Foundations Part 1 Flashcards

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created 1 year ago by KirbyLegs23
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Basic Science Concepts

Substrate (Ligand): creates signal or produces effect by binding

Endogenous: produced by body

Exogenous: produced outside of body

Agonist: combines with receptor to initiate reaction, inc effect

Antagonist: reduces/blocks reaction

Induction: increases activity of an enzyme

Inhibition: decreases/blocks activity of an enzyme


Nervous System

CNS sends signals to PNS

  • Somatic: voluntary (ACh). Binds to nicotinic receptors in skeletal muscles
  • sensory (afferent)
  • motor (efferent)
  • Autonomic: involuntary

Neurotransmitters: body's chemical messengers: ACh, NE, DA, and 5-HT


Autonomic Nervous System

Parasympathetic: Rest and Digest

  • release ACh, binds to muscarinic receptors
  • SLUDD: (salivation, lacrimation, urination, defecation, digestion)

Sympathetic: Fight or Flight

  • release Epi and NE, act on adrenergic receptors (Alpha-1 blood vessels, beta-1 heart, beta-2 lungs
  • inc BP, HR, bronchodilation, inc glucose production, inc pupil dilation
  • (anti-SLUDD) dec urination, dec digestion


Receptors and Substrates

Substrates bind to receptors (endogenous or exogenous)

  • Competitive inhibition: antagonist binds to same active site
  • Non-Competitive Inhibition: antagonist binds to receptor at site other than active site (allosteric)
  1. Albuterol, beta-2 agonist works similarly to Epi by inc cAMP, dec intracellular Ca, bronchial smooth muscle relaxation
  2. Beta-1 Blocker px NT Epi from binding to heart, dec HR/contractility
  3. Isoproterenol: mixed beta-1/2 agonist (Bradycardia, bronchodilation)
  4. Carvedilol inhibits alpha-1, beta-1, and beta-2 (dec BP, peripheral vasodilation, dec HR). can cause bronchoconstriction
  5. Vasopressors stimulate multiple receptors, inc vasoconstriction, HR/BP
  6. Clonidine central A2 agonist dec sympathetic output (dec BP/HR)


Muscarinic Receptor


Agonist: inc SLUDD (pilocarpine, bethanechol, cevimeline)

Antagonist: dec SLUDD (atropine, oxybutynin)


Nicotinic Receptor


Agonist: inc HR/BP (Nicotine)

Antagonist: neuromuscular blockade (rocuronium, NMBAs)


Alpha-1 receptor

Adrenergic (maily peripheral) Epinephrine, Norepinephrine

Agonist: smooth muscle vasoconsctrition, inc BP (phenylephrine, dopamine (high dose), oxymetazoline)

Antagonist: smooth muscle vasodilation, dec BP (doxazosin, carvedilol, phentolamine)


Alpha-2 receptor

Adrenergic (mainly brain, central) Epinephrine, norepinephrine

Agonist: dec release of Epi and NE, dec BP/HR (clonidine, brimonidine)

Antagonist: inc BP/HR (ergot alkaloids, yohimbine


Beta-1 receptor

Adrenergic (mainly heart) Epinephrine, norepinephrine

Agonist: inc myocardial contractility, CO, HR (dobutamine, isoproterenol, dopamine (medium dose))

Antagonist: dec CO, dec HR (beta-1 selective blocks (metoprolol) and non-selective beta-blockers (propranolol, carvedilol)


Beta-2 receptor

Adrenergic (mainly lungs) Epinephrine

Agonist: bronchodilation (albuterol, terbutaline, isoproterenol)

Antagonist: bronchoconstriction (non-selective beta-blockers propranolol, carvedilol)


Dopamine receptor


Agonist: many, including renal, cardiac, and CNS effects (levodopa, pramipexole)

Antagonist: many, including renal, cardiac, and CNS effects (FGA, metoclopramide)


Serotonin receptor


Agonist: many, including platelet, GI, and psychiatric effects (triptans)

Antagonist: many, including platelet, GI, and psychiatric effects (ondansetron, SGAs)


Acetylcholinesterase target

Breaks down acetylcholine

  • acetylcholinesterase inhibitors: donepezil, rivastigmine, galantamine

Block acetylcholinesterase, resulting in inc ACh lvls, tx Alzheimer's diasease


Angiotensin converting enzyme target

Converts angiotensin I to angiotensin II (potent vasoconstrictor)

  • ACE inhibitors (lisinopril, ramipril)

Inhibit production of angiotensin II, resulting in dec vasoconstriction and dec aldosterone secretion; use to tx HTN, HF, kidney disease


Catechol-O-methyltransferse (COMT) target

Breaks down levodopa

  • COMT inhibitor: entacapone

Blocks COMT enzyme to px peripheral breakdown of levodopa, resulting in inc duration of action of levodopa. Used to tx Parkinson disease


Cyclooxygenase (COX) target

Converts arachidonic acid to prostaglandins (cause inflammation) and thromboxane A2 (causes platelet aggregation)

  • NSAIDs (aspirin, ibuprofen)

Block COX enzymes to dec prostaglandins and thromboxane A2, used to tx pain/inflammation and dec platelet activation/aggregation (aspirin)


Monoamine oxidase (MAO) target

Break down catecholamines (DA, NE, Epi, 5-HT)

  • MAO inhibitors: phenelzine, tranylcypromine, isocarboxazid, selegiline, rasagiline, methylene blue, linezolid)
  • Block MAO which inc catecholamine lvls, used to tx depression

If catecholamines inc too much, toxic effects occur

  • hypertensive crisis, serotonin syndrome


Phosphodiesterase (PDE) target

Break down cyclic guanosine monophosphate (cGMP), smooth muscle relaxant

  • PDE-5 inhibitors: sildenafil, tadalafil

Competitively bind to same active site as cGMP on PDE-5 enzyme, px breakdown of cGMP and prolonging smooth muscle relaxation (arteries of penis), tx ED


Vitamin K epoxide reductase target

Converts Vit K to active form, required for production of select clotting

  • Warfarin

Blocks Vit K epoxide reductase enzyme when dec production of clotting factors II, VII, IX, and X, used to tx/px blood clots


Xanthine oxidase target

Break down hypoxanthine and xanthine into uric acid

  • Xanthine oxidase inhibitor: allopurinol

Block xanthine oxidase enzyme which dec uric acid production, px gout attacks


Renal Excretion in urine

Polar drug -> kidneys

Non-Polar Drug -> Phase 1 Oxidation rxns (CYP450, Phase 1)

  • if not polar enough, Phase II Conjugation rxns
  • enzyme-catalyzed rxns
  • drug that is subject to rxns is called the substrate
  • first pass metabolism, results in inactivation of oral drugs


Pharmacodynamic Drug Interactions

Effect that a drug has on the body

1. Agonists at the same receptor cause additive effects

  • opioids are mu-receptor agonists. Two opioids have additive effects, inc SE (excessive sedation, respiratory depression, death)

2. Additive Effects bind to different receptors (BZDs enhance ABA. With opioids, additive effect inc risk of fatal overdose. Warfarin cause anticoagulation. Aspirin blocks effects of platelets. Both cause additive bleeding)

