Usmle Pharm Toxicities

Front 1

Toxicity: Amphotericin B

Back 1

Most notorious = nephrotoxicity (renal vasoconstriction --> decreased GFR. Hypo-K, hypo-Mg due to increased tubular membrane permeability. can also be toxic --> ATN, renal tubular acidosis. renal injury may lead to decreased EPO and normochromic/cytic anemia). Decreased by hydration

IV Phlebitis, hepatotoxicity
fever/chills (shake and bake), hypotension, arrhythmias, anemia
Liposomal amphotericin reduces toxicity

Front 2

Toxicity of Nystatin

Back 2

Can't be given IV (too toxic)
Swish and swallow (not absorbed via GI)

Front 3

Toxicity of -azoles

Back 3

hormone synthesis inhibition --> gynecomastia (especially ketoconazole)
Liver dysfunction (INHIBIT CYP450)

Front 4

Toxicity of Flucytosine

Back 4

Bone Marrow Suppression
NVD

Front 5

Toxicity of Griseofulvin

Back 5

Deposits in keratin-containing tissues (e.g. nails)
CYP450 INDUCERS
Teratogenic, carcinogenic

Front 6

Toxicity of Dapsone

Back 6

hemolysis, methemoglobinemia

Front 7

Toxicity of PCN

Back 7

HPY reactions, hemolytic anemia

Front 8

Toxicity of Penicillinase-resistant penicillins

Back 8

HPY rxns
Methicillin - interstitial nephritis

Front 9

Toxicity: aminopenicillins

Back 9

amp/amox
HPY rxns, ampicillin rash (happens often when given mistakenly to pts with mono, which looks like strep throat), pseudomembranous colitis

Front 10

Toxicity: antipseudomonals

Back 10

HPY rxns

Front 11

Toxicity: Cephalosporins

Back 11

HPY rxns
Cross HPY with penicillins in 30% of pts.
Disulfiram-like reactions with some

Front 12

Disulfiram/reaction

Back 12

inhibits aldehyde dehydrogenase. Aldehyde accumulation - flushing, sweating, nausea, headache, hypotension.

Occurs with disulfiram (antabuse), certain cephalosporins, metronidazole, sulfonylureas (oral DM drugs), procarbezine (anti-cancer)

Front 13

Toxicity: Aztreonam

Back 13

usually nontoxic, occasional GI upset. No PCN/Ceph cross-reactivity

Front 14

Toxicities: Imipenem/cilastatin, meropenem

Back 14

significant side effects - GI distress, skin rash, CNS toxicity (seizures) at high plasma levels - but meropenem has reduced risk of seizures

Front 15

Toxicity: Vancomycin

Back 15

Well tolerated in general
NOT very toxic
Nephrotoxicity + Ototoxicity (like loops, cisplatin, aminoglycosides), Thrombophlebitis
Diffuse flushing - red man syndrome (can prevent with pretreatment of antihistamine and slow infusion rates)

Front 16

Toxicity: Aminoglycosides

Back 16

NOT very nice
Nephrotoxic (especially when used with cephalosporins)
Ototoxic (nephro/oto like loops, vanco, cisplatin)
Teratogen

Front 17

Which drugs cause Ototoxicity and Nephrotoxicity?

Back 17

Aminoglycosides, Vanco, loops, cisplatin (anti-cancer)

Front 18

Toxicity: Tetracyclines

Back 18

Teeth discoloration and bone growth retardation (children)
Photosensitivity
Contra- in pregnancy
GI distress - why most people stop

Front 19

For which ABs is GI discomfort the most common cause of noncompliance?

Back 19

Tetracyclines, Macrolides

Front 20

Toxicity: Macrolides

Back 20

GI Discomfort (most common cause of noncompliance)
Acute cholestatic hepatitis (only with erythromycin estolate), eosinophilia, skin rashes.
Increases serum concentration of theophyllines, oral anticoagulants
Group B in pregnancy

Front 21

Toxicity: Chloramphenicol

Back 21

Anemia (dose dependent), aplastic anemia (dose dependent), gray baby syndrome (in premies because they lack liver UDP-glucuronyl transferase)

Front 22

Gray baby syndrome

Back 22

Chloramphenicol
vs. Gray Man Syndrome - amiodorone-induced photosensitivity

Front 23

Toxicity: Clindamycin

Back 23

C-dif overgrowth (also common in ampicillin use), fever, diarrhea

Front 24

Which drugs cause Photosensitivity rxns?

Back 24

Sulfonamides, Amiadorone, Tetracyclines
"SAT for a Photo"

Front 25

Stevens-Johnson Syndrome

Back 25

Fever, bulla formation and necrosis, sloughing of skin, and high mortality rate
Caused by sulfonamides, ethosuxamide (absence seizures), lamotrigine (anticonvulsant), and others

Front 26

Toxicity: Sulfonamides

Back 26

HPY, hemolysis if G6PDD, nephrotoxicity (tubulointerstitial nephritis), photosensitivity (S-J Syndrome), kernicterus in infants, displace other drugs from albumin (e.g. warfarin)

Front 27

Toxicity: TMP-SMX

Back 27

TMP = Treats marrow poorly
Megaloblastic anemia, leukopenia, granulocytopenia
May alleviate with supplemental folinic acid

Front 28

Sulfa drug allergies

Back 28

fever, pruritic rash, SJ Syndrome, hemolytic anemia, thrombocytopenia, agranulocytosis, urticaria (hives). Sx range from mild to life-threatening.

Front 29

Toxicity: Nitrofurantoin

Back 29

Rare: nausea, headache, flatulence.

Safe in pregnancy

Front 30

Toxicity: [Fluoro]quinolones

Back 30

FluoroquinoLONES hurt attachments to your BONES
Contra- in pregnancy/children because studies show damage to cartilage. Tendonitis/tendon rupture in adults. Leg cramps and myalgias in kids. GI upset, superinfections, skin rashes, headache, dizziness

Front 31

Toxicity: Polymyxins

Back 31

Neurotoxicity, acute tubular necrosis (so restricted to topical use)

Front 32

Toxicity: Anti-Tb Tx

Back 32

Ethambutol - reversible optic neuropathy (Ethambutol - Eye) --> red/green color blindness and decreased visual acuity
Other drugs: hepatotoxicity

Front 33

Toxicity: INH

Back 33

INH Injures Neurons and Hepatocytes
Pyridoxine (B6) can prevent neurotoxins
Drug-induced lupus --> anti-histone Ab

Front 34

Drug-induced SLE

Back 34

HIPPS
Hydralazine
INH
Procainamide
Phenytoin
Sulfonamides

Front 35

Toxicity: Rifampin

Back 35

minor hepatotoxicity and drug interactions (P-450 inducer - BCG PQRS + ethanol); orange body fluids (nonhazardous)

Front 36

CYP450 Inducers - BCG PQRS + ethanol

Back 36

Barbs
Carbamazepine
Griseofulvin
Phenytoin
Quinidine
Rifampin
St. John's Wort
Ethanol

Front 37

CYP450 Inhibitors - PICK EGS

Back 37

Protease inhibitors
INH
Cymetidine (H2 blocker), Cipro
Ketoconazole (azole antifungals)
Erythromycin
Grapefruit Juice
Sulfonamides

Front 38

Toxicity: Acyclovir, Famcyclovir, Valacyclovir

Back 38

generally well tolerated. Acyclovir - crystal nephropathy and neuropathy that manifests as delirium and/or tremor

Front 39

Toxicity: Ganciclovir

Back 39

Bad to BM:
Leukopenia, neutropenia (contra- in HIV pts who are already on ziduvodine), thrombocytopenia, renal toxicity, more toxic to host enzymes than acyclovir.

