Introduction NUR 555

1. IntroductionNUR 555 John Noviasky, PharmD jnoviask@stemc.org

2. Background • Expectations • Chapter Readings • Timeliness • Process development for Life-long Pharmacology course • Limitations • Time • New developments/ New Studies

3. Background (Cont) • Instructor Background • Guest Speakers

4. Medication Evaluation Algorithm(figure 1-2) • Individual Drug Evaluation • Indication • Effective • Adverse Effect • Is cost an Issue

5. Medication Evaluation Algorithm(figure 1-2) • Entire Drug Regimen • Duplicate Therapy • Drug Interactions • Evaluate Adherence

6. Monitoring Questions • Is the treatment working • Is there evidence of side effects (ADR, Allergy, medical problem, lab abnormal) • How adherent is patient to prescribed therapy • Is there Drug interactions or duplications within patients therapy • Are there any contraindications or allergies that need to be considered

7. Monitoring Questions • Is the patient pregnant • Are the doses, dosage regimens, and dosage forms correct • Have adjustments been made for renal function, hepatic function, age and body size • Could a less expensive or more convenient dosage form be used • Do all drugs have an indication • Do all indications have a drug

8. Possible Adverse Drug Effect • Phenytoin Toxicity • Ataxic gait, blurred vision, nystagmus, slurred speech, dizziness, drowsiness, lethargy, coma, rash, fever, nausea, vomiting, confusion • >20 mcg/ml - nystagmus • >30 mcg/ml - ataxia • >40 mcg/ml - decreased mentation • >100 mcg/ml - death

9. Whats the next step? • Take care of the problem • Report the adverse event • Pharmacy • Medwatch/FDA • Rationale for reporting • Can alert for unusual adverse effects

10. Allergy v ADE • Allergy - immune mediated, common in antibiotics, generally reproducible no matter the degree of exposure • ADE - mechanism and concentration related, e.g. phenytoin affects CNS (decrease sodium ions across cell membranes in motor cortex) thus CNS side effects at higher concentrations. Smaller dose may not have same effect

11. Drug Information • Paper - • Not updated, can become worn out • PDR, AHFS • Electronic - • Updated, easier to search, Some are free • Lexi-com - nice search feature, complete, $$$ • epocrates - reasonable database, FREE • Micromedex - extensive database, $$$$$$

12. Corticosteroid (CS) Adverse Effect • Adrenocortical insufficiency • decreased secretion of endogenous CS, • when subject to stress (infection, surgery,trauma) these patients require higher CS dosage • Taper gradually • May persist up to 12 months in pts on large doses for extended periods

13. Corticosteroid (CS) Adverse Effect • Musculoskeletal • Muscle wasting, muscle pain/weakness, delayed wound healing, atrophy of protein matrix of bone resulting in osteoporosis, fractures, aseptic necrosis of femoral or hymeral heads • Increase susceptibility to infection • most common effect of oral inhalation • Candida Albicans, Aspergillus of mouth, pharynx

14. Corticosteroid (CS) Adverse Effect • Fluid and Electrolyte Disturbance • Sodium retention-> edema, hypokalemia, hypertension, congestive heart failure, Less common with methylprednisolone, dexamethasone, but can occur • Ocular Effects • cataracts, glaucoma • Endocrine • Hypercorticism (Cushingnoid state), amenorrhea, hyperglycemia, diabetes, hypercholesterolemia

15. Corticosteroid (CS) Adverse Effect • GI Effects • Nausea (take with food), vomiting, anorexia (weight loss), increased appetite (weight gain), diarrhea, constipation, pancreatitis, ulcerative esophagitis, peptic ulcers • Nervous system effects • Headache, vertigo, insomnia, restlessness, increased motor activity, seizures • euphoria, mood swings, depression, anxiety, psychosis

16. Corticosteroid (CS) Adverse Effect • Dermatologic • Impaired wound healing, skin atrophy and thinning, acne, increased sweating, hirsuitism, facial erythema, easy bruising • Other adverse effects • Abrupt discontinuation (Steroid withdrawal syndrome) • anorexia, nausea, vomiting, lethargy, headache, fever, joint pain, myalgia, hypotension