PHARMACOLOGY DRUG LIST 14

1. PHARMACOLOGYDRUG LIST 14 MOD 200 A. JAMES

2. Immunomodulators • AVONEX • Interferon beta 1a • COPAXONE • glatiramer • TYSABRI • natalizumab

3. AVONEX • Indication: multiple sclerosis • Action: produced by mammalian cells (Chinese hamster ovary cells) where the human interferon beta gene has been introduced. The exact mechanism of action is not understood, but it exhibits immunoregulatory activities.

4. Warnings: photosensitivity, abortifacient potential (Induces abortion). Report symptoms of depression. • Administration: for IM use only. Patient must be trained with proper technique. Dilute with supplied diluents and gently swirl. Use reconstituted solution within 6 hours.

5. COPAXONE • Indication: multiple sclerosis • Action: unknown. It is thought to modify immune processes that are thought to be responsible for the pathogenesis (step by step development of the disease)of MS. • Warnings: for SC injection only. Watch for injection site reactions. Keep refrigerated

6. Administration: allow dose to warm to room temperature (20mins). Visually inspect for particulate matter or discoloration. Return any syringes that contain solution with particulate matter or is discolored.

7. TYSABRI • Indication: multiple sclerosis what is MSor crohn’s disease • Action: a recombinant humanized IgG4x monoclonal antibody. Mechanism of action is not clearly understood. • Restriction: patients must be registered through the TOUCH prescribing program. An MRI scan prior to treatment initiation is recommended – to create a baseline

8. Black box warning: progressive multifocal leukoencephalopathy—an opportunistic viral infection of the brain. Check medwatch web site for updates on this. • Warnings: PML, hypersensitivity reactions, hepatotoxicity. Headache, arthralgia or fatigue.

9. Administration: do not use vials that contain particulate matter or are discolored. Dilute 15ml of concentrate into 100ml of NS. Do not shake. No other diluents is to be used. Again check for discoloration or particulate matter. Use immediately; may be stored up to 8 hours if refrigerated

10. NARCOTIC ANALGESIC • Indications: severe pain or pain management • Action: the precise mechanism of analgesic action of narcotic or opioid analgesics is unknown. • Naturally or synthetically based from opium/opium products

11. Warnings: black box warning concerning addiction potential and risk of respiratory depression (especially when used with other CNS depressants). Withdrawal severity is related to the degree of dependence, the abruptness of withdrawal and the drug used. Chronic pain patients who withdrawn from medication abruptly may experience a severe abstinence syndrome that is similar to heroin. Maintain fluids, use tranquilizers to reduce anxiety. Narcotic replacement with gradual withdrawal may minimize symptoms.

12. No alcohol, D/D, may cause constipation. Take with food. • Drug interactions: numerous especially with agents that also affect the CNS

13. Actiq/Duragesic/Sublimaze CII • Fentanyl • Actiq: oral transmucosal lozenge to be dissolved slowly in the mouth to be absorbed by the transmucousal tissues. The handle is there so that it can be easily removed if signs of excessive opioid effects happen during administration.

14. Use: breakthrough pain in cancer patients 16yrs and older. Not for use in patients who are opiate naive • Warning: only intended for the care of cancer patients and prescribed only by pain specialists

15. Duragesic: transdermal patch • Use: for opioid tolerant patients to treat persistant moderate to severe pain that requires around the clock administration for an extended amount of time. • Administration: patch lasts up to 72hrs. Apply patch to a clean dry area. If hair removal is necessary; it should be clipped not shaven. Follow proper procedure in removal and disposal of used patches.

16. Sublimaze: injection • Use indicated for pain of short duration during anesthesia and in the immediate post op period as needed. Also may be used as a supplement in general or regional anesthesia. • Warning: black box warning concerning respiratory depression or arrest. Patients must be closely monitored

17. DILAUDID CII • Hydromorphone: • a hydrogenated ketone of morphine. • Use: in pain management when appropriate. • Warning: first sign of tolerance is when it doesn’t work well anymore. • Accidental skin exposure by oral solution: personnel should remove any contaminated clothing and rinse affected area with cool water

18. METHADOSE CII • Methadone: • synthetic opioid • Indications: pain management, detoxification and temporary maintenance treatment of narcotic addiction • Warnings: black box for treatment use, respiratory and cardiac effects. • http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&rgn=div5&view=text&node=42:1.0.1.1.9&idno=42 this page is federal code describing requirments for a treatment facility.

19. This medication was developed in Germany at the start of WWII in anticipation of disrupted opium supply. Wikipedia article covers this and rumors about the name dolophine.

20. MS CONTIN CII • Morphine sulfate extended release • Indication: relief of moderate to severe pain in patients requiring continuous opioid therapy for an extended period of time. Not intended for prn usage. • Other extended release forms include: Kadian, Avinza

21. Warnings: do not chew or crush, this may lead to rapid absorption to a potential fatal dose. • Notes about morphine in general: • Morphine is the standard against which all other narcotics are compared. • Heroin (diacetylmorphine) was developed from morphine and marketed by the Bayer drug company in 1898 • Morphine was one of the first drugs controlled (Harrison Narcotics Tax Act of 1914)

22. OXYCONTIN CII • Oxycodone extended release • Indication: same as morphine • Warnings: do not crush or chew, this may lead to rapid absorption to a potentially fatal dosage. • Appropriate dosing of extended release products should be every 12 hours.