Front 40

Toxicity: Foscarnet

Back 40

Nephrotoxic - Mg wasting, PTH release reduction --> decreased Ca
Ca chelator
low Ca and low Mg can cause seizures

Front 41

Toxicity: Amantidine, Rimantidine

Back 41

Ataxia, dizziness, slurred speech, anti-cholinergic Sx

Front 42

Toxicity: Ribavirin

Back 42

hemolytic anemia, severe teratogen

Front 43

Toxicity: Protease inhibitors

Back 43

GI intolerance (nausea, diarrhea)
Kidney stones (increased hydration recommended)
fat redistribution, insulin resistance (hyperglycemia), hyper-TGemia

Front 44

Toxicity: Zidovudine

Back 44

BM suppression, megaloblastic anemia, GI intolerance. Can't give ganciclovir for CMV retinitis to HIV pts. on this because of risk of further neutropenia

Front 45

Toxicity (shared): Zalcitabine, stavudine and didanosine

Back 45

Pancreatitis, peripheral neuropathy

Front 46

Toxicity (shared): Stavudine, didanosine

Back 46

hepatic steatosis

Front 47

Toxicity: Abacavir

Back 47

HPY reactions

Front 48

Toxicity: Indinavir

Back 48

shared toxicities + neprolithiasis (renal stones), insignificant bilirubinemia, thrombocytopenia

Front 49

Toxicity (shared): Saquinavir, amprenavir, indinavir

Back 49

Glucose+lipid increases, not good for DM pts.

Front 50

Toxicity: ritonavir

Back 50

pancreatitis

Front 51

Toxicity: NRTIs

Back 51

possible lactic acidosis

Front 52

Toxicity: Lamivudine

Back 52

least side effects of NRTIs
Occasionally associated with lactic acidosis, peripheral neuropathy

Front 53

Toxicity: NNRTIs

Back 53

rash

Front 54

Toxicity: Efavirenz

Back 54

false + on cannibinoid test, CNS - somnolence, confusion, agitation.

Front 55

Toxicity: Enfuvirtide

Back 55

HPY rxns, rxns at subQ injection site, increased risk of bacterial pneumonia

Front 56

Toxicity: RTIs

Back 56

BM suppression
GM-CSF and EPO can be used to reduce this

Front 57

Toxicity: IFNs

Back 57

neutropenia

Front 58

ABs to avoid in pregnancy

Back 58

Sulfonamides - kernicterus
Aminoglycosides - ototoxicity
Fluoroquinolones - cartilage damage
Metronidazole - mutagenesis (in 1st trimester, okay thereafter)
Tetracyclines - discolored teeth, inhibition of bone growth
Ribavirus (antiviral) - teratogenic
Griseofulvin (antifungal) - teratogenic
Chloramphenicol - "gray baby"

Front 59

Which vitamin can be teratogenic?

Back 59

Vitamin A

Front 60

Toxicity: Vitamin A

Back 60

Arthralgias, fatigue, headaches, skin changes, sore throat, alopecia. Teratogenic: cleft palate, cardiac abnormalities, increased lung cancer risk in smokers.

Front 61

Teratogens – Alcohol

Back 61

Leading cause of birth defects and MR; FAS

Front 62

Teratogens – ACE-I

Back 62

Renal damage

Front 63

Teratogens – Cocaine

Back 63

Abnormal fetal development and fetal addiction; placental abruption due to increased BP
Vasoconstriction → hypoxia → small size of fetus

Front 64

Teratogens – DES

Back 64

Vaginal clear cell adenocarcinoma

Front 65

Teratogens – Iodine lack or excess

Back 65

Congenital goiter or hypothyroidism

Front 66

Teratogens – Vitamin A excess

Back 66

Acts on Hox genes – extremely high risk for spontaneous abortions and birth defects (clef palate, cardiac abnormalities, hydrocephalus)

Front 67

Teratogens – smoking (nicotine, CO)

Back 67

Preterm labor, placental problems, IUGR, ADHD. As with cocaine, no birth defects, but nicotine causes vasoconstriction → hypoplasia

Front 68

Teratogens – thalidomide

Back 68

Used to be used as sedative in pregnancy. Limb defects (“flipper” limbs)

Front 69

Teratogens – X-rays, anticonvulsants

Back 69

Multiple abnormalities

Front 70

Teratogens – Warfarin

Back 70

Bone deformities, fetal hemorrhage, abortion (vs. heparin, which doesn’t cross placenta)

Front 71

Teratogens – Tetracyclines

Back 71

Discolored teeth

Front 72

Teratogens - Alkylating agents

Back 72

Cancer drug. Leads to absence of digits, multiple anomalies

Front 73

Teratogens – aminoglycosides

Back 73

CN VIII toxicity

Front 74

Teratogens – folate antagonists

Back 74

Neural tube defects

Front 75

Teratogens – fluoroquinolones

Back 75

Interrupts cartilage formation

Front 76

Teratogens – lithium

Back 76

Epstein’s anomaly (congenital heart defect in which the opening of the tricuspid valve is displaced towards the apex of the right ventricle of the heart)

Front 77

Class A drugs

Back 77

Studies on humans prove safety
E.g. vaginal nystatin

Front 78

Class B drugs

Back 78

Studies on animals prove safety
Tylenol, benadryl (diphenhydramine), ondonsitrone (nausea med), Meclezine (antihistamine used for dizziness), Beta-lactams, metronidazole, Ca+2 antacids, insulin, metformin, macrolides, nitrophylantoin, H2 blockers, methyldopa (HTN drug in pregnancy)

Front 79

Class C drugs

Back 79

No adverse effects found, poor studies
Pseudoephedrine, Demerol, morphine, hydrocodone, nystatin (oral), heparin, labetalol/hdralazine/niphedipine (all HTN drugs), promethazine (nausea)

Front 80

Fetal Alcohol Syndrome

Back 80

Leading cause of congenital malformations in the US. Increased incidence of congenital abnormalities, including pre-/post-natal developmental retardation, microcephaly, holoprosencephaly, facial abnormalities, limb dislocation, heart and lung fistulas. Mechanism may include inhibition of cell migration. Early drinking is worse. Eyes set apart (can fit one eye in between the two), flattened bridge, philtrum elongated, low set ears

Front 81

Toxicity: Azathioprine

Back 81

BM suppression, active metabolite (mecaptopurine) metabolized by xanthine oxidase, so toxic effects increased by allopurinol use

Front 82

Toxicity: Tacrolimus (FK506)

Back 82

Significant – nephrotoxicity, peripheral neuropathy, hypertension, pleural effusion, hyperglycemia, increased risk of malignancy when used topically.

