Term 3 Quiz #2

Term 3 | Quiz 2| 09/06/24 MedSurg | Chapter 55 Sexually transmitted infections (STIs) What Does Culture Have to Do With Sexually Transmitted Infections? The incidence of sexually transmitted infections (STIs) varies among races, but poverty, lack of education, and limited access to health care probably play a larger role than race and ethnicity. In addition, cultural beliefs about sexual practices, use of condoms, and educating children about STI prevention may all affect the incidence of STIs in any given population. Diagnostic Tests and Procedures Pharmacology Capsule When you have an order to obtain a specimen for culture and another order to administer antiinfective agents, collect the specimen before giving the first dose of the antiinfective. ●​ include several conditions that can be transmitted from one person to another during intimate contact. ●​ The term sexually transmitted disease (STD): ○​ commonly used to describe these same conditions as well. ●​ The difference in the two terms is that: ○​ disease, by definition, has recognizable signs and symptoms, ○​ infections may or may not manifest specific signs and symptoms. ●​ 1 million STI’s are acquired every day ●​ 357 million new infection with 1 of 4 STI’s (chlamydia, gonorrhea, syphilis, and trichomonas) ●​ 20 million new infection occur each year Half of these age are in persons 15-24 years of age ●​ STI’s are more common in people with: ○​ Lower socioeconomic status ○​ Less education ○​ Limited access to health care ●​ Risk factors: ○​ Drug abuse ○​ Multiple sexual partners ●​ STI’s rate are highest among: ○​ African Americans ○​ Latinos ○​ Non-Latino Caucasian ○​ Infected people do not tell their partners they are infected so it continues to be passed to other people ○​ Symptoms are absent or subtle, so it spreads around other parts of the ●​ Nurses must be aware of their feelings about working with people who have STIs. A stigma is associated with these infections, and we must ensure the same quality of care to patients with an STI that we give to patients with any other diagnoses. ●​ Judgmental behavior on the part of health care providers discourages people from seeking appropriate medical care. ●​ Individuals who engage in high-risk sexual behaviors are at increased risk for each of the STIs. ●​ Therefore patients diagnosed with one STI should be evaluated for others as well. ●​ Infections with some STIs appear to increase the risk of human immunodeficiency virus (HIV) infection. ●​ The primary measures used to diagnose STIs are serologic tests and studies of smears and cultures. ●​ Some over-the-counter (OTC) or mail service tests can be purchased for home use. ○​ Concerns with this type of testing include possible false-negative or false-positive results, uncertainty about the reliability of a specific product or laboratory, and possible delayed treatment of serious infections. ●​ Serologic Test: ○​ for HEP A, B, C, D, E, syphilis; HIV herpes, cytomegalovirus ○​ To detect infection by measuring antigen or antibodies in the blood *(Antigen = foreign matter. Antibodies = protective proteins)* ●​ Smears, swabs and cultures: ○​ Pt with gonococcal, chlamydial, herpes, trichomonas, or yeast infections often have discharge from vagina or penis. ○​ Exudate(pus) from lesions can be collected and studied to determine exact infecting organism ○​ women-collected from vagina or cervix ○​ men- swab or special loop may be used ○​ The person who collects the sample wears gloves and treats the sample as a potential source of infection. Pathophysiology ●​ caused by virus, bacteria, parasites through sexual contact ○​ Curable with treatment: Syphilis, gonorrhea, chlamydia, trichomonas, ○​ Not curable at this time: Hep B, Herpes, HIV, HPV Drug Therapy ●​ The drugs recommended by the Centers for Disease Control and Prevention (CDC) are noted with the discussion of each specific infection. ●​ The CDC also recommends alternative drugs for people who are allergic to the primary drugs, pregnant women, infants and children, and people who are being treated for multiple infections. Reporting Sexually Transmitted Infections ●​ Confirmed cases of HIV, acquired immunodeficiency syndrome (AIDS), gonorrhea, syphilis, chlamydia, chancroid, and viral hepatitis are among the infections that must be reported to the local health department. ●​ An investigator asks the patient to name their contacts. ●​ Those individuals are contacted and advised that they have been exposed to the disease and are encouraged to seek medical evaluation. ●​ The purpose of this process is to identify and treat infected individuals so that transmission of the infection can be slowed. ●​ Another approach is to provide the patient with a prescription or additional drugs for their sexual partner without examination of the partner. ●​ This approach, which is legal in some but not all states, is called expedited partner therapy (EPT).​ ​ Specific Sexually Transmitted Infections Chlamydial Infection ●​ Most common bacterial infection in the United States ●​ Chlamydia is intracellular bacterium that compromises multiple genera and species ●​ Chlamydia trachomatis: causes STI ●​ Transmitted by contact with mucous membranes in the : ○​ Mouth, eyes, urethra, vagina, rectum ●​ Newborns of infected women may have eye infections (conjunctivitis) or pneumonia. ○​ Therefore erythromycin ophthalmic ointment may be ordered for the newborn because it is effective against chlamydial infection as well as gonorrhea. ●​ Lymphogranuloma venereum (LGV): ○​ is a more invasive systemic infection caused by the LGV strain of C. trachomatis. ○​ Lesions may affect the inguinal lymph nodes and the rectal mucosa. Clinical Manifestations ●​ One reason chlamydial infection is so common is that most people have no symptoms. ●​ Symptoms, if any, are generally noted 1 to 3 weeks after being infected. ●​ Symptoms are more noticeable in men and include penile discharge, which is initially thin and becomes creamy later. ●​ Another common complaint among men is painful or frequent urination. Epididymitis is manifested by testicular pain, swelling, and tenderness. ●​ Women may experience vaginal discharge, painful urination, nausea, fever, painful intercourse, bleeding between menstrual periods, and lower abdominal pain. ●​ Rectal infection is characterized by pain, discharge, bleeding, or a combination of these problems. ●​ Unlike other forms of chlamydial infection, LGV patients have fever, muscle aches, swollen inguinal lymph nodes, and elevated white blood cell (WBC) count. Complications ●​ Sterility in men and women Sperm ducts can become inflamed and blocked. ●​ Pelvic inflammatory disease (PID): can block the fallopian tubes and damage the uterus. ●​ Risk of ectopic pregnancy (the fertilized ovum developed outside the uterus) ●​ chlamydial infection may increase one’s risk of becoming infected with HIV if exposed to it. Medical diagnosis and treatment syphilis ●​ The most effective diagnostic tool is NAAT (nucleic acid amplification test) ●​ The infection is usually treated with a 7-day course of doxycycline (Vibramycin). ●​ Other antimicrobials may also be administered because patients with chlamydial infection may have gonorrhea as well. ●​ The test should be repeated 3 to 4 months after treatment to confirm successful results of treatment. ●​ The patient is advised to avoid all sexual contact (genital, oral, anal) until a cure has been achieved. ●​ When sexual activity is resumed, condom use is recommended to prevent reinfection Gonorrhea ●​ Most common reported STI in the United States ●​ Transmitted through direct sexual contact. ●​ Transmission to newborn infants by infected mother and to medical personal with Skin laceration who have come in contact with infected fluid ●​ Cannot be picked up from toilet seats, doorknobs, or towels. ●​ Neonates may acquire a gonococcal infection during delivery from an infected mother. ●​ Bacterium: Neisseria gonorrhea; lives in cervix and urethra ●​ High incidence of rectal gonorrhea: men who have sex with men. ●​ Bacteria in the throat: oral sex (fellatio) on an infected partner ●​ Drug resistance is a major threat to reduce the impact of STI worldwide. Signs and symptoms ●​ Many people have no symptoms. ●​ Symptoms occur 2-10 days after exposure and more apparent to men than women. ●​ Men: -whitish or greenish discharge from penis -burning sensation during urination -testicular pain -swelling ●​ Women: -vaginal discharge -bleeding during sex -redness/swelling of genitalia -burning sensation during urination -abdominal pain -abnormal menstruation ●​ Rectal infection (may occur 2-5 days or even 30 days after infection) -discharge -anal itching -soreness -bleeding -painful bowel movement ●​ Throat infection: sore throat ●​ Disappears after a few weeks, but if untreated, person is still highly contagious Complications ●​ Sterility in both sexes ●​ Damage to heart tissue and joints ●​ Men: epididymis, prostatitis ●​ Women: PID, ectopic pregnancy Increased risk for HIV ●​ People with gonorrhea are at increased risk for HIV ●​ People with HIV and gonorrhea are more likely to transmit HIV to another person. Medical Diagnosis ●​ smears and cultures of exudate from infected body parts or urinalysis are still used in some settings ●​ NAAT is now the preferred diagnostic tool. ●​ urinalysis Medical Treatment ●​ single dose of intramuscular ceftriaxone sodium (Rocephin). ●​ One treatment cures most cases of gonorrhea quickly and safely. ●​ Erythromycin ophthalmic ointment may be ordered for the newborn to prevent eye infection caused by exposure to gonococci during delivery. Syphilis ●​ Syphilis is caused by a spirochete (coiled bacterium) called Treponema pallidum. ●​ transmitted by sexual contact but can also be spread through breaks in the skin. ●​ It can also be passed through the placenta, thus causing an infant to be born with the disease (i.e., congenital syphilis). Clinical Manifestations ●​ Signs and symptoms change throughout the course of the disease. ●​ If untreated, syphilis progresses through four stages: (1) primary, (2) secondary, (3) latent, and (4) late (tertiary). ●​ Primary stage (contagious) ○​ Chancfe (lasts 1-5 weeks), typical lesion, first sign of syphilis. First noticed after 1 to 12 weeks after contact. Pharmacology Capsule Patients who do not complete the prescribed course of antiinfective therapy may not be cured of the infection. ○​ Reddish papule appears on genitals, mouth, or anus (where the organism entered). Will become painless red ulcer ○​ When it disappears, pt may think they are cured, but the organism has moved into the blood. ●​ Secondary stage (contagious) ○​ Occurs 1 to 6 months after contact s/s: rash on the extremities, chest or back, palms of the hand, and soles of the feet. ○​ Pustules that contain highly contagious material often develop. ○​ fever, sore throat, generalized aching pustules (highly contagious) ●​ Latent stage ( stage 3) ○​ after the secondary stage, no symptoms ○​ not spread by sexual contact, may be transmitted by blood exposure. ●​ Late (“Tertiary”) Stage 4 ○​ 3 years after developed ○​ Most pt never advance to this stage ○​ s/s: arthritis, numbness of the extremities, lesions of the skin and internal organs (gummas), pain because of damage to heart, blood vessels, or CNS Complications ●​ The patient with untreated syphilis may develop severe, potentially fatal complications: ○​ neurosyphilis (meningitis, blindness, paralysis) ○​ cardiovascular disease. ●​ An infected woman who becomes pregnant has a greatly increased risk of fetal infection, deformities, or death. ●​ The lesions also make it easier for a person to transmit and contract HIV infection. Medical diagnosis ●​ include screening (nontreponemal) and confirmation (treponemal) tests. ●​ Two screening test: ○​ venereal disease research laboratory (VDRL) ○​ rapid plasma reagin (RPR) ○​ Both detect a protein that appears in the blood when a person has syphilis. ○​ Screening tests can be inaccurate because other factors can cause false-positive reactions. ○​ The tests are not effective until antibodies for T. pallidum are present in the blood. This may not occur until 3 to 4 weeks after exposure. ●​ confirmation tests: ○​ specifically detect T. pallidum, are needed to confirm the disease. ○​ fluorescent treponemal antibody absorption (FTA-ABS) ○​ Chemiluminescence ○​ Immunoassays. ○​ Because patients