3. Antagonists block agonist form binding (Naloxone is mu-receptor antagonist, blocks opioid from binding), 4. Synergism when two drugs have greater effect together (opioid and APAP for pain)


Pharmacokinetic Drug Interactions

Effect that body has on the drug

Absorption, Distribution, Metabolism, Excretion

1. Reduced Absorption (polyvalent cations (antacids, multivit, sucralfate, BA resins, Al, Ca, Fe, Mg, zinc, phosphate binders chelate and inhibit absorption. Separate doses 1-2h before/4h after. If GI pH is inc, absorption will be dec)

2. Liver Induction/Inhibition (clarithromycin inhibits warfarin metabolism, inc INR. Ritonavir inhibits darunavir, which boosts darunavir lvls and inc efficacy)

3. Renal Excretion (dec: probenecid blocks excretion of penicillin inc: IV Na bicarbonate alkalinizes urine, causes salicylate overdose to become ionized)


CYP 450 Metabolism

Active Drug -> CYP enzyme -> dec Active Drug

Inactive Prodrug -> CYP enzyme -> inc Active Drug

Inducers: lag time to see effect. Effect means after drug is D/C until enzymes degrade

  • with most drugs, inducers make more enzymes, which dec Active Drug
  • with Prodrugs, more enzyme due to an inducer will inc active drug

Inhibitors: competitive binding or change in binding site to dec affinity. Onset is quick and effects stop when drug is D/C

  • with most drugs, inhibitors make enzymes inactive, which dec Active Drug
  • with Prodrugs, less enzyme due to an inhibitor dec Active Drug



Taken in an inactive form and converted by CYP450 (liver) into active form

  • extend dosing interval
  • px drug abuse

Valacyclovir (prodrug, qd) -> Acyclovir (active metabolite, qid)


CYP Enzyme Inhibitors

Increase concentration of substrate drugs, dec dec rate of drug metabolism. Less drug lost to first-pass metabolism. Enzyme inhibition is fast.

Prodrugs: dec conc/conversion to active drug (opposite)


Grapefruit, Protease Inhibitors (ritonavir), Azole antifungals (-conazole, isavuconazonium)

Cyclosporine, cobicistat, Macrolides (-thromycin, not azithromycin)

Amiodarone, dronedarone, Non-DHP CCBs (diltiazem, verapamil)


CYP Enzyme Inducers

Decrease concentration of substrate drugs, inc rate of drug metabolism. More drug lost to first-pass metabolism

  • lag time 2-4 weeks when inducer is stopped for induction to disappear completely

Prodrug: inc conc/conversion to active drug (opposite)


Phenytoin, Smoking

Phenobarbital, Oxcarbazepine, Rifampin (rifabutin, rifapentine)

Carbamazepine (auto-inducer), St. John's wort


Gut Excretion by Drug Transporters

P-Glycoprotein Efflux Pumps:

Transporters protect against foreign substances in GI tract, pumping them into gut and excreted in stool

  • When a drug inhibits P-gp, a P-gp substrate will have inc absorption

Enterohepatic Recycling: from gut, drug reabsorbed in small intestine, enter into portal vein, and travel back to liver

  • inc duration of action


P-gp substrates

Anticoagulants: apixaban, edoxaban, dabigatran, rivaroxaban

Cardiovascular drugs: digoxin, diltizem, carvedilol, ranolazine, verapamil

Immunosuppressants: cyclosporine, sirolimus, tacrolimus

HCV drugs: dasabuvir, ombitasvir, paritaaprevir, sofosbuvir


  • atazanavir, colchicine, doultegravir, posaconazole, raltegravir, saxagliptin


P-gp Inducers

Dec absorption (more drug pumped into gut), substrate drug lvl will dec

  • CBZ, phenobarbital, phenytoin
  • St. John's wort
  • dexamethasone
  • rifampin
  • tipranavir


P-gp Inhibitors

Inc absorption (less drug pumped into gut), substrate drug lvl will inc

Anti-Infectives: clarithromycin, itraconazole, posaconazole

Cardiovascular: amiodarone, carvedilol, conivaptan, diltiazem, dronedarone, quinidine, verapamil

HIV drugs: cobicistat, ritonavir

HCV drugs: ledipasvir, paritaprevir


  • cyclosporine, flibanserin, ticagrelor


Additive Bleeding Risk

Anticoagulants: warfarin, dabigatran, apixaban, edoxaban, rivaroxaban, heparin, enoxaparin, dalteparin, fondaparinux, argatroban, bivalirudin

Antiplatelets: salicylates (ASA), dipyridamole, clopidogrel, prasugrel, ticagrelor

NSAIDs: IBU, naproxen, diclofenac, indomethacin, others

SSRI/SNRIs: citalopram, escitalopram, fluoxetine, paroxetine, sertraline, duloxetine, venlafaxine

Natural Products: 5 Gs, Vit E, willow bark, fish oils (high doses)

Exceptions: ASA and prn NSAID, SSRI/SNRI and prn NSAID, dual antiplatelet therapy, bridging (enoxaparin and warfarin)


Additive Hyperkalemia Risk

Sx: weakness, heart palpitations, arrhythmia

  • higher risk w/ renal impairment

Reinin-angiotensin-aldosterone system drugs: ACE/ARB, aliskiren, sacubitril/valsartan, spironolactone

  • eplerenone (highest risk w/ aldosterone receptor antagonists)

Potassium-sparing diuretics: amiloriede, triamterene

Others: salt substitutes (KCl), CNI (tacrolimus and cyclosporine), SMX/TMP, canagliflozin, drospirenone-containing OC


QT Prolongation treatment

Inc risk of torsades de pointes (TdP), an often fatal arrhythmia. Risk inc w/ higher doses, higher drug lvls due to concurrent enzyme inhibitors, reduce drug clearance (renal/liver disease), multiple QT prolonging drugs together, 60yo+, CVD (HF, MI)

Tx: amiodarone (w/ HF)

  • max 40mg citalopram qd (20mg qd in elderly, liver disease, or w/ enzyme inhibitors that dec clearance)
  • max 20mg escitalopram qd (10mg qd in elderly)
  • sertraline safest with CVD
  • do not use droperidol for inpatient N/V


Additive QT Prolongation

Antiarrhythmics: Class 1a, 1c, and III

Anti-infectives: antimalarials (hydroxychloroquine), azole antifungal (except isavuconazonium), lefamulin, macrolides, quinolones

Antidepressants: SSRI (highest risk w/ citalopram), escitalopram, TCAs, mirtazapine, trazodone, venlafaxine, Antipsychotics: 1st gen (haloperidol, thioridazine), 2nd gen (highest risk w/ ziprasidone)

Antiemetics: 5-HT3 receptor antagonists (Zofran), droperiodol, metoclopramide, promethazine, Oncology: androgen deprivation (leuprolide), TKI, oxaliplatin

Others: cilostazol, donepezil, fingolimod, hydroxyzine, loperamide, ranolazine, solifenacin, methadone, tacrolimus


Additive CNS Depression

Sx: somnolence, dizz, confusion, cognitive impairment, altered consciousness/delirium, risk of falls

Highest risk for fatality: opioids + BZDs or other CNS depressants

Opioids, skeletal muscle relaxants, antiepileptic drugs, BZDs, barbiturates, hypnotics, sedating antihistamines, cough syrups w/ antihistamine or opioid, some NSAIDS

