Introduction An adverse drug reaction (ADRs) is an unwanted, undesirable effect of a medication that occurs during usual clinical use. Adverse drug reactions occur almost daily in health care institutions and can adversely affect a patient’s quality of life, often causing considerable morbidity and mortality. Adverse drug reactions may cause patients to lose confidence in or have negative emotions toward their physicians and seek self-treatment options, which may consequently precipitate additional ADRs. Around 5% of all hospital admissions are the result of an ADR, and around 10%– 20% of inpatients will have at least one ADR during their hospital stay (Kongkaew 2008; Lundkvist 2004; Pirmohamed 1998). This article discusses methods of ADR detection and classification and associated treatment strategies. Defining ADRs The definition of an ADR is often confused with that of an adverse drug event (ADE). The World Health Organization (WHO) defines an ADE as “Any untoward medical occurrence that may present during treatment with a pharmaceutical product but which does not necessarily have a causal relationship with this treatment” (WHO 2005). The WHO defines an ADR as “a response to a drug which is noxious and unintended and which occurs at doses normally used in man for prophylaxis, diagnosis, or therapy of disease or for the modification of physiologic function.” Classification of ADRs Adverse drug reactions were originally classified into two subtypes. Type A ADRs are dose-dependent and predictable; they are augmentations of known pharmacologic effects of the drug, such as orthostatic hypotension with antihypertensive medications. Type B ADRs are uncommon and unpredictable, depending on the known pharmacology of the drug; they are independent of dose and affect a small population, suggesting that individual patient host factors are important (Pirohamed 2003; Edwards 2000). Hypersensitivity (allergic) reactions to drugs are examples of type B ADRs. Type A reactions were later called augmented, and type B reactions, bizarre. Two further types of reactions were eventually added: chronic reactions, which relates to both dose and time (type C), and delayed reactions (type D). Withdrawal later became the fifth category (type E), and most recently, unexpected failure of therapy became the sixth (type F) (Rohilla 2013; Edwards 2000). Type of Reaction (Mnemonic) Features Examples Management A: Dose related (Augmented) Common Related to the pharmacologic action of the drug – exaggerated pharmacologic response Predictable Low mortality Dry mouth with tricyclic antidepressants, respiratory depression with opioids, bleeding with warfarin, serotonin syndrome with SSRIs, digoxin toxicity Reduce dose or withhold drug Consider effects of concomitant therapy B: Non–dose related (Bizarre) Uncommon Not related to the pharmacologic action of the drug Unpredictable High mortality Immunologic reactions: anaphylaxis to penicillin Idiosyncratic reactions: malignant hyperthermia with general anesthetics Withhold and avoid in future C: Dose related and time related (Chronic) Uncommon Related to the cumulative dose Hypothalamic-pituitary-adrenal axis suppression by corticosteroids, osteonecrosis of the jaw with bisphosphonates Reduce dose or withhold; withdrawal may have to be prolonged D: Time related (Delayed) Uncommon Usually dose related Occurs or becomes apparent sometime after use of the drug Carcinogenesis Tardive dyskinesia Teratogenesis Leucopenia with lomustine Often intractable E: Withdrawal (End of use) Uncommon Occurs soon after withdrawal of the drug Withdrawal syndrome with opiates or benzodiazepines (e.g., insomnia, anxiety) Reintroduce drug and withdraw slowly F: Unexpected failure of therapy (Failure) Common Dose related Often caused by drug interactions Inadequate dosage of an oral contraceptive when used with an enzyme inducer Resistance to antimicrobial agents Increase dosage Consider effects of concomitant therapy Populations at Greatest Risk Due To ADRs Pediatrics Adverse drug reactions are common in the pediatric population. Developmental changes affect the pharmacodynamics and pharmacokinetics of many of the drugs used in neonates, infants, and children. For example, gastric emptying is delayed in neonates and infants, resulting in longer absorption time and potentially increasing the risk of an ADR. The volume of distribution also differs, compared with adults, as does protein-binding capacity, phase I and II metabolic pathways, and glomerular filtrate rate. Therefore, extrapolation of pediatric dosages from adult dosages should be avoided (Fabiano 2012). Geriatrics The WHO defines elderly as individuals 60 years and older. The percentage of people in this age category continues to rise and the total is expected to reach 2 billion by 2050 (Brahma 2013). As the number of drugs increases, the risk of medication nonadherence also increases, further increasing the risk of an ADR. By examining the patient’s medication record and evaluating for duplicate therapies or medications being used to potentially treat ADRs caused by other medications, pharmacists can help reduce unnecessary prescribing and optimize the patient’s drug therapy regimen. Detecting and preventing ADRs in the older adult population remains a challenging, yet important part of good clinical practice. Tools available to assist in evaluating potentially inappropriate prescribing in older adults include the Beers Criteria, IPET (Improved Prescribing in the Elderly Tool), MAI (Medication Appropriateness Index), and STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) (Petrovic 2012). Renal and Hepatic Impairment Most drugs are metabolized by the liver and excreted by the kidneys. Impairment or failure of either of these organs can affect drug absorption, distribution, bioavailability, CYP metabolism, and clearance. Monitoring the laboratory values and adjusting the doses of drugs using these metabolic and excretory pathways can prevent an ADR. Special consideration should be given to identifying and, if possible, avoiding drugs that undergo extensive hepatic first-pass metabolism in patients with hepatic impairment. Pharmacovigilance can be used to assist prescribers with dosing or alternative drug selection in these patients. Conclusion As medication experts, pharmacists are a vital part of the treatment team, especially when an ADR occurs. Treating an ADR consists mainly of supportive therapy with symptom management. Furthermore, additional steps should be taken to determine the cause of the patient’s symptoms and whether they can be attributed to the use of a drug. Begin by evaluating the nature of the event. Thoroughly review the medical history available in the patient’s chart. Identify and document the clinical reaction, including the patient’s subjective report of symptoms. Review the patient’s medication list, and then