with syphilis often have multiple infections, HIV testing is often recommended as well. Medical Treatment ●​ Treatment of syphilis (drug, dosage, length of treatment) varies with the stage and clinical manifestations of the infection. ●​ The treatment of choice for syphilis is parenteral benzathine penicillin G unless contraindicated. For a primary, secondary, or early latent infection, a single dose is usually sufficient. ●​ For more advanced infections, a longer course of therapy is indicated. ●​ Neurosyphilis and ocular syphilis require aqueous crystalline penicillin G ●​ Advise the patient to make a follow-up appointment with a health care provider to determine whether the treatment was effective. ●​ advise the patient not to engage in sexual activity until 1 month after completing treatment for primary or secondary syphilis. Genital Herpes ●​ The viruses Herpes febrilis or herpes simplex virus-1 [HSV-1]) causes cold sores ○​ transmitted through contact with open lesion (lips or inside the mouth) ○​ avoid direct contact (kissing) ●​ nongenital, lesions above waist Genital herpes (considered STI) ○​ caused by herpes simplex virus-2 [HSV-2]) transmitted by sexual contact (vaginal, or anal intercourse, oral-genital contact, hand contact) ●​ HSV-1 and HSV-2 are similar, ●​ type 1 is usually nongenital, with lesions typically above the waist. ●​ Type 2 is considered an STI because it is most often below the waist and is transmitted by genital contact. ●​ However, type 1 is being found in increasing numbers of genital infections, presumably transmitted by oral-genital contact. A characteristic of herpes viruses is the ability to become latent. ●​ virus can remain in an inactive state for long periods of time and then be reactivated Clinical Manifestations ●​ Most patients with genital herpes have no symptoms. ●​ Begins with Rash, Followed by small blister that will ulcerate creating Painful itching sores (2-20 days after infection) ●​ Lasts 2-3 weeks ●​ Burning sensations, flu-like symptoms Complications ●​ An increased risk of cervical cancer exists in women who have genital herpes. ●​ An infected woman should be taught to have a Papanicolaou (Pap) test done annually to detect cervical cancer early. If she is pregnant, a physician should supervise her closely. ●​ Herpes simplex encephalitis is a dangerous complication, usually caused by HSV-1. ●​ It has a mortality rate of 20% to 30% and a significant proportion of survivors have moderate to severe neurologic impairment. ●​ Other neurological complications: Bell palsy may occur as well Medical diagnosis and treatment ●​ Genital lesions, NAAT, antigen tests, and fluid specimen ●​ No cure for HSV ●​ oral antiviral drugs acyclovir (Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir)--control signs and symptoms ●​ episodic therapy: Patients should know to start the drug when preliminary (prodromal) symptoms of recurrence are experienced or within 1 day of the outbreak of lesions. ●​ chronic suppressive therapy: Some patients with especially disabling recurrences take one of these drugs continuously to reduce the frequency of outbreaks. ○​ -clovir Trichomoniasis ●​ Protozoan parasite: trichomonas vaginalis ●​ Sexually transmitted. ●​ Survive for hours on damp clothes and clothing. ●​ Women: vagina ●​ Men: urethra ●​ Increased risk of HIV transmission ●​ May cause premature birth or low birth weight. Signs and symptoms ●​ Women: ○​ some women have no symptoms ○​ frothy, yellowish vaginal discharge, with foul odor ○​ vaginal irritation and itching ○​ urinary frequency, burning ●​ Men: ○​ usually no symptoms ○​ mild discharge ○​ slight burning after urination and ejaculation Medical diagnosis and treatment ●​ Microscopic study of vaginal discharge or urine (men) ●​ Culture to reveal the organism ●​ metronidazole (flagyl): drug of choice ●​ Tinidazole (tindamax): alternative ●​ A single dose is usually effective. ●​ It is important that the patient and any sexual partners be treated at the same time to avoid reinfection. Medical diagnosis ●​ Detected by microscopic study of vaginal discharge or urine ●​ Discharge can be cultured Medical treatment ●​ Tinidazole (Tindamax) is the drug of choice ●​ Metronidazole (Flagyl) is less expensive option ●​ Important that patient and sexual partners be treated at the same time to avoid reinfection Human papillomavirus (HPV) ●​ There are more than 200 types of HPV ●​ High-risk types have been associated with cervical, vulvar, vaginal, anal, penile, oral, and oropharyngeal cancer ●​ low-risk types of HPV are associated with condylomata acuminata, or genital warts. ●​ Caused by the Human Papillomavirus ●​ Affect genital, anal regions of men and women ●​ Transmission by vaginal, anal, or genital contact ●​ Can be transmitted by people who had no visible signs of infection ●​ Incubation period: 3 weeks to 8 months ●​ three vaccines are available ○​ Gardasil protects against four types of HPV, including types 6 and 11 that cause 90% of all genital warts and types 16 and 18 that cause 70% of cervical cancers. ○​ Gardasil 9, which is used in the U.S., protects against types 6, 11, 16, 18, 31, 33, 45, 52, and 58. ○​ Cervarix protects against types 16 and 18 only but is believed to confer protection for a longer period of time. ○​ The CDC (2021) recommends that girls and boys who begin the vaccination series between ages 9 and 14 years receive two doses. Those who initiate the series between ages 15 and 26​ Signs and symptoms ●​ Condylomata warts are generally pink or red and soft, with a cauliflower-like appearance. ●​ These lesions may be single or multiple. ●​ Males ○​ Glans, foreskin, urethral opening, penile shaft, or scrotum ●​ Females ○​ In/around vulva, vagina, cervix, perineum, anal canal, urethra ○​ Also on labia, deep within the vaginal canal and endocervix ●​ Oral, pharyngeal, and laryngeal lesions common as well ●​ Multiple warts can become so large that they obstruct the vaginal opening or rectal canal. ●​ For unknown reasons, pregnancy can stimulate genital warts to grow very large Medical Diagnosis ●​ The diagnosis is usually made based on a simple observation of the warts. ●​ A biopsy of the lesions is necessary to make a definitive diagnosis. ●​ When genital warts are present, the physician will usually screen for cervical cancer as well as for HPV. Medical treatment ●​ No cure ●​ Removal provides symptomatic relief ●​ Cryotherapy ●​ Topical agents to remove warts ●​ Surgical removal ●​ Injection of interferon into the lesions ●​ Some treatments: ○​ application of podofilox, imiquimod, or kunecatechins, Other treatments must be administered by the physician (i.e., cryotherapy, which uses liquid nitrogen or solid carbon dioxide [CO2] to freeze the warts; topical trichloroacetic acid, bichloroacetic acid, or podophyllin resin; surgical removal; injection of interferon into the lesions). ●​ Dermatologic agent: Imiquimod( Aldara) ○​ Bacterial Vaginosis ●​ Caused by Gardnerella vaginalis ●​ Infectious bacteria emerge when normal bacteria in vagina are suppressed ●​ Associated with having multiple sex partners and douching ●​ Signs and symptoms ●​ Genital irritation ●​ Itching ●​ Painful urination ●​ Thin gray discharge ●​ Fishy odor Medical management ●​ Metronidazole (Flagyl) administered orally or vaginally ○​ Avoid alcohol, may trigger vomiting, tachycardia, and hypotension ○​ Metronidazole can trigger a disulfiram like reaction so avoid alcohol ●​ Clindamycin vaginal cream ○​ Can weaken latex condoms and diaphragms ●​ Infection in a pregnant female may be caused from bacterial vaginosis. Human Immunodeficiency Virus Infection ●​ HIV gradually destroys T4 lymphocytes, which are essential for resisting pathogens ●​ As lymphocytes decline, patient increasingly susceptible to opportunistic infections ●​ Opportunistic infection thrives when immune system is impaired ●​ When immune system ceases to function, patient has acquired immunodeficiency syndrome (AIDS) Nursing Care of the Patient With a Sexually Transmitted Infection Focused Assessment: ●​ Nurses must be aware of their own feelings and values and be nonjudgmental to the patient ●​ Privacy is essential for the patient interview ●​ Questions about sexuality should be addressed in straightforward manner ●​ The nurse must be careful not to embarrass or shame the patient. ●​ History of present illness ○​ Obtain description of the signs and symptoms, including onset, duration, and severity ●​ Medical history ○​ Serious conditions or chronic illnesses; obstetric history may be significant ○​ Date of last menstrual period ●​ Functional assessment ○​ Frequency and variety of sexual behaviors ○​ IV drug use ○​ Past infections with STIs ○​ Sexual contact with a person known to have an STI ○​ Sexual abuse ○​ Occupation ○​ Health care providers at risk for exposure include nursing personnel, physicians, emergency medical technicians, operating room technicians, housekeepers in health care facilities, and medical laboratory technicians. ●​ Physical examination ○​ Skin for rashes and lesions ○​ Mouth is inspected for lesions ○​ Neck palpated for enlarged lymph nodes ○​ Abdomen is inspected for distention and palpated for tenderness ○​ Examination of genitals ○​ In cases of sexual assault, it is especially important that the examiner be specially trained Use of a Female Condom • The female condom has a thick inner ring that is placed in the vagina and holds the condom in place. • The thin outer ring remains outside the body and covers the vaginal opening. • Hold the outside of the condom at the closed end. Squeeze the sides of the inner ring together with the thumb and forefinger and insert into the vagina. • Use a finger to push the inner ring up as far as it will go until it rests against the cervix. • Be sure the condom is not twisted. • Insert the partner’s penis into the opening of the condom. • Stop intercourse if the penis slips outside the condom or the outer ring is pushed into the vagina. • When finished, twist the outer ring and pull the condom out of the vagina. Discard. ○​ If discharge present, its color, amount, and consistency are recorded. Specimens may be collected for laboratory study ■​ Specimens collected are treated as infective ○​ ●​ Interventions ○​ Provide topical medications or sitz baths for pain as ordered ○​ Assess temperature daily to monitor for infections ○​ Assess for allergies to medications ○​ Administer epinephrine, corticosteroids or benadryl for allegic reactions ○​ Allow patient to express themselves ○​ Assist the patient to trace or document all of their sexual partners so that they may be informed and treated ○​ Encourage completion of treatment ○​ 2000 mL of fluid a day ●​ Patient teaching ○​ Complete course of antibiotics ○​ Avoid sexual contact until infection cured ○​ Avoid contact with high-risk individuals ○​ Condom use ○​ Women with HSV or genital warts are at higher risk of cervical cancer, they need annual Pap smears ○​ Patients with HSV can still spread disease when lesions are not present, use condoms ○​ Cannot donate blood with HIV ○​ Knowledge does not guarantee compliance ○​ Determine what patient knows about the infection ○​ Stress importance of completing course of therapy and to return for follow-up ○​ Evaluate the patient’s understanding CONDOM USE ●​ Condoms do not provide 100% protection against disease transmission ●​ Latex preferred because some pathogens can pass through natural membrane condoms ●​ Protect from heat and sunlight to keep them from deteriorating ●​ Do not use condoms that are brittle, discolored, or in damaged packages ●​ Use only water-based lubricants; others can cause condom to break; spermicides may be used ●​ To put a condom on, hold it by the tip and unroll it onto the penis. Leave a space of about 1 inch at the tip for semen ●​ Withdraw penis carefully after ejaculation to keep condom from slipping off and spilling the contents and to avoid unprotected contact ●​ Always discard used condoms DENTAL DAM USE ●​ Dental dams are latex or polyurethane sheets used to prevent contact between the mouth and vagina or anus during oral sex. ●​ Use of a Dental Dam ●​ Use a new latex or polyurethane dental dam with every oral sex encounter. ●​ Read the package and check for expiration date. ●​ Use only water-based or silicone-based lubricant to prevent breakage. ●​ Make sure there are no tears or defects. ●​ Put the dental dam on before starting