Medications and Treatments Overview

Rheumatoid Arthritis NSAIDS/Cox-2 enzyme blocker (Treatment begins with these!) Corticosteroids • Celecoxib Celecoxib causes less GI distress Monitor for renal dysfunction • Prednisone • Acute exacerbations • Not long term Monitor for: • Osteoporosis • Hyperglycemia • Immunosuppression • Cushing-like symptoms • Weight/BP • DMARDs- can affect liver: avoid alcohol • MONITOR FOR: • Slows the progression of RA. • Suppressed immune system reaction that cause pain/inflammation DMARDS (below) Antimalarial Antibiotic Sulfonamide Biologic Response Modifiers Cytotoxic Medications Hydroxychloroquine Neutropenia, hepatoxicity, anemia Mild to moderate disease -rapidly absorbed, relatively safe, well tolerated Minocycline Sulfasalazine • • • • • • • • Mild to moderate disease -rapidly absorbed, relatively safe, well tolerated Etanercept Infliximab Adalimumab Chelator penicillamine Methotrexate Leflunomide Cyclophosphamide Azathioprine • Relief of medications may not occur for a few weeks • LEFLUNOMIDE- monitor lab results for decreased WBC’s and platelets/ increased liver enzymes • LEFLUNOMIDE- Hair loss/diarrhea and fetal birth defects • METHOTREXATE: Preferred for early treatment, lower toxicity but may not get relief from this drug alone Stroke Tissue plasminogen Activator (tPA) -Must be given within 3-4.5 hours of ischemic stroke -Digest fibrin/fibrinogen -Not recommended in emergency phase due to bleeding/ICP • Warfarin Anticoagulant -appropriate for Afib -PT/INR- Time it takes blot to clot Direct factor Xa Inhibitors Antiplatelets • Rivaroxaban • Dabigatran • Apixaban -Alternative to warfarin therapy for those with Afib • Lose dose aspirin • Clopidogrel • Dipyridamole -Platelet inhibitors INR: therapeutic level between 2-3 -Must receive periodic lab work -Novel oral anticoagulants ICP Antiseizure • Phenytoin Antipyretic/Muscle Relaxant -Prophylactic -reduce metabolism BP Medication -Maintain cerebral perfusion Corticosteroids -Decrease cerebral edema -Reduce leakiness of BBB -Osmotic diuretic, causes edema -Increases intravascular pressure by drawing fluid from the brain Hyperosmotic agent • Mannitol (IV) Opioids • Morphine -Only in mechanically ventilated pts. -pain and restlessness -ASSESS LOC every hour -STRICT I&O -Insert indwelling catheter -Monitor electrolytes closely Addiction Alcohol: Vitamin B Complex • Thiamine • Folic acid • Vitamin C • Naltrexone Blocks the high feeling • Acamprosate Reduce physical distress and emotional discomfort • Disulfiram Opiates • Methadone • Buprenorphine (Subutex) • Buprenorphine AND Naloxone -Severe adverse reactions -Fatigue, flushing, sweating, headache, neck pain, N/V, HYPOtension, tachycardia, Respiratory distress -Most effective -Agonist -FIRST PHASE -Isn’t a full opioid but acts like one. -Less likely to be abused (Long term) (Suboxone) • Clonidine Stimulants • Antipsychotics • Bromocriptine • Antidepressants Nicotine Marijuana • Varenicline(Chantix) • Bupropion (Wellbutrin) • Marinol (dronabinol) • Cesamet (nabilone) -Alpha-adrenergic blocker -Reduces severity of SNS withdrawal discomfort -Overdose treatment -Withdrawal -Bupropion 1st choice with depression -Marinol: appetite -Cesamet: N/V -Abstain for at least 12 hours, begins withing minutes-30min, last 30min to 2 hrs. -stays in body 2 weeks Hypersensitivity Antihistamines 1st gen 2nd Gen • Diphenhydramine -Anticholinergic -sedating • Cetirizine • Fexofenadine • loratadine -minimal side effects -more expensive • Pseudoephedrine -Promotes Sympathomimetic/decongestant vasoconstriction of drugs superficial vessels in • Oxymetazoline nose (Afrin) • Fluticasone (Flonase) Corticosteroids • Mometasone (Nasonex) • Budesonide -decrease mucosal inflammation and facilitates drainage of sinuses -Allergic rhinitis -CNS stimulation, Insomnia, irritability, Increase BP, Tachycardia, palpitations - Tolerance/rebound congestion -Systemic effects at high doses -DO NOT take PRN, Adherence inportant (Rhinocort) Mast cell-stabilizing drugs Leukotriene receptor antagonist • Cromolyn spray • Montelukast -Nasal or ophthalmic -suppresses release of histamine from mast cells - Minimal SA -allergic rhinitis -asthma TB: Isoniazid, Rifampin, Ethambutol, Pyrazinamide Empty stomach, 8oz water, avoid antacids Sputum samples every 2-4weeks -Can be used before mowing grass, etc DUAL ROLE! Decrease inflammation and bronchodilates MS Potassium Channel Blocker Immunomodulators (DMD) • Dalfampridine Can cause seizures! (oral) • Interferon Beta 1a/1b (Subcut) • Teriflunomide (oral) • Fingolimod (oral) • Dimethyl Fumarate -Depression/suicidal thoughts -Wear sunscreen/protective clothing -Flu-like symptoms common -Life threatening Liver toxicity -Viral brain infection: Progressive multifocal leukoencephalopathy (PML) -Viral brain infection: Progressive multifocal leukoencephalopathy (PML) -Improves nerve conduction in damaged nerve segments -MAY IMPROVE WALKING SPEED DMDS: Decrease frequency and severity of relapses -Reduce brain lesions -Increase functional capability -Increase QOL -Anti inflammatory -Reduces disease activity by preventing lymphocytes from reaching CNS -Helps defend against inflammation and oxidative stress • Glatiramer acetate (Subcut) Monoclonal Antibodies • Alemtuzumab • Natalizumab • Ocrelizumab (IV Infusion) Immunosuppressants Corticosteroids • Mitoxantrone • Methylprednisolone • dexamethasone -PML -Given when pts don’t have a good response to other treatments -suppress immunological activity -reduce freq of reactions -Last resort because it causes PML -suppress immune system during treatment, depletes cells attacking myelin -High dose over 3-5 days followed by prednisone taper -reduces edema/speed recovery -DOES NOT SLOW DOWN NEUROLOGICAL IMPAIRMENT Fatigue Bladder spasms Depression • Amantadine • Modafinil • Oxybutynin • Propantheline -Drink water/dry mouth • SSRI Spasms • Dantrolene • Tizanidine • Baclofen Antispasmodic • Diazepam Neuropathic pain -Anticholinergic Baclofen: Dizziness and drowsiness and CANNOT STOP ABRUPTLY because it can cause CONFUSION AND PSYCHOSIS • Gabapentin • Carbamazepine Gout Acute Gout Prevention: Xanthin oxidase inhibitor • Colchicine • NSAID • Corticosteroids • ACTH • Indocin • Allopurinol -DOES NOT LOWER URIC ACID LEVELS -Prevent or treat attacks of gout -works within 1224 hours Colchicine- relief when given within 12 hours and help in diagnosis. -Colchicine is antiinflammatory but not analgesic, so NSAID is added -Indocin, Corticosteroids also anti-inflammatory -Causes less Uric -Can be used in pts with uric acid to be produced acid kidney stones or renal by the body impairment -Can cause vision changes Parkinson’s Dopaminergic • Levodopa with Carbidopa -Dyskinesia with prolonged use -Wearing off phenomenon -Hallucinations, Ortho hypo, red/brown urine/saliva/sweat -protruding tongue not normal -NO HIGH PROTIEN MEALS • -Block the effects of the overactive cholinergic neurons in the striatum Anticholinergic (Both can take several weeks to work) Dopamine Agonists Anticholinergic Monoamine Oxidase type B inhibitors • Ropinirole** • Apomorphine** • Amantadine** • Bromocriptine • Pramipexole • Benztropine (Cogentin) • Rasagiline • Selegiline • Entacapone • Opicapone COMT inhibitors -Primary treatment -Enhance the release/supply of dopamine -Levodopa converted to dopamine in the brain -CARBIDOPA inhibits enzyme that breaks down levodopa - Monitor for orthostatic hypertension, dyskinesia, and HULLICINATIONS -Activate release of dopamine Apomorphine-Improvement in -Monitor for anticholinergic effects Dry mouth, constipation, urinary retention, acute confusion AVOID tyramine containing foods-hypertensive crisis -Dizziness, dry mouth, headache, orthostatic BP -Helps control