Warning! 10 Drugs That May Cause Memory Loss
Dementia is an overall term for diseases and conditions characterized by a decline in memory, language, problem-solving and other thinking skills that affect a person’s ability to perform everyday activities. Memory loss is an example. Alzheimer’s is the most common cause of dementia. Causes Of Dementia Dementia is caused by damage to brain cells. This damage interferes with the ability of brain cells to communicate with each other. When brain cells cannot communicate normally, thinking, behavior and feelings can be affected. The brain has many distinct regions, each of which is responsible for different functions (for example, memory, judgment, and movement). When cells in a particular region are damaged, that region cannot carry out its functions normally. Different types of dementia are associated with particular types of brain cell damage in particular regions of the brain. For example, in Alzheimer’s disease, high levels of certain proteins inside and outside brain cells make it hard for brain cells to stay healthy and to communicate with each other. The brain region called the hippocampus is the center of learning and memory in the brain, and the brain cells in this region are often the first to be damaged. That’s why memory loss is often one of the earliest symptoms of Alzheimer’s. While most changes in the brain that cause dementia are permanent and worsen over time, thinking and memory problems caused by the following conditions may improve when the condition is treated or addressed: Depression Medication side effects Excess use of alcohol Thyroid problems Vitamin deficiencies 10 Drugs That May Cause Memory Loss 1. Antianxiety drugs2. Cholesterol drugs3. Antiseizure drugs4. Antidepressant drugs5. Narcotic painkillers6. Parkinson’s drugs7. Hypertension drugs8. Sleeping aids9. Incontinence drugs10. Antihistamines 1. Antianxiety drugs (Benzodiazepines) Why they are prescribed: Benzodiazepines are used to treat a variety of anxiety disorders, agitation, delirium and muscle spasms, and to prevent seizures. Because benzodiazepines have a sedative effect, they are sometimes used to treat insomnia and the anxiety that can accompany depression. Examples: Alprazolam (Xanax), chlordiazepoxide (Librium), clonazepam (Klonopin), diazepam (Valium), flurazepam (Dalmane), lorazepam (Ativan), midazolam (Versed), quazepam (Doral), temazepam (Restoril) and triazolam (Halcion) 2. Cholesterol-lowering drugs (Statins) Why they are prescribed: Statins are used to treat high cholesterol. Examples: Atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), pravastatin (Pravachol), rosuvastatin (Crestor) and simvastatin (Zocor). How they can cause memory loss: Drugs that lower blood levels of cholesterol may impair memory and other mental processes by depleting brain levels of cholesterol as well. In the brain, these lipids are vital to the formation of connections between nerve cells — the links underlying memory and learning. (The brain, in fact, contains a quarter of the body’s cholesterol.) A study published in the journal Pharmacotherapy in 2009 found that three out of four people using these drugs experienced adverse cognitive effects “probably or definitely related to” the drug. The researchers also found that 90 percent of the patients who stopped statin therapy reported improvements in cognition, sometimes within days. In February 2012, the Food and Drug Administration ordered drug companies to add a new warning label about possible memory problems to the prescribing information for statins. Alternatives: If you’re among the many older Americans without known coronary disease who are taking these drugs to treat your slightly elevated LDL (“bad”) cholesterol and low HDL (“good”) cholesterol), ask your doctor or other health care provider about instead taking a combination of sublingual (under-the-tongue) vitamin B12 (1,000 mcg daily), folic acid (800 mcg daily) and vitamin B6 (200 mg daily). 3. Antiseizure drugs Why they are prescribed: Long used to treat seizures, these medications are increasingly prescribed for nerve pain, bipolar disorder, mood disorders, and mania. Examples: Acetazolamide (Diamox), carbamazepine (Tegretol), ezogabine (Potiga), gabapentin (Neurontin), lamotrigine (Lamictal), levetiracetam (Keppra), oxcarbazepine (Trileptal), pregabalin (Lyrica), rufinamide (Banzel), topiramate (Topamax), valproic acid (Depakote) and zonisamide (Zonegran). How they can cause memory loss: Anticonvulsants are believed to limit seizures by dampening the flow of signals within the central nervous system (CNS). All drugs that depress signaling in the CNS can cause memory loss. Alternatives: Many patients with seizures do well on phenytoin (Dilantin), which has little if any impact on memory. Many patients with chronic nerve pain find that venlafaxine (Effexor) — which also spares memory — alleviates their pain. 4. Antidepressant drugs (Tricyclic antidepressants) Why they are prescribed: TCAs are prescribed for depression and, increasingly, anxiety disorders, eating disorders, obsessive-compulsive disorder, chronic pain, smoking cessation and some hormone-mediated disorders, such as severe menstrual cramps and hot flashes. Examples: Amitriptyline (Elavil), clomipramine (Anafranil), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), nortriptyline (Pamelor), protriptyline (Vivactil) and trimipramine (Surmontil). How they can cause memory loss: About 35 percent of adults taking TCAs report some degree of memory impairment and about 54 percent report having difficulty concentrating. TCAs are thought to cause memory problems by blocking the action of serotonin and norepinephrine — two of the brain’s key chemical messengers. Alternatives: Talk with your health care provider about whether nondrug therapies might work just as well or better for you than a drug. 5. Narcotic painkillers Why they are prescribed: Also called opioid analgesics, these medications are used to relieve moderate to severe chronic pain, such as the pain caused by rheumatoid arthritis. Examples: Fentanyl (Duragesic), hydrocodone (Norco, Vicodin), hydromorphone (Dilaudid, Exalgo), morphine (Astramorph, Avinza) and oxycodone (OxyContin, Percocet). These drugs come in many different forms, including tablets, solutions for injection, transdermal patches, and suppositories. How they can cause memory loss: These drugs work by stemming the flow of pain signals within the central nervous system and by blunting one’s emotional reaction to pain. Both these actions are mediated by chemical messengers that are also involved in many aspects of cognition. So the use of these drugs can interfere with long- and short-term memory, especially when used for extended periods of time. Alternatives: In patients under the age of 50 years, nonsteroidal anti-inflammatory drugs (NSAIDs) are the frontline therapy for pain. Unfortunately, NSAID therapy is less appropriate for older patients, who have a much higher risk of dangerous gastrointestinal bleeding. Research shows the risk goes up with the dosage and duration of treatment. 6. Parkinson’s drugs (Dopamine agonists) Why they are
Handling of LASA (Look-Alike Sound-Alike) Drugs
Look-Alike Sound-Alike (LASA) medications include medications that are visually the same in physical appearance or packaging and names of medications that have similar spelling or similar phonetics. As more medicines and new brands are being marketed in addition to the thousands already available, many of these medication names may look or sound alike. Confusing medication names and similar product packaging may lead to potentially harmful medication errors. The increasing potential for LASA medication errors was also highlighted in the Joint Commission’s Sentinel Event Alert. Emphasis on patient safety in the naming of medicines is now undertaken by national and international regulatory and advisory boards. The World Health Organisation’s International Non-proprietary Names Expert Group works to develop international non-proprietary names for pharmaceutical medicinal substances for acceptance worldwide. Healthcare organizations need to institute risk management strategies to minimize adverse events with LASA medications and enhance patient safety. To aid in this effort, this article on Handling of Look-Alike Sound-Alike Medications is published, it is hoped that errors relating to LASA medications can be minimized, if not eliminated, through identification and implementation of safety precautions. Common Risk Factors Common risk factors associated with LASA medications include: Illegible handwriting Incomplete knowledge of drug names Newly available products Same packaging or labeling Similar strengths, dosage forms, frequency of administration Similar clinical use Strategies To Avoid Errors Procurement Storage Prescribing Dispensing/Supply Administration Patient Education 1. Procurement (a) Minimize the availability of multiple medicine’s strengths. (b) Whenever possible, avoid the purchase of medicines with similar packaging and appearance. As new products or packages are introduced, compare them with existing packaging. 2. Storage (a) Use Tall Man lettering to emphasize differences in medications with sound-alike names. Tall Man lettering (or Tallman lettering) is the practice of writing part of a medicine name in upper case letters to help distinguish soundalike, look-alike medications from one another to avoid medication errors. Tall Man lettering involves highlighting the dissimilar letters in two names to aid in distinguishing between the two. The Institute for Safe Medication Practices (ISMP), U.S Food and Drug Administration (FDA), The Joint Commission and other safety-conscious organizations have promoted the use of Tall Man lettering as one means of reducing confusion between similar medication names. Examples of Tall Man lettering are metFORMIN and metoPROLOL. (b) Use additional warning labels for look-alike medicines. Warning labels should be uniform throughout the respective facility to facilitate identification. 3. Prescribing (a) Write legibly. Write clearly whether on an inpatient order or on a prescription. (b) The prescription should clearly specify the name of the medication, dosage form, dose and complete direction for use. (c) Include the diagnosis or medication’s indication for use. This information helps to differentiate possible choices in illegible orders. (d) Whenever possible, drug names in computerized prescriber order entry (CPOE) should incorporate Tall Man lettering. (e) Communicate clearly. Take your time in pronouncing the drug name whenever an oral order has to be made. Ask that the recipient of the oral communication repeat the medication name and dose. Verbal orders should be limited to emergency situations only. 4. Dispensing (a) Identify medicines based on their name and strength and not by its appearance or location. (b) Check the appropriateness of the dose for the medicines dispensed. (c) READ medication labels carefully at all dispensing stages and perform a triangle check. Triangle check is to check actual medicines against the medicines’ labels and against the prescription. (d) Double-checking should be conducted during the dispensing and supply process. (e) Highlight changes in medication appearances to patients upon dispensing. 5. Administration Read medication labels carefully during the administration process and perform a triangle check. Triangle check is to check medicine against the medication label and against the prescription. 6. Patient Education (a) Inform patients on changes in medication appearances. (b) Educate patients and their caregivers to alert healthcare providers whenever a medication appears to vary from what is usually taken or administered. (c) Encourage patients and their caregivers to learn the names of their medications. Table 1. FDA-Approved List of Generic Drug Names with Tall Man Letters
11 Drug Interactions Every Pharmacist Should Know
