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168 Cards in this Set
- Front
- Back
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pharmacology
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study of how drugs interact with the body constituents to produce therapeutic effects
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medical pharmacology
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the effects of drugs on humans
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drug
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anthing that can be used to treat, diagnose, or prevent disease.
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What is the classification of a drug based on?
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may be based on structure, mechanism of action (MOA), or the effects that it produces.
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What are the 4 phases of clinical testing of a drug?
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1- clinical pharmacology
2- clinical investigation 3- clinical trials 4- post marketing studies |
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How long is the average amount of time that it takes to get a drug to market?
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10-15 years
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what is the average cost of the marketing of a drug?
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$800 million
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Pharmacodynamics
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Biochemical and physiological effects of drugs and their mechanisms of action. What a drug does to the body and how that drug does it. Describes the action of the drug both quantitatively and qualitatively.
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Pharmacokinetics
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Study of how the body absorbs, distributes, metabolizes and excretes drugs. Body's effect on a drug and MOA.
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Risk-benefit ratio
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Describes how safe a drug is to use. Indicates if the risks of using the drug will out weigh any possible therapeutic benefit.
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Pharmacotherapeutics
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Prevention and treatment of disease
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Toxicology
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Study of poisons
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Are chemicals used in therapy?
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NO
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Teratology
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Study of monsters. how drugs taken during pregnacy can cause fetal morphology.
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Category A drug
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No risk to the fetus. Example: folic acid.
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Category B drug
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Animal reproduction studies have not demonstrated a getal risk, but there are no controlled studies in preganant women, or animal reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in a controlled study in women in the first trimester (and there is no evidence of risk in later trimesters).
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Category C drug
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Studies in animals have revealed adverse effects on the fetus (teratogenic or embyocidal effects or other) and there are no controlled studies in women, or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus.
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Category D drug
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There is positive evidence of human fetal risk, but the benefits from use in pregnant woment may be acceptable despite the possible risk. (e.g. if the drug is needed to sustain the life of the mother). There will be an appropriate statement in the "warnings" section of the labeling.
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Category X drug
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Studies in animals or humans have demonstrated fetal abnormalitites, or there is evidence of fetal rsik based on human experience, or both. The risk of using the drug in pregnant women clearly outweighs any possible benefit. The drug is containdicated in women who are or may become pregnant. There will be an appropriate statement in the "contraindications" section of the labeling.
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Therapeutic index
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The margin of safety. Minimum toxic dose over the minimum efficacious dose. (TD1/ED1)
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What kind of TI indicates that the drug is safe? Unsafe?
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high TI = safe
low TI = unsafe (blood levele monitoring) |
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Receptor
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Site of action of the drug. May be: membrane, membrane protein, cytoplasmic or extracellular enzyme.
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Drug binding site
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proteins, glycoproteins, or lipoproteins.
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Specificity
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Drug must recognize the receptor for the drug to work. (Lock and key mechanism)
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Drug-receptor complex
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Produces a biochemical or physiologic response. The receptor goes through a conformational change to begin the chain of events to start a physiological response.
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Effects of Drug Binding
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1. Release of neurotransmitter, hormone, or endogenous chemicals.
2. Change of the electrical potential or membrane permeability. 3. Causes cascade effect. |
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Agonist
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Drug that combines with a receptor and activates that receptor to produce the same response as an endogenous chemical. This drug will have an affinity for the receptor and have efficacy. Example: epiniepherine (andrenergic agonist)
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Affinity
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Tendency for the drug or substance to bind to the receptor site.
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Efficacy
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Relationship between the receptor occupancy and the reability to initiate a response.
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Antagonist
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Drug that combines with a receptor used by an endogenous chemical and blocks or diminishes the response of the endogenous agent. Can also be a drug that combines with a receptor and inhibits the release of an endogenous compound or intercepts the signal that is generated by an endogenous agent. Example: atrophine (cholenergic antagonist)
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Partial Agonist
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Drug that has affinity, but low efficacy.