oral sex and keep it on until finished. ●​ Carefully open the dental dam from the package. ●​ Place the dental dam flat to cover the vaginal opening or anus. ●​ When finished, throw away used dental dam in trash. Pharm | Chapter 38 The Gonads and Gonadal Hormones -​ Pt with diabetes who receive gonadal hormones may experience alterations in blood glucose level. Monitor pt glucose levels -​ Gonads ●​ Reproductive glands: the ovaries of female & testicles of the make -​ Ovaries ●​ Produces eggs needed for reproduction & hormones estrogen & progesterone . These hormones stimulate maturation of female sex organs, help breast development, voice intonation, & broader pelvis of female body form. ●​ Hormone establishes menstruation and production of ovaries and action on the uterus. -​ Estrogen ●​ Responsible for most of these changes -​ Progesterone ●​ Associated with body changes that favor implantation of fertilized ovum, continuation of pregnancy, and preparation of breasts for lactation. -​ Testicles ●​ Produce androgens, primarily testosterone, the male sex hormone, as well as sperm necessary for egg fertilization for reproduction. ●​ testosterone :controles development of male sex organs & influences characteristics such as voice intonation, hair distribution, and masculinization of male body form. -​ Nursing implication for gonadal hormones ●​ history : current pt problems & how long symptoms been present ●​ Female pt describe menses ( duration, amount, last menstrual period), # of pregnancies, live births, miscarriages, abortions, vaginal discharges, itching, infections, how treated, breast self examination routine ( explain if not performed regularly) ●​ Male pt if testicular self examinations are performed ( if not, explain importance) ●​ Prior illnesses ●​ Medications ●​ Smoking -​ Drug Therapy with Gonadal Hormones -​ Drug class: Estrogens ●​ Action: ●​ is a natural hormone released from ovaries composed of , estradiol, estrone, and estriol. ●​ Estradiol is most most potent ●​ Estrone metabolized to estriol which is less potent ●​ Estrogen is responsible for development of sex organs during growth in utero and for maturation at puberty, growth of hair, texture of skin, and distribution of body fat. ●​ Estrogen affects release of pituitary gonadotropins, cause capillary dilation, fluid retention, and protein metabolism, and it inhibit ovulation and postpartum breast engorgement Uses ●​ Used to relief of hot flash symptoms (vasomotor) of menopause ●​ Contraception ●​ Hormone replacement therapy after an oophorectomy ●​ Prevention of osteoporosis ●​ Treatment of severe acne in female pt ( contained in oral contraceptives) ●​ Slow the disease progress in pt with advanced prostatic cancer & certain types of breast cancer -​ ●​ Postmenopausal women are at high risk of developing endometrial cancer with use of estrogens alone. If pt is to take estrogen, pt should also take progestin to reduce risk of endometrial cancer. -​ Primary Therapeutic Outcomes: 1.​ Contraception 2.​ Prevention of osteoporosis 3.​ Palliative treatment of prostate and breast cancer 4.​ Treatment of severe acne in females -​ Medication Safety Alert ●​ Use of estrogens during early pregnancy is contraindicated. Serious birth defects have been reported, and it has been found that ithe female offspring have and increased risk of developing vaginal or cervical late in line -​ Common adverse effects ●​ Headache, migraine, dizziness, insomnia, anxiety, nervousness, emotional lability. ●​ Weight gain, edema, breast tenderness, nausea -​ Serious adverse effects ●​ Hypertension ●​ Thrombophlebitis ●​ Thromboembolism ●​ Metabolic: Hyperglycemia ●​ Gynecologic: long term exposure to estrogens can increase risks of breast, endometrial, and vaginal cancers in women. ●​ Too much estrogen aggravates endometriosis, a painful growth of uterine lining outside the uterus, whereas too little estrogen weakens bones (osteoporosis). -​ Drug interactions ●​ Estrogen may diminish the anticoagulant effects of warfarin. Monitory INR and increase dosage of warfarin if necessary ●​ Estrogens contained in contraceptives may decrease risk of seizures. Monitor serum concentration of lamotrigine ●​ Phenytoin enhances the metabolism of estrogens. Spotting or bleeding may be an indication of reduced estrogen levels and reduced contraceptive activity with estrogen containing contraceptives. Alternative forms of birth control are recommended. ●​ Pt with thyroid therapy who starts estrogen therapy may require an increase in thyroid hormone dosage. -​ -​ Drug Class: Progestins Action ●​ Progesterone & its derivatives (progestins) inhibits secretion of pituitary gonadotropins, preventing maturation of ovarian follicles and thus inhibiting ovulation Uses ●​ Used to treat secondary amenorrhea, breakthrough uterine bleeding, and endometriosis but they also may be used in combination with estrogen and contraceptives -​ -​ Therapeutic Outcomes 1.​ Contraception 2.​ Relief of symptoms of endometriosis 3.​ Hormonal balance to relieve amenorrhea or abnormal uterine bleeding -​ Medication Safety Alert ●​ Use of progestins in early pregnancy has been associated with birth defects. If pregnancy is suspected, health care provider should be consulted immediately -​ Common adverse effects ●​ Weight gain, edema, tiredness, oily scalp, acne ●​ Nausea, vomiting, diarrhea -​ Serious adverse effects ●​ Breakthrough bleeding ●​ Amenorrhea ●​ Breast enlargement ●​ Teratogenicity ●​ Because of birth defects HCP must be consulted immediately if pt becomes pregnant. ●​ Continuing headache, depression ●​ Cholestatic jaundice -​ Drug interactions ●​ Rifampin may enhance metabolism of norethindrone. Dosage may need to be increased to provide therapeutic benefit. -​ -​ Drug Class: Androgens Actions ●​ Testosterone and androstenedione are the principal androgens. ●​ Testosterone: dominant male sex hormone ●​ It is the primary natural androgen produced by testicles ●​ Androgens are responsible for normal growth and development of male sex organs and for maintenance of secondary sex characteristics which include growth and maturation of prostate, seminal vesicles, penis, and scrotum. Also development of male hair, laryngeal enlargement (Adam's apple), vocal cord thickening, alterations in musculature, and fat distribution. -​ Uses ●​ Androgens used to treat hypogonadism, androgen deficiency, delayed puberty in male pt and is used for palliation of breast cancer in postmenopausal women with certain cell types of cancer. ●​ Andreosen use to treat wasting syndrome associated with acquired immunodeficiency -​ Therapeutic Outcomes 1.​ Restoration of hormonal balance in androgen deficiency 2.​ Reduced discomfort with breast cancer 3.​ Increased muscle mass when used to treat wasting syndrome 4.​ Stimulation of puberty in carefully selected male pt with delayed puberty -​ Common adverse effects ●​ Gastric irritation ●​ Increase prostate specific antigen (PSA) level and Increase risk of benign prostate hyperplasia ●​ Men age >40 at increased risk for prostate cancer -​ Serious adverse effects ●​ Hypertension: BP should be monitored before treatment 3-6 weeks and then periodically ●​ DVT and pulmonary embolism (PE) ●​ Monitor pt with S/S pa pain, edema, warmth, and erythema in lower extremity for DVT and those with acute shortness of breath for PE ●​ Increased hematocrit and hemoglobin ●​ Electrolyte imbalance, edema ●​ Hypercalcemia ●​ Hepatoroxicity -​ Vaginitis Drug Therapy for Leukorrhea and Genital Infections Sexually Transmitted Infections BACTERIA ●​ Neisseria gonorrhoeae ●​ Gardnerella vaginalis ●​ Treponema pallidum ●​ Klebsiella granulomatis CHLAMYDIAE ●​ Chlamydia trachomatis ECTOPARASITES ●​ Sarcoptes scabiei ●​ Phthirus pubis FUNGUS ●​ Candida albicans MYCOPLASMA ●​ Ureaplasma urealyticum ●​ Mycoplasma hominis PROTOZOA ●​ Trichomonas vaginalis ●​ Entamoeba histolytica ●​ Giardia lamblia VIRUSES ●​ Herpes simplex virus ●​ Hepatitis A, B, C ●​ Cytomegalovirus ●​ Human papillomavirus (HPV) ●​ Poxvirus ●​ HIV ●​ Norlyda ●​ Norlyroc Drug interactions ●​ Androgens may enhance the anticoagulant effects of warfarin. Observe INR ●​ Monetary for hypoglycemia ( headache, weakness, decreased coordination, diaphoresis, hunger, blurred vision, ●​ Corticosteroids: concurrent use may increase the possibility of electrolyte imbalance and fluid retention. Pharm | Chapter 40 Vaginal Secretions: Normal process; may become abnormal if excessive → leukorrhea. ●​ Leukorrhea: Abnormal, whitish vaginal discharge; common in females; symptom of an underlying disorder (not a disease). ●​ Causes: ○​ Infectious: Often due to lower reproductive tract infections. ○​ Noninfectious: Various physiologic causes. ●​ Common Pathogens: ○​ Candida albicans: Fungal infection; may also cause secondary infections (mouth, GI tract, vagina) during broad-spectrum antibiotic use (e.g., penicillins, tetracyclines, cephalosporins). ○​ Trichomonas vaginalis: Protozoan infection. ○​ Gardnerella vaginalis: Bacterial infection. STIs: Diseases where pathogens are transmitted mainly by sexual contact. ●​ Ex: Gonorrhea, syphilis, chlamydia, genital herpes (HSV), HPV. ●​ Nonsexual Transmission: Some diseases (giardiasis, shigellosis, hepatitis viruses) have both sexual and nonsexual transmission routes. Incidence of STIs: True rates are unknown due to unreported cases. Female Reproductive History: ●​ Menarche: Age of first menstruation. ●​ Menses Pattern: Duration, number of pads used, date of last menstrual period (LMP). ●​ Menstrual Symptoms: Pain, discomfort, spotting, prolonged menstrual flow. ●​ Pregnancy hx: Number of pregnancies, live births, miscarriages, abortions. ●​ Vaginal Issues: Discharges (color, odor, amount), infections, lesions, warts, itching, pain w/ urination/sex. ●​ Contraceptive Use: Type (oral contraceptives, IUD, condoms, spermicides), duration, regularity, adverse effects. ●​ Sexual History: Number of partners, gender, protection methods used. ●​ Breast Health: Regular self-exams, any abnormal findings (lumps, discharge). ●​ Menopause: Age of onset, postmenopausal bleeding. ●​ Pap Tests: Frequency and hx. ●​ Reproductive Problems: E.g., endometriosis, ovarian cysts, uterine fibroids. ●​ STIs: hx of infections (chlamydia, syphilis, gonorrhea, herpes, HIV, HPV), tx received. ●​ Oral Contraceptive Requests: Screen for HTN, heart/liver disease, thromboembolic disorders, smoking, reproductive organ cancers. Male Reproductive History: ●​ Urination Pattern: Recent changes? (e.g., difficulty starting stream, straining, nocturia, dysuria, frequency, urgency, hematuria, incontinence, dribbling, retention). ●​ Urethral Discharge or Lesions: Presence of discharge, genital or perianal lesions, penile swelling. ●​ Pain: Lower back, perineum, or pelvic pain. ●​ Prostate Health: History of prostatitis, BPH, or prostate cancer. ●​ Testicular Self-Exam: Regularity and abnormal findings (lumps, masses). ●​ STIs: History of infections (chlamydia, syphilis, gonorrhea, herpes, HIV, HPV), and treatments. ●​ Sexual History: Number of partners, gender, protection methods. ●​ Symptoms: Arthralgia, fever, chills, malaise, pharyngitis, oral lesions. ●​ Past Illnesses: Any relevant prior illnesses. ●​ Erectile Dysfunction (ED): ○​ History and pattern of ED. ○​ Vascular conditions affecting blood flow (e.g., stroke). ○​ Impact of smoking, drugs (e.g., antihypertensives). ○​ Onset relative to any prostate surgery. Causes of Vaginal Discharge PHYSIOLOGIC ○​ Ovulation ○​ Coitus ○​ Oral contraceptives ○​ Pregnancy ○​ Premenstruation ○​ Premenarche ○​ Intrauterine device INFECTIOUS ○​ Vaginal ○​ Candida ○​ Trichomonas ○​ Gardnerella ○​ Toxic shock syndrome ○​ Vulvar ○​ Herpes ○​ Condylomata acuminata ○​ Syphilis ○​ Bartholinitis ○​ Lymphogranuloma venereum ○​ Granuloma inguinale ○​ Urethritis ○​ Pyoderma ○​ Cervical ○​ Gonorrhea ○​ Chlamydial or bacterial cervicitis ○​ Chronic cervicitis ○​ Pelvic inflammatory disease NONINFECTIOUS ○​ Atrophic vaginitis ○​ Foreign body ○​ Vaginal adenosis ○​ Allergic vulvovaginitis ○​ Vulvar, vaginal carcinoma ○​ Cervical polyps ○​ Cervical erosions, ulcers ○​ Uterine carcinoma ○​ Endometrial myoma ○​ Vesicovaginal fistula ○​ Enterovaginal fistula ●​ Neurologic Disorders: Parkinson's, spinal cord injuries affecting sexual function. ●​ Genitourinary Conditions: E.g., testicular injury linked to sexual dysfunction. ●​ Endocrine Disorders: Thyroid disease, adrenal