Drug-Drug interactions are defined as the change in efficacy or toxicity of one drug by prior or concomitant administration of a second drug. Drug interactions always involve Pharmacokinetics Pharmacodynamics In pharmacodynamic interactions, one drug alters the sensitivity or responsiveness of tissues to another drug by having the same (agonistic) or a blocking (antagonistic) effect. These effects usually occur at the receptor level but may occur intracellularly. In pharmacokinetic interactions, a drug usually alters absorption, distribution, protein binding, metabolism, or excretion of another drug. Thus, the amount and persistence of available drugs at receptor sites change. Pharmacokinetic interactions alter magnitude and duration, not type, of effect. They are often predicted based on knowledge of individual drugs or detected by monitoring drug concentrations or clinical signs. 11 Drug Interactions Following below are the clinically important drug interactions a pharmacist should know. 1. Fluoxetine and Phenelzine Object drug Precipitant Drug Effect Mechanism Related Drugs Options Fluoxetine Phenelzine Central serotonin syndrome Inhibit serotonin metabolism, monoamine oxidase inhibitors (MAOIs) may potentiate the pharmacologic activity of selective serotonin reuptake inhibitors (SSRIs) Dextromethorphan, Meperidine, and other selective serotonin reuptake inhibitors (SSRIs) You should wait at least 14 days after stopping Phenelzine before you start treatment with Fluoxetine. 2. Digoxin and Quinidine Object drug Precipitant Drug Effect Mechanism Related Drugs Options Digoxin Quinidine Interaction range from nausea and vomiting to death A marked increase in plasma concentration levels of digoxin – Pharmacists should anticipate the need to reduce the digoxin dose by one half 3. Sildenafil and Isosorbide Mononitrate Object drug Precipitant Drug Effect Mechanism Related Drugs Options Sildenafil Isosorbide mononitrate Sildenafil may markedly increase the hypotensive effects of isosorbide mononitrate In the presence of PDE5 inhibitors, nitrates can cause intense increases in cyclic guanosine monophosphate and dramatic drops in blood pressure Nitroglycerin Pharmacists should advise patients not to take sildenafil with isosorbide mononitrate and nitroglycerin 4. Potassium Chloride and Spironolactone Object drug Precipitant Drug Effect Mechanism Related Drugs Options Potassium Chloride Spironolactone Hyperkalemia which will lead to cardiac failure and death Excretion of sodium ions while saving potassium ions Amiloride or triamterene absorbable forms of potassium bicarbonate, citrate, acetate, glauconite, and iodide salts Patients who are prescribed spironolactone must undergo an evaluation of serum potassium levels 5. Clonidine and Propranolol Object drug Precipitant Drug Effect Mechanism Related Drugs Options Clonidine Propranolol Mysterious hypertension Clonidine is a central alpha-2 adrenergic agonist that suppresses the sympathetic nervous system from the brain. This activity leads to a decrease in the norepinephrine amounts available in the synaptic cleft of the adrenergic neuron. Alpha-1 receptors then become sensitized because of less norepinephrine available in the cleft. When clonidine is suddenly withdrawn, the result is a large increase in norepinephrine in the synaptic cleft of the adrenergic neuron. The sensitized alpha-1 receptors are stimulated, leading to an exaggerated vasoconstriction. — Avoid taking these two drugs simultaneously 6. Warfarin and Diflunisal Object drug Precipitant Drug Effect Mechanism Related Drugs Options Warfarin Diflunisal G.I Bleeding ·Antiplatelet effects and GI erosion associated with NSAIDs and the anticoagulant effect of warfarin.·Some individual NSAIDs may also alter the pharmacokinetics of warfarin Keto-profen, piroxicam, sulindac, diclofenac, and ketorolac A non-NSAID alternative such as acetaminophen or opioid analgesics is preferred. To be cautious, limit the acetaminophen dose to 2 g/day for no more than 7 days. INR should be monitored closely when acetaminophen exceeds 2 g/day or chronic use >7 days occurs. 7. Theophylline and Ciprofloxacin Object drug Precipitant Drug Effect Mechanism Related Drugs Options Theophylline Ciprofloxacin Toxic increases in theophylline Hepatic metabolism of theophylline is inhibited by ciprofloxacin via the cytochrome P-450 enzyme system Clarithromycin, erythromycin, fluvoxamine, and cimetidine Levofloxacin or ofloxacin should be considered as an alternative to ciprofloxacin 8. Pimozide and Ketoconazole Object drug Precipitant Drug Effect Mechanism Related Drugs Options Pimozide Ketoconazole Prolong the QT interval, Ventricular arrhythmias Pimozide is a CYP3A4 enzyme substrate, and ketoconazole is a potent inhibitor of CYP3A4. This leads to marked increases in pimozide serum levels Itraconazole, clarithromycin, erythromycin, diltiazem, and nefazodone Terbinafine should be considered as an alternative to Ketoconazole 9. Methotrexate and Probenecid Object drug Precipitant Drug Effect Mechanism Related Drugs Options Methotrexate Probenecid Increase in methotrexate levels Probenecid acts as an active tubular secretion inhibitor and prevents methotrexate from being excreted, thus potentially causing toxicity. Penicillin’s and Salicylates Use Acetaminophen alternative to Salicylates or NSAID’s 10. Bromocriptine and Pseudoephedrine Object drug Precipitant Drug Effect Mechanism Related Drugs Options Bromocriptine Pseudoephedrine Severe peripheral vasoconstriction, ventricular tachycardia, seizures, and possibly death The mechanism may be due to the synergistic effects of both drugs on the dopaminergic system. — If these two drugs must be taken concurrently, the patient’s cardiovascular and mental status should be closely monitored. 11. Simvastatin and Amiodarone Object drug Precipitant Drug Effect Mechanism Related Drugs Options Simvastatin Amiodarone Increased simvastatin/ lovastatin concentrations and risk of myopathy/ rhabdomyolysis Inhibition of the metabolism of simvastatin/ lovastatin by CYP3A4 — Preferable statin alternatives include fluvastatin, rosuvastatin, or pravastatin. Predisposing risk factors for rhabdomyolysis include advanced age (>65 years), uncontrolled hypothyroidism, and renal impairment.