tremors and rigidity -decrease activity of acetycholine -monitor for dyskinesia, diarrhea -Dark urine normal hypomobility (Off episodes) and MUST take with antiemetic that is NOT Ondansetron -severely low BP Take bp/pulse before giving. -may cause falls, dizziness, spontaneous sleepiness -inhibit type b activity and increases dopamine (it’s the enzyme that degrades dopamine) -Reduces wearing off phenomeneon -Decrease breakdown of levodopa (comt breaks it down) -Used when response to levodopa is wearing offprolongs effect of Carb-levo -Advanced PD and intense motor fluctuations Lupus • NSAIDS Corticosteroids Immunosuppressants Antimalarial Reduce inflammation and arthritic pain -Suppress immune system/reduce inflammation • Prednisone -Cream for skin rashes -Methotrexate and Azathioprine suppress immune response • Methotrexate -belimumab inhibits • Azathioprine stimulation of B • belimumab cells/reduce autoimmune response Suppression of synovitis, • Hydroxychloroquine fever, and fatigue DO NOT TAKE if there is renal involvement Monitor for fluid retention, hypertension, and impaired Kidney function MONITOR Liver enzymes, hepatotoxicity, and bone marrow suppression ALSO decreases risk of developing skin lesions from the absorption of UV light from sun exposure. Osteoarthritis • Diclofenac (Topical) • Celecoxib • Indomethacin • Meloxicam • Naproxen • Ibuprofen • Methylprednisolone acetate(depoCorticosteroids Medrol) • Triamcinolone NSAIDS OCT Topicals FIRST LINE TREATMENT -Some start with topical -Celecoxib good option for older pts-selective properties on cartilage. -inhibit synthesis and release of inflammatory mediators -Intraarticular injections -4 or more injections without relief suggests need for further intervention. -strict aseptic -joint may feel temporarily worse after injection -lasts weeks to months -May affect cartilage metabolism -Inhibit prostaglandin synthesis -nephrotoxic SYSTEMIC CORTICOSTEROIDS NOT USED-HASTEN DISEASE PROCESS! -AVOID using joint right after injection • Bengay • Aspercreme • Capsaicin Sickle cell-Hydroxyurea, Adakveo, voxelotor can reduce sickles episodes Fracture Muscle Relaxants Bone-penetrating antibiotics • Carisoprodol • Cyclobenzaprine • Methocarbamol • Cephalosporins • Cefazolin Muscle spasms/pain -Cephazolin give prophylactically Fibromyalgia Chronic widespread • Pregabalin Pain • Duloxetine • Milnacipran • Low dose tricyclic antidepressants -pregabalin (nerve) -duloxetine/milnacipran (antidepressant) -High dose SSRI for depression (Amitriptyline) Sleep Muscle relaxant • SSRI • Benzo(diazepam) • Tramadol (nonopioid) • Zolpidem • Trazodone • Cyclobenzaprine Osteoporosis • Alendronate Bisphosphonates • Risedronate Supplements • Mg • Ca • Vitamin D • Calcium Carbonate Slow bone reabsorption by binding with crystal elements in bone. Especially spongy porous bone tissue -Calcium Carbonate-Take in divides doses of <500mg -Monitor bone density -Take on empty stomach and sit up for 30 minutes to avoid esophagitis - HIV Fusion inhibitors CCR5 Inhibitor -Subcut 2x daily Peripheral neuropathy -PO -Liver injury -Cardiovascular events -Liver problems -Hyperglycemia -High cholesterol SHOULD NOT TAKE WITH MOST STATIN DRUGS -Liver problems Neuropsychiatric problems, nightmares, hallucinations, suicidal thoughts -Rash -Liver problems -peripheral neuropathy -Lactic acidosis -Liver injury -SEVERE SKIN REACTIONS -WIDESPREAD INFLAMMATION -PO Protease inhibitors Non-Nucleoside reverse transcriptase Nucleoside-reverse -PO -PO -Liquid Integrase PrEP- Discovy/Truvada nPEP-72hrs Block the fusion/binding of HIV to cells Binds with CCR5 and blocks viral entry Inhibit protease, which is needed for the virus to replicate Inhibit reverse transcriptase to inhibit viral replication in cells Interferes with the ability to convert RNA to DNA Binds w/integrase. Prevents HIV from incorporating into host cell