Front 83

Toxicity: cyclosporine

Back 83

Predisposes pts to viral infections and lymphoma; nephrotoxic (preventable with mannitol diuresis)

Front 84

Toxicity: Sirolimus (rapamycin)

Back 84

Hyperlipidemia, thrombocytopenia, leucopenia

Front 85

Cholinesterase Inhibitor Poisoning

Back 85

DUMBBELSS. Make you leaky
Diarrhea, Urination, Miosis, Bronchospasm, Bradycardia, Excitation of sk. mm. and CNS, Lacrimation, Sweating, Salivation (and abdominal cramping)
Occurs often because of Parathion and organophosphates (insecticides) – irreversible inhibitors)

Front 86

Muscarinic antagonists – Contraindications

Back 86

Angle-closure glaucoma, Alzheimer’s, BPH pts., infant under conscious sedation (because of hyperthermia), GI obstruction

Front 87

Atropine (antimuscarinic) Toxicity

Back 87

Blocks DUMBBELSS – Hot as a hare, Dry as a bone, Red as a beet, Blind as a bat, Mad as a hatter, Bloated as a toad, The bowel and bladder lose their tone, and the heart runs alone (tachycardia)
Hot – increased temperature; hyperthermia in infants. Dry/Red – Dry mouth, dry flushed skin. Blind – paralysis of ciliary body → cycloplegia → cycloplegia. Also can cause acute closure glaucoma in elderly. Mad – disorientation, especially in elderly. Bloated – constipation and urinary retention, especially in men with BPH.
Also decreased secretions in stomach and airway (blocks vagal stimulation through Ach)

Front 88

Toxicity: Hexamethonium

Back 88

Severe orthostatic hypotension, blurred vision, constipation, sexual dysfunction

Front 89

Toxicity: Phenoxybenzamine

Back 89

Orthostatic hypotention, reflex tachycardia (nonselective alpha blocker)

Front 90

Toxicity: Phentolamine

Back 90

Orthostatic hypotention, reflex tachycardia (nonselective alpha blocker)

Front 91

Toxicity: Prazosin

Back 91

1st dose orthostatic hypotension, dizziness, headache

Front 92

Toxicity: Terazosin

Back 92

1st dose orthostatic hypotension, dizziness, headache

Front 93

Toxicity: Doxazosin

Back 93

1st dose orthostatic hypotension, dizziness, headache

Front 94

Toxicity: Mirtazapine

Back 94

Sedation, increase in serum cholesterol, increased appetite. Good in pts with depression who have insomnia or anorexia

Front 95

Antidote: Acetaminophen

Back 95

N-acetylcysteine (reforms glutathione)

Front 96

Antidote: Salicylates

Back 96

NaHCO3 (alkalinze urine), dialysis

Front 97

Antidote: Amphetamines (basic)

Back 97

NH4Cl (acidify urine)

Front 98

Antidote: Anticholinesterases, organophosphates

Back 98

Atropine, pralidoxime

Front 99

Antidote: Antimuscarinic, anticholinergic agents

Back 99

Physostigmine salicylate
“Phyxes” atropine OD

Front 100

Antidote: Beta-blockers, verapamil

Back 100

Glucagon, calcium, atropine

Front 101

Antidote: Digitalis

Back 101

Stop dig, normalize K+, lidocaine (or phenytoin – both Class IB antiarrhythmic), anti-dig Fab fragments (if very severe), normalize Mg+2

Front 102

Antidote: Iron

Back 102

deFeroxamine

Front 103

Antidote: Lead

Back 103

CaEDTA + dimercaprol (first line), succimer (kids), penicillamine

Front 104

Antidote: Mercury, arsenic, gold

Back 104

Dime = money. Merc = mercury
Dimercaprol (BAL), succimer

Front 105

Antidote: Copper, Arsenic, Gold

Back 105

Think: Pennies = money
Penicillamine

Front 106

Antidote: Cyanide (nitroprusside can cause CN toxicity)

Back 106

Nitrite (oxidize Hb to MetHb, which binds CN, allowing cytochrome oxidase to function), hydroxocobalamin, thiosulfate (binds CN on MetHb, forming thiocyanate, which is renally excreted.

Front 107

Drugs that produce Methemoglobin

Back 107

Chlorquine, primaquine, Dapsone, Sulfonamides, Local anesthetics (lidocaine), Metoclopramide, Nitrates

Front 108

Antidote: Methemoglobin

Back 108

Methylene blue, Vitamin C (adjuvant reducing agent), Cimetidine (only for slow reversal, not acute)
MetHb is oxidized form, Fe+3

Front 109

Antidote: CO

Back 109

100% O2, hyperbaric O2

Front 110

Antidote: Methanol, ethylene glycol (antifreeze)

Back 110

Ethanol (competitive inhibitor), dialysis, fomepizole (inhibits alcohol dehydrogenase. Drug of choice)

Front 111

Antidote: Opioids

Back 111

Naloxone, naltrexone

Front 112

Antidote: Benzodiazepines

Back 112

Flumazenil (can induce withdrawal in addict)

Front 113

Antidote: TCAs

Back 113

NaHCO3 (serum alkalinization)

Front 114

Antidote: Heparin

Back 114

Follow PTT
Protamine sulfate (positively charged – binds negatively charged heparin)

Front 115

Antidote: Warfarin

Back 115

Vitamin K (takes few days to work), fresh frozen plasma (immediate response)

Front 116

Antidote: tPA, streptokinase

Back 116

Aminocaproic acid

Front 117

Antidote: Theophylline

Back 117

Used in asthma
Beta-blocker

Front 118

Drug reaction: Prolonged QT

Back 118

Macrolides, haloperidol, risperidone, methadone, HIV protease inhibitors. These contra-indicated in pts with already long QT

Front 119

Drug reaction: Atropine-like side effects

Back 119

TCAs, low potency typical neuroleptics, 1st generation antihistamines, promethazine (nausea meds)

Front 120

Drug reaction: Coronary vasospasm

Back 120

Cocaine, sumatriptan, methamphetamines, ergots (used for vasoconstriction in headaches)

Front 121

Drug reaction: Cutaneous flushing

Back 121

Niacin, Ca channel blockers, adenosine, vancomycin (if given too fast)

Front 122

Drug reaction: Dilated cardiomyopathy

Back 122

Doxorubicin (adriamycin), daunorubicin

Front 123

Drug reaction: Torsades de pointes

Back 123

Class III (sotalol), Class IA (quinidine) antiarrhythmics, cisapride
Tx: Mg Sulfate push

Front 124

Drug reaction: Agranulocytosis

Back 124

Clozapine, carbamazepine, colchicines, propylthioracil, methimazole

Front 125

Drug reaction: Direct coombs positive hemolytic anemia

Back 125

Methyldopa

Front 126

Drug reaction: Gray baby syndrome

Back 126

Chloramphenicol

Front 127

Drug reaction: Hemolysis in G6PD deficient patients

Back 127

Hemolysis IS PAIN
INH, Sulfonamides, Primaquine, Aspirin (high dose), Ibuprofen, Nitrofurantoin
Also: Dapsone, Napthalene, fava beans

Front 128

Drug reaction: Megaloblastic anemia

Back 128

Phenytoin, MTX, Sulfa drugs (having a blast with PMS)

Front 129

Drug reaction: Thrombotic complications

Back 129

OCPs (never give to smokers over 35, though hormone therapy fine in them)
Pts with migraines with aura (increased stroke risk)

Front 130

Drug reaction: Cough

Back 130

ACE-I

Front 131

Drug reaction: Pulmonary fibrosis

Back 131

Bleomycin, busulfan, amiodarone

Front 132

Drug reaction: acute cholestatic hepatitis

Back 132

Erythromycin estolate (can’t use in pts with preexisting liver dz)

Front 133

Drug reaction: Focal to massive hepatic necrosis

Back 133

Halothane, valproic acid, acetaminophen (toxic dose = 4g/day), Amanita phalloides

Front 134

Drug reaction: Hepatitis

Back 134

INH

Front 135

Drug reaction: Pseudomembranous colitis

Back 135

Ampicillin, Clindamycin

Front 136

Drug reaction: Adrenocortical insufficiency

Back 136

Glucocorticoid withdrawal (HPA suppression)