Coronavirus: Must-Know Information For Pharmacists
A novel coronavirus is a new strain of coronavirus that has not been previously identified in humans. Coronaviruses (CoV) are a large family of viruses transmitting between animals and people that cause illness ranging from the common cold to more severe diseases such as the Middle East respiratory syndrome (MERS-CoV) and severe acute respiratory syndrome (SARS-CoV). Symptoms Common human coronaviruses, including types 229E, NL63, OC43, and HKU1, usually cause mild to moderate upper-respiratory tract illnesses, like the common cold. Most people get infected with these viruses at some point in their lives. These illnesses usually only last for a short amount of time. Symptoms may include runny nose headache cough sore throat fever a general feeling of being unwell Human coronaviruses can sometimes cause lower-respiratory tract illnesses, such as pneumonia or bronchitis. This is more common in people with cardiopulmonary disease, people with weakened immune systems, infants, and older adults. Diagnosis A community pharmacist or health care provider may order laboratory tests on respiratory specimens and serum (part of your blood) to detect human coronaviruses. Laboratory testing is more likely to be used if someone suffering from severe disease or is suspected of having MERS. If your patient experiencing symptoms, you should ask him about any recent travel or contact with animals. Most MERS-CoV infections have been reported from countries in the Arabian Peninsula. Therefore reporting a travel history or contact with camels or camel products is very important when trying to diagnose MERS. Transmission Human coronaviruses most commonly spread from an infected person to others through the air by coughing and sneezing close personal contact, such as touching or shaking hands touching an object or surface with the virus on it, then touching your mouth, nose, or eyes before washing your hands rarely, fecal contamination In the United States, people usually get infected with common human coronaviruses in the fall and winter. However, you can get infected at any time of the year. Most people will get infected with one or more of the common human coronaviruses in their lifetime. Young children are most likely to get infected. However, people can have multiple infections in their lifetime. Prevention How to Protect Yourself? There are currently no vaccines available to protect you against human coronavirus infection. You may be able to reduce your risk of infection by doing the following wash your hands often with soap and water for at least 20 seconds avoid touching your eyes, nose, or mouth with unwashed hands avoid close contact with people who are sick How to Protect Others? If you have cold-like symptoms, you can help protect others by doing the following stay home while you are sick avoid close contact with others cover your mouth and nose with a tissue when you cough or sneeze, then throw the tissue in the trash and wash your hands clean and disinfect objects and surfaces Treatment There are no specific treatments for illnesses cause by human coronaviruses. Most people with common human coronavirus illness will recover on their own. However, you can do some things to relieve your symptoms take pain and fever medications (Caution: do not give Aspirin to children) use a room humidifier or take a hot shower to help ease a sore throat and cough If you are mildly sick, you should drink plenty of liquids stay home and rest
Hypertension Drugs: A Comprehensive Review
Blood pressure is the force exerted by circulating blood against the walls of the body’s arteries, the major blood vessels in the body. Hypertension is when blood pressure is too high. The drugs which are used to treat hypertension are known as hypertension drugs. Blood pressure is written as two numbers. The first (systolic) number represents the pressure in blood vessels when the heart contracts or beats. The second (diastolic) number represents the pressure in the vessels when the heart rests between beats. WHO Key Facts on Hypertension Hypertension – or elevated blood pressure – is a serious medical condition that significantly increases the risks of heart, brain, kidney and other diseases. An estimated 1.13 billion people worldwide have hypertension, most (two-thirds) living in low- and middle-income countries. In 2015, 1 in 4 men and 1 in 5 women had hypertension. Fewer than 1 in 5 people with hypertension have the problem under control. Hypertension is a major cause of premature death worldwide. Hypertension Drugs List There are several classes of hypertension drugs. Each class lowers blood pressure in a different way. 1. DIURETICS Diuretics increase urination which reduces sodium and fluid in the body. That can help lower blood pressure because it lowers blood volume. Mild hypertension can sometimes be treated using diuretics alone, although they are more commonly used in combination with other high blood pressure medications. Examples of diuretics include: Bumetanide (Bumex) Chlorthalidone (Hygroton) Chlorothiazide (Diuril) Ethacrynate (Edecrin) Furosemide (Lasix) Hydrochlorothiazide HCTZ (Esidrix, Hydrodiuril, Microzide) Indapamide (Lozol) Methyclothiazide (Enduron) Metolazone (Mykroz, Zaroxolyn) Torsemide (Demadex) One side effect of diuretics is a loss of potassium, which carry out of the body in urine along with sodium. Potassium is essential for proper muscular movement and a deficiency of this mineral can result in fatigue, weakness, leg cramps, and even problems with the heart. So often, patients on traditional diuretics advise to take their medication with a potassium-rich food, such as orange juice or a banana, or they will take a potassium supplement.Some diuretics developed to address the issue of potassium loss. These blood pressure medications are known as “potassium-sparing” diuretics. They include Amiloride (Midamor) Spironolactone (Aldactone) Triamterene (Dyrenium). Finally, there are the combination diuretics, which include a potassium-sparing agent and a traditional diuretic. These include Amiloride hydrochloride and hydrochlorothiazide HCTZ (Moduretic) Spironolactone and HCTZ (Aldactazide) Triamterene and HCTZ (Dyazide, Maxzide). 2. BETA BLOCKERS Beta-blockers lower blood pressure by acting directly on the heart. These high blood pressure medications reduce heart rate and force of pumping, as well as reduce blood volume. Beta-blockers includes Acebutolol (Sectral) Atenolol (Tenormin) Bisoprolol fumarate (Zebeta) Carvedilol (Coreg) — Combined alpha/beta-blocker Esmilol (Brevibloc) Labetalol (Trandate, Normodyne) — Combined alpha/beta-blocker Metoprolol tartrate (Lopressor) and metoprolol succinate (Toprol-XL) Nadolol (Corgard) Nebivolol (Bystolic) Penbutolol sulfate (Levatol) Propranolol (Inderal) Sotalol (Betapace) HCTZ and bisoprolol (Ziac) is a beta-blocker plus 3. ACE INHIBITORS Angiotensin is a hormone in the body that causes blood vessels to narrow. The angiotensin-converting enzyme (ACE) inhibitors decrease the production of angiotensin and, in turn, that helps lower blood pressure. Examples of ACE inhibitors include: Benazepril hydrochloride (Lotensin) Captopril (Capoten) Enalapril Maleate (Vasotec) Fosinopril sodium (Monopril) Lisinopril (Prinivil, Zestril) Moexipril (Univasc) Perindopril (Aceon) Quinapril hydrochloride (Accupril) Ramipril (Altace) Trandolapril (Mavik) 4. ANGIOTENSIN II RECEPTOR BLOCKERS The hormone angiotensin narrows blood vessels, but to do its job it needs a place to bind. That’s where angiotensin II receptor blockers come in. They prevent angiotensin from binding to receptors on the blood vessels and that helps lower blood pressure. Angiotensin II receptor blockers include: Azilsartan (Edarbi) Candesartan (Atacand) Eprosartan mesylate (Teveten) Irbesartan (Avapro) Losartan Potassium (Cozaar) Olmesartan (Benicar) Telmisartan (Micardis) Valsartan (Diovan) 5. CALCIUM CHANNEL BLOCKERS Calcium increases the strength and force of contractions in the heart and blood vessels. Blocking its entry into smooth muscle tissue reduces this effect. Calcium channel blockers lower blood pressure by relaxing blood vessels and reducing heart rate. Examples of calcium channel blockers include: Amlodipine besylate (Norvasc, Lotrel) Clevidipine (Cleviprex) Diltiazem hydrochloride (Cardizem CD, Cardizem SR, Dilacor XR, Tiazac) Felodipine (Plendil) Isradipine (DynaCirc, DynaCirc CR) Nicardipine (Cardene SR) Nifedipine (Adalat CC, Procardia XL) Nimodipine (Nimotop, Nymalize) Nisoldipine (Sular) Verapamil hydrochloride (Calan SR, Isoptin SR, Verelan, Covera HS) 6. ALPHA BLOCKERS Alpha-blockers cause blood vessels to dilate, thereby lowering blood pressure. These medications are also used to treat prostate enlargement in men. Alpha-blockers include Doxazosin mesylate (Cardura) Prazosin hydrochloride (Minipress) Terazosin hydrochloride (Hytrin) 7. ALPHA-2 RECEPTOR AGONIST Methyldopa, formerly known under the brand name Aldomet, is one of the oldest blood pressure medications still in use. It was first introduced more than 50 years ago. Methyldopa works in the central nervous system to lower blood pressure. While its general use has declined over the years, methyldopa is considered the first-line of treatment for high blood pressure that develops during pregnancy. 8. CENTRAL AGONISTS Some hypertension medications work in the central nervous system rather than directly on the cardiovascular system. Central agonists thus have a tendency to cause drowsiness. Drugs in this class include Clonidine hydrochloride (Catapres) and Guanfacine hydrochloride (Tenex). 9. PERIPHERAL ADRENERGIC INHIBITORS There was a time when the high blood pressure medication list was very short indeed. In the 1950s, reserpine was one of the few products on the market to treat hypertension. It rarely uses due to its numerous side effects and drug interactions. The peripheral adrenergic inhibitors work in the brain to block signals that tell blood vessels to constrict. They are mostly used when other high blood pressure medications fail to solve the problem. Guanadrel (Hylorel), guanethidine monosulfate (Ismelin), and reserpine (Serpasil) are peripheral adrenergic inhibitors. 10. VASODILATORS Vasodilators relax artery wall muscles, and that causes blood pressure to drop. These drugs usually not use alone — and, in the case of Minoxidil (Loniten) — used only in severe hypertension. Hydralazine (Apresoline) Minoxidil (Loniten) are vasodilators.