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Competitive Antagonism
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agonist and antagonist that are competing for the same receptor site.
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Non-competitive Antagonist
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agonist and antagonist bind at diggerent sites on the same receptor.
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Potency
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A lower dose of the drug is needed to achieve the desired physiological effect. (e.g. 1 mg vs. 100 mg)
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Efficacy
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The magnitude of the maximum effect (predefined). Often expressed in percentages of morbidity and mortality.
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Tolerance
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Reduced response to the same dose or increased dose needed for the same response due to repeated administration. Change in receptor sensitivity due to repeated administration. Change in pharmacokinetics of the drug due to repeated administration. Usually happens slowly (depends on drug). Examples: narcotics, nitroglycerine.
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Dependence
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Need for the drug that can be either psychological or physiological. Pathway for addiction.
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Placebo effect
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Psychological effect. A well designed clinical trial will always include a placebo group.
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Allergy
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Hypersensitivity reaction. An adverse immune reaction that results from a previous exposure to a particular chemical or one that is structurally similar.
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Type I Allergic Reaction
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Anaphylaxis. Mediated by IgE antibodies. Symptoms are a result of the release of histamine, prostaglandins, and leukotrienes. Symptoms include: uticaria, rash, vasodilation, hypotension, edema, inflammation, rhinitis, asthma, tachycardia. Example: penicillin
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Type II Allergic Reaction
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Cytolytic reactions mediated by IgG and IgM antibodies that affect the cells of the circulatory system. Autoimmune reactions to drugs usually subside within several months after drug discontinuation. Symptoms include: hemolytic anemia, thrombocytopenia, granulocytopenia. Example: quinidine, Methyldopa
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Type III Allergic Reaction
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Arthus reactions that are IgG mediated wher immune complexes are deposited in the vascular endothelium where a destructive inflammatory response called serum sickness occurs. Symptoms include: erythema multiforme, arthritis, nephritis, CNS abnormalities, myocarditis, and systemic lupus erythematosus. Example: sulfonamide antibiotics.
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Type IV Allergic Reaction
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Delayed hypersensitivity reactions that are mediated by T-lymphocytes and macrophages. Sensitized cells come in contact with the antigen, lymphokines cause an inflammatory response. Example: poison ivy, poison oak, antibiotics, benzocaine.
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Idiosyncratic Reactions
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Unusual response to a drug caused by genetic differences in metabolism or immunologic mechanisms.
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Hyperreactivity
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Intensity of a given dose of drug is greated than anticipated.
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Hyporeactivity
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Intensity of a given dose of drug is less than expected.
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When is reactivity a concern?
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When the therapeutic effect is not observable. Important in low therapeutic index medications. Underdosing can be as lethal as overdosing. >
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What can you do to monitor the reactivity?
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Monitor blood levels and plasma levels.
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What is included in pharmacokinetics?
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Absorption, distribution, metabolism, excretion.
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What is a membrane?
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Lipid bilayer that is composed of phospholipids and cholesterols (sometimes carbohydrates for the anchoring of proteins).
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What kind of drug will be able to readily cross a membrane?
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Highly lipid soluble drugs. Most of these drugs will be of a lower pH.
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4 Possible Routes of Entrance for a Drug into a Membrane
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Passive diffusion
Facilitated diffusion Active transport Pinocytosis |
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Passive Diffusion
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Movement of the drug from an area of high concentration to an area of low concentration. For electrolytes, it is proportional to lipid solubility. For non-electrolytes, it is related to the pH.
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Facilitated Diffusion
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Passes with concentration gradient, but requires a transporter (example: carrier protein)
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Active Transport
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Movement against the concentration gradient that requires ATP.
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Pincocytosis
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Formation and movement of vesicles (packages) across membranes. Requires ATP.
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Absorption
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Rate at which a drug leaves its site of administration and the extent to which it occurs.
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Bioavailability
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Percent to which a drug reaches the site of action or biological fluid that has access to the site.