  • Antidepressants: mirtazapine, trazodone, AntiHTN: propranolol, clonidine, Cannabis: dronabinol, nabilone

Counseling: do not use alcohol, do not operate vehicle/machines, can inc risk of falls/confusion. ER become shorter-acting when taking w/ alcohol, inc risk of fatality


Additive Ototoxicity

Sx: hearing loss, tinnitus, vertigo

Monitoring: audiology consult

Aminoglycosides: gentamicin, tobramycin, amikacin, others


Loop diuretics (esp rapid IV admin): furosemide, bumetanide, ethacrynic acid

Salicylates: ASA, salsalate, Mg salicylate, others



Additive Anticholinergic toxicity

Sx: CNS depression (sedation), peripheral effects of dry mouth, dry eyes, blurry vision, constipation, urinary retention. Highest risk in elderly

Antidepressants/antipsychotics: paroxetine, TCAs, 1st-gen antipsychotics

Sedating Antihistamines: diphenhydramine, brompheniramine, chlorpheniramine, doxylamine, hydroxyzine, cyproheptadine, meclizine

Centrally-acting anticholinergics: benztropine, trihexyphenidyl, Muscle relaxants: baclofen, carisoprodol, cyclobenzaprine, Antimuscarinics (urinary incontinence): oxybutynin, darifenacin, tolterodine

Others: atropine, belladonna, dicyclomine


Additive Hypotension/Orthostasis

PDE-5 Inhibitors (sildenafil, tadalafil, avanafil, vardenafil)

+ CYP3A4 inhibitors OR nitrates OR Alpha-1 blockers (doxazosin, terazosin, selective tamsulosin)

w/ CYP3A4 inhibitors: dec PDE-5 inhibitor metabolism causes inc SE, including HA, dizz, flushing (inc risk of falls/injury)

  • start with half the usual starting dose of PDE-5 inhibitor

w/ nitrates or alpha-1 blockers: vasodilation

  • w/ nitrates, contra due to severe hypoT cause chest pain, CV events (fatal), w/ alpha-1 blockers, start with lose dose


CYP 3A4 Substrates


Analgesics: buprenorphine, diclofenac, fentanyl, hydrocodone, meloxicam, methadone, oxycodone, tramadol. 3A4 inhibitor inc ADR, including sedation (Fatal)

Anticoagulants: apixaban, rivaroxaban, R-warfarin, CVD drugs: amiodarone, amlodipine, bosentan, diltiazem, eplerenone, ivabradine, nifedipine, quinidine, ranolazine, tolvaptan, verapamil

Immunosuppressants: cyclosporine, tacrolimus, sirolimus

Statins: atorvastatin, lovastatin, simvastatin

HIV: NNRTIs, ritonavir, tipranavir

PDE-5 inhibitors, ethinyl estradiol


CYP 3A4 Inducers and Inhibitors

Inducers: CBZ, efavirenz, etravirine, oxCBZ, phenobarbital, phenytoin, primidone, rifabutin, rifampin, rifapentine, smoking, St. John's wort


Anti-infectives: clarithromycin, erythromycin, azole antifungal, isoniazid

CBD: amiodarone, diltiazem, dronedarone, quinidine, ranolazine, verapamil

HIV: cobicistat, efavirenz, ritonavir, PIs

Others: aprepitant, cimetidine, cyclosporine, fluvoxamine, grapefruit juice, haloperidol, nefazodone, sertraline

  • do not take grapefruit w/ amiodarone, simvastatin, lovastatin, nifedipine, tacrolimus




Alosetron, aprepitant, clozapine, cyclobenzaprine, duloxetine, ethinyl estradiol, fluvoxamine, methadone, mirtazapine, olanzapine, ondansetron, pimozide, propranolol, rasagiline, ropinirole, theophylline, tizanidine, R-warfarin, zolpidem


CBZ, phenobarbital, phenytoin, primidone, rifampin, ritonavir, smoking, St. John's wort


Atazanavir, cimetidine, cirpo, fluvoxamine, zileuton




Amiodarone, dasabuvir, pioglitazone, repaglinide, rosiglitazone


Phenytoin, rifampin


Amiodarone, atazanavir, clopidogrel, gemfibrozil, ketoconazole, SMX/TMP, ritonavir




Alosetron, carvedilol, celecoxib, diazepam, diclofenac, fluvastatin, glyburide, glipizide, glimepiride, meloxicam, nateglinide, phenytoin, ramelteon, S-warfarin, tamoxifen, zolpidem


Aprepitant, CBZ, phenobarbital, phenytoin, primidone, rifampin, rifapentine, ritonavir, smoking, St. John's wort


Amiodarone, atazanavir, capecitabine, cimetidine, efavirenz, etravirine, gemfibrozil, fluconazole, fluvoxamine, fluorouracil, isoniazid, ketoconazole, metronidazole, oritavancin, tamoxifen, SMX/TMP, VA, voriconazole, vafirlukast


CYP 2C19


Clopidogrel, phenytoin, thioridazine, voriconazole


CBZ, phenobarbital, phenytoin, rifampin


Cimetidine, esomeprazole, efavirenz, etravirine, fluoxetine, fluvoxamine, isoniazid, ketoconazole, modafinil, omeprazole, topiramate, voriconazole




Analgesics: codeine, hydrocodone, meperidine, methadone, oxycodone, tramadol

Antipsychotics/Antidepressants: aripiprazole, brexipiprazole, doxepin, fluoxetine, haloperidol, mirtazapine, risperidone, thioridazine, trazodone, TCA, venlafaxine

Others: atomoxetine, carvedilol, dextromethorphan, flecainide, methamphetamine, metoprolol, propafenone, propranolol, tamoxifen


Amiodarone, bupropion, cimetidine, cobicistat, darifenacin, dronedarone, duloxetine, fluoxetine, mirabegron, paroxetine, propafenone, quinidine, ritonavir, sertraline


Complete Bood Count

WBCs, neutrophils, RBCs, and platelets, Hgb, Hct

  • CBC with differential: types of neutrophils are analyzed

WBC >--Hgb / Hct --< PLT

Hct = Hgb x 3


Basic Metabolic Panel/Comprehensive Metabolic Panel

BMP: 7-8 tests that analyze electrolytes, glucose, renal func, and acid/base (with HCO3 or bicarbonate) status

Na/K -- Cl/HCO3 -- BUN/SCr --< Glucose

CMP: BMP + albumin, ALT, AST, Tbili, and total protein


Blood Cell Lines

Increase/Decrease in Individual Cell Lines:

  • inc/dec WBC (Leukocytosis/Leukopenia)
  • inc/dec RBC (Polycythemia/Anemia)
  • inc Platelets (Thrombocytosis/Thrombocytopenia)

Decrease in Multiple Cell Lines:

  • Myelosuppression: dec WBCs, RBCs, platelets
  • Agranulocytosis: dec granulocytes (WBCs that have secretory granules in cytoplasm - dec neutrophils/basophils/eosinophils
  • Causes: clozapine, PTU, methimazole, procainamide, CBZ, Bactrim, isoniazid


Calcium (8.5-10.5 mg/dL)

Ionized (4.5-5.1 mg/dL)