Front 137

Drug reaction: Gynecomastia

Back 137

“Some Drugs Create Awesome Knockers”
Spironolactone (worst), Digitalis, Cimetidine, chronic Alcohol, estrogens, Ketoconazole

Front 138

Drug reaction: Hot flashes

Back 138

Tamoxifen, clomiphene (induces ovulation)

Front 139

Drug reaction: Gingival hyperplasia

Back 139

Phenytoin

Front 140

Drug reaction: Gout

Back 140

Furosemide, thiazides

Front 141

Drug reaction: Osteoporosis

Back 141

Corticosteroids, heparin

Front 142

Drug reaction: Photosensitivity

Back 142

“SAT for a photo”
Sulfonamides, Amiodarone, Tetracycline

Front 143

Drug reaction: Rash (Stevens-Johnson syndrome)

Back 143

Ethosuximide, lamotrigine, carbamezepine, Phenobarbital, phenytoin, sulfa drugs, PCN, allopurinol

Front 144

Drug reaction: SLE-like syndrome

Back 144

SHIPP
Sulfonamides, Hydralazine, INH, Procainamide, Phenytoin
See anti-histone antibodies

Front 145

Drug reaction: Tendonitis, tendon rupture, cartilage damage (kids)

Back 145

Fluoroquinolones

Front 146

Drug reaction: Fanconi’s syndrome

Back 146

Expired tetracycline, cisplatin

Front 147

Drug reaction: Interstitial nephritis

Back 147

Methicillin, NSAIDs, Furosemide

Front 148

Drug reaction: Hemorrhagic cystitis

Back 148

Cyclophosphamide, ifosfamide
Prevent by coadministering with mesna

Front 149

Drug reaction: Cinchonism

Back 149

Quinidine, quinine

Front 150

Drug reaction: DI

Back 150

Lithium, demeclocycline

Front 151

Drug reaction: Parkinson-like syndrome

Back 151

Haloperidol, chlorpromazine, reserpine, metoclopramide

Front 152

Drug reaction: Seizures

Back 152

Bupropion, imipenem/cilastatin, INH

Front 153

Drug reaction: Tardive dyskinesia

Back 153

Antipsychotics

Front 154

Drug reaction: Nephrotoxicity/neurotoxicity

Back 154

Polymyxins

Front 155

Drug reaction: Nephrotoxicity/ototoxicity

Back 155

Aminoglycosides, vancomycin, loops, cisplatin

Front 156

CYP450 inducers

Back 156

BCG PQRS + Ethanol
Barbs, Carbamazepine, Griseofulvin, Phenytoin, Quinidine, Rifampin, St. John’s Wort, Ethanol

Front 157

CYP450 inhibitors

Back 157

PICK EGS
Protease inhibitors
INH
Cimetidine (H2 Blocker)
Ketoconazole
Erythromycin
Grapefruit juice
Sulfonamides

Front 158

Toxicity: Ethylene glycol

Back 158

Found in antifreeze. Alcohol dehydrogenase converts to oxalic acid → acidosis and nephrotoxicity (calcium oxalate crystals)

Front 159

Toxicity: Methanol

Back 159

Wood Alcohol. Alcohol dehydrogenase converts to formaldehyde (not further metabolized) and formic acid. Causes severe acidosis, retinal damage

Front 160

Toxicity: Ethanol

Back 160

Alcohol dehydrogenase converts to acetaldehyde (causes nausea, vomiting, headache, hypotension) and acetaldehyde dehydrogenase converts that to acetic acid. Disulfiram blocks latter reaction, leading to above symptoms

Front 161

Tx: Methanol/Ethylene Glycol OD

Back 161

Fomepizole drug of choice – blocks alcohol dehydrogenase. Can also use ethanol, since alcohol dehydrogenase has higher affinity (lower km) for it than other two.

Front 162

Sulfa Drugs

Back 162

Celecoxib, furosemide, probenecid, thiazides, TMP-SMX, sulfasalazine, sulfonylureas, sumatriptan, acetazolamide, sulfonamide ABs

Front 163

Toxicity: Sulfa drugs

Back 163

Pts with sulfa allergies may develop fever, pruritic rash, Stevens-Johnson Syndrome, hemolytic anemia, thrombocytopenia, agranulocytosis, urticaria (hives)

Front 164

Epstein’s anomaly is associated with maternal use of what?

Back 164

Li

Front 165

What causes peeling of finger tips?

Back 165

Kawasaki dz, Hg toxicity

Front 166

Hydrochlorothiazide vs. loops – Ca effects

Back 166

Both very strong diuretics, but “LOOPS LOOSE” calcium, while hydrochlorothiazide retains it, so it is preferred for pts with renal stones or hypocalcemia (and has decreased risk of osteoporosis), while loops in pts with hypercalcemia

Front 167

Toxicity: Hydrochlorothiazide

Back 167

Anti-HTN Diuretic
Hypokalemia, mild hyperlipidemia, hyperuricemia (can lead to gout), hypercalcemia, hyperglycemia

Front 168

Toxicity: Loops

Back 168

Anti-HTN Diuretics
Hypotension, ototoxicity (aminoglycosides particularly ototoxic if given in combination), potassium wasting, metabolic alkalosis

Front 169

Toxicity: Clonidine

Back 169

Anti-HTN Sympathoplegic
Dry mouth, sedation, severe rebound hypertension, bradycardia, so be careful if giving with beta blockers, etc.

Front 170

Toxicity: Methyldopa

Back 170

Anti-HTN Sympathoplegic
Safe in pregnancy
Sedation, positive Coombs’ test

Front 171

Toxicity: Reserpine

Back 171

Anti-HTN Sympathoplegic
Not used much
Sedation, depression, nasal stuffiness, diarrhea

Front 172

Toxicity: Guanethidine

Back 172

Anti-HTN Sympathoplegic
Orthostatic and exercise hypotension, sexual dysfunction, diarrhea.
Blocks NE release, not used much

Front 173

Toxicity: Prazosin

Back 173

Anti-HTN Sympathoplegic
Alpha1 blocker
1st dose orthostatic hypotension, dizziness, headache

Front 174

Toxicity: Beta blockers

Back 174

Anti-HTN Sympathoplegic
Impotence, asthma, cardiovascular effects (bradycardia, CHF, AV block – contra- in patients with preexisting AV block), CNS effects (sedation, sleep alterations)

Front 175

Toxicity: Hydralazine

Back 175

Anti-HTN Vasodilator
Nausea, headache, lupus-like syndrome, reflex tachycardia (contra- in angina/CAD), angina, salt retention
Use with Beta Blocker to prevent reflex tachycardia and salt retention (caused because it causes arteriole sm. mm. relaxation, not in veins. This leads to reflex tachycardia, renin secretion, leading to fluid/salt retention)

Front 176

Toxicity: Minoxidil

Back 176

Anti-HTN Vasodilator
hypertrichosis (abnormally increased body hair growth), pericardial effusion, reflex tachycardia, angina, salt retention
Use with Beta Blocker to prevent reflex tachycardia/salt retention - because it causes arteriole sm mm. relaxation, not in veins - leads to renin secretion --> water/salt retention

Front 177

Toxicity: Nifedipine, Verapamil

Back 177

Anti-HTN Vasodilators
Dizziness, flushing, constipation (verapamil), AV block (verapamil), nausea, edema

Front 178

Toxicity: Nitroprusside

Back 178

Anti-HTN Vasodilator
CN toxicity (releases CN) – bitter almond taste. Used in HTN emergencies, not long-term