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First Pass Effect
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Drugs that are absorbed through the GI tract and metabolized in the liver before they can reach systemic circulation.
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Drug solubility
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Solution > suspension > capsule > tablet
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Factors that modify absorption
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Drug solubility, circulation at the site, drug concentration, absorbing surface area, gastric emptying time, intestinal motility, food
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Should most medications be taken with food?
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No- most drugs work best on an empty stomach.
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Enteral routes of absorption
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Oral, sublingual, rectal.
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PO Route of Administration
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By mouth. Safest, easiest, cheapest. First 1/3 of the small intestines is where drugs are absorbed. Large surface area. High blood volume.
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SL Route of Administration
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Sublingual or under the tongue. Highly lipid soluble drugs. Quick onset of action.
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Rectal Route of Administration
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Only useful when PO is not possible. Elderly, pediatrics, or the patient is unconscious or has N/V. Most irritate the rectal mucosa. Absorption is mostly unpredictable.
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Parenteral Routes of Administration
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IV, IM, SQ
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Intravenous Administration
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No absorption phase. 100% bioavailability. Immediate and irreversable.
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Intramuscular administration
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Onset is slower. Duration is longer than IV. Absorption is delayed and related to vascularity of the muscle.
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SQ administration
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Duration longer, slower absorption because less vascular.
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Miscellaneous Routes of Administration
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Topical, transdermal, Aerosol
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Topical administration
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Local effect. Creams, drops (eyes, ears). Little systemic absorption.
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Transdermal administration
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Unique delivery system- drug crosses skin and goes into systemic circulation.
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Aerosol administration
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Very rapid onset. Extremely large surface area for absorption and good blood supply. Used mostly for a local effect.
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Distribution
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Movement of a drug through compartments. Each time a drug enters a new compartment it must cross a membrane. The partition between the two compartments is dependent upon the lipid and protein content, pH, some osmotic pressure, and blood supply.
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Volume of Distribution
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Total volume of fluid in which a drug may be distributed.
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Protein Binding
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Effects drug distribution. Sometimes referred to as reservoirs. The bindign of a drug to protein may significantly affect tis bioavailability. Drugs taht are abound to anything other than a receptor are deemed inactive.
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What are the two important compartments in distribution?
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Blood brain barrier, placental barrier
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Blood brain barrier
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the membranes separating the blood from the CDF and brina is considerably more restrictive than any other membrane and is highly lipophilic. Some drugs will conecentrate in the brain or others may be excluded.
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Placental barrier
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Membranes separating the blood from the placenta are less restrictive than most membranes. As a result, drugs pass through it easily. MUST ASSUME THAT ALL DRUGS WILL CROSS.
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Biotransformation
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Metabolism of drugs. Body tries to convert any chemical into one that is anacted and water soluble, so that it can be excreted. MOST biotransformations occur in the liver.
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Phase I Biotransformation
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Non-synthetic oxidation reduction rxn or hydrolysis. This can sometimes convert the drug to the active form. (CYP450 mixed fxn oxidases)
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Phase II Biotransformation
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Synthetic. Addition of conjugates. Enzymatic reactions. Occur primarily in the liver, but can occur in the GI tract, lung, skin, or kidneys.
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CYP450 Enzymes
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Main phase I enzyme system involved in the oxidative metabolism of drugs, chemicals, and some endogenous substances. MANY ISOFORMS.
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CYP3A4
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Predominant isoform. 50% of CYP mediated metabolism. Substrates: benzos, HIV drugs, calcium channel blockers.
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CYP2D6
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Second most common isoform. 30% of CYP metabolism. Substrates: psychotropics, codeine, beta-blockers.
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CYP2C9
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Third most common isoform. 10% CYP metabolism. Substrates: phenytoin, warfarin, NSAIDs
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Regulation of CYP450 System
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Enzyme inhibitors: slow down the metabolism of tohter drugs metabolized by CYP450
Enzyme Inducers: speed up metabolism of other drugs metabolized by CYP450 |
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Pharmacogenomics
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General study of all the many different genes that determine drug behavior.