Calculate correct calcium if albumin is low

  • low albumin will lead to measured serum calcium conc that is falsely low

Cacorrected (mg/dL) = calciumreported (serum) + [(4.0 - albumin) x (0.8)]

Inc: Vit D, thiazide diuretics

Dec: long-term heparin, loop diuretics, bisphosphonates, cinacalcet, systemic steroids, calcitonin, foscarnet, topiramate


Magnesium (1.3-2.1 mEq/L)

Inc: Mg antacids and laxatives (higher risk with renal impairment)

Dec: PPIs, diuretics, amphotericin B, foscarnet, echinocandins, diarrhea, chronic alcohol intake


Phosphate PO4 (2.3-4.7 mg/dL)

Inc: CKD

Dec: phosphate binders, foscarnet, oral Ca intake


Potassium (3.5-5 mEq/L)

Inc: ACE/ARB, aldosterone receptor antagonists, aliskiren, canagliflozin, cyclosporine, tacrolimus, mycophenolate, K supplements, Bactrim, drospireneone OC, chronic heparin, NSAIDs, pentamidine

Dec: beta-2 agonists, diuretics, insulin, steroids, conivaptan

Mycophenolate: inc and dec


Sodium (135-145 mEq/L)

Inc: hypertonic saline, tolvaptan, conivaptan

Dec: CBZ, oxcarbazepine, SSRI, diuretics, desmopressin


Bicarbonate HCO3

Venous (24-40 mEq/L)

Arterial (22-26 mEq/L)

Inc: loop diuretics, systemic steroids

Dec: topiramate, zonisamide, salicylate overdose


White Blood Cells (4,000-11,000 cells/mm3)

Neutrophils, and Bands

Assess likelihood of acute infn (inc as acute phase reactant, indicating systemic rxn to inflammation or stress). WBCs used in ANC calculation

  • Neutrophils: polymorphonuclear (PMNs, polys) or segmented neutrophils (segs)
  • Bands: immature neutrophils released from bone marrow to fight infn (left shift)

Inc: systemic steroids, CSFs, epinephrine

Dec: clozapine, chemotherapy for bone marrow, CBZ, cephalosporins, immunosuppressants (DMARDs, biologics), procainamide, vancomycin


Eosinophils, Basophils, Lymphocytes Labs

Eosinophils: inc in drug allergy, asthma, inflammation, parasitic infn

Basophils: inc in inflammation, hypersensitivity rxns, leukemia


  • inc in viral infns, lymphoma
  • dec in bone marrow suppression, hIV, systemic steroids


Anticoagulation Labs

Antifactor Xa Activity (Anti-Xa):

  • therapeutic doses of LMWH (obtain a peak lvl 4h after SC dose), monitoring recommended in PREG
  • unfractionated heparin (obtain 6h after IV infusion starts and every 6h until therapeutic)

PT/INR: monitor warfarin

  • inc due to liver disease
  • false inc w/ daptomycin, oritavancin, telavancin

aPTT or PTT: monitor UFH and DTIs (obtain 6h after IV infusion and every 6h until therapeutic)

  • false inc w/ oritavancin, telavancin

Platelets: average life span of 7-10d

  • dec w/ heparin, LMWHs, fondaparinux, glycoprotein IIb/IIIa receptor, linezolid, VA, chemotherapy (bone marrow)


Liver and Gastroenterology Labs

Fasting begins 9-12h prior to lipid blood draw

Non-HDL = TC - HDL

Albumin: 3.5-5 dec due to cirrhosis and malnutrition

  • warfarin, Ca, phenytoin impacted (inc) by low albumin
  • phenytoin, VA, and Ca require correction for low albumin

AST/ALT: enzymes released from injured hepatocytes

Bilirubin: liver damage and detect bile duct blockage

Ammonia: often measured in suspected hepatic encephalopathy

  • dec due to VA, topiramate
  • dec due to lactulose

LFTs: liver panel to assess acute/chronic liver inflammation/disease


Pancreatic Enzymes

Amylase: 60-180 u/L

Lipase: 5-160 u/L

Inc in pancreatitis, which can be caused by

  • didanosine, stavudine, GLP-1 agonists, DPP-4 inhibitors, VA, hypertriglyceridemia


Cardiac Enzymes

  • Troponin T (TnT)
  • Troponin I (TnI)

CK-MB, TnT, and TnI used to diagnosis MI. Troponins can be elevated with other conditions (sepsis, PE, CKD)

  • B-Type Natriuretic Peptide (BNP)
  • N-Terminal-ProBNP (NT-proBNP)

BNP and NT-proBNP both markers of cardiac stress. Higher values indicate likelihood when consistent with HF sx


Lipids and Cardiovascular Risk Labs

Total Cholesterol: < 200 mg/dL

LDL: < 100 mg/dL, desirable

HDL: < 40 mg/dL, low (male), 60+ mg/dL, desirable

Non-HDL: < 130 mg/dL, desirable

TG: < 150 mg/dL

C-reactive Protein (CRP): inc indicates inflammation (infn, trauma, malignancy), more sensitive to CVD


Diabetes Labs

Fasting Plasma Glucose (FPG): 126mg/dL+ is positive (100-125mg/dL positive for pre-diabetes)

  • fasting beings 8h+ prior to blood draw

Hemoglobin A1c: <7% (ADA), <=6.5% (AACE)

  • average BG over past 3 months

Estimated Average Glucose (eAG): < 154 mg/dL (ADA)

Preprandial BG: 80-130 mg/dL (ADA) < 100mg/dL (AACE)

Postprandial BG: < 180mg/dL (ADA), < 140 mg/dL (AACE)

C-Peptide (fasting): 0.78-1.89 ng/mL (dec or absent in type 1)


Hormonal Labs

Prostate specific Antigen (PSA):

  • inc with testosterone supplementation
  • used in detecting prostate cancer and BPH

Human Chorionic Gonadotropin (hCG): positive indicates PREG

Luteinizing Hormone (LH): rises mid-cycle, causing egg release from ovaries (ovulation)

  • tested in urine with ovulation predictor kits for women attempting PREG


Package Inserts

FDA approved drug information

  1. DailyMed (NLM) online;
  2. Drugs@FDA online and mobile app;
  3. Drug Manufacturer's Website: individual URL address
  4. attached to physical product, printed

When drug safety information changes, FDA publishes safety communication or alert, and an updated PI will reflect drug's safety-related labeling changes

  • BOX: strictest warnings, risk of death/permanent disability
  • Contra: cannot be used in that patient, risk outweigh benefit
  • Warning: serious reactions that can result in death, hospitalization, medical intervention, disability, or teratogenicity
  • Adverse: undesirable, uncomfortable, or dangerous effects


OTC Drug Information

Self-diagnosed conditions by the general public, have adequate written direction for self-use, do not require physician supervision

  • labeling written for patients who may not have medical training
  1. active ingredients
  2. uses
  3. specific warnings, including when the drug should not be used
  4. side effects
  5. dosage instructions
  6. inactive ingredients

Approval: NDA managed through FDA's CDER or OTC monograph

  • NDA are FDA approved, found on FDA website through Drugs@FDA and listed in common general drug information resources (Lexicomp, Micromedex)
  • labeling for OTC drugs does not require to be separate document, can be on container itself


