Pharmacology - Most Used Drugs Review

Front 1

albuterol

Back 1

ProAir, Proventil, Ventolin

Selective Beta-2 Adrenergic Agonist

• bronchospasm secondary to hyperreactive airway disease (asthma) & COPD
• exercise-induced bronchospasm

Pearls:

• since inhaled, little effect on beta-1 receptors in heart at low to moderate doses
• appropriate use with a spacer is equal or more effective than nebulizer for delivery in most patients
• not a controller or maintenance med in asthma; rescue only
• also rescue inhaler option for COPD per guidelines even though it's not FDA approved for COPD
• MDI, Preg:C
  

Front 2

alendronate

Back 2

fosamax

Bisphosphonate

• osteoporosis prevention & treatment in post menopausal women, men & secondary to steroid use.
• Paget's disease

Pearls:

• dosed daily or weekly
• due to significant risk for esophagitis/Barrett's esophagus & poor oral absorption, must take with 8 oz of water 30 minutes or more before first food/drink of the day; remain upright for at least 30 minutes after dose.
• sufficient calcium/Vit D intake or supplimentation required for drug efficacy
• increased risk for osteonecrosis of the jaw in certain invasive oral/dental surgeries and steroid use
• avoid if patients have CrCl <35ml/min, esophageal strictures or achalasia
• preg: C

Front 3

allopurinol

Back 3

zyloprim

Xanthine oxidase inhibitor

• gout prophylaxis
• chemotherapy-related hyperuricemia
• recurrent calcium oxalate calculi (kidney stones)

Pearls:

• only used for prevention of gout, NOT for accute attacks.
• monitor for skin rash or hypersensitivity reactions, especially in patients with kidney disease
• caution if renal or hepatic impairment or myelosuppression; requires renal dose adjustment
• drug interactions: 6-mercaptopurine: azathioprine (may cause severe bone marrow supression)

Front 4

alprazolam

Back 4

Xanax

Benzodiazepine

• anxiety
• panic disorder
• ETOH withdrawl
• Pre-op sedation

Pearls:

• considered a high potency, intermediate action benzo (10-24 hours)
• not a good option for long-term tx of anxiety disorders due to risk of dependency, but good for acute anxiety or panic attacks
• avoid abrupt discontinuation if used for >3-4 weeks - will cause withdrawl and possible seizures.
• avoid use with ETOH due to risk for respiratory depression and not operate machinery while taking.
• substrate of CYP3A4; high DDI risk
• Preg: D, Lact: L4
  

Front 5

amitriptyline

Back 5

Elavil

Tricyclic Antidepressant (TCA)

• depression
• insomnia
• chronic pain (specifically neuropathic)

Pearls:

• monitor for anticholinergic effects (blurry vision, dry mouth, constipation, urinary retention). Use caution with elderly
• low doses (<100 mg daily) are commonly used for sleep aid, neuropathic pain
• doses > 100-150 mg/day (antidepressant doses) require drug level monitoring due to concern of QT interval prolongation
• active metabolite is nortriptyline
• Preg: C
  

Front 6

amlodipine

Back 6

Norvasc

Dihydropyridine Calcium Channel Blocker

• HTN
• vasospastic angina
• CAD
• achalasia and esophageal spasms
• anal fissures (applied topically)
• kidney stone elimination

Pearls:

• dosed once-a-day and only once-a-day CCB product that can be crushed for pediatrics.
• a preferred CCB in ESRD & dialysis since not renally eliminated.
• dihydropyridine CCBs are more selective for vascular smooth muscle than non-dihydropyridine CCBs and does not reduce the pulse (or cause AV node blockade)
• can cause constipation, worsen GERD or symptoms of reflux due to relaxation of LES, and/or lower extremity edema
• use if calcium channel blockers have been used to help relax ureters to facilitate kidney stone passage
• Preg: C

Front 7

amoxicillin

Back 7

Amoxil, Moxatag

PCN/Beta-lactam Antibiotic

• bacterial sinusitis, OM, pharyngitis
• H. pylori infection (component of triple therapy)
• dental prophylaxis against endocarditis with invasive dental procedures in high risk patients or treatment of absecess

Pearls:

• available as generic and is a cost effective option for many situations
• avoid in patients with PCN allergy
• has better bioavailablity than ampicillin
• if given to pts with mononucleosis, can cause rash
• Preg: B

Front 8

amoxicillin/clavulante

Back 8

Augmentin

PCN/Beta-lactam Antibiotic

• bacterial sinusitis, OM
• community acquired pneumonia

Pearls:

• good for many upper (such as OM & sinusitis) & some lower resp. infections.
• GI symptoms associated with this preparation are mostly related to dose of clavulanic acid (CA); higher doses of CA do not result in clinical improvement or improved activity against bacterial resistance mechanisms.
• does not cover pseudomonas or MRSA
• since streptococcus bacteria do not make beta-lactamase there is no need for clavulanate when treating infections due to strep
• Preg: B

Front 9

amphetamine salts

Back 9

Adderall

Stimulant

• ADD/ADHD
• narcolepsy

Pearls:

• monitor for changes in appetiet, weight, height, BP, HR
• avoid abrupt discontinuation if prolonged use
• can worsen ticks in patients with Tourette's disease and lower sz threshold
• avoid use in patients with pre-existing structural cardiac abnormalities
• substrate of CYP3A4; high DDI risk
• Preg: C

Front 10

aripiprazole

Back 10

Abilify

Atypical antipsychotic

• schizophrenia
• bipolar disorder
• major depression
• agitation

Pearls:

• weight neutral verses others that cause weight gain
• caution in elderly, especially in nursing home
• monitor lipids and glucose as with all antipsychotics
• commonly associated with akathisia or restlessness
• new FDA warning for all antipsychotics to avoid use in 3rd trimester due to inc. EPS, withdrawl, feeding problems, hypo-hypertonia, & tremors
• Substrate for CYP2D6, 3A4
• Preg: C

Front 11

atenolol

Back 11

Tenormin

Selective Beta-1 adrenergic antagonist

• HTN
• angina
• secondary prevention of MI

Pearls:

• vaughn-williams class II antiarrhythmic
• NOT FDA approved for HF
• montior pulse and BP
• hydrophilic beta blocker; renally elimated (renal dose CrCl<35 ml/min)
• longer half-life than metoprolol tartrate allowing for once daily dosing
• as with other beta blockers, can mask s/s of hypoglycemia in DM (no tremors or tachycardia, but they do still sweat)
• use caustion in pts with asthma or hyperreactive airway disease
• has potential to worsen symptoms related to PVD or with claudication
• Preg: D

Front 12

atorvastatin

Back 12

Lipitor

HMG-CoA Reductase Inhibitor (Statin)

• dislipidemia due to eleveated cholesterol and/or triglycerides
• primary and secondary prevention of cardiovascular events

Pearls:

• can lower LDL up to 55%
• monitor liver enzymes (AST/ALT), hold is s/s myopathy, change in Cr (rhabdo) & lipid profile
• drug interations with foods/drugs that use/modify CYP3A4 enzyme; also gemfibrozil can inc. levels (but not fenofibrate); low dose (10mg) appears to be safe in HIV pts on protease inhibitors
• Preg: X

Front 13

azithromycin

Back 13

zithromax

Macrolide antibiotics

• bacterial sinusitis, OM
• community acquired pneumonia
• chlamydia
• PID

Pearls:

• predominantly used for STIs and respiratroy infections; may be good alternative in PCN allergic pts
• "Z-Pak" dosing not approved for inpatient pneumonia tx because it does not cover MDR strep pneumo
• not indicated for replacement of clarithromycin for tx of H. pylori
• no major drug interactions, does not require renal or hepatic adjustments
• Preg: B
  

Front 14

carisoprodol

Back 14

Soma

Skeletal muscle relaxant

• acute musculoskeletal pain

Pearls:

• risk of abuse is a concern
• meprobamate (C-IV) is active metabolite; treated as a controlled substance in some states
• effects of drug augmented by other depressants (ETOH, meds)
• avoid in elderly (on Beer's list)
• abrupt withdrawl or discontinuation after prolonged use can precipitate withdrawl
• major substrate of CYP2C19. Note: patients who are CYP2C19 poor metabolizers have a 4xgreater exposure to Soma
• Preg: C

Front 15

carvedilol

Back 15

Coreg

Mixed alpha/beta adrenergic antagonist

• HTN
• heart failure
• secondary prevention of cardiovascular event

Pearls:

• vaughn-williams class II antiarrhythmic
• comes in IR formulation (now generic) that is dosed twice daily (max 50 mg bid) & CR form dosed once daily (max 80 mg qd)
• FDA approved for both HTN and HF
• for HF, start at low dose and titrate slowly
• caution in pts with bronchospastic disease, asthma, claudication, and/or heart block; monitor HR and BP
• as with other beta blockers can mask s/s of hypoglycemia in DM (can still sweat)

Front 16

celecoxib

Back 16

Celebrex

Cox-2 selective NSAID

• OA
• RA
• acute pain
• dysmenorrhea
• familial adenomatous polyposis (FAP)