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Pharmacogenetics
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Study of inherited difference in drug metabolism
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What is the most studied genetic polymorphism?
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CYP2D6
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Advantages of pharmacogenomic research
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1. determine the gentic basis of drug response in individuals
2. develop individualized drug therapies for treating disease 3. provide tailored therapy based on genetically determied effectiveness and ADRs. |
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Excretion
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Drugs are eliminated from teh body either unchanged or as metabolites
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Most important routes of excretion in humans
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kidney, feces, breast milk
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Control of excretion via the kidney
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Controlled by level of pH. More alkaline urine increases the excretion of weak acid and more acidic urine increases the excretions of weak base.
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Clearance
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rate at which the drug is eliminated from the body
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Steady state
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when the rate of administration is equal to the clearance.
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Half-life (t 1/2)
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the time it takes for the concentration of the drug to be reduced by 1/2.
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Plasma half life
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time it takes for the concentration of the drug in the plasma to be reduced by 1/2
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Elimination half life
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time it takes for the concentration of the drug in the fecal matter to be reduced by 1/2
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Factors affecting pharmacokinetics and pharmacodynamics
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Age, weight, gender, genetics, underlying disease, immune status, psychological or placebo effect. Also, drug-drug and drug-food interactions.
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Dosing in the geriatric patient
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consider chronic conditions
altered psychological conditions altered pharmacokinetics START LOW, GO SLOW. |
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Chronic conditions in the elderly
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Arthritis, HTN, CAD, hearing loss, vision loss, depression, delirium, confusion, altered ADLs
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Physiologic changes in the elderly
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1. Changes in body composition- increase fat, decrease water
2. CVS decreased sensitivity to B-adrenergic stimulation 3. CNS- memory/cognitive impairment 4. Gait & mobility- altered balance 5. GI changes- decreased saliva, constipation 6. GU changes- incontinence 7. Decreased hepatic function 8. Decreased renal function 9. Senses- visual changes (glaucoma, cateracts) |
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Alterations to physiology that affect ABSORPTION in the elderly
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Increased gastric pH
Decreased intestinal blood flow Decreased intestinal mobility Decreased intestinal S.A. Decreased gastric emptying- increased stasis of the urine (increase in bad microbes. DELAY ABSORPTION, DELAY ONSET. Decreased muscle mass. Skin changes (decreased: hydration, surface lipids, peripheral circulation) |
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Alterations to physiology that affect DISTRIBUTION in the elderly
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Decreased total body water
Decreased lean body mass Decreased serum albumin Increase body fat |
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Alterations in physiology that affect METABOLISM of drugs in the elderly
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Decreased hepatic mass
Decreased hepatic blood flow Greatest problems with phase I reactions (mostly in the liver). Decreased abililty of the liver to heal may have an effect. |
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Alterations in physiology that may affect RENAL EXCRETION in the elderly
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decreased functional cells in kidney
decreased renal blood flow decreased glomerular filtration rate |
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Name some renally eliminated drugs
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MANY antibiotics
Digoxin, metformin, allopurinol, H2 blocker, ACE inhibitors, Li |
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Cockcroft-Gault Equation
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CrCl(men) = [(140-age) x IBW]/[SCr* x 72]
* SCr - If Cr < 1 mg/dL in elderly- round up CrCl(women) = CrCl(men) x 0.85 IBW(men) = 50kg + (2.3 x inches >5 ft) IBW(women) = 45.5kg =(2.3 inches> 5ft) |
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Pharmacodynamic changes in the elderly
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1. Decreased baroreceptor sensitivity- orthostatic hypotension, VD, TCA, PTZ
2. CNS Changes- increased risk of taive dyskinesia w/antipsychotics, increased sensitivity to anticholinergics 3. Receptor alterations |
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General Principles for appropriate medication usage in the elderly
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1. Consider diagnosis
2. Base choice for drug on: efficacy, drug interactions, disease interactions, SE, cost, ease of admin, quality of life 3. FOR DOSES: START LOW, GO SLOW 4. Monitor GOALS for therapy |
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Medications requiring special attention in the elderly