12 Drugs Every Emergency Pharmacist Should Know
An emerging field of practice for pharmacists is emergency medicine. Emergency Pharmacist deals with emergency drugs. The Centers for Disease Control and Prevention (CDC) states that there were 130.4 million visits to the emergency department (ED) in 2013. Following below are the key role of an emergency pharmacist. Direct Patient Care Rounds Medication Order Review Medication Therapy Monitoring Patient Care Involving High-Risk Medications and Procedures Resuscitation ( Pharmacists prepare medications for immediate administration) Medication Procurement and Preparation Medication Information Documentation Emergency drugs may be divided into two categories. The first category is drugs that are essential and should be part of every emergency drug kit. The second category consists of drugs that are useful but are optional depending on the practitioner’s training in emergency medical procedures and whether sedation and general anesthesia are used for behavior and anxiety management. Thus, emergency drug kits will vary from office to office. 1. Acetylcysteine MOA: Replenishes glutathione stores serves as glutathione substitute and enhances sulfate conjugation of acetaminophen (Tylenol) PO Dose: 140 mg/kg x 1, then 70 mg/kg q 4 hours x 17 doses (72 hours total) IV Dose: 150 mg/kg in 200ml D5W over 1 hour, 50 mg/kg in 500ml D5W over 4 hours, 100 mg/kg in 1 liter D5W over 16 hours (21 total hours, may need to continue until LFTs and APAP level normalize) Emergent Indications: Acetaminophen (Tylenol) overdose Where you’ll get in Trouble: Hypersensitivity reaction (stop infusion, switch to PO or slow infusion rate), while rare, you can also see hypersensitivity with PO as well, Preg B 2. Atropine MOA: Direct anticholinergic Dose: Organophosphate/carbamate toxicity: 1-6 mg IV q 3-5 minutes PRN, until dry secretions (can double dose each time until adequate response achieved) Peds Bradycardia: 0.02 mg/kg IVx1; 0.5 mg maximum single dose; 1 mg max cumulative dose Adult bradycardia: 0.5 mg IV, 3 mg max cumulative dose Emergent Indications: Organophosphate/carbamate toxicity, bradycardia Where you’ll get in Trouble: Hyperthermic patients, tachydysrhythmias, Preg C 3. Diazepam MOA: Enhances inhibitory effects of GABA Dose: 2-10 mg PO/IV/IM q 6 hours PRN Emergent Indications: Seizure abortion, alcohol withdrawal, agitation, muscle spasm Where you’ll get in Trouble: Respiratory depression, hypotension, Preg D 4. Diltiazem MOA: Inhibits calcium influx in myocardium > vascular smooth muscle; prolongs AV nodal conduction Dose: 0.25 mg/kg IV x1; may give 0.35 mg/kg IV x1 after 15 minutes; continuous infusion 5-15 mg/hr Emergent Indications: Stable Afib with RVR, stable SVT Where you’ll get in Trouble: Latrogenic hypotension, bradycardia, Preg C 5. Epinephrine MOA: Alpha and beta-receptor agonist Dose: ACLS: 1 mg 1:10,000 IV PALS: 0.01 mg/kg 1:10,000 IV Anaphylaxis: 0.1-0.5 mg 1:1,000 IM/SQ (IM preferred) Peds anaphylaxis/asthma: 0.01 mg/kg 1:1,000 IM/SQ (max single dose 0.3 mg) Hypotension refractory to IVF: 1-10 mcg/min IV Emergent Indications: Anaphylaxis, ACLS arrest, PALS/NRP arrest, severe asthma Where you’ll get in Trouble: Dosing errors (10 fold errors), tissue necrosis (needs to administer via central venous line), dysrhythmias, Preg C 6. Esomeprazole MOA: Inhibits parietal cell hydrogen-potassium ATPase (PPI) Dose: 80 mg IV bolus followed by 8 mg/hour Emergent Indications: Upper GI bleed (non-variceal) Where you’ll get in Trouble: Fairly benign when used acutely, Preg B 7. Furosemide MOA: Inhibits Na and Cl reabsorption in the distal renal tubule and ascending loop of Henle Dose: The usual dose in ED 20-40 mg IV, reassess, increase to desired effect (maximum single dose 200mg) Emergent Indications: Pulmonary edema, CHF exacerbation, hyperkalemia (if making urine) Where you’ll get in Trouble: Volume depletion, hypokalemia, metabolic alkalosis, ototoxicity, Preg C 8. Fomepizole MOA: Inhibits alcohol dehydrogenase Dose: 15 mg/kg IV loading dose, then 10 mg/kg q 12 hours x 4 doses, then 15 mg/kg q 12 hours until ethylene glycol levels < 20 mg/dL and patient asymptomatic with normal pH Emergent Indications: Methanol or ethylene glycol toxicity Where you’ll get in Trouble: Fairly safe, Preg C 9. Glucagon MOA: Stimulates cAMP production independent of the beta receptor, increases gluconeogenesis and glycogenolysis Dose: Beta-blocker/Ca channel blocker toxicity: 3-10 mg IV loading dose, then 1-10 mg/hour IV continuous infusion if responsive to loading dose Hypoglycemia: 1 mg IV/SQ/IM Emergent Indications: Beta-blocker toxicity Ca channel blocker toxicity, hypoglycemia Where you’ll get in Trouble: Anaphylactoid reaction, can cause hypotension, emesis (aspiration risk in the altered patient), Preg B 10. Heparin MOA: Binds to antithrombin III thereby potentiating inactivation of thrombin and factors IX, Xa, XI, XII; prevents fibrinogen → fibrin; preferential inactivation of thrombin over other clotting factors Dose: Venous thromboembolism: 80 units/kg IV x 1, then 18 units/kg/hour ACS or Afib: 60 units/kg IV x 1, then 12 units/kg/hr Emergent Indications: Thromboembolism; ACS (enoxaparin preferred for NSTEMI) Where you’ll get in Trouble: Bleeding (protamine may be given for reversal), dosing errors, Preg C 11. Insulin Regular MOA: ↑ peripheral glucose uptake increased inotropy, shifts potassium intracellularly Dose: Hyperkalemia: 5-10 units IV x 1 CCB overdose: 1 unit/kg bolus given with 25 grams of dextrose if initial BG < 250 mg/dL; then initiate insulin drip at 0.1 – 1 unit/kg/hr titrated to SBP along with 0.5 g/kg/hr of dextrose titrated to maintain BG 100 – 200 mg/dL DKA/HHS: 0.1 unit/kg bolus followed by continuous infusion 0.1 unit/kg/hour Emergent Indications: Hyperkalemia, DKA/HHS, CCB overdose Where you’ll get in Trouble: Hypokalemia, hypoglycemia, only regular insulin can be given IV, Preg B 12. Sodium Bicarbonate MOA: Increases serum bicarbonate (increases buffer stores) Dose: Hyperkalemia or metabolic acidosis: 50 mEq IV x 1 (1 amp = 50 mEq) TCA toxicity: 1-2 mEq/kg IV bolus to achieve a serum pH of 7.45-7.55 and QRS narrowing; effective serum alkalinization unlikely with continuous infusion Salicylate toxicity: 3 amps (150mEq) in 1 liter D5W given as 10-20 ml/kg bolus, then 2-3ml/kg/hr; goal urine pH 7.5-8.0 Emergent Indications: Hyperkalemia, TCA toxicity, salicylate toxicity, metabolic acidosis Where you’ll get in Trouble: caution in CHF, overshooting into metabolic alkalosis, hypernatremia, Preg C
