Pharm Test Monday December 12

GI

Peptic ulcer disease occurs in the lesser curvature of the stomach and the duodenm. There
are 2 types gastric and duodenal. Gastric is commonly caused by NSAIDS and ASA. The
stomach has a difficult time protecting and repairing itself. Duodenal ulcers (80% of
peptic ulcers) are caused by hypersecretion of gastric acid.

There is typically an imbalance between the protective mucosal defense factors (mucous
lining etc) and aggressive factors (NSAIDS, ASA, H-Pylori).

People with peptic ulcers should not smoke, avoid NSAIDS and ASA and drink no
alcohol.

Treatment of Peptic ulcers include antibiotics, PPI, H2RA’s, Mucosal Protectants

Antisecretory agents, and antacids.

GERD Gastro Esophageal Reflux Disease. Weakened LES heartburn, after a fatty meal
or when lying down, esophagitis, acid taste belching and coughing.

Treatment:

ANTIBIOTICS:
Given to all pts with confirmed H.Pylori
Pepto Bismol: topically destroys H-Pylori
SE: black tongue/stool, tinnitus, neurotoxicity, fecal impaction, dark stools, Reyes
Syndrome.

Amoxicillin: BS Antibiotic (Anthrax, Gangrene, Meningitis, Pneumonia)

Clarithromycin: Indicated for H-Pylori, SE
H2RA’s –O, IM, IV
Axid, Pepsid, Tagament, Zantac
Block Histamine Release to secrete Gastric Acid
:Indicated for PUD, GERD, Zollinger-Ellison (hypersecretory)
SE: TAGAMENT CAUSES IMPOTENCE AND MAN BOOBS
Lethargy, confusion, hallucinations

, Antibiotics

1.Tetracycline is a narrow spectrum antibiotic

TF
2. This Drug is indicated for G+, G-, PUD Peridontal Disease and Acne
Azythromycin, Linezolid, Amiken, Isoniazid, Tetracycline.
3. H. Pylori can be treated with which of the following:
Tetracycline, Bismuth Subsalicyate, clarithromycin, amoxicillin, metronidazole
3. Which Drug does not cause black discoloration of the tongue?
Clarythromycin, Bismuth Subsalicylate, Tetracycline, Ampicillin
4. H2RA’2 are indicated for PUD, GERD, Zollinger-Ellison, (ine’s). PPI’s are indicated
for PUD, GERD, Zollinger Ellison as well. Why do we need both?
5. Treatment with H2RA’s is 4-6 weeks while Treatment withPPI’s is _____
6. The Nurse knows that one of the key features of Cimetidine and other H2RA’s is that
the onset is ….
Immediate, Delayed,
7. The most important teaching a nurse can give a young man taking famotidine is….
8. for an Elderly woman suffering from osteoporosis taking esomeprazole (Nexium) for a
long period of time, the nurse is most concerned about….
9. When taking PPI’s is it important to instruct the patient to take the drug…
At night, with lunch, Chew up with pudding or approx 1 hour before the first meal of the
day
10. Ms. Applewhite takes a large number of NSAIDS Due to her Sciatica. The nurse
knows that to prevent gastric ulcers a prescription for……would be a good idea.
Sucralfate,(Carafate), Misoprotol, (Cytotec) Omeprazple(Prolosec)
11Antacids are contraindicated in all of the following except:
Cimetidine, clarythromycin, Sucralfate, azythromycin
12. To overcome constipation in the colon, which Laxitive is indicated
13. 0

Antibiotic
Antibiotic drugs work by being selective. The goal is to injure the target cell without
causing harm to the normal cells. Antibiotics can achieve their goal in 3 ways. Disruption
of the cell wall (lysis), inhibition of bacterial enzymes/proteins. After achieving their
goal, normal defense mechanisms can control the infection.
Different groups of antibiotics kill different bacteria and antibiotics are also classified by
their MOA, bactericidal (Cell wall destruction) or bacteriostatic (inhibition of
protein/enzyme). We can also use these drugs in conjunction with I and D for those really
nasty bugs. We want the right drug for the right bug so some bugs require that we bust
‘em open while the others prefer that we screw up their DNA 

There are 2 types of infection, Local and Systemic. Local infections are affect a certain
part of the body and remains in that area. Systemic infections affect a number of organs
and tissues. Systemic infections can include bacteremia (blood infections that can be
cured) or septicemia that causes an elevation in temp, HR, RR and WBC and may include
death.