disorders, diabetes — any relation to sexual dysfunction. History of Current Symptoms: ●​ Description of current problem(s), duration, recurrence of previous symptoms. Medication History: ●​ Recent use of steroids/antibiotics: Condition treated, duration, and when discontinued. ●​ Current Medications: OTC, herbal, prescribed, recreational drugs — type, purpose, duration. ●​ Allergies: Especially to medications like antibiotics. ●​ STI Recurrence: Details of previous treatment. ●​ ED-related Drugs: Identify any contributing meds (e.g., antihypertensives, antipsychotics, antidepressants, hormones, sedatives, opiates, steroids). Psychosocial Considerations: ●​ High anxiety levels common with STIs. ●​ Discuss confidentiality before questioning about sexual partners. ●​ Assess lifestyle orientation (heterosexual, bisexual, homosexual), number of partners, known contact with STIs, precautions used. ●​ Evaluate anxiety levels, coping mechanisms. Laboratory and Diagnostic Studies: ●​ Review: ○​ Gram stains/cultures: Anus, throat, urethra (gonorrhea). ○​ Syphilis Tests: VDRL, RPR, FTA-ABS. ○​ HSV-2 Tissue Cultures, HIV Testing: Enzyme immunoassay, confirm with Western blot or immunofluorescence assay. ●​ Diagnostic studies tailored to symptoms (e.g., CBC, prostate secretion cultures, urine cultures, PSA, BUN, creatinine). Physical Examination: ●​ Females: Routine exam, pelvic exam, Pap test, cultures, breast exam. ●​ Males: Routine exam, testicular exam, prostate palpation (after age 40), anorectal exam (for homosexual/bisexual men), throat, tonsils, mouth exam. Implementation: ●​ Record height, weight, vital signs. ●​ Assist with physical exam and specimen collection. ●​ Observe body hair distribution, scars, lesions, rashes, pubic lice, mites. ●​ Inspect genital area for abnormalities/discharge. ●​ Provide psychological support; refer to counseling as needed. Patient Education for Adolescents: ●​ Assess sexual activity/practices thoroughly. ●​ Offer counseling on safe sex practices, voluntary testing, and treatment. ●​ Medical care for STIs can be provided without parental consent (check state laws). ●​ Teach about abstinence and safe sex practices. Instructions for Women: ●​ Use warm sitz baths for vaginal/perineal irritation. ●​ Avoid douching unless prescribed (can alter vaginal pH). ●​ Maintain personal hygiene: wipe front to back, void before/after intercourse, cleanse genitals, change tampons/pads frequently, wear cotton underwear. ●​ Contraceptives (e.g., IUDs, oral contraceptives) do not protect against HIV/STIs — use condoms or spermicides. ●​ Annual Pap test to detect cervical cancer. Instructions for Men: ●​ Practice good personal hygiene; cleanse thoroughly before/after intercourse, urinate post-intercourse, wash hands. ●​ Prostatitis: Treated with antibiotics, anti-inflammatory agents, stool softeners; sitz baths, fluids, rest help relieve symptoms. ●​ Annual physical exams after age 40, including rectal exam for prostate. ●​ Discuss ED treatment: Meds (e.g., Viagra, Cialis) or surgery; consult a provider before using meds. ●​ Use latex condoms to reduce transmission of some STIs (less effective against skin-to-skin STIs like herpes, HPV). ●​ Men in homosexual relationships and IV drug users: Vaccinate for hepatitis A. Instructions for Both Women and Men: ●​ Abstain from sex if infected; prevent reinfection. ●​ Use condoms for protection; frequent use of nonoxynol-9 may increase risk of HIV. ●​ During the communicable phase of any disease, practice sexual abstinence. ●​ Test for STIs/HIV before the first sexual encounter. ●​ Educate on safe sex and proper condom use. ●​ Arrange follow-up appointments; refer to counseling/social services as needed. ●​ Emphasize "partner services" to identify and treat exposed partners. Medications for Women: ●​ Teach application of topical/intravaginal meds (ointments/suppositories). ●​ Proper cleansing of the genital area; wash hands before/after application. ●​ Remain in a recumbent position for 30 min after applying vaginal meds; use a mini-pad for drainage. ●​ With oral contraceptives: Teach dosage, missed dose instructions, follow-up, common and serious adverse effects. Medications for Men and Women: ●​ Educate on the medication regimen; ensure both partners understand and adhere to treatment. The consistent use of male latex Fostering Health Maintenance: condoms significantly reduces the risk of ●​ Discuss medication info and benefits. HIV infection, gonorrhea and ●​ Stress importance of nonpharmacologic interventions (nutrition, hygiene). chlamydia, herpes simplex virus in men ●​ Provide information on common/serious drug effects. and women, and HPV in wom-en, but ●​ Increase adherence by explaining medication names, dosages, routes, times, and male condoms may be less effective in adverse effects. protecting against STls transmitted by skin-to-skin contact (e.g., genital herpes, Patient Self-Assessment: syphilis) because the infected areas may ●​ Develop a written record for monitoring parameters (e.g., BP, pulse, weight, relief not be covered by the condom. from symptoms). ●​ Track STI symptoms and responses to therapy; complete a baseline before starting therapy. ●​ Use the form during follow-ups to discuss adherence issues. Causative Organisms and Products Used to Treat Genital CAUSATIVE ORGANISM GENERIC/BRAND NAME VULVOVAGINITIS Candida albicans (fungus) butoconazole vaginal cream(Gynazole-I) clotrimazole vaginal cream(Gyne-Lotrimin) fluconazole oral tablets(Diflucan) miconazole vaginal cream, suppositories(Monistat 1, Monistat 3, Monistat 7) terconazole vaginal cream, suppositories Trichomonas vaginalis (protozoa) metronidazole oral tablets(Flagyl) tinidazole oral tablets (alternative)(Tindamax) Bacterial vaginosis (formerly known Metronidazole oral tablets, vaginal gel(Flagyl; MetroGel-Vaginal) as Gardnerella vaginalis (bacteria]) sechidazole oral packet (alternative)(Solosec) tinidazole oral tablets (alternative)(Tindamax) clindamycin vaginal cream(Cleocin) GONORRHEA Neisseria gonorrhea (bacteria) ceftriaxone Gentamicin + azithromycin or Cefixime (alternative regimens if Ceftriaxone is unavailable)(Gentamicin +Zithromax or Suprax) SYPHILIS Treponema pallidum (spirochete) penicillin G benzathine(Bicillin L-A) tetracycline Doxycycline(Vibramycin) GENITAL HERPES Herpes simplex genitalis (virus) acyclovir oral capsules(Zovirax) famciclovir oral tablets valacyclovir oral tablets(Valtrex) CHLAMYDIAE Chlamydia trachomatis (chlamydia) doxycycline(Vibramycin) azithromycin (alternative)(Zithromycin) Levofloxacin--alternative Drug Therapy for Contraception Oral Contraceptives: Common form of birth control in the U.S.; widely used by women aged 18-44 yrs since becoming available in 1960. Drug Class: Oral Contraceptives Action ●​ Estrogens: Inhibit ovulation by blocking pituitary release of follicle-stimulating hormone (FSH). Prevents follicle development and ovum release. ●​ Progestins: Inhibit ovulation by blocking pituitary release of luteinizing hormone (LH), preventing ovum release from a follicle. ●​ Other Mechanisms: ○​ Alter cervical mucus (thick, viscous) → Inhibits sperm migration. ○​ Change endometrial wall → Impairs implantation of fertilized ovum. Uses ●​ Oral Contraceptives (OCs): Two Types ○​ Combination Pill: Contains both estrogen and progestin. ■​ Subdivided into: Monophasic, Biphasic, Triphasic, and Quadriphasic. ■​ Monophasic: Fixed ratio of estrogen/progestin for 21 days starting day 5 of menstrual cycle. ■​ Biphasic: Fixed estrogen, varied progestin doses; days 1-10 (lower), days 11-21 (higher). ■​ Triphasic: Three concentrations of hormones. ■​ Quadriphasic: Four concentrations of hormones. ■​ Packaged in 28-tablet units; last 7 tablets are inert (placebo). ○​ Minipill: Contains only progestin. ■​ Packaged in 28 tablets; all active. Taken daily at the same time without a cyclic break. ■​ Preferred for women with migraine, HTN, depression, weight gain, breast tenderness, or who are breastfeeding. ■​ Risks: 30-40% continue to ovulate; may cause dysmenorrhea (irregular, infrequent periods, spotting); higher incidence of uterine and tubal pregnancies. ●​ Alternative Dosage Forms ○​ Extended-Cycle: 24 active days + 4 placebo (e.g., Yaz, Loestrin 24 Fe). ○​ Continuous-Cycle: 84 active days + 7 placebo (e.g., Jolessa, Setlakin) or continuous use without placebo (e.g., Amethyst). ○​ Advantages: ■​ Shorten or eliminate menses (e.g., 4 times/year or none). ■​ Lower cumulative hormone dose. ■​ Alleviates symptoms of conditions worsened during menses (e.g., anemia). ■​ Adverse Effects: Similar to monthly OCs; more breakthrough bleeding and spotting. ●​ Risks and Considerations ○​ Smoking: Increases risk of serious cardiovascular effects (e.g., blood clots) with combination OCs. ○​ Risk rises with age (women >35) and heavy smoking (≥15 cigarettes/day). ○​ Strong recommendation: Women using OCs should not smoke. Therapeutic Outcome ●​ Prevent pregnancy Nursing Implications for Oral Contraceptives Premedication Assessment 1.​ Review medical history for risk factors: obesity, smoking, HTN, gallbladder disease, DM, varicose veins, seizure disorders, oligomenorrhea/amenorrhea, rheumatic heart disease, thromboembolic disease, stroke, breast/reproductive malignancy, renal/liver disease, severe depression, suspected pregnancy, contraceptive failure. ●​ Consult a healthcare provider if any conditions are present before dispensing OCs. 2.​ Measure baseline body weight and BP in both supine and sitting positions. 3.​ Confirm a negative pregnancy test Dosage and Administration ●​ Most adverse effects of combination OCs are due to the estrogen component. ●​ The FDA recommends starting with a low-estrogen dose product. ●​ Adjust therapy based on individual adverse effects and patient history. Before initiating therapy ●​ Pt. should have complete physical examination(BP, weight, pelvic & breast examinations, pap test, urinalysis, and HGB or HCT) Instructions for Using Combination Oral Contraceptives ●​ Start first pill on the first Sunday after menstrual period begins. ●​ Take 1 pill daily, same time, until the pack is gone. ●​ 21-day pack: Wait 1 week; restart on next Sunday. ●​ 28-day pack: Start new pack the day after finishing the last. ●​ Use additional birth control (e.g., condoms, foam) during the first month. ●​ If pills contain iron supplements, take the 7 inert tablets monthly; iron is in these, not in hormone tablets. ●​ Severe Diarrhea/Vomiting: ○​ Within 3-4 hours of taking a pill = missed dose. Use additional contraceptive measures. ●​ Missed Pills: ○​ 1 pill missed: Take as soon as remembered; next pill at regular time. ○​ 2 pills missed: Take 2 pills as soon as remembered, 2 pills the next day. Use another birth control method until the pack is finished. ○​ 3 or more pills missed: Use another birth control method immediately. Start new pack next Sunday, even if menstruating. Use another form of contraception for the next month. ○​ Missed pills & skipped period: Consult healthcare provider for a pregnancy test. ●​ Skipping Period without Missing Pills: ○​ May miss a period occasionally; start next pack as scheduled. ●​ Spotting for Two or More Cycles: ○​ Consult healthcare provider; dosage adjustment may be needed. ●​ Periodic Examinations: ○​ Yearly exams: BP check, pelvic exam, urinalysis, breast exam, Pap test. ●​ Discontinuing Pills for Conception: ○​ Stop pills 3 months before attempting pregnancy; use other contraceptive methods. ●​ Duration of Therapy: ○​ Some providers advise stopping pills for 3 months every 28 months to normalize cycles; use other contraception methods. ○​ Long-term use (≥3 years) is individualized. ●​ Serious Adverse Effects to Report Immediately: ○​ Severe headaches, dizziness, blurred vision, leg pain, SOB, chest pain—could indicate serious conditions. ●​ Notify Healthcare Providers: ○​ Inform about OC use when seeing healthcare providers or dentists. Instructions for Using the Minipill ●​ Starting the minipill: ○​ Begin on the first day of menstruation. ○​ Take one tablet daily, at the same time every day, regardless of the menstrual cycle. ●​ Missed pills: ○​ 1 pill missed: Take as soon as remembered, then take the next pill at the regular time. Use additional birth control until the next period. ○​ 2 pills missed: Take one missed pill immediately, then the scheduled pill for that day. The next day, take the scheduled pill and the other missed pill. Use additional