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Analegesics, anticholiergics, anticoagulants, antidepressants, antidiabetics, antihypertensives, antipsychotics, beta blockers, digoxin, h2 antagonists, hypnotics, anxiolytics, OTCs
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Pediatric pharmacokinetics
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Big changes within the first year which can greatly alter pharmacokinetics
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Alterations that can affect ABSORPTION in pediatrics
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1. decreased gastric acidity
2. decreased gastric and intestinal motility 3. variable oral bioavailability of some drugs 4. increased topical absorption 5. IM administration not recommended 6. rectal administration is common |
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Alterations that can affect DISTRIBUTION in pediatrics
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1. increased total body water
2. decreased protein binding 3. decreased amount of fat in neonates and infants |
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Alterations that can affect METABOLISM in pediatrics
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1. phase I rxns- working at 50-75% of full capacity in neonates
2. glucuronidation takes up to 1 year to develop, decreases clearance rate |
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Alterations that can affect ELIMINATION in pediatrics
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only at 50% of GFR at 1 month, takes time to develop.
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Calculation of creatinine clearance
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Clcr = K * L/Scr
Normal = 2-5 cc/kg/hr Renal insufficient = <1 cc/kg/hr |
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What is considered to be a health care facility?
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Hospital, clinic, nursing home. NOT A PRIVATE PRACTICE.
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In a health care facility, what are Rx orders written on?
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MEDICATION ORDER
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What does the medication order have to include?
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Patient name (sometimes on patient stamp)
Paitent allergies Date and time Rx info PA signature, printed name, and title. Co signature of supervising physician |
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What medication information must be included on the medication order?
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Name of drug (NO ABBREVIATION)
Strength Dosage form (tab, capsule, etc) Route of administration Dose Frequency (BID, QD, HS, etc) Special information |
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Should trailing zeros be used? Should leading zeros be used?
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Trailing = NO
Leading = YES |
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For an outpatient Rx order, what type of slip must be used?
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Official state prescription form.
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If you would like your patient to receive the generic instead of the brand name, what do you need to write on the script?
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DAW (dispense as written)
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Refills
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You must indicate the amount of refills that you want the patient to have, even if it's zero!
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Can you call in an oral prescription to the pharmacy?
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YES
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How long do you have to send in a hard copy of the Rx?
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72 hours
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Why are controlled substances available for Rx?
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They can be effective in the treatment of illness, pain, and disease and must therefore be made available. They can be addictive, cause injury, impairment, and death when abused, misused, or diverted to illegal use.
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Schedule I (C-I)
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very high potential for abused. No current therapeutic use.
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Schedule II (C-II)
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High potential for abse with seves liability to cause psychic or physical dependence. Morphine, benzos (NYS), anabolic steroids (NYS), oxycodone
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Schedule III (C-III)
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Less potential for abuse than C1 or C2. Some cough prep, Tylenol + codine
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Schedule IV (C-IV)
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Even less abuse potential. Phenobarbital, some cough prep.
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Schedule V (C-V)
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Least potential for abuse. Lomotil.
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Can PAs prescribe all controlled substances available for Rx?
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YES
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Antibiotic
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traditionally referred to substances that are produced by microorganisms to suppress the growth of other microorganisms.
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Antimicrobial
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Broader term. Used to refer to antibiotics synthesized in the laboratory as well as those synthesized by microorganisms.
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Bacteriocidal
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Antimicrobial drug that kills sensitive organisms. Organism falls rapidly after drug exposure. Induce lethal changes in microbial metabolism or block activities that are essential for viability. Less likely to cause resistance. Includes most antimicrobial drugs.