Fevers are associated with infection. There are several types:

Constant: rises and falls only a few degrees (Typhoid) “A Typhoid is coming! Causing
the Waves to Constantly rise and Fall
Intermittent: Returns to normal 1-3* in 24 hours (pyogenic infection) “That damn Pyo,
She comes here in her mittens 1-3 times a day!”
Remittent: Fluctuates but does not return to normal: (viral or bacterial) Vira and Bacter
keep remitting fluctuating stories. They will never be normal
FUO Temp > 103 for more than 2 weeks. FU! O, you’re too high to care. Been high for
2 weeks!

Drug Resistant Infections are a serious problem. The bug laughs at the drug and keeps
growning! In the 40’s every S. Aureus was susceptible to the Cillins, now more than 95%
are not. Strep Pneumoniae has a 300% resistance reate to penicillin within the last years.
The bugs mutate and change their DNA because of a few reasons. Antiobiotics are given
unnecessarily and the normal flora bacteria adapt, many don’t finish their antibiotics and
the remaining nasties adapt because the drug never reaches the target site. Antibiotics in
our food and veggies.

The CDC has proposed a program to combat this problem: Vaccinate against the
diseases, decrease the use of catheters , target the correct Pathogen∫ Call Infectious
Experts, assess the community and locate high risk/affected areas, treat the infection, if a
person is truly infected and not the colonization or contamination if the patient has no
symptoms. STOP treatment if there is no likely cure, get a good culture, WASH your
Hands.

The drug needs to get to the but so the host must maintain a therapeutic level in the
blood, every 6 or 8 hours 9,1,5,9.

In a perfect world the doctor would be able to get a culture back quick enough to
prescribe the correct antibiotic. So the big would be matched with the drug, the specimen
would be obtained from the affected area and culture and sensitivity would be obtained
before initiating therapy. But alas, the world is not perfect so Dr’s must make their best
guess.

Now, to select the correct antibiotic the doctor would consider the former, determine drug
sensitivity of the infecting organism, examine the host factors ( immune system,
phagocytic cells) age, and any previous allergic reactions. Antibiotics will not work if the
host defense mechanisms are inadequate. The age is a serious factor because infants and
the elderly are vulnerable to the toxicities of the drugs. So, all relevant lab values must be
checked.The trough must be drawn prior to administering the drug (Therapeutic,
subtherapeutic and toxic) the peak is drawn shortly after drug is given.

Allergic reactions are common with antibiotics, more common with penicillin. Determine
if any reactions have occurred previously, check the allergy band, and watch the patient
closely for 30 min after the drug has been given. 600-800 people die annually from
anaphylactic deaths + Insulin, protamine sulfate, cephalosporins. The mortality rate is
10%. The exposure to the allergen can cause a massive release of histamines,
leukotrienes, kinins, seratonind, and anaphylatoxins. It can occur within several seconds
to 30 min after the injection, accelerated 1-72 hours, or , late days-weeks.

The signs of allergic reaction have 2 phases. In phase 1 the skin is flushed, itchy and
warm and hives begin to appear on the face and neck. In phase 2, there is
generalized body edema, swelling of the face, lips, tongue, and upperairway. There
are broncho/laryngospasm, choking, stridor, wheezing, SOB chest pain and
tightness, severe hypotension, shock, restlessness, dizziness, confusion and then
LOC.

To treat the allergic reaction, the antibiotic should be stopped first, ABC’s, administer O2
high flow at 15L/min, IV therapy NS or LR) 1-2 liters in first hour to maintain BP. Drug
therapy can begin epinephrine: 1:1000 .5 ml SQ q10-20min. diphenhydramine
(Benadryl) 50 mg IM or IV, aminophylline/theophylline, nbebulizers, vaspressors,
Corticosteriods, IV

The Deadliest of the Deadliest drug Induce reactions allergic reactions are Stevens
Johnson and Toxic Epidermal Necrolysis (TEN). Steven Johnson is more common and
has approximately 7/mill. It has a lower mortality rate and was discovered in 1922. TEN
is much more rare occurring in .4-1.3/mill but the mortality rate is 40%. The difference is
made by the sloughing of the skin, With SJ 10% of skin is sloughed with more than 30%
with TEN. Steven Johnsen is more likely to affect patients <40 with a weakened immune
system whie TEN affect the elderly with a weakened immune system. Both reactions are
causesd by the liver improperly breaking down a drug and having the inability to excrete
it. The by product elevate to toxic levels and bind with epidermal proteins and form
allergic compounds which causes an exaggerated response by the immune system. The
immune system attacks the skin and mucous membranes with the drug particles attached
to them causing multi system organ failure and death.