Medicines To Be Avoided During Pregnancy
Doctors usually tell women to avoid medicines during pregnancy, if possible, especially during the first 3 months. That is when a baby’s organs form. Early in the first trimester, many women don’t yet know that they are pregnant. While the science is very limited (pregnant women are generally not included in medication safety studies) there are a handful of medications that are considered category X drugs, or drugs that should not be taken in women who are or may become pregnant. Which Medicines Can I Take During Pregnancy? Before prescribing any medicine, your doctor or midwife will look at whether the risk of taking medicine is higher than the risk of not treating your illness. It can be hard to know if a medicine is safe for your baby. Most medicines are not studied in pregnant women, because researchers worry about how the medicines might affect the baby. If you are planning a pregnancy, talk to your doctor or midwife about any medicines you are taking, including over-the-counter ones. In general, doctors say it is usually safe to take Acetaminophen (such as Tylenol) for fever and pain. Penicillin and some other antibiotics. HIV medicines. Allergy medicines (A few). Over-the-counter cold medicines (A Few). Some medicines for high blood pressure. Most asthma medicines. Some medicines for depression. Some medicines for heartburn. Which Medicine I Should Not Use During Pregnancy? Some of the over-the-counter medicines that increase the chances of birth defects are: Bismuth subsalicylate (such as Pepto-Bismol). Phenylephrine or pseudoephedrine, which is decongestants. Avoid medicines with these ingredients during the first trimester. Cough and cold medicines that contain guaifenesin. Avoid medicines with this ingredient during the first trimester. Pain medicines like aspirin and ibuprofen (such as Advil and Motrin) and naproxen (such as Aleve). The risk of birth defects with these medicines is low. Some of the prescription medicines that increase the chances of birth defects are: The acne medicine isotretinoin (such as Accutane). This medicine is very likely to cause birth defects. It should not be taken by women who are pregnant or who may become pregnant. ACE inhibitors, such as benazepril and lisinopril, which lower blood pressure. Some medicines to control seizures, such as valproic acid. Some antibiotics, such as doxycycline and tetracycline. Methotrexate, which is sometimes used to treat arthritis. Warfarin (such as Coumadin), which helps prevent blood clots. Lithium, which is used to treat bipolar depression. Alprazolam (such as Xanax), diazepam (such as Valium), and some other medicines used to treat anxiety. Paroxetine (such as Paxil), which is used to treat depression and other conditions. I hope this will help you. Please share it with people you care about.
Important Drug Interactions of the High Alert Drugs
High-alert drugs are drugs that bear a heightened risk of causing significant patient harm when they are used in error. High-alert drugs carry a significant risk of causing serious injury or death to patients when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients. For years, the Institute for Safe Medication Practices (ISMP) has published a list of high-alert medications for acute care settings. ISMP gives the following strategies to reduce the risk of errors and minimize harm. Standardizing the ordering, storage, preparation, and administration of these medications Improving access to information about these drugs Limiting access to high-alert medications Using auxiliary labels and automated alerts Employing redundancies High Alert Drugs The following medicines should ‘ring alarm bells’ as having important interactions: Warfarin Statins Macrolide Antibiotics Calcium Channel Blockers Azole antifungals SSRIs – fluoxetine Amiodarone Digoxin Rifampicin, Isoniazid Antiepileptic medicines – particularly carbamazepine, phenytoin; less so valproate Important Drug Interactions of High Alert Drugs Warfarin Monitor INR and patient closely when adding metronidazole, ciprofloxacin, cotrimoxazole, clarithromycin, doxycycline, fluconazole, azathioprine, rifampicin, isoniazid, carbamazepine, phenytoin, sulfasalazine, amiodarone Adjust dose of warfarin, at the outset, when adding these drugs Switch to LMWH or UFH Atorvastatin Do not use with verapamil, clarithromycin, itraconazole, fluconazole, ciclosporine Monitor CPK levels Switch to rosuvastatin (with warfarin, atorvastatin may be better) when adding any of these drugs Clarithromycin Do not use with atorvastatin, digoxin, warfarin, dabigatran, rivaroxaban, apixaban, colchicine, phenytoin, carbamazepine and drugs that prolong QT interval May use azithromycin or another antibiotic in patients taking any of these drugs Itraconazole, Fluconazole Do not use with atorvastatin, dabigatran, rivaroxaban, apixaban, digoxin Use carefully with warfarin, carbamazepine, phenytoin, rifampicin Digoxin Do not use with clarithromycin, itraconazole, ciclosporine, verapamil, diltiazem Use carefully with diuretics, amiodarone, rifampicin, phenytoin, carbamazepine Rifampicin, Isoniazid Use carefully with hepatotoxic drugs Use carefully with phenytoin, carbamazepine, warfarin, digoxin, calcium channel blockers, oral contraceptives, corticosteroids, sulfonylureas, macrolide antibiotics, azole antifungals Carbamazepine, Phenytoin Do not use with clarithromycin, oral contraceptive pills Use carefully with warfarin, itraconazole, isoniazid, rifampicin Amiodarone Use carefully with digoxin, warfarin, carbamazepine, phenytoin, and drugs that prolong QT interval Sildenafil Do not use with nitrates Allopurinol Do not use with azathioprine For Further Information Please Subscribe