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Bacteriostatic
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Inhibits the growth of bacteria but does not kill. Number of microorganisms remains relatively constant after drug exposure. Require immunologic mechanisms to eliminate the organism. Inhibit a metabolic rxn needed for cell growth but not necessary for cell viability. More likely to cause resistance.
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Narrow spectrum
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Drug targeted at specific microbes or a limited group of microbes.
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Broad spectrum
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Activity against a wide range of pathogens.
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Which should you choose, a narrow or broad spectrum drug, if the option is available?
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NARROW. Less likely to cause resistance and superinfection.
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Culture and Sensitivity
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Determines exact organism responsible for infection and indicates the antibiotics that it is both sensitive and resistant to.
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Emperic therapy
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Make educated guess as to which microbe has caused the infection and use the antibiotics known to eliminate the microbe until laboratory results have been returned.
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Microbial resistance
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Can be innate or acquired. Often develops over time due to misuse of drugs.
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Primary Mechanisms for Bacterial Resistance
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Inactivation by microbial enzymes (beta lactamase) *Most common.
Decreased accumulation of drug by microbe. Reduced affinity of the target molecule by the drug. |
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Appropriate Selection of Antimicrobial Drugs
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1. Infection type
2. Status of Patient (pregnancy, allergies, immune status, age, renal impairment, hepatic insufficiency, abscess, indwelling catheters) 3. Drug Properties(pharmacokinetics, ADR, cost, convenience) |
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When a pregnant woman needs antibiotics...
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Must be sure that the benefits out weigh the risks. 3 classes that can be used are P, C, M.
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When a person who has an allergy history needs antibiotics...
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As long as the allergy is not an IgE hypersensitivity, you may prescribe the antibiotic.
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When a person who is in an immunocompromised state needs antibiotics...
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Can impair already dwindling immunity. Dose may need to be increased or duration increased. MUST USE BACTERIOCIDAL.
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When a patient who is renally impaired needs antibiotics...
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Be sure that you take care when using renally eliminated drugs because they can accumulate and become toxic if not excreted quickly enough. Adjust dose to CrCl level.
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When a person who has an abscess needs antibiotics...
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Drain abscess first for better penetration. Be sure to accommodate for anaerobic bacteria.
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Patients who have osteomyelitis and are using antibiotics...
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must be treated for several weeks because the drug will take longer to distribute.
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When prescribing the antibiotic, these aspects of cost must be taken into consideration.
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Drug cost
Administration cost Monitoring Frequency and duration |
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Inhibitors of metabolism
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Sulfonamides
Trimehoprim |
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Inhibitors of cell wall synthesis
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beta-lactam
vancomycin (Penicillin and cephalosporin) |
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Inhibitors of protein synthesis
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tetracyclines
aminoglycosides macrolides clindamycin chloramphenicol |
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Inhibitors of nucleic acid function or synthesis
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Fluoroquinolones
Rifampin |
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Inhibitors of cell membrane function
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Isoniazid
Amphotericin |
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SULFONAMIDES
MOA |
inhibits one of sequential steps in production of folic acid.
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SULFONAMIDES
SPECTRUM |
S. aureus (includes MRSA), some gram negatives.
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SULFONAMIDES
INDICATION |
CA-MRSA, UTI, PCP, prophylaxis
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SULFONAMIDES
ADRs |
Skin rash, dermatitis, erythema multiforme, Steven Johnson Syndrome, GI rxns, renal damage, liver damage, bone marrow suppression
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SULFONAMIDES
DDIs |
CYP2D6 inhibitor, highly protein bound, contraindicated with methanamine.
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SULFONAMIDES
PREGNANCY INDICATIONS |
NOT FIRST CHOICE IN PREGNANCY. Category B in trimesters 1 and 2, Category C in 3rd trimester.
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PENICILLIN
MOA |
inhibit bacterial wall synthesis
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PENICILLIN
ADRs |
FAIRLY NON-TOXIC. Common rxns: derm, GI.
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