscope (instrument to examine the drum membrane of the ear)

c. ophthalmoscope (device to study interior of eye)

d. tonometer (device to measure intraocular pressure)

e. barometer (device to measure the atmospheric pressure)

PG 136

Drugs for Glaucoma TreatmentDrugs for Glaucoma Treatment

Goal of Therapy – reduced intraocular pressure (IOP)Goal of Therapy – reduced intraocular pressure (IOP)

- measured by a tonometer (10-20mmhg)- measured by a tonometer (10-20mmhg)

- decrease rate of aqueous humor production- decrease rate of aqueous humor production

- increase rate of outflow (drainage) of aqueous - increase rate of outflow (drainage) of aqueous

humor humor

SympathomimeticsSympathomimetics— — increase outflow and decrease increase outflow and decrease production of aqueous humorproduction of aqueous humor

- epinephrine (Epifrin, Glaucon) – discard if color change - epinephrine (Epifrin, Glaucon) – discard if color change occurs occurs

- dipiverfrin (Propine) – epinephrine prodrug – less side - dipiverfrin (Propine) – epinephrine prodrug – less side effectseffects

- apraclonidine (Iopidine) – alpha-2 agonist; - apraclonidine (Iopidine) – alpha-2 agonist; watch for watch for ocular ocular allergy allergy

- brimonidine (Alphagan) - - brimonidine (Alphagan) - alpha-2 agonist, alpha-2 agonist, more selectivemore selective

PG 136

Drugs for Glaucoma TreatmentDrugs for Glaucoma TreatmentMiotics (direct acting)—Miotics (direct acting)—have direct have direct cholinergic actioncholinergic action causing causing miosis; increases outflow, may cause eye pain, burning, blurred vision; miosis; increases outflow, may cause eye pain, burning, blurred vision; less with gel and Ocusert formulationsless with gel and Ocusert formulations

- acetylcholine (Miochol)- acetylcholine (Miochol)

- carbachol (Isoptocarbachol)- carbachol (Isoptocarbachol)

- - Pilocarpine (Isoptocarpine, Pilocar, Pilostat, Pilopine HS, Pilocarpine (Isoptocarpine, Pilocar, Pilostat, Pilopine HS, Ocusert Pilo)Ocusert Pilo)

Miotics (cholinesterase inhibitors)—Miotics (cholinesterase inhibitors)—increase cholinergic action by increase cholinergic action by inhibiting cholinesterase; similar adverse effects as direct-acting inhibiting cholinesterase; similar adverse effects as direct-acting mioticsmiotics

- physostigmine (Eserine) – may cause cataracts- physostigmine (Eserine) – may cause cataracts

- Demecarium (Humersol)- Demecarium (Humersol)

- Echothiophate (phospholine iodide)- Echothiophate (phospholine iodide)

mydriasismydriasis

PG 136

Drugs for Glaucoma TreatmentDrugs for Glaucoma TreatmentBeta-adrenergic blocking agentsBeta-adrenergic blocking agents — — reduce production of aqueous reduce production of aqueous humor; watch for possible breathing difficulty, bradycardia, humor; watch for possible breathing difficulty, bradycardia, hypotension, and CNS depressionhypotension, and CNS depression

- betaxolol (Betopic, Betoptic S) – beta 1 selective- betaxolol (Betopic, Betoptic S) – beta 1 selective

- levobetaxolol (Betaxon) – beta 1 selective- levobetaxolol (Betaxon) – beta 1 selective

- carteolol (Ocupress), levobunolol (Betagan, AKBeta)- carteolol (Ocupress), levobunolol (Betagan, AKBeta)

- metipranolol (Optipranolol), - metipranolol (Optipranolol),

- timolol (Timoptic, Timoptic XE) - timolol (Timoptic, Timoptic XE) B1 & B2B1 & B2

Prostaglandin analogsProstaglandin analogs — — increase outflow of aqueous humor; may increase outflow of aqueous humor; may darken iris color and cause thickened lashesdarken iris color and cause thickened lashes

- latanoprost (Xalatan)- latanoprost (Xalatan)

- bimatoprost (Lumigan)- bimatoprost (Lumigan)

- travoprost (Travatan)- travoprost (Travatan)

- Unoprostone (Rescula) - Unoprostone (Rescula) Not available in U.S.Not available in U.S.