Pearls:

• avoid in pts with a sulfa allergy
• use for shortest duration and at lowest dose possible
• use caustion in pts with hx of CV disease, HF, and HTN (add ASA if high risk); caution in pts with hx of GI or renal disease
• Preg: C

Front 17

cephalexin

Back 17

Keflex

Cephalosporin antibiotic (1st generation)

• bacterial sinusitis; pharyngitis
• uncomplicated cystitis
• uncomplicated skin infection

Pearls:

• due to short half-life usually requires 4x daily dose
• primarily gram + coverage (but not MRSA), some gram - organisms of outpatient related infections
• avoid in pts with anaphylactic reactions to pcn/beta-lactam antibiotics
• Preg: B

Front 18

ciprofloxican

Back 18

Cipro

Fluoroquinolone antibiotic

• bacterial sinusitis
• UTI
• acute bronchitis
• community & hosptial aquired pneumonia
• prostatits
• skin/bone/joint inf.
• intraabdominal infections (diverticulitis)
• prophylaxis and tx of spontaneous bacterial peritonitis (SBP) in cirrhotics
• anthrax

Pearls:

• one of 2 fluoroquinolones that cover pseudomonas aeruginosa (other is high dose levofloxican); note: inc. resistance from P. aeruginosa to Cipro is now a concern
• renal dose when CrCl>50ml/min
• well known strong inhibitor of CPY1A2; common interaction with theophylline and caffine
• avoid taking within 2 hours of di- or tri-valent cations (Mg, Fe, Al, Zn (eg. antacids, MVI)) as will decrease absorption of cipro
• caution in childre, rare cases of tendon rupture
• can inc. QT interval slightly & risk for sz (especially if on theophylline)
• Preg: C

Front 19

citalopram

Back 19

Celexa

SSRI

• depression
• anxiety disorders
• OCD

Pearls:

• takes @ 4 weeks for efficacy in depression, true trial 6-8 wks.
• least liekly to cause drug interactions of all SSRIs
• associated with sexual dysfctn - common problem with all SSRIs
• monitoring for serotonin syndrome may be needed if certain other medicaitons used that affect neurotransmitter release or metabolism
• avoid abrupt discontinuation of all SSRIs (less likely problems with fluoxetine due to long half-life)
• inc. risk of suicidal thinging & behavior in children, adolescents & young adults with major depressive disorder and psych disorder
• Preg: C

Front 20

clindamycin

Back 20

Cleocin

Linosamide antibiotic

• anaerobic infections (e.g. cnanine bite wounds, orofacial infections)
• PID
• alternative option for: MRSA skin/soft tissue/bone infections, prophylaxis for infective endocarditis and dental procedures

Pearls:

• bite wounds: typically combined with a fluoroquinolone
• frequently implicated in C. Diff associated diarrhea and pseudomembranous colitis
• GI and skin manifestations are most common adverse effects
• monitor CBC, kidney and liver fctn if prolonged tx
• Preg: B

Front 21

clonazepam

Back 21

Klonopin

Benzodiazepin

• anxiety
• panic disorder
• seizure disorder

Pearls:

• considered a high-potency, intermediate acting benzo (10-24 hours)
• not good option for long-term tx of anxiety diserder due to risk of dependency, but good for acute anxiety or panic attack
• avoid abrupt discontinuation if used for >3-4 wekks- will cause withdrawl and inc risk of seizures
• avoid use of ETOH
• significant drug interactions via CYP3A4
• Preg: D

Front 22

clopidogrel

Back 22

Plavix

Antiplatelet Agent

• secondary prevention of cardiovascular and cerebrovascular events
• acute coronary syndrome
• patients allergic to ASA

Pearls:

• monitor for s/s of bleeding (especially GI)
• is prodrug; effect may be decreased by calcium channel blockers, PPI (especially omeprazole & lansoprazole) or drugs that inhibit CYP2C19
• may be less effective in pts with genetic polymorphisms to CYP2C19
• should be given with ASA when used with drug eluting coronary stent (use for at least 12 months) & for bare metal stents (use for at least 1 month)
• if bolus used and a CABG is needed then wait 5 days for surgery unless emergent (due to inc. bleeding)
• Preg: B

Front 23

conjugated estrogen

Back 23

Premarin

Estrogen derivative

• vasomotor symptoms associated with menopause

Pearls:

• should use only for controlling of hot flashes and symptoms of menopause
• estrogen products should be used at the lowest dose and shortest duration possible; contraindicated in women with VTE disorders, vascular disease, active biliary or gallbladder disease, at inc risk of strok, uncontrolled sz or hx of breast cancer.
• Preg: x, Lact: L4
  