Front 179

Toxicity: Diazoxide

Back 179

Not used in US as Anti-HTN
Hyperglycemia (reduces insulin release), hypotension
Decreases insulin release in insulinomas

Front 180

Toxicity: ACE-I

Back 180

Captopril, Enalapril, Fosinopril; anti-HTN
Hyperkalemia, cough (can develop early or late, due to bradykinin), taste changes, hypotension, pregnancy problems, (fetal renal damage), rash, increased renin, angioedema

Front 181

Toxicity: ARBs

Back 181

Losartan
Fetal renal toxicity, hyperkalemia

Front 182

Toxicity: Ca Channel Blockers

Back 182

Cardiac depression (Verapamil, diltiazem), peripheral edema (Dihydropyridines), flushing, dizziness, constipation

Front 183

Toxicity: Nitroglycerin, Isosorbide dinitrate

Back 183

Tachycardia, hypotension, flushing, headache, “Monday disease” in industrial exposure, development of tolerance for the vasodilating action during the work week and loss of tolerance over the weekend, resulting in tachycardia, dizziness and headache on reexposure

Front 184

Toxicity: Statins

Back 184

Reversible increase in LFTs (up to 3x increase allowable), rhabdomyolysis

Front 185

Toxicity: Niacin

Back 185

Initial red, flushed face, which is decreased by aspirin or long-term use

Front 186

Toxicity: Cholestyramine, Colestipol, Colesevelam

Back 186

Bile Acid Resin Lipid Lowering Agent
Patients hate taste and GI discomfort; decreased absorption of fat-soluble vitamins and drugs; contra- in pts with gall stones

Front 187

Toxicity: Ezetimibe

Back 187

Rare increase in LFTs, so don’t mix with statins

Front 188

Toxicity: Fibrates

Back 188

Lipid-lowering agents
Myositis, increased LFTs – don’t give with statins!

Front 189

Toxicity: Digoxin

Back 189

May cause increased PR, decreased QT, scooping of ST segment, T-wave inversion on ECG. Increases PNS activity (NVD), blurry yellow vision. Arrhythmia. Gynecomastia (SDCAK)

Front 190

Digoxin Toxicity increased by

Back 190

Renal failure (decreased excretion)
Hypokalemia (digoxin competes with K+ for binding on Na/K ATPase)
Quinidine (decreased digoxin clearance, displaces digoxin from tissue-binding sites

Front 191

Toxicity: Class IA Antiarrhythmics

Back 191

Quinidine – cinchonism (headache, tinnitus, thrombocytopenia, tosades de pointes due to increased QT)
Procainamide – reversible SLE-like syndrome

Front 192

Toxicity: Class IB Antiarrhythmics

Back 192

Tocainide, Lidocaine, Mexiletine
Local anesthetic. CNS stimulation/depression, cardiovascular depression

Front 193

Toxicity: Class II Antiarrhythmics

Back 193

Propranolol, esmolol, metoprolol, atenolol, timolol
Impotence, exacerbation of asthma, cardiovascular effects (bradycardia, AV block, CHF), CNS effects (sedation, sleep alteration). May mask signs of hypoglycemia. Metoprolol can cause dyslipidemia

Front 194

Toxicity: Sotalol

Back 194

Class III Antiarrhythmic
torsades de pointes, excessive Beta block

Front 195

Toxicity: Ibutilide

Back 195

Class III Antiarrhythmic
Torsades

Front 196

Toxicity: Bretylium

Back 196

Class III Antiarrhythmic
new arrhythmias, hypotension

Front 197

Toxicity: Amiodarone

Back 197

Class III Antiarrhythmic
Very dirty drug, pulmonary fibrosis (like bleomycin, busulfan. check PFTs), Hepatotoxicity (Check LFTs), hypo/hyperthyroidism (has I- in it), corneal deposits, skin deposits resulting in photodermatitis, neurologic effects, constipation, cardiovascular effects (bradycardia, heart block, CHF)

Front 198

Toxicity: Class IV Antiarrhythmics

Back 198

Constipation, flushing, edema, CV effects (like beta blockers – CHF, AV block, sinus node depression).

Front 199

Toxicity: Adenosine

Back 199

Antiarrhythmic
Flushing + hypotension (vasodilator because adenosine is sign of lack of energy in tissue – increases blood flow and nutrients washing over tissue), chest pain

Front 200

Antidote: Lithium

Back 200

Amiloride (Closes the Na channels opened by Li)

Front 201

Toxicity: Insulin

Back 201

Hypoglycemia, HPY reaction (rare)

Front 202

Toxicities: Sulfonylureas

Back 202

First generation (Tolbutamide, Chlorpropamide) – disulfiram-like
Second generation (Glyburide, Glimepiride, Glipizide) – hypoglycemia – difficult to correct. Have to be in hospital for 24 hours

Front 203

Toxicity: Metformin/Biguanides

Back 203

Most grave adverse effect is lactic acidosis, so can’t use in liver/renal dz or CHF. Can’t use IV contrast dye w/in 24 hours of taking Metformin

Front 204

Toxicity: Glitazones (aka thiazolidinediones, aka TZDs)

Back 204

Rosiglitazone, pioglitazone - DM Drugs
GI disturbances
Contra- in liver cirrhoses, IBD, increased creatinine
Rosiglitazone may increase MI risk

Front 205

Toxicity: Pramlintide

Back 205

Hypoglycemia
Nausea, diarrhea

Front 206

Toxicity: Exenatide

Back 206

GLP-1 (an incretin) mimetic – DM Drug
Nausea, vomiting, possibly pancreatitis

Front 207

Toxicity: Orlistat

Back 207

Obesity drug – pancreatic lipase inhibitor
Steatorrhea, GI discomfort, reduced absorption of fat-soluble vitamins, headache

Front 208

Toxicity: Sibutramine

Back 208

HTN, tachycardia, serotonin syndrome, so contra- in pts taking other SSRIs or MAOIs. Also contra-: CAD, CVA, CHF, arrhythmia history

Front 209

Toxicity: PTU, Methimazole

Back 209

Skin rash, agranulocytosis (rare), aplastic anemia, Methimazole associated with more birth defects

Front 210

Toxicity: Levothyroxine, triiodothyronine

Back 210

Tachycardia, heat intolerance, tremors, arrhythmias

Front 211

Toxicity: Glucocorticoids

Back 211

Hydrocortisone, prednisone, triamcinolone, dexamethasone, beclomethasone
Iatrogenic Cushing’s syndrome (buffalo hump, moon facies, truncal obesity, muscle wasting, thin skin, easy bruisability, osteoporosis, adrenocortical atrophy, peptic ulcers, diabetes [if chronic]), psychosis, insonmnia

Front 212

Toxicity: Demeclocycline

Back 212

Nephrogenic DI, Photosensitivity, abnormalities of bone and teeth

Front 213

Toxicity: H2 blockers

Back 213

Cimetidine – CYP450 inhibitor (piCk egs); antiandrogenic effect (prolactin release, gynecomastia [SDCAK], impotence, decreased libido in males); can crause BBB (confusion, dizziness, headaches) and placenta (not teratogen – these are safe in pregnancy).
Cimetidine + ranitidine → decreased renal excretion of creatinine.
Other H2 blockers relatively free of these effects

Front 214

Toxicity: Misoprostol

Back 214

Diarrhea – contra- in pts with IBD. Contraindicated in women of childbearing potential (abortifactant)

Front 215

Toxicity: Pirenzepine

Back 215

Muscarinic antagonist
Tachycardia, dry mouth, difficulty focusing eyes
(Blind as a bat, Hot as a hare, etc.)