General Drug Information Resource

Rely on PI for much of drug monograph content

  • describes general drug info resources commonly used
  • include FDA approved info from drug's PI, plus some other items

Drug monograph sites pull in information from PI and other Sources: Clinical Pharmacology, Facts and Comparisons, Lexicomp, and Micromedex

  • Trissel's IV drug compatibility and stability data, drug class comparisons, natural products, drug (tab/cap) identification, and international drug names
  • AFHS: comprehensive monographs that link to supporting evidence and references
  • pharmacists need to check multiple sources as drug information can have a lag time to update


American Hospital Formulary Service (AHFS)

ASHP Product. Drug monographs in acute care settings

  • AHFS CDI book, online, and mobile app
  • included with Lexicomp online
  • off-label
  • IV drug compatibility
  • international drug names (via USP dictionary of USAN and international drug names)

(no drug/pill identification, natural products, drug class comparisons, pricing)


Clinical Pharmacology

Monographs for Rx and OTC drugs, natural products, and investigational drugs

  • online and mobile app
  • off-label
  • IV drug compatibility (via Trissel's)
  • drug/pill identification
  • natural products
  • drug class comparisons
  • pricing
  • international drug names (via index nominum)



Free for professionals and consumers, primarily sourced from AHFS drug information, Micromedex, and Cerner Multum

  • online (free)
  • off-label
  • drug/pill identification
  • natural products
  • drug class comparisons
  • pricing
  • international drug names

(no IV drug compatbility)



Free with registration, drug information plus guidelines. + expands into evidence-based disease management, natural products, lab and diagnostic information, and ICD-10 coding

  • online and mobile app
  • off-label
  • drug/pill identification
  • natural (+)
  • drug class comparisons
  • pricing

(not IV drug compatibility, international, drug names)


Facts and Comparisons eAnswers

Databases, including drug monographs, comparative drug charts, and other unique resources

  • online
  • off-label
  • IV drug compatibility (via Trissel's)
  • drug/pill identification
  • natural products
  • drug class comparisons
  • international drug names (via Martindale)

(not pricing)



Drug monographs organized alphabetically. Multiple clinical databases

  • book, online, and mobile app
  • off-label
  • IV drug compatibility (via Trissel's)
  • drug/pill identification (Lexi-Drug ID)
  • natural products (via Lexi-Natural Products)
  • drug class comparisons (via Facts and Comparisons)
  • pricing
  • international drug names (via Martindale)




Multiple clinical databases

  • DRUGDEX: online and mobile app
  • off-label
  • IV drug compatibility (via Trissel's)
  • drug/pill identification (IDENTIDEX)
  • natural products (AltMedDex)
  • drug class comparisons (via Facts and Comparisons)
  • pricing (Red Book)
  • international drug names (via Martindale, index nominum, and others)




Prescriber's Digital Reference drugs, vaccines, and biologics

  • online and mobile app (free)
  • drug/pill identification
  • drug class comparisons


Pharmacist's Letter

Monthly newsletter with short summaries on new or updated drug info, and have online access to helpful practice tools

  • new drug approvals, drug withdrawals, new dosage forms, and first-time generics
  • charts (drug class comparisons, disease-state tx summaries)
  • patient education summaries and patient flyers
  • continuing education
  • training materials for technicians and intern pharmacists


Adverse Reactions Resources

ASHP's Drug-Induced Diseases: Px, Detection, and Management

FDAble: FDA searchable database caused by medicines, vaccines, devices, tobacco products, dietary supplements

  • MedWatch adverse event: FAERS
  • Vaccines: VAERS
  • Manufacturer and User Facility Device: MAUDE
  • Safety reporting Portal

Meyler's Side Effects of Drugs


Compounding and Pharmaceutics Resources

USP 795 (non-sterile), 797 (sterile), 800 (hazardous), NF (monographs) for drug substances, dosage forms, compounded preparations and excipients

  1. Allen's The Art, Science, and Technology of Pharmaceutical Compounding
  2. ASHP Guidelines on Compounding Sterile Preparations
  3. Handbook of Pharmaceutical Excipients
  4. Safety Data Sheets SDS (previously MSDS)
  5. Merck Index: encyclopedia of chemicals, drugs, and biologicals
  6. Remington: science and practice of pharmacy
  7. Trissel's Stability of Compounded Formulations
  8. United States Pharmacopeia National Formulary


Drug Interactions Resources

  1. Hansten and Horn's Drug Interactions Analysis and Management
  2. Drug Interaction Facts: Facts and Comparisons


Drug Pricing Resources

  1. Red Book (Micromedex)
  2. Medi-Span Price Rx


Drug Shortage Resources

  1. ASHP Current Drug Shortages
  2. FDA Drug Shortages
  3. CDC Current Vaccine Shortages and Delays
  4. AHFS CDI Formulary service


Drug Substitution Resources

  1. FDA's Orange Book: therapeutic equivalence evaluations
  2. FDA's Purple Book: licensed biological products with reference product exclusivity and biosimilarity or interchangeability evaluations


Geriatrics Resources

  1. AGS Beers Criteria for potentially inappropriate meds used in older adults
  2. ASHP's Fundamentals of Geriatric Pharmacotherapy
  3. Geriatric Dosage Handbook (Lexicomp)


International Drug Information Resources

  1. Index Nominum: International drug directory
  2. Martindale: complete drug reference
  3. USP Dictionary of US Adopted Names (USAN) and International Drug Names
  4. Lexicomp
  5. European Drug Index
  6. Micromedex


Investigational Drug Resource

  1. (NIH)


IV Drug Compatibility and Stability Resources

  1. ASHP's Handbook on Injectable Drugs
  2. King Guide to Parenteral Admixtures
  3. Trissel's 2 Clinical Pharmaceutics Database


Medication Safety Resources

  1. FDA MedWatch (report adverse events and medication Errors
  2. ISMP (report errors to the ISMP MERP medication errors
  3. NIOSH list of antineoplastic (chemo) and other hazardous drugs in healthcare settings
  4. (QT drugs lists)

FDA: drug and biologic recalls, drug safety label changes, medication guides, drug communication and safety alerts


Natural Products/Alternative Medicine Resources

  1. Natural Medicines Database (Therapeutic Research Center)
  2. Dietary Supplements Label Database (NIH)
  3. USP Dietary Supplements Compendium


Overdoses, Poisoning, and Toxicology Resources

  1. Lexi-Tox (Lexicomp)
  2. Micromedex Toxicology Management (previously POISINDEX)
  3. TOXLINE (Pubmed)
  4. Godfrank's Toxicologic Emergencies
  5. State Poison Control Center
  6. AA Poison Control Centers


Pediatrics Resources

  1. NeoFax and Pediatrics (Micromedex)
  2. Pediatric and Neonatal Dosage Handbook (Lexicomp)
  3. RedBook: Report of the Committee on Infectious Diseases (AAP)
  4. The Harriet Lane Handbook
  5. AAP
  6. ASHP's Pediatric Injectable Drugs (Teddy Bear Book)
  7. Nelson Textbook of Pediatrics
  8. PPA Key Potentially Inappropriate Drugs in Pediatrics: The KIDs List
  9. AHFS Drug Information