birth control until the next period. ●​ Missed periods: ○​ Changes in period timing and duration are common. ○​ If menses occur every 28-30 days, ovulation may still happen. Use alternative contraception on days 10-18 for safety. ○​ If irregular bleeding occurs every 25-45 days, ovulation is likely irregular. ○​ If no period occurs for more than 60 days despite taking all tablets correctly, consult a healthcare provider for a pregnancy test. ●​ Note: ○​ Report sudden, severe abdominal pain (with or without nausea/vomiting) to a healthcare provider immediately due to the higher risk of ectopic pregnancy with the minipill. ●​ Serious adverse effects to report immediately: ○​ Severe headaches, dizziness, blurred vision, leg pain, shortness of breath, chest pain, acute abdominal pain. ●​ Duration of oral contraceptive therapy: ○​ Some healthcare providers recommend discontinuing the pill for 3 of every 28 months to allow the body to return to a normal cycle. Use alternative contraception during this time. ○​ Long-term use (3+ years) should be individualized. ●​ Discontinuing the pill for conception: ○​ Discontinue 3 months before attempting pregnancy to avoid birth defects. Use other contraception during this period. Common Adverse Effects ●​ If unresolved after 3 months: ○​ Return to HCP for reevaluation and possible prescription change. ●​ Gastrointestinal: ○​ Nausea. ●​ Gynecologic/Hormonal: ○​ Weight gain. ○​ Spotting. ○​ Changed menstrual flow. ○​ Missed periods. ○​ Chloasma (facial pigmentation). ●​ Psychological/Neurologic: ○​ Depression. ○​ Mood changes. ○​ Headaches. Serious Adverse Effects: ●​ Gynecologic: ○​ Vaginal discharge. ○​ Breakthrough bleeding. ○​ Yeast infection. ●​ Neurologic: ○​ Blurred vision. ○​ Severe headaches. ○​ Dizziness. ○​ Note: Report these symptoms as soon as possible. Though usually minor, they may indicate serious issues. ●​ Cardiovascular: ○​ Venous thromboembolism. ○​ Report leg pain, chest pain, or shortness of breath immediately. Drug interactions Drugs That Reduce Therapeutic Effects: ●​ Increased metabolism in the liver: ○​ Carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, St. John's wort, antiviral protease inhibitors (e.g., saquinavir, ritonavir, indinavir, nelfinavir, amprenavir). ○​ May decrease contraceptive effect. ○​ Recommendation: Use an alternative or additional form of birth control during concurrent use. ●​ Altered metabolism in the gut: ○​ Antibacterial agents (e.g., penicillins, tetracyclines, rifampin, isoniazid, griseofulvin). ○​ May decrease contraceptive effectiveness. ○​ Recommendation: Use an alternative or additional form of birth control during concurrent use. Reduced Therapeutic Effects of Drugs by Oral Contraceptives: ●​ Lamotrigine: ○​ Oral contraceptives reduce lamotrigine blood levels. ○​ Recommendation: Monitor lamotrigine levels and observe for seizure activity. An increase in dosage may be required to prevent seizures. Drugs That Enhance Therapeutic and Toxic Effects: ●​ Itraconazole and ketoconazole: ○​ May inhibit the metabolism of oral contraceptives. ○​ Possible effect: Menstrual irregularities. ○​ Recommendation: Adjustment of hormone dosage may be necessary. ●​ Warfarin: ○​ Oral contraceptives may diminish or enhance the anticoagulant effects of St. John's wort may increase the warfarin. liver's metabolism of oral ○​ Recommendation: Monitor prothrombin time and INR. Adjust warfarin contraceptive hormones, possibly dosage if necessary. resulting in decreased contraceptive ●​ Phenytoin: effect. An alternative or additional ○​ Monitor for signs of breakthrough seizures or phenytoin toxicity (e.g., form of birth control is advisable nystagmus, sedation, lethargy). during concurrent use. ○​ Recommendation: Serum levels may be ordered, and a dosage change may be required. ●​ Thyroid hormones: ○​ In patients with no thyroid function, starting estrogen therapy may require an increase in thyroid hormone dosage. ○​ Reason: Estrogens increase thyroid-binding globulin, reducing circulating free thyroxine (T4). ○​ Recommendation: Do not adjust thyroid hormone dosage until clinical signs of hypothyroidism appear. ●​ Benzodiazepines: ○​ Oral contraceptives may have variable effects on the metabolism of norelgestromin–ethinyl estradiol benzodiazepines: transdermal system(Xulane) ■​ Reduced metabolism (increased effects/toxicity): Alprazolam, clorazepate, chlordiazepoxide, diazepam, flurazepam. ■​ Enhanced metabolism (reduced effects): Lorazepam, oxazepam, temazepam. ○​ Recommendation: Adjust the benzodiazepine dosage accordingly. ○​ Drug Class: Transdermal Contraceptive Actions ●​ Ethinyl estradiol (estrogen) and norelgestromin (progestin) work together to prevent pregnancy by: ○​ Inhibiting ovulation: ■​ Estrogens block pituitary release of FSH, preventing follicle development. ■​ Progestins inhibit pituitary release of LH, preventing ovum release from the follicle. ○​ Altering cervical mucus: ■​ Makes it thick and viscous, inhibiting sperm migration. ○​ Changing the endometrial wall: ■​ Impairs implantation of the fertilized ovum. Uses ●​ Transdermal contraceptive system: ○​ Similar to combination oral contraceptives but delivered via a transdermal patch. ○​ Application: ■​ Patch is applied weekly for 3 weeks. ■​ No patch is worn during the fourth week, triggering withdrawal bleeding (menses). ●​ FDA caution (November 2005): ○​ Concern over greater estrogen exposure from the patch compared to oral contraceptives. ○​ Risk: ■​ Increased estrogen exposure raises the risk of blood clots. ○​ Recommendation: ■​ Discuss with a healthcare provider, especially if at higher risk for cardiovascular diseases (e.g., hypertension, obesity, diabetes, smoking, older age). ●​ Cigarette smoking: ○​ Significantly increases the risk of serious cardiovascular effects (e.g., blood clots) when combined with combination contraceptives like the transdermal patch. ○​ Risk factors: ■​ Age > 35 years. ■​ Heavy smoking (≥ 15 cigarettes/day). ○​ Strong recommendation: ■​ Women using combination contraceptives should avoid smoking. Therapeutic Outcome ●​ Prevent pregnancy Nursing Implications for Oral Contraceptives Premedication Assessment 1.​ Review Medical History: ●​ Check for history of hypertension, gallbladder disease, diabetes mellitus, severe varicose veins, seizure disorders, oligomenorrhea or amenorrhea, rheumatic heart disease, thromboembolic disease, stroke, malignancy of breast or reproductive system, renal or liver disease, severe mental depression, suspected pregnancy, or repeated contraceptive failure. ●​ Consult HCP if any of these conditions are present, or if the patient smokes. 2.​ Baseline BP: Measure in supine and sitting positions. 3.​ Pregnancy Test: Ensure a negative result before dispensing the patch. Availability ●​ Transdermal Patch Composition: ○​ Contains 4.86 mg norelgestromin and 0.53 mg ethinyl estradiol per patch. ○​ Releases 150 mcg norelgestromin and 35 mcg ethinyl estradiol per 24 hours. Implementation Before Initiating Therapy: ●​ Pt. should have complete physical examination(BP, weight, pelvic & breast examinations, pap test, urinalysis, and HGB or HCT) ​ ●​ Perform a pregnancy test on sexually active female patients. ​ ​ Instructions for Using Transdermal Contraceptives: ​ ​ ●​ Patch Application: ○​ Apply a new patch on the same day of the week ("patch change day"). ○​ Place the patch on clean, dry, intact, healthy skin (buttock, abdomen, upper When removing the patch, dispose of it outer arm, or upper torso). properly. Fold the used patch over on ○​ Avoid placing the patch on red, irritated skin or breasts. itself and place in a sturdy container, ○​ Do not cut the patches. preferably with a child-resistant cap, ○​ Avoid topical products (makeup, powder, lotions, creams) on or near the and discard in a waste receptacle out of patch area to ensure proper adhesion and hormone absorption. reach of children and pets. It still ●​ Starting Contraception: contains active hormone residual. Do ○​ First Day Start: not flush down the toilet. ■​ Apply the first patch within the first 24 hours of the menstrual period. ​ ​ ​ ​ ■​ Mark the day of the week on a calendar as a reminder for "patch ​ ​ ​ change day." ​ ​ ■​ If started after the first 24 hours of the cycle, use a nonhormonal backup contraceptive (condoms, spermicidal foam, diaphragm) for the first 7 days. ○​ Sunday Start: ■​ Apply the first patch on the first Sunday after menses begins. ■​ Use a nonhormonal backup contraceptive for the first 7 days. ○​ Switching from Oral Contraceptives to Patch: ■​ Apply a patch on the first day of menses. ■​ If no withdrawal bleeding occurs within 5 days after the last active hormone tablet (post day 21), perform a pregnancy test before starting the patch. ●​ If a Patch is Partially or Completely Detached: ○​ Less than 24 Hours: ■​ Reapply patch in same spot or replace it w/ new patch immediately. ■​ No backup contraception is necessary. ■​ Patch change day remains the same. ■​ Do not reapply if adhesive fails; do not use other adhesives or tape. ■​ Apply a new patch in a different location. ○​ More than 24 Hours or Unsure of Detachment Duration: ■​ Stop current cycle and start a new one by applying a new patch immediately. ■​ This is a new day 1 and a new patch change day. ■​ Use a nonhormonal backup contraceptive for the first 7 days. ●​ If a Woman Forgets to Change the Patch: ○​ Start of Patch Cycle (Week 1/Day 1): ■​ Apply new patch as soon as remembered; this becomes a new day 1 and patch change day. ■​ Use a nonhormonal backup contraceptive for the first 7 days. ○​ Middle of Patch Cycle (Week 2/Day 8 or Week 3/Day 15): ■​ Up to 48 Hours: Apply a new patch immediately; continue next patch on usual patch change day. No backup contraception needed. ■​ More than 48 Hours: Stop the current cycle, start a new 4-week cycle immediately with a new patch, establishing a new day 1 and patch change day. Use a nonhormonal backup contraceptive for the first 7 days. ○​ End of Patch Cycle (Week 4/Day 22): ■​ Remove the patch as soon as remembered. ■​ Start the new cycle on the usual patch change day (day after day 28). No backup contraception needed. ●​ Other Important Points: ○​ Missed Patches and Skipped Periods: ■​ Return to the healthcare provider for a pregnancy test. ○​ Skipping One Period but Not Missing a Patch: ■​ Missing a period occasionally is common during hormone therapy. ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ etonogestrel–ethinyl estradiol vaginal ring NuvaRing​ EluRyng segesterone–ethinyl estradiol vaginal ring Annovera (ahn-ov-rah) ​ ​ ​ ​ ​ ​ ​ ​ ​ ■​ Start the next cycle on the same patch change day. ■​ If two consecutive periods are missed, a pregnancy test is required. ■​ Discontinue contraceptive therapy if pregnancy is confirmed. ○​ Spotting for Two or More Cycles: ■​ Consult the healthcare provider to assess other causes of bleeding. ○​ Periodic Examinations: ■​ Annual exams should include blood pressure tests, pelvic examination, urinalysis, breast examination, and Pap test. ○​ Serious Adverse Effects to Report Immediately: ■​ Severe headaches, dizziness, blurred vision, leg pain, shortness of breath, chest pain, acute abdominal pain. ■​ These symptoms, though often minor, must be evaluated to rule out serious conditions like thromboembolism or ectopic pregnancy. ○​ Note: Always inform healthcare providers or dentists about hormonal contraceptive use during other medical consultations. Drug Class: Intravaginal Hormonal Contraceptives Actions ●​ Combination of estrogen (ethinyl estradiol) and progestin (etonogestrel or segesterone). ●​ Inhibits ovulation: ○​ Estrogens block pituitary release of FSH, preventing follicle development and ovum release. ○​ Progestins inhibit pituitary release of LH, blocking ovum release from the follicle. ●​ Additional contraceptive mechanisms: ○​ Alters cervical mucus, making it thick & viscous, inhibiting sperm migration. ○​ Changes endometrial wall, impairing implantation of the fertilized ovum. Uses ●​ NuvaRing and Annovera vaginal rings: ○​ Function similarly to combination oral contraceptives. ○​ Contain estrogen and progestin in a plastic ring form. ○​ Inserted into the vagina for 3 weeks. ○​ Removed for a 1-week break; withdrawal bleeding (menses) typically occurs. ●​ Warnings: ○​ Cigarette Smoking: ■​ Increases risk of serious cardiovascular effects (e.g., blood clots) in users of combination contraceptives who smoke. ■​ Risk is heightened with age and heavy smoking (≥15 cigarettes/day). ■​ Significant risk for women >35 years. ■​ Women using hormonal contraceptives are strongly encouraged not to smoke. Therapeutic Outcome ●​ Prevent pregnancy Nursing Implications for Intravaginal Hormonal Contraceptives Premedication Assessment 1.