The onset of the disease varies respectively, SJ 1-14 days of starting the meds while TEN
can begin as early a 1-3 days. The nurse should watch for signs and while both seem to
have similar early stages of general sickness like fever, malaise and a sore throat, SJ
exhibits more of a respiratory infection while TEN will include muscle aches and skin
tenderness. SJ will have a rash within 1-3 days later and then target lesions abruptly erupt
within 2-4 weeks that looks like chicken pox (round red raised macules less than 3cm in
diameter irregular borders with blistered necrotic centers). The rash will display on the
face, trunk, palms, hands, joint areas, soles of feet + blistering lesions on at least 2
mucous membranes. TEN begins its critical phase is 2-3 days exhibiting a rash and
within 48 hours THE ENTIRE TOP LAYER OF SKIN INCLUDING THE MUCOUS
MEMBRANES WILL DETACH! This is to include multi organs as well. Even the
slightest touch will cause the skin to peel. Placing the patient at risk for infection an fluid
an electrolyte loss. Then the convalescent phase begins and the sloughing stops and
healing starts. 40-0% have eye involvement (YIKES)

The treatment is supportive so the first thing is to stop the drug. Transfer the TEN pt to
the burn unit. Both need Nutrition support , TPN, enteral. Fluid replacement, Meticulous
eye care, thermoregulation. TEN must follow infection control precautions, may need
surgical repair, pain management and physical therapy. The SJ pt should receive antacids,
sedation, analgesics wound care and NO STERIODS.

Antibiotics, while we are trying to control their use can also be give prophylacticly in
surgery (no more than 1 hr b4 the incision) bacterial endocarditis, neutropenia, and
UTI’s.

Super infections are also a concern while taking antibiotics because they wipe out the
normal flora and a new infection appears. It’s common and the risk of it occurring
increases when doses, the number of agent and broad spectrum antibiotic are used.

Penicillin, is a drug that weakens the bacterial wall.

Amoxicillin and Ampicillin treat enterococcal, Piperacillan(BROAD), Penicillin V, G
treat gonorrhea, and naficillin treats Staph.. We use Penicillin to treat Anthrax, Gangrene,
Meningitis, Pneumonia, and Tetanus. Penicillin G is IM, IV The others are oral

Ind: G+bact G-cocci, anaerobic, spirochetes (Anthrax, Gangrene, Meningitis, Pneumonia,

and Tetanus)

SE: Eating Pens taste like metal, gives you mouth sores and it makes black hair
grow on you tongue. Toxic too, makes you confused, hallucinate, and gives seizures.

NI: Ask of Allergy. What Reaction. Skin Test. Interact K

Conservators/Aminoglycosides. TAKE ON EMPTY 1 B4 2 A, MONITOR INC K
AND Na

Cephalosporins, weaken the cell wall

Cefazolin (Ancef) Cefepime (Maxipime)

Ind: G-

SE: Ceph woke up bleeding, her kidneys were toxic because her Antabused her. I
told her not to drink that alcohol and to take her blood with her food and put it in
the fridge next to pro’s benicid.

Carbapenems: weaken the cell wall

Imipenem (Primaxin) BROAD SPECTRUM

Ind: mixed infections (anaerobes, S. areus, G-)

Route IM, IV HOSPITAL ONLY

Vancomycin(Vancocin) inhibits cell wall synthesis

Ind: G+ SERIOUS ONLY

Parmacology of Cytotoxic Agents

Normal Cell reproduction occurs during the cell cycle and cells are stimulated to do so.
Cancer cells are not stimulated and they do not die. Cancer cells form into masses
because the replicate so quickly and they do not have adhesive properties and split off the
mass and travel to other parts of the body ie metastasis.

CHEMO GOALS
Chemo therapy is designed to either Cure, Control or for Palliation. A cure is a complex
response that lasts approximately 5 years with no evidence of cancer. Control is to
decrease the size of the tumor and prevent metastasis and extend life when there is no
cure. Palliation provides for comfort when cure or control is impossible. It allows for
normal function of the affected organ like relieving pain or respiratory distress.

CHEMO OPTIONS
Chemotherapy can be adjuvant ( in addition to surgery pre or post), Preventative (Given
to those that have the BRCA1 or hormonal like tamoxifen). Myeloablation is complete
obliteration of the bone marrow and then receiving a bone marrow transplant.

CHEMO MOA
Chemo either Crosslinks DNA so that it cannot separate or duplicate. It mimicks or fills
in for DNA, incorporating it into the DNA strand and it can no longer be repaired or
synthesized. It produces free radicals, binds to tumor cell surfaces to promote an immune
response, and it antagonizes hormone receptors to prevent hormonally induced tumor
growth.