Front 216

Toxicity: Antacids

Back 216

Aluminum hydroxide – constipation and hypophosphatemia (Al and Ca can acutely lower PO4 levels in renal pts); proximal muscle weakness, osteodystrophy, seizures
Magnesium hydroxide – diarrhea, hypotension, hyporeflexia (loss of DTRs), cardiac arrest
Calcium carbonate – hypercalcemia, rebound acid increase (calcium increase stimulates gastrin release
All can cause hypokalemia (decreased acid → metabolic alkalosis, K exchanged for intracellular H)
Can chelate and decrease effectiveness of other drugs, e.g. tetracycline

Front 217

Toxicity: Anti-TNF Ab

Back 217

Infliximab, Etanercept, Adalimumab
Respiratory infection (including Tb reactivation), fever, hypotension
Tb will run rampant in these pts, so have to test for it first

Front 218

Toxicity: Sulfasalazine

Back 218

Malaise, nausea, sulfonamide toxicity, reversible oligospermia

Front 219

Toxicity: 5-HT3 antagonists

Back 219

Ondansetron, Granisetron
Headache, constipation
Think: sumatriptan (5HT agonist) treats headaches, vasoconstriction, so this is opposite)

Front 220

Toxicity: Metoclopramide

Back 220

5HT receptor agonist, D2 receptor antagonist
Parkinsonian effects. Restlessness, drowsiness, fatigue, depression, nausea, diarrhea. Drug interaction with digoxin and diabetic agents. Contraindicated in patients with small bowel obstruction (try to empty their bowels, not stimulate). Contra- in epilepsy (increases seizures)

Front 221

Toxicity: Heparin

Back 221

Bleeding, thrombocytopenia (HIT), osteoporosis, drug-drug interactions.

Front 222

HIT

Back 222

Heparin-induced thrombocytopenia (most-feared complication of heparin use). Heparin binds to platelets, causing auto-Ab production that destroys platelets and overactivates remaining ones, resulting in thrombocytopenic, hypercoagulable state

Front 223

Toxicity: Warfarin

Back 223

Bleeding, teratogenic, skin/tissue necrosis, drug-drug interactions

Front 224

Toxicity: Thrombolytics

Back 224

Bleeding. Contra- in patients with active bleeding, Hx of intracranial bleeding, recent surgery, known bleeding diatheses, or severe HTN

Front 225

Toxicity: Aspirin

Back 225

Gastric ulceration, bleeding, hyperventilation, Reye’s syndrome (flu, chicken pox tx in children), tinnitus (CN VIII). Chronic use can lead to acute renal failure (b/c PGs important for maintaining patency of renal vasculature), interstitial nephritis, upper GI bleed, ototoxicity.

Front 226

Toxicity: Ticlopidine

Back 226

Neutropenia

Front 227

Toxicity: Abciximab, Tirafiban, Eptifibatide

Back 227

Bleeding, thrombocytopenia

Front 228

Toxicity: MTX

Back 228

Pancytopenia, which is reversible with leucovorin (folinic acid) “rescue.” Macrovesicular fatty change in liver. Mucositis. HPY pneumonitis

Front 229

Toxicity: 6-MP

Back 229

Bone marrow, GI, liver. Metabolized by xanthine oxidase, thus increased toxicity with allopurinol (like azathioprine, a less toxic mercaptopurine)

Front 230

Toxicity: Cytarabine (ara-C)

Back 230

Leukopenia, thrombocytopenia, megaloblastic anemia

Front 231

Toxicity: Cyclophosphamide

Back 231

Myelosuppression. Toxic metabolite acrolein causes increased risk for hemorrhagic cystitis (transitional cell bladder cancer), which can be partially prevented by mesna, which binds acrolein

Front 232

Toxicity: Nitrosureas

Back 232

Carmustine, lomustine, semustine, streptozocin
Used in brain tumors, crosses BBB, so CNS toxicity (dizziness, ataxia)

Front 233

Toxicity: Cisplatin, Carboplatin

Back 233

Nephro+Ototoxicity (like loops, Aminoglycosides and Vancomycin)

Front 234

Toxicity: Busulfan

Back 234

Pulmonary fibrosis (like amiodarone and bleomycin), hyperpigmentation

Front 235

Toxicity: Doxorubicin (adriamycin), Daunorubicin

Back 235

Cardiotoxicity, myelosuppression, marked alopecia. Toxic extravasation.

Front 236

Toxicity: Dactinomycin (Actinomycin D)

Back 236

Myelosuppression

Front 237

Toxicity: Bleomycin

Back 237

Pulmonary fibrosis (Bleomycin, busulfan, amiodarone), skin changes, MINIMAL myelosuppression

Front 238

Toxicity: Hydroxyurea

Back 238

BM suppression, GI upset

Front 239

Toxicity: Etoposide (VP-16)

Back 239

Myelosuppression, GI irritation, alopecia

Front 240

Toxicity: Prednisone

Back 240

Cushing-like syndromes, immunosuppression, cataracts, acne, osteoporosis (give bisphosphonates to anyone on steroids > 3 mos), peptic ulcers, hyperglycemia, psychosis, insomnia. Oral thrush when used for asthma (use spacer to avoid)

Front 241

Toxicity: Clomiphene

Back 241

May cause hot flashes, ovarian enlargement, multiple simultaneous pregnancies, visual disturbances

Front 242

Toxicity: Tamoxifen, Raloxifene

Back 242

May increase risk of endometrial carcinoma via partial agonist effects. Hot flashes. Raloxifene does not cause endometrial carcinoma because it is an endometrial antagonist

Front 243

Toxicity: Trastuzumab (Herceptin)

Back 243

Cardiotoxicity (like doxorubicin, daunorubicin)

Front 244

Toxicity: Imatinib (Gleevac)

Back 244

Fluid retention

Front 245

Toxicity: Vincristine

Back 245

Neurotoxicity (areflexia, peripheral neuritis), paralytic ileus

Front 246

Toxicity: Vinblastine

Back 246

“Blasts BM” (suppression)

Front 247

Toxicity: Taxols

Back 247

e.g. paclitaxel
Myelosuppression, HPY

Front 248

Toxicity: Colchicine

Back 248

GI side effects, especially if taken orally (indomethacin is less toxic, used in acute gout). Lethal if take too much because of MT effect. Dosed in acute gout until 1) it works, 2) diarrhea too bad or 3) upper limit reached. Causes agranulocytosis

Front 249

Toxicity: Allopurinol

Back 249

Blocks xanthine oxidase, preventing metabolism of azathioprine and 6-MP. Stevens-Johnson syndrome

Front 250

Toxicity: NSAIDs

Back 250

Renal damage (b/c PGs important for maintaining patency of renal vasculature), aplastic anemia, GI distress, ulcers

Front 251

Toxicity: Cox-2 inhibitors

Back 251

e.g. celecoxib
Increased risk of thrombosis. Sulfa allergy. Less toxicity to GI mucosa (lower incidence of ulcers, bleeding than NSAIDs)

Front 252

Toxicity: Acetaminophen

Back 252

OD (>4g/day) produces hepatic necrosis; acetaminophen intermediate metabolite NAPQI depletes glutathione and forms toxic tissue adducts in liver. N-acetylcysteine (cysteine precursor) is antidote – regenerates glutathione (made from cysteine).