Pharmacology Resources

  1. Goodman and Gilman's The Pharmacological Basis of Therapeutics
  2. Katzung's Basic and Clinical Pharmacology


Pregnancy and Lactation Resources

  1. Brigg's Drugs in Preg and Lact
  2. CDC: Meds during Preg/Breastfeeding
  3. Hale's Medications and Mother's Milk
  4. LactMed (NLM)
  5. Reprotox and Reproisk (Micromedex)
  6. MotherToBaby


Regulatory and Business Development Resources

  1. FDA Center for Drug Evaluation and Research (CDER)
  2. Pink Sheet


Therapeutics and Disease Management Resources

  1. DiPiro's Pharmacotherapy: A pathophysiologic Approach
  2. Handbook of Nonprescription Drugs: an interactive approach to self-care (OTC)
  3. Koda-Kimble's Applied Therapeutics: The Clinical Use of Drugs
  4. The Merck Manual
  5. UpToDate
  6. CDC: Diseases and Conditions
  7. Harrison's Principles of Internal Medicine
  8. Medscape


Veterinary Resources

  1. Plumb's Veterinary Drug Handbook
  2. Green Book


Color Drug References

  1. Orange Book (FDA): drugs that can be interchanged with generics based on therapeutic equivalence
  2. Purple Book (FDA): biological drugs, biosimilars
  3. Green Book (FDSA): animal drug products
  4. Pink Book (CDC): epidemiology and vaccine-px diseases
  5. Yellow Book (CDC): international travel, required vaccines, and px meds
  6. Red Book (AAP): pediatrics infectious diseases, antimicrobial tx, and vaccinations
  7. Pink Sheet (Pharma Intelligence): new reports on regulatory, legislative, legal, and business developments
  8. Red Book: drug pricing


Clinical Study Data and Research Summaries

Searches done using Medical Subject Headings (MeSH) terms

  1. PubMed: access MEDLINE (journal articles) and is a free service available from NLM
  2. Cochrane Library: provides evidence-based info to guide clinical decision making
  • many systemic review


Consumer Resources

  1. CDC: infectious diseases, immunizations, and traveler's health
  2., RxList: drug monographs
  3. MayoClinic: diseases, sx, tests and procedures, drugs and supplements
  4. MedlinePlus from NLM: health topics, drugs and supplements, videos, images
  5. WebMD: diseases, preg, Rx/OTC info, pill identifier and interaction checker
  6. FDA Consumer website
  7. MyHealthfinder
  8. SafeMedication


Long-Acting Oral Tablets/Capsules

Long duration releases slowly to avoid N and smooth lvl of drug release over time, reduces peaks (inc SE)

  • do not crush/chew, releases all med at once (fatal)
  • [Kadian, Xtampza ER] can be opened and contents sprinkled. Do not crush or chew. Consult package labeling
  • [Toprol XL, Sinemet CR] cut on score line

OROS: use fast drug delivery, followed by ER. Water from gut absorbed, inc pressure inside and forces drug out through small opening. Tab/cap shell may be visible in patient's stool (ghost)

  • Concerta, Cardua XL, Procardia XL, Asacol HD, Delzicol
  • extended drug delivery, immediate drug release, reduced fluctuations in serum drug lvl


Liquid Oral Susp/Solutions

Useful in pts with swallowing difficulty or unable to follow directions (infants, young children, adults with altered mental status, animals). Most administered by dropper or feeding tube

Suspensions: shaken to redisperse med

  • Augmentin (Amox/Clav)
  • Tylenol Children's (APAP)

Solutions: shaking not required

  • Constulose (lactulose for hepatic encephalopathy)
  • Neurontin (gabapentin for neuropathic pain)
  • Rapamune (Sirolimus for px of rejection after organ transplant)


Chewable Tablets

Primarily for children

  • chewable Ca products probably because tabs are large and hard to swallow
  • lanthanum carbonate chewed to bind phosphate in the gut
  1. Suprax (cefixime)
  2. Singular (montelukast)
  3. Lamictal (lamotrigine)


Orally Disintegrating Tablets and Films

ODTs: Placed on tongue and disintegrates rapidly in saliva. Peel back foil of one blister and remove. Helpful when pt cannot swallow tabs/caps due to dysphagia., paralysis of throat from stroke. Children are unable to swallow tabs/caps. N can make it difficult to tolerate anything orally.

  • esophagitis, esophageal tumors, dec LEs pressure/reflux, facial swelling from allergic rxn, worsening of motor func (PD)
  • avoid vomiting
  • helps with non-adherence, dissolves quickly
  1. Lamictal ODT (lamotrigine for seizures)
  2. Remeron SolTab (mirtazapine for depression)
  3. Zyprexa Zydis (olanzapine for schizophrenia)
  4. Ondansetron (for N, dysphagia)

Films: dissolve in mouth (similar). Place tab/film on tongue. It will dissolve in seconds. Once dissolved, swallow with saliva.

  • ondansetron (Zuplenz) film


Sublingual or Buccal deliver with a tab, film, powder, or spray

SL and buccal have same benefits as ODTs. Onset is faster than swallowed tab/cap that is swallowed. Readily absorbed into venous circulation at the admin site. Less drug lost to gut degradation and first-pass metabolism

  • Edluar (zolpidem Sl tab)
  • Nitrostat (nitroglycerin Sl tab)
  • (Subsys) SL, (Actiq) transmucosal lozenge lollipop, (Fentora) buccal tab (fentanyl)


Granules, powders, or capsules that can be opened/sprinkled into soft food or water

Primarily for pediatric or geriatric who have difficulty swallowing. Usually cheaper to give oral med via NG tube rather than converting to IV admin

  • do not chew any long-acting pellets or beads emptied from a capsule
  • if capsule contents are mixed in food or liquid, do not let mixture sit too long
  • do not add to anything warm or hot

Sprinkled on applesauce: Adderall XR, Focalin XR, Ritalin LA, Coreg CR, Dexilant, Nexium, Namenda XR

Other Specific Instructions:

  • Cambia powder in water
  • Creon and other pancreatic enzyme products: soft food with low pH (Applesauce, pureed pears, or banana
  • Depakote sprinkles on soft food
  • Kadian on applesauce or soft food
  • Potassium chloride ER caps on applesauce or pudding
  • Questran/Light in 2-6oz water or non-carbonated liquid
  • Singular granules in 5mL of baby formula or breast milk or in spoonful of applesauce, carrots, rice, or ice cream



ODTs often contain sweeteners (aspartame, saccharin)

  • Sorbitol metabolism produces gas, cramping, and bloating in sensitive pts including IBS
  • Phenylalanine used in many ODT, chewable, and granule med formulations
  • avoid in phenylketonuria (PKU)
  • lactose is most commonly used



Subcutaneous SC patients can mostly self-admin. Used for rapid effect and for drugs that would degrade or not be absorbed by oral admin (enoxaparin, etanercept)

  • Naloxone, Imitrex, Insulins, GLP-1 agonists

Long-Acting IM generally hurt more due to longer needle (muscle soreness). Improve adherence (antipsychotics) or dec need for more frequent inj

  • EpiPen given in thigh for acute need
  • Abilify Maintena, Haldol, Invega Sustenna, Invega Trinza, Lupron Depot, Risperdal COnsta, VIvitrol, Zyprexa Relprevv