​ Same as transdermal contraceptives Availability ●​ NuvaRing and EluRyng: ○​ Release 0.12 mg etonogestrel and 0.015 mg ethinyl estradiol per day (3-week duration). ●​ Annovera: ○​ Releases 0.15 mg segesterone and 0.013 mg ethinyl estradiol per day (3-week duration). Implementation Before Initiating Therapy ●​ Pt. should have complete physical examination(BP, weight, pelvic & breast examinations, pap test, urinalysis, and HGB or HCT) Instructions for using the intravaginal hormonal contraceptive ●​ Insertion ○​ Comfortable position; compress ring and insert to vagina. Position is not important, but should be behind pelvic bone ○​ Insert on appropriate day, and leave in place for 3 weeks. ○​ Check regularly(before & after intercourse) to ensure placement ●​ Removal ○​ Remove the ring 3 weeks later(same time & day it was inserted) ○​ Remove by hooking index finger under forward rim or by grasping rim between index & middle fingers and pulling it out ●​ NuvaRing ○​ Place used ring in foil pouch and discard in waste receptacle out of reach of children & pets. Still contains active hormone residual ○​ No flushing on toilet; insert new ring on day 7 (same day & time of the week) that old ring was removed ●​ Annovera ○​ After removal, wash w/ warm water & mild soap, dry w/ clean cloth/paper towel, and store in case provided; ○​ Reinsert same ring on day 7 (same day & time of the week) Method to start contraception ●​ If No Hormonal Contraceptive in the Past Month: ○​ Insert the ring on or before day 5 of the menstrual cycle (counting the first day of menstruation as day 1), even if menses continues. ○​ Mark the day on a calendar to remember removal 3 weeks later. ○​ Use a nonhormonal backup contraceptive (e.g., condoms, spermicidal foam, diaphragm) for the first 7 days of ring use. ●​ Switching from a Combination Oral Contraceptive: ○​ Insert the ring within 7 days after the last active pill and no later than when a new cycle of pills would have started. ○​ No backup contraception needed. ●​ Switching from a Progestin-Only Minipill: ○​ Insert the ring the day after stopping the minipill. ○​ Use a nonhormonal backup contraceptive for the first 7 days of ring use. Handling Ring Expulsion or Removal: ●​ Expelled or Removed for Less Than 2 Hours: ○​ Rinse ring in cool or lukewarm water. ○​ Reinsert as soon as possible. ●​ Expelled for More Than 2 Hours or Uncertain Duration: ○​ Reinsert the ring. ○​ Use a nonhormonal backup contraceptive (e.g., condoms, spermicidal foam, diaphragm) for 7 consecutive days of continuous ring use. If the Ring is Left in Longer Than Recommended(3 weeks): ●​ Up to 1 Extra Week (4 Weeks Total): ○​ Remove and insert a new ring after a 1-week ring-free interval. ○​ Use nonhormonal backup contraception for 7 days. ●​ More Than 4 Weeks: ○​ Remove the ring, rule out pregnancy. ○​ If not pregnant, insert a new ring after a 1-week ring-free interval. ○​ Use nonhormonal backup contraception for 7 days. Missed Period or Prolonged Use: ●​ Missing 1 Period but Adherent: ○​ Occasionally missed periods are normal. ○​ Start the next cycle on the same insertion day (29th day). ○​ If 2 consecutive periods are missed, perform a pregnancy test. ●​ Missed 1 Period and Ring Was Out for >2 Hours or Left in >4 Weeks: ○​ See healthcare provider for a pregnancy test. Spotting or Bleeding Issues: ●​ Spotting for 2 or More Cycles: ○​ Consult healthcare provider for assessment of other causes of bleeding. Periodic Examinations: ●​ Annual checkups should include BP tests, pelvic exam, urinalysis, breast exam, and Pap test. Serious Adverse Effects to Report Immediately: ●​ Severe headaches, dizziness, blurred vision, leg pain, SOB, chest pain, acute abdominal pain. ●​ Serious conditions such as thromboembolism or ectopic pregnancy must be ruled out. General Note: Inform any healthcare provider or dentist of hormonal contraceptive use. Osteoporosis Drug Class: Intravaginal Nonhormonal Contraceptives ●​ Phexxi: Vaginal gel containing lactic acid, citric acid, potassium bitartrate. ●​ Mechanism of Action: ○​ Acts as a vaginal regulator by lowering pH to prevent pregnancy. ○​ On-demand contraception: Insert 1 applicatorful intravaginally up to 1 hour before intercourse. ○​ If intercourse doesn't occur within 1 hour, insert another dose. ○​ Not effective if used after intercourse. ○​ Does not protect against STIs or HIV. ○​ Can be used any time during the menstrual cycle. ●​ Compatibility: ○​ Can be used with hormonal contraceptives, male/female condoms, vaginal diaphragms. ○​ Should not be used with vaginal ring contraceptives. ●​ Efficacy: ○​ Cumulative pregnancy rate of 13% over 7 cycles of typical use in premarketing studies. ●​ Common Adverse Reactions: ○​ Women: Burning sensation, vulvovaginal pruritus, mycotic infection, UTI, discomfort, bacterial vaginosis, vaginal discharge, genital discomfort, dysuria, vulvovaginal pain. ○​ Male partners: Localized burning, itching, or pain. ●​ Most common bone disease. ●​ Characterized by low bone mineral density (BMD) and microarchitectural changes. ●​ Leads to bone fragility and increased fracture risk. ●​ Commonly affects hip, spine, and wrist. Prevalence: ●​ >50 million people in the U.S. have osteoporosis or osteopenia. ●​ 1 in 2 individuals over 50 years at risk for an osteoporotic fracture. Bone Remodeling: ●​ Bone is living tissue that undergoes constant remodeling (breakdown and replacement). ●​ Bone remodeling occurs in a specific order: resorption (breakdown) by osteoclasts, followed by formation (building) by osteoblasts. ●​ Osteoclasts: Responsible for bone resorption; take weeks to break down bone. ●​ Osteoblasts: Responsible for bone formation; take months to build new bone. ●​ Osteoclasts and osteoblasts are dependent on each other for effective remodeling. Pathophysiology in Osteopenia & Osteoporosis: ●​ Imbalance between osteoclasts and osteoblasts leads to greater bone resorption than formation. ●​ Results in net bone loss over time, leading to osteopenia (mild loss) or osteoporosis (severe loss). ●​ Process that increases the rate of bone remodeling can lead to net bone loss. Risk Factors for Osteoporosis & Fractures: ●​ Increasing age ●​ Female sex ●​ Postmenopausal status ●​ Hypogonadism (↓ sex hormones) ●​ Low body weight ●​ Parental hx of hip fracture ●​ Race/Ethnicity: Higher risk in white persons than black persons ●​ Rheumatoid arthritis ●​ Current smoking ●​ Alcohol intake: ≥ 3 drinks/day ●​ Low BMD ●​ Vitamin D deficiency ●​ Low calcium intake ●​ Medications: Glucocorticoids, anticoagulants, antiepileptics, aromatase inhibitors, anticancer drugs, gonadotropin-releasing hormone agonists Diagnosis of Osteoporosis: ●​ Often diagnosed after a fragility fracture (fracture from normal activities like a fall from standing height or less). Drug Therapy for Osteoporosis ●​ In those without fractures, diagnosed by low BMD. ●​ Dual-energy x-ray absorptiometry (DEXA): Gold standard test for diagnosis. ●​ T scores from DEXA results indicate BMD deviations from a healthy norm: ○​ T score -2.5 or less = Osteoporosis ○​ Example: T score -2 indicates BMD 2 SDs below the norm. ●​ International Standard: Femoral neck BMD of -2.5 SDs or more below young female adult mean. ●​ Note: Low BMD is an imperfect predictor; identifies <50% of those who will have fractures. Interventions to Preserve Bone Strength: ●​ Adequate calcium & vitamin D intake ●​ Regular weight-bearing & muscle-strengthening exercises ●​ Smoking cessation ●​ Identify/treat alcoholism ●​ Identify risk factors for falling ●​ First-line Therapies: ○​ Bisphosphonates: Alendronate, Risedronate, Zoledronic acid ○​ Denosumab ○​ Both groups reduce hip, nonvertebral, and vertebral fractures. ●​ Other Treatments: ○​ Ibandronate, Raloxifene, Romosozumab, Abaloparatide, Teriparatide ○​ High-Risk Fracture Patients: Abaloparatide, Teriparatide, Romosozumab ■​ Abaloparatide, Teriparatide: Recombinant parathyroid hormone analogs; stimulate osteoblast function, ↑ GI calcium absorption, and ↑ renal calcium reabsorption. ■​ Romosozumab: Binds/inhibits sclerostin; ↑ bone formation and ↓ bone resorption. ○​ Calcium and Vitamin D: Dietary and supplemental use for treatment. Nursing Implications for Osteoporosis Assessment: ●​ History of Risk Factors: ○​ Smoking: ■​ Assess daily use of cigarettes, cigars, other nicotine sources (chewing tobacco, replacements). ■​ Duration of smoking, attempts to quit, and understanding of smoking's impact on bone health. ■​ Discuss feelings about modifying smoking habits. ○​ Dietary Habits: ■​ Obtain dietary history focused on calcium and vitamin D intake (e.g., milk consumption). ○​ Psychomotor Functions: ■​ Evaluate lifestyle: Amount, intensity, and frequency of physical activity (e.g., walking 3 miles at 3 mph every other day). ■​ Assess if the patient has a physically demanding or sedentary job. ■​ Assess stress levels and coping mechanisms at home/work. ○​ Alcohol Consumption: ■​ Assess daily intake; >3 drinks/day may need reduction or cessation. ○​ Dentition: ■​ Educate on dental exams prior to initiating medication. ■​ Discuss complications linked to dental procedures (e.g., tooth extractions, implants) and stress the importance of good oral hygiene. ○​ Pain: ■​ Monitor and report increased pain in hips, groin, or thighs with long-term medication use. Implementation: ●​ Perform nursing assessments regularly. ●​ Make referrals as needed for stress management, smoking cessation, dietary counseling, and exercise programs tailored to the patient. ●​ Protect patients from falls by assisting with ambulation. Patient Education: ●​ Advise patients to stop smoking; provide educational materials on smoking cessation. ●​ Inform patients that nicotine affects osteoblast function and contributes to osteoporosis. ●​ Emphasize the importance of reducing or quitting smoking; include support resources for cessation. Fostering Health Maintenance: ●​ Discuss medication information and its benefits throughout treatment. ●​ Teach patients how to manage osteoporosis symptoms, especially pain. ●​ Explain the importance of maintaining an exercise program and modifying diet to increase calcium and vitamin D intake. ●​ Recommend cessation of smoking and minimizing alcohol intake. ●​ Provide patients and their families with detailed drug information from monographs. ●​ Teach about medication compliance: name, dosage, routes, administration times, and common/serious adverse effects. Patient Self-Assessment: ●​ Encourage patients to assist in developing and maintaining a written record of monitoring parameters (e.g., BP, weight, exercise). ●​ Complete the Premedication Data column as a baseline for tracking drug therapy response. ●​ Ensure the patient understands how to use the form. ●​ Instruct the patient to bring the completed form to follow-up visits. ●​ During follow-ups, focus on fostering adherence to prescribed therapeutic interventions. Drug Class: Bisphosphonates Actions ●​ Bisphosphonates (alendronate, risedronate, zoledronic acid) inhibit bone resorption Administer bisphosphonates in the by acting on osteoclasts. morning 30 minutes or more before ●​ Decreased bone resorption indirectly increases bone mineral density (BMD). the first food, beverage (except plain Uses water), or other medications) of the ●​ Alendronate: day. Do not take with mineral water ○​ Treats and prevents osteoporosis in postmenopausal women. or with other beverages. Patients ○​ Treats osteoporosis in men. should be instructed to sit or stand ○​ Treats glucocorticoid-induced osteoporosis in men and women on ≥7.5 upright (not to lie down) for at least mg/day of prednisone. 30 minutes after administration and ●​ Risedronate: until after first food of the day (to ○​ Treats and prevents osteoporosis in postmenopausal women. reduce esophageal irritation). ○​ Treats osteoporosis in men. ○​ Treats and prevents glucocorticoid-induced osteoporosis. ●​ Zoledronic acid: ○​ Treats and prevents osteoporosis in postmenopausal women. ○​ Treats osteoporosis in men. ○​ Treats and prevents glucocorticoid-induced osteoporosis in men and women on ≥7.5 mg/day of prednisone for ≥12 months. Therapeutic Outcome ●​ The primary outcome is the reduction of fractures in patients with osteoporosis. Nursing Implications for Bisphosphonates Premedication Assessment: 1.