Front 253

Toxicity: epinephrine (in glaucoma)

Back 253

Mydriasis, stinging. Do not use in closed-angle glaucoma

Front 254

Toxicity: Beta blockers (in glaucoma)

Back 254

No pupillary or vision changes

Front 255

Toxicity: Acetazolamide (in glaucoma)

Back 255

No pupillary/vision changes. Decreased serum pH, metabolic acidosis

Front 256

Toxicity: Mannitol

Back 256

Pulmonary edema, dehydration, nausea, vomiting, headache. Contra- in anuria, CHF

Front 257

Toxicity: Cholinomimetics (in glaucoma)

Back 257

Miosis, cyclospasm

Front 258

Toxicity: Latanoprost

Back 258

PGF-2alpha
Darkens color of iris (browning), lengthens eyelashes

Front 259

Toxicity: opioid analgesics

Back 259

Morphine, fentanyl, codeine, heroin, methadone, meperidine, dextromethorphan
Addiction, respiratory depression, pinpoint pupils, CNS depression (additive with other drugs), constipation. Toxicity treated with naloxone or naltrexone (opioid receptor antagonist). Tolerance does not develop to miosis and constipation. Morphine – histamine release – itching. Fentanyl – no histamine release.

Front 260

Toxicity: Butorphanol

Back 260

Causes withdrawal if on full opioid agonist. Safe in pregnancy

Front 261

Toxicity: Tramadol

Back 261

Similar to opioids, non-addictive. Decreases seizure threshold, like Bupropion

Front 262

Toxicity: Phenytoin

Back 262

Nystagmus, ataxia, diplopia, sedation, SLE-like syndrome (SHIPP), induction of CYP450 (BCG PQRS + EtOH), Stevens-Johnson Syndrome. Chronic use produces gingival hyperplasia in children, peripheral neuropathy, hirsutism, megaloblastic anemia (decreased folate absorption), generalized lymphadenopathy. Teratogenic (Fetal hydantoin syndrome)

Front 263

Toxicity: Barbiturates

Back 263

Dependence, additive CNS depression effects with alcohol, respiratory or cardiovascular depression (can lead to death), drug interactions (CYP450 induction – BCG PQRS + EtOH). Phenobarbital first line in pregnancy, children. Contraindicated in porphyria. Treat OD with Sx mgmt (assist respiration, increase BP). Phenobarbital – Stevens-Johnson Syndrome

Front 264

Toxicity: Benzos

Back 264

Dependence, additive CNS depression effects with alcohol, less risk of respiratory depression and coma than with barbs. Can cause severe post-op respiratory depression when used as anesthetic. Decreases BP. Amnesia (desirable in surgeries). OD treated with flumazenil (competitive antagonist at GABA receptor)

Front 265

Hepatotoxic Epilepsy drugs

Back 265

Carbamazepine, Valproic acid

Front 266

CYP450 inducing Epilepsy drugs

Back 266

Carbamazepine, Phenobarbital, Phenytoin
(BCG PQRS + Ethanol
Barbs, Carbamazepine, Griseofulvin, Phenytoin, Quinidine, Rifampin, St. John’s Wort, Ethanol)

Front 267

Epilepsy drugs that cause Stevens-Johnson Syndrome

Back 267

Carbamazepine, Ethosuximide, Phenobarbital, Phenytoin, Lamotrigine
(others that cause S-JS: sulfa drugs, allopurinol, PCN)

Front 268

General toxicities of most seizure meds

Back 268

Diplopia, sedation, ataxia, nystagmus, dizziness

Front 269

Seizure med that causes agranulocytosis

Back 269

Carbamazepine (also causes aplastic anemia)
Other drugs that cause agranulocytosis: Clozepine, Colchicine, PTU, Methimazole (Three start with C, the other two are anti-thyroid drugs)

Front 270

Toxicity: Lamotrigine

Back 270

Stevens-Johnson Syndrome

Front 271

Toxicity: Gabapentin

Back 271

Sedation, ataxia

Front 272

Toxicity: Topiramate

Back 272

Sedation, mental dulling, kidney stones, weight loss

Front 273

Toxicity: Valproic acid

Back 273

Rare but fatal hepatotoxicity (measure LFTs), neural defects in fetus (spina bifida – contra- in pregnancy. inhibits GI absorption of folic acid), GI distress, tremor, weight gain

Front 274

Toxicity: Ethosuximide

Back 274

Stevens-Johnson syndrome, GI distress, fatigue, headache, urticaria (hives)
EFGH – Ethosuximide, Fatigue, GI, Headache

Front 275

Toxicity: Carbamazepine

Back 275

Diplopia, ataxia, blood dyscrasias (agranulocytosis, aplastic anemia), liver toxicity, teratogenesis, CYP450 induction (BCG PQRS + EtOH), Stevens-Johnson Syndrome

Front 276

Toxicity: Inhaled anesthetics

Back 276

Halothane – Hepatotoxicity. METHoxyflurane – NEPHrotoxicity. Enflurane – Epileptic side effects. Malignant hyperthermia (rare – succinyl choline + halothane), expansion of trapped gas (nitrous oxide)

Front 277

Toxicity: Ketamine

Back 277

Arylcyclohexylamine –disorientation, hallucination and bad dreams. Give only to children < 13 – no bad trips.

Front 278

Toxicity: Propofol

Back 278

Less postoperative nausea than thiopental. High TG content, so long term use → risk for pancreatitis

Front 279

Toxicity: Local anesthetics

Back 279

CNS excitation, severe cardiovascular toxicity (bupivacaine), HTN, hypotension, arrhythmias (cocaine)

Front 280

Toxicity: Amantadine

Back 280

Ataxia

Front 281

Toxicity: L-dopa+Carbidopa/Tolcapone

Back 281

Arrhythmias from peripheral conversion to dopamine (though less than dopamine itself). Long term use can lead to dyskinesia following administration, akinesia between doses. Carbidopa/Tolcapone decrease peripheral effects.

Front 282

Toxicity: Selegiline

Back 282

May enhance adverse effects of L-dopa. Can’t give Dopa to pts with malignant melanoma, since Dopa → [Melanin +] Dopamine → NE → Epi, feeding the tumor

Front 283

Toxicity: Sumatriptan

Back 283

Coronary vasospasm (contraindicated in patients with CAD, Prinzmetal’s angina), mild tingling

Front 284

Toxicity: Memantine

Back 284

Dizziness, confusion, hallucinations

Front 285

Toxicity: Donepezil, Rivastigmine, Galantamine

Back 285

Nausea, dizziness, insomnia

Front 286

Toxicity: Typical antipsychotics

Back 286

1. extrapyramidal system (EPS) side effects
2. Endocrine side effects (e.g. dopamine receptor antagonism → hyperprolactinemia → galactorrhea + amenorrhea (more common) + decreased libido (men)
3. Antimuscarinic effects (red as a beat…), alpha blockage (hypotension), histamine blockage (sedation, hunger, weight gain)
4. NMS
5. Tardive Dyskinesia

Front 287

Toxicity: Typical antipsychotics – NMS

Back 287

Neuroleptic malignant syndrome – Muscle spasms → rigidity, rhabdomyolysis → myoglobinuria, autonomic instability, hyperpyrexia. (Think FEVER: Fever, Encephalopathy, Vitals unstable, Elevated enzymes Rigidity of muscles)

Front 288

Tardive dyskinesia
Which atypicals are most/least likely to cause it

Back 288

Toxicity of antipsychotics – stereotypic oral-facial movements due to long-term antipsychotic use. Often irreversible. Risperidone is the atypical most likely to cause it, clozapine the least

Front 289

Toxicity: Atypical antipsychotics

Back 289

Clozapine, Olanzapine, Risperidone, Aripiprazole, Quetiapine, Ziprasidone
Fewer extrapyramidal and anticholinergic side effects than traditionals. Clozapine (last-line) may cause agranulocytosis (requires weekly WBC monitoring).
Long-term toxicity: weight gain and DM, especially olanzapine, quetiapine
Ziprasidone – least common offender

Front 290

Toxicity: Lithium

Back 290

Tremor, hypothyroidism, polyuria (ADH antagonist causing nephrogenic DI), teratogenesis. Narrow therapeutic window – close monitoring of serum levels. LMNOP: Lithium Movement (tremor) Nephrogenic DI, hypOthyroidism, Pregnancy problems (teratogen → Epstein’s anomaly).