Intravenous IV bypass oral route who are intubated or sedated; fast response, avoids loss of drug due to N/V


Injectable Medication Counseling

Inject 1in from previous site. With single-use devices, discard needle or entire assembly. Do not rub near anticoagulation inj (enoxaparin, fondaparinux). Do not use any device to heat up cold inj. Let sit at room temp for 20min. Liquids can degrade. If a solution is discolored, do not use

  1. Wash hands
  2. prepare injection
  3. select and clean injection site
  4. inject
  5. discard syringes, pen needs, or entire assembly in sharps container

Monoclonal Antibodies: proteins can easily denature (break apart) if handled incorrectly. Do not shake and avoid exposing to extreme temps. Store in refrigerator prior to use


Patch Frequency

Twice daily: Diclofenac


  • Daytrana qam 2h prior to school
  • Nicoderm CQ, Exelon, Neupro, Emsam
  • Androderm nightly, not on scrotum
  • Lidocaine 1-3 patches prn on for 12h, off for 12h, can be cut
  • Nitroglycerin on for 12-14h, then off for 10-12h

Every 72 Hours:

  • Duragesic, if wears off after 48 hours change to 48h
  • Transderm Scop q72h prn


  • Butrans, Catapress-TTS, Estradiol (Climara), Estradiol/Levonorgestrel
  • Xulane weekly for 3w, off for 1w

Twice weekly: Estradiol (Alora, Vivelle-Dot), Oxytrol)


Patch Counseling

Contain metal (remove before MRI): Catapress-TTS, Neupro, Transderm Scope, Androderm

  1. Cannot be cut except Lidoderm
  2. Avoid heat, causes rapid absorption
  3. Never apply to irritated skin. alternate application sites. Skin should not be shaved shortly before applying
  4. Topical steroid (HC) can be applied after patch is removed

Most patches cannot be covered with tape:

  1. Duragesic and Butrans permitted Bioclusive or Tegaderm
  2. Catapress-TTS come with its own adhesive cover


  • in most cases, remove and fold patch for disposal. Include lidded container or flushing down toilet
  • highly potent can be fatal. Recommend flushing
  • drug located in raised pouch, reservoir, or into adhesive of patch


Nasal Spray Counseling

Faster onset and useful for acute conditions. Bypasses gut absorption (proteins like calcitonin would be destroyed in the gut)

  • Imitrex fast onset, alt to inj
  • Oxymetazoline, Flonase Allergy relief [both local]
  1. Shake bottle gently and remove cap
  2. prime before first use or not used in 7-14d
  3. blow nose to clear nostrils
  4. close 1 nostril and insert into other nostril. Breathe in through nose and press firmly and quickly on applicator
  5. breathe out through mouth
  6. use bottle for labeled number of sprays
  7. do not blow nose right after using


Eye Drop Counseling

Local effects

Eye drops must be sterile and close to pH of body. Eye drops can be administered in ear, but ear drops can never be administered in eyes

  1. Shake a few times. Gels should be inverted and shaken once
  2. bend your neck back so you are looking up. Use one finger to pull down your lower eyelid
  3. without letting tip of bottle touch your eye, release one drop between eye and lower eyelid
  4. close your eye. press finger between eye and top of your nose for 1min
  5. do not admin 2 drops at once. wait 5-10min. If gel, apply last. wait 10min between gels
  6. if eye drops contain preservative (BAK), remove contact lenses prior to admin and wait 15min


Ear Drop Counseling

Local Effects

Ear drops can never be administered in eyes

  1. Lie down or tilt head so that affected ear faces up
  2. Adults: pull earlobe up and back
  3. Children < 3yo: pull earlobe down and back
  4. keep ear facing up for 5min
  5. wipe dropped with clean tissue


Rectal Counseling

Localized (constipation, hemorrhoids) or systemic (diazepam for seizures)

  • (Feverall) suppository (fever in infant)
  • (Rowsa) enema (local distal UC)
  • (Pedia-Lax) glycerin suppository (constipation)
  1. empty bowel before use

Enema: shake well. Remove protective sheath from applicator tip. Best results obtained by lying on left side with left leg extended and right leg flexed forward for balance. Gently insert med or applicator tip into rectum, pointed slightly toward the navel. Grasp bottle firmly and tilt slightly so that nozzle aimed towards the back. Remain in position for at least 30min

Suppositories: detach from strip. Remove foil wrapper carefully while holding suppository upright. Do not handle suppository too much (heat can cause it to melt). Insert with pointed end first. Keep in for 1-3h


Missed Doses

If you miss a dose, take it as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the next dose at your regularly scheduled time

  • Do not take two doses at the same time unless instructed

Exceptions: high-risk drugs (anticoagulants, transplant), OCs

  • phosphate binders pancreatic enzymes, and prandial insulin taken before a meal


Adherence Counseling and Monitoring

Pharmacists often review refill histories. If the medication is used to px/control a disease, nonadherence can imply patient does not understand how to use medication, is experiencing side effects, or requires assistance in remember reminders

If the med is used as needed for acute sx, refill history can reveal how well patient's condition is controlled

  • frequent use can imply patient is suffering from sx or not using the med correctly

Motivational interviewing techniques can help pharmacist to better understand needs

  • counseling approach that focuses on the patient's priorities to help facilitate change. Asking open-ended questions


Venous Catheters

A catheter inserted into a vein, called a line

Peripheral Line: inserted into smaller veins (cephalic vein in arm, saphenous vein near ankle)

  • drugs into smaller veins cause phlebitis (vein irritation), venous thrombosis (clots), and interstitial fluid extravasation

Central Line: empties into larger vein (superior vena cava)

  • highly concentrated rugs (potassium 20meQ/100mL+
  • long term abx (osteomyelitis)
  • toxic drugs that cause severe phlebitis (chemo, esp vesicants)
  • pH or osmolality not close to blood pH or osmolality (parenteral nutrition)
  • PICC inserted by placing line into peripheral vein and advancing catheter through vein until tip ends in superior vena cava

Vesicants: severe tissue damage if catheter tip comes out of vein, allowing drug to seep into surrounding tissues (extravasate).