PG 136

Drugs for Glaucoma TreatmentDrugs for Glaucoma Treatment

Carbonic anhydrase inhibitorsCarbonic anhydrase inhibitors — — suppress production of aqueous suppress production of aqueous humor; watch for urinary frequency and nephrolithiasishumor; watch for urinary frequency and nephrolithiasis

- dichlorphenarnide (Daranide)- dichlorphenarnide (Daranide)

- acetazolamide (Diamox)----oral capsules, IV – - acetazolamide (Diamox)----oral capsules, IV – Also used for Also used for mountain sicknessmountain sickness

- methazolamide (Neptazane)- methazolamide (Neptazane)

- dorzolamide (Trusopt)- dorzolamide (Trusopt)

- brinzolamide (Azopt) - brinzolamide (Azopt)

Osmotic diuretics----given orally or IVOsmotic diuretics----given orally or IV

-- glycerin (Osmoglyn) , mannitol (Osmitrol)glycerin (Osmoglyn) , mannitol (Osmitrol)

- urea (Ureaphil), isosorbide (Isomotic)- urea (Ureaphil), isosorbide (Isomotic)

Timoptic dosage forms include:I. capsule

II. tablet

III. ophthlamic solution

a. I only

b. III only

c. I and II only

d. II and III only

e. I, II, and III

Timoptic dosage forms include:I. capsule

II. tablet


a. I only

b. III only

c. I and II only

d. II and III only

e. I, II, and III

Dosage forms for timolol maleate include:I. gel

II. tablet


a. I only

b. III only

c. I and II only

d. II and III only

e. I, II, and III

Dosage forms for timolol maleate include:I. gel

II. tablet


a. I only

b. III only

c. I and II only

d. II and III only

e. I, II, and III

Glaucoma Case StudyGlaucoma Case Study

Page 138Page 138

Pilocarpine can be classified as a(n):

a. anticholinergic agent

b. carbonic anhydrase inhibitor

c. beta-adrenergic blocking agent

d. cholinergic agent

e. sympathomimetic agent

Pilocarpine can be classified as a(n):

a. anticholinergic agent

b. carbonic anhydrase inhibitor

c. beta-adrenergic blocking agent

d. cholinergic agent

e. sympathomimetic agent

An Ocusert Pilo-20 system:

a. is administered orally once daily

b. releases 20 mg of pilocarpine each day

c. must be replaced each month

d. releases 20 µg of pilocarpine each hour

e. must be soaked in normal saline just prior to use

An Ocusert Pilo-20 system:

a. is administered orally once daily

b. releases 20 mg of pilocarpine each day

c. must be replaced each month

d. releases 20 µg of pilocarpine each hour

e. must be soaked in normal saline just prior to use

A normal intraocular pressure reading would be:

a. 10-20 mm Hg

b. 20-30 mm Hg

c. 30-40 mm Hg

d. 40-50 mm Hg

e. 50-60 mm Hg


a. 10-20 mm Hg

b. 20-30 mm Hg

c. 30-40 mm Hg

d. 40-50 mm Hg

e. 50-60 mm Hg


a. 10-20 mm Hgb. 20-30 mm Hg c. 30-40 mm Hg d. 40-50 mm Hg e. 50-60 mm Hg


a. 10-20 mm Hgb. 20-30 mm Hg c. 30-40 mm Hg d. 40-50 mm Hg e. 50-60 mm Hg

Special caution must be used when timolol is used in patients with:

a. sulfonamide allergyb. asthma c. cancer d. hypertension e. NSAID hypersensitivity

Special caution must be used when timolol is used in patients with:

a. sulfonamide allergyb. asthma c. cancer d. hypertension e. NSAID hypersensitivity

analgesics naplex pg 132. treatment algorithm for pain patient in pain rating scale 0-10 mild pain...

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baclofen slide

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hydromorphone slide

pain patient

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abuse slide