Front 291

Side effects: TCAs

Back 291

Sedation (helps fibromyalgia pts to sleep), alpha blocking effects (orthostatic hypotension + dizziness), anticholinergic side effects (tachycardia, urinary retention). Tertiary TCAs (amitryptiline) have more anticholinergic effects (so don’t give to elderly) than do secondary (Nortryptiline). Desipramine least sedating

Front 292

Toxicity: TCAs

Back 292

Tri-Cs – convulsions, coma, cardiotoxicity (arrhythmias - MC COD); respiratory depression, hyperpyrexia. Confusion and hallucinations in elderly (due to anticholinergic effects – use nortyrptiline).
Tx: NaHCO3 for CV toxicity

Front 293

Toxicity: SSRIs

Back 293

Fluoxetine, paroxetine, sertraline, citalopram, fluvoxemine
Fewer than TCAs. GI distress, sexual dysfunction (anorgasmia), serotonin syndrome

Front 294

Serotonin syndrome

Back 294

Hyperthermia, muscle rigidity, cardiovascular collapse, flushing, diarrhea, neuromuscular hyperactivity, ocular clonus (slow continueous horizontal eye movements)
Caused by any drug that increases serotonin – SSRIs, SNRIs, MAOIs, St. John’s Wort, KavaKava, Sibutramine (SNRI for weight loss), Tryptophan, cocaine, amphetamines, ecstasy

Front 295

Toxicity: Bupropion

Back 295

Stimulant effects (tach, insomnia), headache, seizure in bulimic patients, no sexual side effects. Lowers seizure threshold.

Front 296

Toxicity: Venlafaxine

Back 296

Increased BP (most common). Stimulant effects, sedation, nausea (same as Duloxetine)

Front 297

Toxicity: Nefazodone

Back 297

Increased sleep. No sexual side effects

Front 298

Toxicity: Duloxetine

Back 298

Increased BP (most common). Stimulant effects, sedation, nausea (Same as venlafaxine)

Front 299

Toxicity: Mirtazapine

Back 299

Tetracyclic. Sedation, increased appetite and weight gain (histamine receptor side effects – good for skinny pts), dry mouth

Front 300

Toxicity: Maprotiline

Back 300

Sedation, orthostatic hypotension

Front 301

Toxicity: Trazodone

Back 301

Sedation, nausea, priapism, postural hypotension

Front 302

Toxicity: MAOI

Back 302

Hypertensive crisis + cardiac arrhythmia with tyramine ingestion and beta agonists. CNS stimulation. Contra- with SSRIs or meperidine (opioid analgesic) to prevent serotonin syndrome.

Front 303

Tyramine

Back 303

in foods that are spoiled, aged, smoked, soy sauce, miso soup, sauerkraut, ripened bananas, sausage. Tyramine can induce migraines in pts who get them. MAO in gut breaks down tyramine. Excess tyramine in system → increased NE released (tyramine is NE/Epi releasing agent)

Front 304

Toxicity: Acetazolamide

Back 304

Hyperchloremic metabolic acidosis, somnolence, neuropathy (paresthesia), NH3 toxicity, sulfa allergy

Front 305

Toxicity: Loop diuretics

Back 305

OH DANG: Ototoxicity (can’t give in conjunction with aminoglycosides), Hypokalemia, Dehydration, Allergy (sulfa), Nephritis (interstitial), Gout

Front 306

Toxicity: Ethacrynic acid

Back 306

Similar to furosemide; can be used in hyperuricemia, acute gout (but not used to Tx gout)

Front 307

Toxicity: Thiazides

Back 307

Hypokalemic metabolic alkalosis, hyponatremia, hyperglycemia, hyperlipidemia, hyperuricemia, hypercalcemia. Sulfa allergy

Front 308

Toxicity: K-sparing diuretics

Back 308

Hyperkalemia (ACE-I also do this, so be careful if using together), possibly leading to arrhythmias, endocrine effects with aldosterone antagonists (e.g. spironolactone causes gynecomastia [SDCAK], acts as antiandrogen [anti-: hirsutism, acne] effects

Front 309

Toxicity: ACE-I

Back 309

CAPTOPRIL – Cough, Angioedema (these two produced by bradykinin), Proteinuria, Taste changes, hypotension, Pregnancy problems (fetal renal damage), Rash, Increased renin, Lower ATII. Hyperkalemia as well. Avoid with bilateral renal artery stenosis because ACE-I significantly decrease GFR by preventing constriction of efferent arterioles. Use caution if Cr>3.

Front 310

Toxicity: Leuprolide

Back 310

Antiandrogen, nausea, vomiting

Front 311

Toxicity: Sildenafil, Vardenafil, Tadalafil

Back 311

Headache, flushing, dyspepsia, impaired blue-green color vision. Risk of life-threatening hypotension in pts taking nitrates.

Front 312

Toxicity: Mifepristone (RU-486)

Back 312

Heavy bleeding, GI effects (nausea, vomiting, anorexia), abdominal pain

Front 313

Toxicity: Testosterone (methyltestosterone)

Back 313

Causes masculinization in females; reduces intratesticular testosterone in males by inhibiting Leydig cells; leads to gonadal atrophy. Premature closure of epiphyseal plates. Increases LDL, decreases HDL (vs. favorable lipid profile with estrogen). Polycythemia

Front 314

Toxicity: Estrogens (ethinyl estradiol, DES, mestranol)

Back 314

Increased risk of endometrial cancer, bleeding in postmenopausal women, clear cell adenocarcinoma of vagina in females exposed to DES in utero, increased risk of thrombi. Contra- with ER+ BrCa

Front 315

Toxicity: H1 Blockers – 1st generation

Back 315

1st generation – Diphenhydramine, Dimenhydrinate, Chlorpheniramine, Hydroxazine
Sedation, antimuscarinic - pupillary dilation and lack of accommodation (don’t give to Alzheimer’s, demented pts). Anti-alpha-adrenergic, anti-serotonergic.

Front 316

Toxicity: H1 Blockers – 2nd generation

Back 316

2nd Generation – Loratadine, foxofenadine, Destoratadine, Ceterizine
Far less sedating than 1st generations because of decreased entry in CNS

Front 317

What drugs cause/exacerbate Lithium toxicity and what is the mechanism?

Back 317

Thiazides - Li follows Na reabsorption, thiazides cause volume depletion, increasing PCT reabsorption of Na and Li
NSAIDs - cause relative ischemia in kidneys (due to PG inhibition) --> kidneys retain salt to increase volume. For this reason, NSAIDs are relatively contra- in heart failure

Front 318

Drugs that cause nephrogenic diabetes insipidus

Back 318

lithium, demeclocycline (ADH antagonist), tetracycline