​ Obtain baseline vital signs and assess for bone pain before starting treatment. 2.​ Encourage adequate calcium and vitamin D intake while on bisphosphonates. 3.​ Educate the patient on the importance of a dental examination before beginning medication. 4.​ Check lab values for calcium, magnesium, and phosphate. Administration Guidelines: ●​ Oral Solution: Follow with at least 2 oz of plain water. ●​ Tablets: Take with 6-8 oz of plain water; swallow the tablet whole. ●​ Effervescent Tablet: Dissolve one tablet in 4 oz of room-temperature plain water. After effervescence stops, wait 5+ minutes, stir for ~10 seconds to remove bubbles, then drink. Common adverse effects ●​ Neurologic: ○​ Headache: Common but usually self-limiting. Patients should be informed. ●​ Gastrointestinal: ○​ Abdominal pain, GERD, dyspepsia, constipation, diarrhea: Most common; generally mild and resolve with continued therapy. Severe cases require contacting a healthcare provider. ●​ Musculoskeletal: ○​ Musculoskeletal pain: Common, mild, and typically resolves with continued therapy. Severe symptoms warrant contacting a healthcare provider. Serious Adverse Effects ●​ Gastrointestinal: ○​ Dysphagia, gastritis, gastric ulcers: Oral bisphosphonates can cause upper GI mucosa irritation. Caution in patients with active upper GI issues (dysphagia, gastritis, ulcers). Discontinue and alert the healthcare provider if swallowing difficulties, chest pain, or worsening heartburn occur. ●​ Musculoskeletal: ○​ Severe musculoskeletal pain: Incapacitating bone, joint, or muscle pain reported. Onset can vary from 1 day to several months. Discontinue and contact healthcare provider if severe symptoms develop. ●​ Renal: ○​ Nephrotoxicity: Bisphosphonates contraindicated in patients with creatinine clearance < 35 mL/min. Zoledronic acid should be used cautiously in patients with chronic renal impairment, advanced age, nephrotoxic medications, diuretics, or severe dehydration. ●​ Osteonecrosis of the Jaw: ○​ Associated with tooth extractions, dental implants/surgery, cancer diagnosis, poor oral hygiene. Risk increases with treatment duration. ●​ Atypical Femoral Fractures: ○​ Can occur with minimal or no trauma. Patients should report thigh or groin pain. Consider stopping bisphosphonates after discussion with HCP Drug Interactions ●​ Calcium Supplements/Antacids: ○​ Calcium and antacids interfere with the absorption of oral bisphosphonates. Patients should wait at least 30 minutes after taking bisphosphonates before consuming calcium or antacids. ●​ Aspirin and Nonsteroidal Antiinflammatory Drugs (NSAIDs): ○​ Daily use of aspirin or NSAIDs increases the risk of upper gastrointestinal adverse effects when taken with bisphosphonates. Caution is advised due to the potential for gastrointestinal irritation. ●​ Nephrotoxic Drugs: ○​ Use caution when administering zoledronic acid with other nephrotoxic drugs, such as NSAIDs and aminoglycosides, due to increased risk of nephrotoxicity. DENOSUMAB(Prolia) Actions Benign Prostatic Hyperplasia ●​ Monoclonal antibody that prevents osteoclast formation, decreasing bone resorption and increasing bone mass. Uses ●​ Osteoporosis in postmenopausal women and men at high risk of fractures. ●​ Glucocorticoid-induced osteoporosis. ●​ Bone loss tx in men on androgen deprivation therapy (e.g., leuprolide) for nonmetastatic prostate cancer. ●​ Bone loss tx in women on aromatase inhibitor therapy (e.g., anastrozole) for breast cancer. Therapeutic Outcomes ●​ Reduction in fractures in patients with osteoporosis. ●​ Prevention of bone loss in men receiving androgen deprivation therapy. ●​ Prevention of bone loss in women receiving aromatase inhibitors for breast cancer. Nursing Implications Premedication Assessment 1.​ Obtain baseline temp, BP, HR. 2.​ Check lab values for calcium, magnesium, phosphate. Availability ●​ SC solution: Prolia: 60 mg/mL in a 1-mL prefilled syringe. Dosage and Administration ●​ Administered SC by a healthcare professional in upper arm, upper thigh, or abdomen. ●​ Patients should take 1000 mg calcium daily + 400 IU vitamin D daily. ●​ Dosage for Specific Conditions: ○​ Androgen Deprivation-Induced Bone Loss in Men w/ Prostate Cancer: SC: 60 mg once every 6 months. ○​ Aromatase Inhibitor-Induced Bone Loss in Women w/ Breast Cancer: SC: 60 mg once every 6 months. ○​ Osteoporosis in Men or Postmenopausal Women: SC: 60 mg once every 6 months. ○​ Glucocorticoid-Induced Osteoporosis: SC: 60 mg once every 6 months. Common Adverse Effects: ●​ Dermatologic: Dermatitis (4-11%), eczema (4-11%), skin rash (3-11%). ●​ Cardiovascular: HTN, hypercholesterolemia (women). ●​ Musculoskeletal: Arthralgia (7-14%), limb pain (10-12%), back pain (8-12%). ●​ Urinary: Cystitis may occur (women). Instruct patient to contact HCP. Serious Adverse Effects: Instruct patient to contact HCP if these occur: ●​ Hypersensitivity: Anaphylactic reactions; may require discontinuation of denosumab. ●​ Hypocalcemia: Check calcium levels before starting therapy; correct deficiency; supplement with calcium and vit D. ●​ Osteonecrosis of the Jaw: Monitor for jaw pain, difficulty chewing. ●​ Atypical Femoral Fractures: Evaluate for thigh or groin pain to rule out fracture. ●​ Infections: Watch for fever, tenderness, inflammation, muscle/joint pain. ●​ Dermatologic Reactions: Severe dermatitis, rashes, eczema. Drug Interactions: No known interactions. Prostate Gland: ●​ Part of the male reproductive system. ●​ Firm organ, ~20 g, size of a walnut. ●​ Located at the base of the urinary bladder; surrounds proximal urethra. Fx: ●​ Produces fluid during ejaculation that mixes with sperm (from testes) and seminal vesicle fluid to form semen. ●​ Secretes prostatic antibacterial factor to protect against UTIs. ●​ Secretes acid phosphatase and prostate-specific antigen (PSA). ○​ Elevated PSA may indicate prostate cancer. Enlargement of Prostate: ●​ Common with aging; affects >50% of men in their 60s, ~90% in 70s-80s. ●​ Known as enlarged prostate, prostatism, or benign prostatic hyperplasia (BPH). ●​ BPH can cause urinary problems; not a normal part of aging despite being common. BPH vs. Prostate Cancer: ●​ BPH is more common than prostate cancer. ●​ Symptoms of BPH can be similar to those of prostate cancer. Drug Therapy for Benign Prostatic Hyperplasia Medication Safety Alert ●​ Important to get a HCP's opinion for proper diagnosis and to rule out other conditions (e.g., prostate infection). Pathogenesis of BPH: ●​ Not fully understood. ●​ Involves increased levels of dihydrotestosterone (DHT) due to increased production, reduced metabolism, or both. ●​ DHT is formed from testosterone (produced in testes) in the prostate via 5-alpha reductase enzyme. Symptoms of BPH: ●​ Highly variable, patient-specific. ●​ Divided into two categories: ○​ Obstructive Symptoms: Due to narrowing of the bladder neck and urethra. ○​ Irritative Symptoms: Due to incomplete bladder emptying or UTI secondary to prostatic obstruction. ●​ As the prostate enlarges, it compresses the urethra, leading to partial or complete obstruction of urine flow from the bladder. ●​ Symptoms worsen over time, often requiring medical attention. Treatment of BPH: ●​ Surgical Removal of hyperplastic tissue if necessary to reduce urinary obstruction. ○​ Transurethral Resection (TURP) or laser therapy for glands <60 g. ○​ Prostatectomy for glands >60 g. ●​ Intermittent Catheterization or permanent indwelling catheter if surgery is not an option ●​ Alpha-1 Adrenergic Blocking Agents: ○​ Alfuzosin, Silodosin, Tamsulosin: Relax smooth muscle of the bladder and prostate. ○​ Other agents like Doxazosin, Terazosin also treat HTN. ●​ Antiandrogen Agents: ○​ Finasteride, Dutasteride: Block androgens at the prostate cellular level, causing the prostate gland to shrink. ●​ Combination Therapy: ○​ Combining an alpha blocker with a 5-alpha reductase inhibitor (e.g., finasteride or dutasteride) is more effective in slowing BPH progression than either agent alone. ●​ Phosphodiesterase Inhibitor: ○​ Tadalafil is also approved for BPH treatment. Drug Class: Alpha-1 Adrenergic Blocking Agents Actions ●​ Selective for alpha-1A receptors on the prostate gland. ●​ Approximately 70% of alpha-1 receptors in the prostate are alpha-1A subtype. ●​ Alfuzosin, silodosin, tamsulosin: Alpha-1A-specific adrenergic blockers. ●​ Doxazosin, terazosin: Nonspecific alpha-1 blockers. ●​ Block alpha-1 receptors on the prostate gland and bladder neck, causing muscle relaxation and improving urinary outflow in men with enlarged prostates. ●​ Do not reduce prostate size, inhibit testosterone synthesis, or affect PSA levels. Uses ●​ Reduce mild to moderate urinary obstruction symptoms (e.g., hesitancy, terminal urine dribbling, interrupted stream, impaired size and force of stream, sensation of incomplete bladder emptying) in men with BPH. ●​ Increase urine flow rate by 20% to 30% in up to 50% of men with urinary symptoms. ●​ Symptom improvement seen after 1 week, with full effect assessed after 2-3 months of continued therapy. ●​ Alpha-1A-specific drugs (alfuzosin, tamsulosin, silodosin) are not used for hypertension treatment. Therapeutic Outcomes ●​ Reduced symptoms and improved urine flow in patients with prostate gland enlargement. Nursing Implications Premedication Assessment 1.​ Obtain baseline BP readings in both supine and standing positions. The initial doses of the alpha-1 2.​ Check for a history of severe cerebral or coronary arteriosclerosis, gastritis, or peptic blocking agents may cause dizziness ulcer disease, as BP reduction may worsen these conditions. (6% to 7% and hypotension with Common adverse effects tachycardia and fainting (<0.5%) in ●​ Neurologic: patients starting therapy. This effect ○​ Symptoms: Drowsiness, headache, dizziness, weakness, lethargy. may be minimized by giving the first ○​ Patient Guidance: Adverse effects are usually self-limiting; patient should not doses with food. Patients should be discontinue medication but consult HCP if effects are intolerable. warned that this adverse effect ●​ Cardiovascular: might occur, it is transient, and they ○​ Symptoms: Dizziness, tachycardia, fainting. should lie down immediately if ○​ Incidence: Dizziness may occur in >2% of patients, orthostatic hypotension in symptoms develop. <0.5% upon initiation of therapy. ○​ Onset: Symptoms typically develop 15-90 minutes after the first dose. ○​ Management: Administer first dose with food, instruct patient to lie down if symptoms occur, and ensure patient safety. Drug Interactions ●​ Drugs that enhance therapeutic and toxic effects: ○​ Diuretics, cimetidine, tranquilizers, alcohol, antihistamines, beta-adrenergic blockers (e.g., propranolol, atenolol), and other antihypertensive agents should not be used with alfuzosin. ○​ Monitor BP response to cumulative effects of antihypertensive agents. ○​ Take BP in both supine and erect positions. ●​ Cytochrome P-450 Inhibitors: ○​ Ketoconazole, itraconazole, ritonavir, diltiazem, and other potent CYP3A4 inhibitors inhibit the metabolism of alfuzosin and silodosin. Avoid concurrent use. ○​ Monitor for increased severity of adverse effects such as sedation, hypotension, bradycardia, or tachycardia. ●​ ED Medications: ○​ Avanafil, sildenafil, tadalafil, vardenafil (used for ED) may aggravate hypotensive effects of doxazosin and terazosin, leading to dizziness and tachycardia. ○​ Adjust by reducing the dose of the ED medications. Drug Class: Antiandrogen Agents DUTASTERIDE(AVODART) Actions ●​ An androgen hormone inhibitor that inhibits the enzyme 5-alpha reductase. ●​ 5-alpha reductase types 1 and 2 catalyze the conversion of testosterone to DHT (dihydrotestosterone). ●​ Reducing DHT levels decreases hyperplastic cell growth associated with prostatic hyperplasia. Uses ●​ Dutasteride inhibits 5-alpha reductase types 1 and 2. ●​ Used to treat BPH (Benign Prostatic Hyperplasia) symptoms, reduce urinary retention risks, and minimize the need for surgery associated with BPH. ●​ Therapy duration of 6 to 12 months may be necessary to assess effectiveness. ●​ Effective in reducing symptoms of partial obstruction, improving urinary flow rates, and shrinking the prostate gland. ●​ Not FDA-approved for treating male pattern