SIDE EFFECTS OF CHEMO

Myelosuppression, Mucositosis, N, V D, C, Alopecia, Fatigue

TOXICITIES OF CHEMO:
Cardio, Pulmonary fibrosis, Nephro, Neuro Hepato, Hemorrhagic Cystitis
Multiple chemotherapy agents can be used to decrease or fight various types of cancers if
one is not working.

Different types of Chemo Drugs

Aklylating Agents (NOT Cell Cycle SPECIFIC)
cyclophosphamide (CYTOTOXAN)
Break DNA HELIX
Used in Combo Regimen

Indicated for:
Bladder, Breast, Ovary, Testicular,
RA
LUPUS

NI: Hydration, Pee Often and B4 bed. MESNA B4, Give Early

SE Outside of the common ones: teratogenic, decreaed libido, 50% Alopecia, N, V

Anthracycline (antibiotics) S-Phase

Doxorubicin (Adriamycin
Binds to cancer cell DNA and blocks enzyme that causes the DNA to tangle; cant divide
or grow.

Indicated for:
Bladder, Breast, Hodg/NonHodge , Lung, Ovarian, sarcoma

SE: NVD, stomatitis, 100% Alopecia, Cardiotoxicity, necro/extravasation,

photosensitivity, Red/Orange body fluid

NI:
Cumulative lifetime max of 500mg/m2
Oral care
Red orange pee pee
Sunscreen
Central line

Antimetabolites:
Fluouracil (5FU and Xeloda)
Stop cells from making and repairing DNA

IVPB, IVP, Continuous Infusion (Xeloda metastatic approved)

Indication:
Breast, Esophagus, Head/Neck, Liver, Ovary, Pancreas, Rectum, Stomach

SE: NVD, myelosuppression, stomatitis, diffuse thinning of hair, hyperpigmentation,

Hand Foot, brittle nails.

NI: Electrolytes, Nutritive support

Plant Alkaloids:
Vincristine (Oncovin)
Mitotic inhibitors for the M-Phase

Indicated for: leukemia, Hodg/Nonhodg, neuroblastoma, rhabdomyosarcoma, Wilms

tumor, Kaposis Sarcoma (AIDS); Also other sarcomas

SE: Peripheral Neuropathy, alopecia, constipation, paralytic ileus, jaw pain and foot drop

NI; Cumulative, reversible NT, withhold for extreme, parestesia.motor weakness, reduce
dose for hepatotoxicity, give stool softeners, assess bowel sounds

Subcategory of Plant Alkaloid (periwinkle)

Docetaxel, (Taxotere)
Inhibits microtubule structures within cell (Cell dies)

Indication:
Breast, non-small cell, advanced stomach, head/neck metastatic prostate

SE: hypersensitivity reaction, fluid retention, neurotoxicity, TOTAL NAIL LOSS

NI: Premedicate with Decadron 1 day prior for 3 days, administer in presence of O2,
Don’t use PVC tubing.

We also use Biotherapy agent to fight cancer. They are not chemotherapy, they act on the
cancer cell to add a marker so that the immune system can attack it. Biotherapy agents
enhance the immune response. Increase vulnerability of the cancer cell, prevent
metastasis, enhance repair of normal cells, Force cancer cells to behave and modify
normal cells in area of tumor.

Types of Biotherapy:
Monoclonal Antibodies:
Bevacizamub (Avastin)
Binds and inhibits vascular endothelial growth factor leading to antiangiogenesis

Binds with VEG-F and starves the tumor

(Others are Rituxan, gemtzumab ( Myotarg) Herceptin (trastuzumab)
Made to react with specific antigens on the cancer cell surface. It is a combination of
human and mouse.

Zumab human + little mouse

Ximab human + mouse
Momab mice
unam human

Indication:
NonHodg, AML (acute myeloid leukemia, CLL (chronic lymphocytic leukemia) breast

SE: RIGORS, Intestinal and fistula bleeding, HTN

Colony stimulating Factors

Decreases incidence of infections manifested by febrile neutropenia in pts with non

myeloid malignancies who receive myelosuppressive anticancer drugs

SE BONE PAIN, decreased platelets, changes in liver

NI: Do not shake and give at room temp (subq)

Hematopoetic Growth Factor

Stimulates red blood cells

Indication: Anemia caused by chemo and chronic renal failure.

SE: Pain and Inj site, NVDHA edema, fever and hypertension

NI: Give when hemoglobin is < 12.9% Stop when > 40%
Do not shake keep fridge

Transplant drugs
Cyclosporin, Cell Cept Immuran