Front 24

cyclobenzaprine

Back 24

Flexeril

skeletal muscle relaxant

• acute treatment of muscle spasm

Pearls:

• structurally similar to TCAs; has potention to inc. risk of serotonin syndrome
• significant risk for sedation, drowsiness, CNS depression; effect augmented by other depressants (e.g. ETOH, meds)
• preferred by more providers than carisoprodol (Soma)
• Preg: B
  

Front 25

diazepam

Back 25

Valium

Benzodiazepine

• CHF
• rate control in pts with atrial flutter of fibrillation with RVR

Pearls:

• narrow therapeutic index drug CHF
• sometimes used for "rate control" in pts with a-fib or a-flutter
• takes 5-7 days to reach steady state after dose change; monitor for toxicity (halos around lights, N/V, EKG changes)
• digibind is reversal agent
• has a large volume of distribution (Vd); binds to a lot of muscle tissue
• highly dependent on renal elimination via efflux pump, P-gp; decrease dose with renal impairment
• major drug interaction with inhibitors of P-gp (e.g. amiodarone(decresase dose of digoxin up to 50%))
• Preg: C

Front 26

doxycycline

Back 26

vibramycin, doryx

Tetracycline antibiotics

• community acquired pneumonia (outpatient use)
• community acquired MRSA skin infection (outpatient use)
• acne vulgaris
• tick borne diseases
• malaria prophylaxis for travel to endemic areas

Pearls:

• contraindicated if < 8 years (except for anthrax exposure) & pregnancy
• risk of photosensitivity, GI side effects common; also associated with blue-gray tooth discoloration
• drug interactions: avoid taking with antacids, calcium, iron, magnesium due to decreased absorption (seperate by 2-4 hours)
• Preg: D

Front 27

duloxetine

Back 27

Cymbalta

SNRI

• depression
• anxiety
• diabetic neuropathy
• fibromyalgia

Pearls:

• not FDA approved for children
• counsel on initial inc of N/V (reason for dose titration)
• monitor BP (can inc), suicidal ideation. Monitor for serotonin syndrome if combined with certain other medications.
• significant drug interactions via Cyp1A2, 2D6 and/or inhibitors of monamine oxidase (MAO)
• avoid if CrCl<30 ml/min
• Preg: C

Front 28

enalapril

Back 28

Vasotec

ACE Inhibitor

• HTN
• HF
• kidney disease
• prevention of the progression of diabetic neuropathy
• Post-MI

Pearls:

• monitor potassium (inc. risk for hyperkalemia), and Cr
• counsel to avoid salt-substitutes since most replace Na and K
• avoid if K> 5.0, patients with angioedema & non-stented "bilateral" renal artery stenosis
• discontinue if inc Cr. by >50% baseline
• can cause a non-productive cough in "ACE intolerant" patients
• renal protection in diabetics comes from efferent arterial relaxation resulting in reduced glomerular filtration pressures
• Preg: C (1st trimester) D(2nd and 3rd trimesters)

Front 29

escitalopram

Back 29

Lexapro

SSRI

• depression
• anxiety
• OCD

Pearls:

• S-enantiomer (active form) of citalopram (Celexa)
• thought to have a more rapid onset and fewer side effects than other SSRIs - the clinical relevance of this is questionable
• associated with sexual dysfunction
• monitoring for serotonin syndrome may be needed if used with certain medication
• avoid abrupt discontinuation of all SSRIs (less likely problem with fluoxetine due to long half-life)
• Preg: C

Front 30

esomeprazole

Back 30

Nexium

PPI

• GERD
• PUD
• H. pylori infection

Pearls:

• active isomer of omeprazole
• caustion: can decrease absorption of atazanavir, dasatinib, itraconazole, ketoconazole, posaconazole.
• decrease clopidogrel activation/efficacy due to CYP2C19 inhibition
• all PPIs: chronic use (>1yr) in patients > 50 years has been associated with increase fractures of hip, wrist, spine
• all PPIs: use for >3months, especially >1 year of use, has rarely been associated with hypomagnesemia; not always corrected with MG suppliments
• Preg: B

Front 31

ezetimibe

Back 31

Zetia

Cholesterol Absorption Inhibitor

• dyslipidemia due to elevated cholesterol

Pearls:

• typically an adjunct to statin or other LDL-C lowering therapy
• dosed once a day due to long-half of glucuronide metabolite
• does not appear to cause significant drug interactions in HIV patients or in patients taking cyclosporine for prevention of kidney transplant rejection
• no data available to suppor decr. mortality
• Preg: C