baldness. Therapeutic Outcomes ●​ Reduced symptoms and improved urine flow related to prostatic enlargement. ●​ Reduced need for surgery in treating BPH. Nursing Implications Premedication Assessment ●​ Obtain baseline PSA blood level. ●​ Dutasteride decreases serum PSA levels by ~50% in BPH patients, even w/ prostate cancer. ●​ Any sustained increase in PSA levels during therapy should prompt investigation for prostate cancer and assess noncompliance with therapy. Availability ●​ PO (Oral): 0.5-mg capsules. Dosage and Administration ●​ PO: 0.5 mg once daily, with or without food. Common Adverse Effects ●​ Reproductive: ○​ Impotence, decreased libido, decreased volume of ejaculate. ○​ These effects occur in a small number of men, especially at higher doses. ○​ Inform patients that these effects may occur but are typically self-limiting. ○​ The incidence of impotence, decreased libido, and ejaculation disorder tends to decrease with longer treatment duration. ○​ Decreased volume of ejaculate does not usually interfere with normal sexual function. ○​ Advise patients not to stop the medication and to consult their healthcare Medication Safety Alert provider if these issues become unacceptable. Dutasteride is contraindicated in Drug Interactions women who are or may become ●​ Drugs that enhance toxic effects: pregnant because it may cause ○​ Ketoconazole, itraconazole, ritonavir, diltiazem, verapamil, cimetidine, and abnormalities of the external ciprofloxacin inhibit the metabolism of dutasteride. genitalia of a male fetus of a ○​ Administer dutasteride with extreme caution to men taking any of these pregnant woman who received the medications. drug. Dutasteride is absorbed ​ through human skin. A woman who FINASTERIDE(PROSCAR, PROPECIA) is pregnant or who may become Actions pregnant should not handle crushed ●​ An androgen hormone inhibitor that inhibits the enzyme 5-alpha reductase. or broken dutasteride capsules. ●​ 5-alpha reductase catalyzes the conversion of testosterone to DHT Men treated with dutasteride should (dihydrotestosterone). not donate blood until at least 6 ●​ Reduced DHT levels decrease hyperplastic cell growth associated with prostatic months after stopping therapy to hyperplasia. avoid introducing the drug to a ●​ Elevated DHT levels also contribute to androgenetic alopecia (male pattern baldness) pregnant woman. at the vertex and anterior midscalp. Uses ●​ Finasteride inhibits 5-alpha reductase type 2. ●​ Proscar: Used to treat BPH symptoms, reduce urinary retention risks, and minimize the need for BPH-related surgery. ○​ Requires 6 to 12 months of treatment to assess effectiveness. ○​ Patients typically experience fewer symptoms of partial obstruction, improved urinary flow rates, and a reduction in prostate size. ●​ Propecia: Used to treat androgenetic alopecia. ○​ After at least 3 months of daily use, it maintains hair count and stimulates new hair growth. ○​ Continued use is necessary to sustain results; discontinuation reverses effects within 1 year. ○​ Does not affect nonscalp body hair. Therapeutic Outcomes ●​ Reduced symptoms and improved urine flow related to prostatic enlargement. Erectile Dysfunction ●​ Reversal of male pattern hair loss. ●​ Reduced need for surgery in treating BPH. Nursing Implications Premedication Assessment ●​ Obtain a baseline PSA blood level. ●​ Finasteride decreases serum PSA levels by ~50% in BPH patients, even with prostate cancer. ●​ Investigate any sustained increase in PSA levels during treatment for potential prostate cancer and assess for noncompliance. Availability ●​ Proscar: 5-mg tablets. ●​ Propecia: 1-mg tablets. Dosage and Administration ●​ BPH: PO: 5 mg once daily, with or without food. ●​ Androgenetic Alopecia: PO: 1 mg once daily, with or without food. Common Adverse Effects ●​ Reproductive: ○​ Reproductive: ○​ Impotence, decreased libido, decreased volume of ejaculate. ○​ These effects occur in a small number of men, particularly at higher doses. ○​ Inform patients these effects may occur but are generally self-limiting. ○​ Decreased volume of ejaculate typically does not affect normal sexual function. ○​ Advise patients not to stop medication and to consult their healthcare provider if symptoms become unacceptable. Drug Interactions: No clinically significant drug interactions reported. ED(impotency): Consistent inability to achieve or maintain an erection sufficient for sexual activity; ●​ Prevalence: ○​ Increases with age; not inevitable. ○​ ~5% of men at age 40. ○​ 15-25% of men aged 65+. ●​ Causes: ○​ Vascular: Blood flow issues increase with age. ○​ Neurologic: Nerve damage, increase with age. ○​ Psychological: Stress, depression, interpersonal issues. ○​ Medications: Often prescribed for other conditions (e.g., hypertension, depression). ○​ Other Factors: ■​ Lifestyle: Cigarette smoking, alcohol abuse. ■​ Medical Conditions: Hyperlipidemia, HTN, DM, CAD, PVD. ■​ Trauma: Bicycle seat injury, prostate surgery (prostatectomy, TURP). ●​ Challenges: ○​ Difficult to determine if ED is caused by the medication, the condition being treated, or both. Dx: Based on medical/sexual history, physical exam, lab studies. ●​ Abrupt onset + Intermittent pattern: Suggests psychological cause. ●​ Gradual onset: Suggests vascular or neurologic cause. Causes of ED: Often multifactorial. Treatment Options: ●​ Psychotherapy ●​ Intracavernosal injection ●​ Intraurethral prostaglandin ●​ Vacuum constriction devices ●​ Vascular surgery ●​ Hormonal therapy ●​ Penile prostheses ●​ Oral phosphodiesterase inhibitor therapy Drug Therapy for Erectile Dysfunction DRUG CLASS: PHOSPHODIESTERASE INHIBITORS Actions ●​ Selective inhibition of phosphodiesterase 5 (PDE5) enzyme. ●​ Nitric oxide activates guanylate cyclase → Converts guanosine triphosphate (GTP) to cyclic guanosine monophosphate (cGMP) in smooth muscle cells. ●​ cGMP increase → Smooth muscle relaxation. ●​ In the corpus cavernosum(penis)): ○​ Smooth muscle relaxation allows blood inflow → Fills small sinusoidal spaces → Erection. ○​ PDE5 inactivates cGMP. ●​ Phosphodiesterase inhibitors enhance nitric oxide's effect by increasing cGMP in the corpus cavernosum → Smooth muscle relaxation & greater blood flow → Erection. Uses ●​ Sildenafil: 1st oral therapy for male ED (approved 1998). ●​ Other agents: Vardenafil, Tadalafil, Avanafil (approved later). ●​ Mechanism: ○​ Require sexual stimulation for effectiveness. ○​ No direct relaxant effect on smooth muscle in corpus cavernosum without stimulation. ○​ Not aphrodisiacs; don't ↑ sexual desire/stimulation or intercourse frequency. ●​ Administration: ○​ Sildenafil, Vardenafil: Take 30 min to 4 hrs before sexual activity. ○​ Avanafil: Take 15 min before sexual activity. ○​ Tadalafil: ■​ Begins working in 30 min, lasts up to 36 hrs. ■​ Approved for once-daily dosing for spontaneous sexual activity. ■​ Also approved for BPH treatment. ●​ Effect Duration: ○​ Erection lasts ~1 hr; varies based on stimulation, orgasm, and patient factors. ○​ Shouldn't be taken more than once in 24 hrs. ●​ Use in Women: ○​ Tested for female sexual dysfunction, but inconclusive results. ○​ Not recommended for women. Drugs That May Cause Erectile ●​ Other Therapeutic Use: Dysfunction ○​ Used in pulmonary arterial hypertension. ANTIHYPERTENSIVE AGENTS ○​ ↑ GMP in pulmonary tissue → smooth muscle relaxation & vasodilation. ●​ Thiazide diuretics (most ○​ Sildenafil (Revatio) and Tadalafil (Adcirca) approved for this condition. common) Therapeutic Outcomes ●​ Beta-adrenergic blocking ●​ Primary Outcome: Improved erectile function and overall sexual satisfaction in men agents (especially with ED. propranoio and nonselective ●​ Secondary Outcome (Tadalafil): Reduction of symptoms and improved urinary flow in agents; less so with beta-1 prostatic enlargement. selective agents) Nursing Implications ●​ Alpha-adrenergic blocking Premedication Assessment agents (e.g., prazosin, ●​ Obtain baseline vital signs. terazosin) ●​ Review recent use of medicines, including recreational drugs. ●​ Sympatholytic agents (e.g., ●​ Patients with cardiovascular disease should get approval from their healthcare clonidine, methyidopa, provider before starting therapy. reserpine) Availability, Dosage, and Administration ●​ Spironolactone ●​ STI/HIV/Pregnancy Protection: (antiandrogen effect) ○​ Phosphodiesterase inhibitors do not protect against STIs, HIV, or pregnancy. CENTRAL NERVOUS SYSTEM ○​ Recommend using a condom and spermicide (nonoxynol-9) for protection DEPRESSANTS against STIs and unwanted pregnancy. ●​ Phenothiazine antipsychotic ●​ Fertility: agents (e.g., fluphenazine, ○​ No effect on sperm count, motility, or fertility. thioridazine) Common Adverse Effects ●​ Butyrophenones (e.g., ●​ Vascular: haloperidol) ○​ Headache, flushing (face/neck). ●​ Monoamine oxidase ○​ More common in men on higher doses. inhibitors ○​ Generally self-limiting; may reduce with a lower dosage. ●​ Tricyclic antidepressants ○​ Advise patients to consult healthcare provider if adverse effects are ●​ Selective serotonin reuptake persistent/unacceptable. inhibitors (e.g., sertraline, ●​ Sensory: paroxetine) ●​ Lithium CARDIOVASCULAR AGENTS ○​ Color vision impairment: Mild, transient, reversible issues with blue/green color interpretation. ●​ Digoxin (estrogen effect) ●​ Clofibrate ○​ Caused by inhibition of phosphodiesterase 6 in the retina. ●​ Gemfibrozil ○​ May improve with reduced dosage. MISCELLANEOUS AGENTS ○​ Advise consultation with healthcare provider if the problem is unacceptable. ●​ Substances of abuse (e.g., Serious Adverse Effects smoking, alcohol, cocaine, ●​ Cardiovascular: marijuana) ○​ Hypotension, dizziness, angina: ●​ Chemotherapy agents (e.g., ■​ High-risk in patients with heart disease, angina, DM, HTN. chlorambucil, ■​ Contraindicated with nitroglycerin or isosorbide due to potentially cyclophosphamide, fatal interaction. methotrexate) ■​ If these symptoms occur: ●​ Anabolic steroids ●​ Discontinue sexual activity. ●​ Estrogens ●​ Lie down. ●​ Corticosteroids ●​ Do not take nitroglycerin for angina; may worsen symptoms. ●​ Cimetidine (antiandrogen ●​ Seek medical attention as needed. effect) ●​ Sensory: ●​ 5-Alpha reductase inhibitors ○​ Loss of vision: (finasteride, dutasteride) ■​ Rare cases of sudden vision loss linked to nonarteritic ischemic optic ●​ Interferon-a neuropathy (NAION). ■​ NAION: Blocked blood flow to optic nerve. ■​ If sudden vision reduction/loss occurs, stop medication and seek medical help immediately. ■​ Patients should inform healthcare provider of any history of severe vision loss or prior NAION episodes. ■​ Unclear if ED medications directly cause vision loss or if it's related to other conditions (e.g., HTN, DM). ○​ Sudden decrease/loss of hearing: ■​ Rare cases reported. ■​ May be accompanied by tinnitus and dizziness. ■​ Advise patients to seek medical help if hearing changes occur. ●​ Reproductive: ○​ Sustained erection (priapism): ■​ Erection lasting >4 hours requires immediate medical attention. ■​ Untreated priapism can cause permanent penile damage, including erectile dysfunction. Drug Interactions ●​ Nitrates: ○​ Nitroglycerin patches/ointment, amyl nitrate: ■​ ↑ Nitric oxide production → risk of hypotension and arrhythmias. ■​ Recreational nitrates ("poppers") have similar risks when combined with phosphodiesterase inhibitors. ■​ Note: Nitrates from food sources do not interact with these drugs. ●​ Metabolism Inhibitors: ○​ Cimetidine, erythromycin, ketoconazole, itraconazole, ritonavir, indinavir, saquinavir: ■​ Inhibit metabolism of phosphodiesterase inhibitors → ↑ adverse effects (e.g., flushing, hypotension, dizziness). ■​ May require a reduced dosage of phosphodiesterase inhibitor. ●​ Alcohol: ○​ Both alcohol and phosphodiesterase inhibitors act as mild vasodilators. ○​ Excessive alcohol intake with these drugs → risk of decreased BP, dizziness, orthostatic hypotension. ○​ Advise caution when combining alcohol with phosphodiesterase inhibitors. ●​ Alpha-Adrenergic Blocking Agents: ○​ Tamsulosin, alfuzosin, terazosin, doxazosin, prazosin: ■​ Combined use may lead to significant hypotension. ■​ Monitor BP and report dizziness. ■​ Dosage reduction or change in phosphodiesterase inhibitor may be needed to prevent excessive hypotension. ●​ Rifampin: ○​ Enhances metabolism of sildenafil and tadalafil → ↓ duration of action. ○​ Consider increasing dosage or adjusting timing of sexual activity to manage this interaction