  • safer with a central line
  • Vasopressors (DA, NE), anthracyclines, vinca alkaloids, digoxin, foscarnet, nafcillin, mannitol, mitomycin, promethazine



Substances are unsuitable for use together causes hydrolysis, oxidation, or decomposition

  • Handbook on Injectables Drugs (Trissel's)
  • the King Guide to Parenteral Admixtures (King's)
  • drug's package insert
  • Recent concerns: Pharmacy Practice News and in Hospital Pharmacy

DEHP from the Container: PVC containers use DEHP as a "plasticizer" to make plastic bags more flexible. DEHP can leach into container, harm liver and testes. Reduce drug's concentration

  • Absorption: drug moves into PVC container
  • Adsorption: drug adheres to container

Alternative (Non-PVC) Containers: polyolefin, polypropylene, or glass containers


Drugs with Leaching/Adsorption/Absorption Issues with PVC Containers

Leach Absorbs To Take In Nutrients

  1. Lorazepam
  2. Amiodarone
  3. Tacrolimus
  4. Taxanes
  5. Insulin does adsorb to PVC but is used in all containers/tubing
  6. Nitroglycerin

Others: carmustine, cyclosporine, Ixabepilone, Sufentanil, Temsirolimus


Drugs with Diluent Solution Requirements

50 mL or larger IV piggybacks that contain 5% dextrose (D5W) or 0.9% sodium chloride (normal saline, NS)

Saline (No Dextrose): A DIAbetic Can't Eat Pie

  • Ampicillin, Daptomycin, Infliximab, Ampicillin/Sulbactam, Caspofungin, Ertapenem, Phenytoin

Dextrose (No Saline): Outrageous Bakers Avoid Salt

  1. Oxaliplatin
  2. Bactrim
  3. Amphotericin B
  4. Synercid


Drug-Drug Incompatability

Infusion bags are joined together in a Y-site and run together in the same line during admin

  • important that drug solutions are compatible with y-site admin
  • listed separately in Trissel's and others
  • risk of precipitates -> emboli -> fatality
  • calcium and ceftriaxone, calcium and phosphate


  • calcium and phosphate can form a deadly precipitate
  • amphotericin B and sodium bicarbonate incompatible with the majority of IV drugs
  • piperacillin and acyclovir form precipitate
  • heparin incompatible with many (NG, alteplase, hydromorphone)
  • caspofungin has many incompatibilities


Common Drugs with Filter Requirements

Majority of drugs requiring filters use 0.22 micron, 1.2 microns for lipids. Parenteral nutrition filtered with 0.22 micron filter

  • filter needles/straws if compounding IV meds in glass ampules


  1. Golimumab
  2. Amiodarone
  3. Lorazepam
  4. Phenytoin
  5. Lipids - 1.2 micron
  6. Amphotericin B
  7. Taxanes (except docetaxel)


Do not Refrigerate Drugs

Dear Sweet Pharmacist, Freezing Makes Me Edgy!

  1. Dexmedetomidine (diluted can be cold)
  2. Bactrim (sulfa)
  3. Phenytoin - crystalizes
  4. Furosemide - crystalizes (diluted can be cold)
  5. Metronidazole
  6. Moxifloxacin
  7. Enoxaparin

Others: APAP, acyclovir (crystalizes), Deferoxamine (precipitates), Keppra, pentamidine (crystallizes), valproate


Protect form Light During Administration Drugs

Light exposure causes photo-degradation, dispense with light-protective cover

Protect Every Necessary Med from Daylight

  1. Phytonadione
  2. Epoprostenol
  3. Nitroprusside
  4. Micafungin
  5. Doxycycline

Others: Amphotericin B, anthracyclines, Dacarbazine, Thiotepa, Pentamidine


Do not Shake/Agitate

Agitation destroys some drugs, including hormones and other proteins

  • cannot be transported via pneumatic tube systems


  1. protein/blood products such as albumin, immune globulins, monoclonal antibodies, and insulin (some manufacturers allow transported via pneumatic tube one time)
  2. Alteplase, etanercept, rasburicase, Synercid, infliximab, caspofungin foam. Only be swirled when reconstituting. Wait for foam to dissolve
  3. Vaccines that have been reconstituted
  4. emulsions (propofol, injected lipid emulsions)


Electronic Health Records

Immediate access to information

  • linked to computerized prescriber order entry (CPOE) and electronic prescribing
  • clinical decision support (CDS) tools built into order entry process

HIPAA 1996 requires security protections for all protected health information (PHI)

  • uses pins and passwords for encryption
  • all personnel responsible for security


Patient Medical Record

"this is what I am having done at this facility" a Joint Commision requirement and advance directive

  • documents patient's wishes if they are unable to make decisions on their own behalf
  • interventions require documentation for reimbursement since quality of care is tied to payment
  • polices describe authority of pharmacists to document PMR
  • goals include inc adherence, avoiding unnecessary or unsafe meds, inc use of med indicated for certain conditions


Medicare and Medicaid

CMS: penalties for poor care and incentives for quality care

  • hospital-acquired infns
  • readmission rate (both expensive and avoidable)

Medicare: federal health ins for 65yo, < 65yo with disability, and ESRD

  • Part A: hospital
  • Part B: medical costs (doctor visits, some vaccines)
  • Part D: prescription drug benefit

Medicaid: low income (<133% of federal poverty). Federal and satate program


Soap Note

Subjective info recorded from patient, personal narrative of their own sx. Avoid closed-ended/leading questions

  • one line Chief Complaint (specific reason patient is being seen today in patient's own words)
  • detailed history of present illness (HPI)
  • detailed past medical history (PMH): allergies, medication use

Objective obtained by clinician

  • vital signs (RR, HR, BP, temp)
  • physical findings, diagnostic tests, laboratory results
  • critical results outside reference range

Assessment: possible cause, differential diagnosis, list of possible diagnoses that explain current s/sx (possible causes of patient's condition)

Plan (medication and referrals)


Celsius to Fahrenheit, and Fahrenheit to Celsius

C = (F - 32) / 1.8

F = (C x 1.8) + 32


Drugs that cause Blood Pressure Changes


Conditions: renal insufficiency/failure, PREG, excess salt intake, obesity, adrenal tumors


  • antiHTN, vasodilators, opioids, BZDs, anesthetics, phosphodiesterase inhibitors

Conditions: anaphylaxis, blood loss, infn (sepsis), dehydration (orthostatic hypotension)


Drugs that Cause Hyperthermia/Hypothermia


  • inhaled anesthetics (malignant hyperthermia)
  • antipsychotics (NMS)
  • topiramate

Conditions: fever, hyperthyroidism, trauma, cancer, serotonin syndrome


Conditions: exposure to cold, hypothyroidism (myxedema coma), hypoglycemia


Drugs that Affect Heart Rate


  • stimulants, caffeine, nicotine, illicit drug use
  • decongestants, beta-agonists, theophylline
  • anticholinergics (tricyclics, antihistamines)
  • bupropion, antipsychotics
  • vasodilators (nitrates, hydralazine, DHP-CCBs) cause reflex tachycardia

Conditions: arrhythmias, hyperthyroidism, anemia, dehydration, anxiety, stress, pain, hypoglycemia, infn, drug withdrawal, serotonin syndrome


  • beta-blockers, non-DHP CCBs, Digoxin, clonidine, guanfacine, antiarrhythmics (esp Class II)
  • opioids, sedatives, anesthetics, neuromuscular blockers
  • acetylcholinesterase inhibitors

Conditions: arrhythmias (sinus bradycardia), hypothyroidism


Drugs that Affect Respiratory Rate


  • stimulants

Conditions: asthma/COPD, anxiety/stress, ketoacidosis, pneumonia

Respiratory Depression:

  • opioids
  • sedatives

Conditions: hypothyroidism


Patient Communication

Communication skills are essential

Health literacy: degree to which individuals able to obtain, process, and understand basic health and med info to make appropriate health decisions

  • different than simply being able to read or being well educated
  • low literacy is linked to poor health outcomes


  1. approach all patients as if they do not understand
  2. use non-medical language
  3. ask open-ended questions, avoid leading questions
  4. confirm understanding by asking to repeat info
  5. use different communication strategies (verbal, written, visual aids)
  6. Use active listening, speak clearly, make contact, and induce yourself