23. Notes about oxycodone in general: • Developed in Germany as a replacement for heroin in early 20th century • In 2007, USA had the highest consumption world wide at a staggering 51.6 tons! • Washington State is considered one of the highest for number of prescriptions and number of thefts of oxycodone and other narcotics

24. Narcotic analgesic combos • Indication: relief of mild to moderately severe pain • Action: narcotic action plus non non-narcotic action of ASA or APAP for increased analgesic effect. • Warnings: take with food, D/D, no alcohol. May cause constipation. Watch OTC usage for additive APAP dosing

25. Watch for potentially fatal hepatic necrosis and APAP overdose. • Current standard of 4gms maximum APAP daily. • Acetylcysteine may be indicated as an antidote for APAP. http://www.rxlist.com/tylenol-drug.htm gives overdose management information

26. TYLENOL/CODEINE #3 CIII • Acetaminophen/Codeine #3 • Toxicity may result from codeine or APAP • If hypoprothrombinemia* occurs with APAP overdose, treat with IV vitamin K • *blood disorder , impaired clotting (factor II)

27. VICODIN CII • Hydrocodone/APAP • Use: moderate pain. May also be used as an antitussive • Watch APAP amounts • Watch strength • Generic tends to be #1 prescribed drug in USA • Usual dosing = 1-2 q4-6h prn pain

28. ENDOCET/PERCOCET CII • Oxycodone/APAP • Use moderate to mod. Severe pain. • If used for more than a few weeks; taper gradually to prevent symptoms of withdrawal. • Watch the use of additional CNS depressants ( alcohol, other opioids)

29. DARVOCET CIV • Propoxyphenenapsylate/APAP • Use: mild to moderate pain. CIV • Warning: metabolism of propoxyphene may be altered by strong CYP3A4 inhibitors like ritonovir, -azoleantifungals, grapefruit juice • Black box warning: major cause of drug related deaths. (medwatch has articles on this) http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm171714.htm . (article dated 7/09)

30. Non-narcotic analgesic • ULTRAM • tramadol • Indications: non narcotic analgesic for management of moderate to moderately severe pain in adults 17yr and older. • Action: centrally acting analgesic not chemically related to opiates. Causes less respiratory depression than morphine. Exact mechanism of action is unknown.

31. Warnings: no alcohol, D/D. • Drug interactions: MAOIs, carbamazepine, cyclobenzaprine, digoxin, SSRIs, TCAs

32. BENZODIAZEPINES • Indications: antianxiety, anticonvulsants, sedative hypnotics, muscle relaxants • Action: appear to potentiate the effects of GABA by binding to specific benzodiazepine receptor sites. • Warnings: avoid alcohol, D/D. do not drink grapefruit juice. Prolonged use may lead to dependence.

33. XANAX CIV • Alprazolam • Use: panic disorder, anxiety, depression • Do not use with grapefruit juice, -azoleantifungals. Nicotine decreases effect of medication • Drug interactions: BCPs, phenytoin, -azoleantifungals, digoxin, alcohol • Preg category D: may cause fetal harm

34. VALIUM CIV • Diazepam • Use: anxiety, muscle relaxant • Was given to sharpshooters during Vietnam conflict to calm nerves and give them a steady hand. • May also be used in acute alcohol withdrawal • Anterograde amnesia* may occur while using it for therapeutic dosages (*Anterograde amnesia is a loss of the ability to create memories after the event that caused the amnesiaoccurs) • Liver function tests are advisable for long term use

35. ATIVAN CIV • Lorazepam: • Use: anxiety disorders, or short term anxiety associated with depression, insomnia • Not indicated for long term use • Injection indicated for use in status epilepticus, preanesthetic. Store refrigerated, protect from light

36. MISC. ANXIETY • BUSPAR • Buspirone • Indication: short term use for anxiety. Off-label: reduce the symptoms of premenstrual syndrome • Action: MOA is unknown. It differs from typical benzodiazepines anxiolytics in that it does not exert anticonvulsant or muscle relaxant effects. • Warnings: D/D, avoid grapefruit juice • Drug interactions: CYP 3A inhibitors (azoleantifungals, some anticonvulsants etc), MAOIs

37. SEDATIVE HYPNOTIC • DIPRIVAN • Propofol • Indication: anesthesia • Action: fast acting hypnotic agent (within 40 seconds) • Warnings: only to be used by trained professional. Ability to perform activities may be impaired for some time after anesthesia/sedation • Medication is more stable in glass than plastic. • Medication is available as an injectableemulsion

38. VERSED CIV • Midazolam • Indication: sedation, anxiolysis, amnesia • Action: short acting benzodiazepine CNS depressant • Warnings: black box concerning noncritical care use. Patient must be monitored during use. To be used only by trained professionals. Drug is considered 3-4 times more potent than diazepam. Not for use on infants

39. ZEMURON • Rocuronium bromide • Indication: facilitate intubation, provide skeletal relaxation during surgery or mechanical ventilation (paralyzing agent) • Action: a nondepolarizing neuromuscular blocking agent with rapid to intermediate onset depending on dose and intermediate duration.

40. Warnings: to administered only by trained professionals. Patients must be monitored during use. • Drug interactions: anticonvulsants, lithium