The APhA Complete Review For Pharmacy

THE APhA COMPLETE REVIEW FOR PHARMACY - 7th Ed.
(2010)
Front Matter
Title Page
The APhA Complete Review for Pharmacy, Seventh Edition
Dick R. Gourley PharmD, FAPhA

Editor-in-Chief
Dean and Professor
University of Tennessee College of Pharmacy
Memphis, Tennessee
James C. Eoff III PharmD

Associate Editor-in-Chief
Executive Associate Dean and Professor, Clinical Pharmacy
Memphis, Tennessee
Washington, D.C.
Copyright Page
Acquiring Editor: Sandra J. Cannon

Managing Editors: Linda Stringer and Ashley Young, Publications Professionals LLC
Copyeditors: Laura Glassman, Jennie Golden, and Mary-Ann Moalli, Publications Professionals
LLC
Proofreaders: Liz Horowitz and Ben Justesen, Publications Professionals LLC
Composition: Circle Graphics
Cover Design: Richard Muringer, APhA Creative Services
©2010 by the American Pharmacists Association

Published by the American Pharmacists Association
2215 Constitution Avenue, NW
Washington, DC 20037-2985
www.pharmacist.com
All rights reserved

APhA was founded in 1852 as the American Pharmaceutical Association.
No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or
by any means, electronic, mechanical, photocopying, recording, or otherwise, without written
permission from the publisher.
To comment on this book via e-mail, send your message to the publisher at
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Library of Congress Cataloging-in-Publication Data
The APhA complete review for pharmacy / Dick R. Gourley,

editor-in-chief; James C. Eoff III, associate editor-in-chief. — 7th ed.
p.; cm.
Includes bibliographical references.
ISBN 978-1-58212-145-1 (alk. paper)
1. Pharmacy—Outlines, syllabi, etc. 2. Pharmacy—Examinations,
questions, etc. I. Gourley, D. R. (Dick R.), 1944- II. Eoff, James C.
III. American Pharmacists Association. IV. Title: Complete review
for pharmacy.
[DNLM: 1. Pharmacy—Examination Questions. 2. Pharmaceutical
Preparations—Examination Questions. QV 18.2 A641 2010]
RS98.A64 2010
615.1076—dc22
2009046934
How To Order This Book

Online: www.pharmacist.com
By phone: 800-878-0729 (770-280-0085 from outside the United States)
VISA®, MasterCard®, and American Express® cards accepted
ISBN-13: 978-1-58212-145-1
ISBN-10: 1-58212-145-1
Contents
Preface… vii
Acknowledgments… viii
Contributors… ix
Eoff's NAPLEX Study Guide… xiii

Join APhA Today!… xvii
1 Pharmacy Math… 1
Hassan Almoazen, PhD
2 Federal Pharmacy Law… 21

Walter L. Fitzgerald, Jr, BPharm, MS, JD
3 Dosage Forms and Drug Delivery Systems… 43

Ram I. Mahato, PhD
4 Compounding… 71
Charles N. May, BSPh, MSHP
5 Sterile Products… 89
Laura A. Thoma, PharmD
6 Pharmacokinetics, Drug Metabolism, and Drug Disposition… 109

Bernd Meibohm, PhD Charles R. Yates, PharmD, PhD
7 Biotechnology and Pharmacogenomics… 135

Stephanie A. Flowers, PharmD P. David Rogers, PharmD, PhD, FCCP
8 Hypertension… 151
Benjamin Gross, PharmD, BCPS L. Brian Cross, PharmD, CDE
9 Heart Failure… 179

Robert B. Parker, PharmD, FCCP
10 Cardiac Arrhythmias… 199

11 Ischemic Heart Disease… 219

Kelly C. Rogers, PharmD Carrie S. Oliphant, PharmD, BCPS Shannon Finks, PharmD, BCPS
(AQ Cardiology)
12 Hyperlipidemia… 251
Lawrence M. Brown, PharmD, PhD
13 Diabetes Mellitus… 265

Joni Foard, PharmD, CDE L. Brian Cross, PharmD, CDE
14 Thyroid, Adrenal, and Miscellaneous Endocrine Drugs… 289

Jeremy Thomas, PharmD, CDE
15 Women's Health… 305
Andrea S. Franks, PharmD, BCPS
16 Kidney Disease… 323

Joanna Q. Hudson, PharmD, BCPS, FASN
17 Critical Care, Fluids, and Electrolytes… 349

G. Christopher Wood, PharmD, FCCP, BCPS with Added Qualifications in Infectious Diseases
18 Nutrition… 369
Rex O. Brown, PharmD, BCNSP
19 Oncology… 385
J. Aubrey Waddell, PharmD, FAPhA, BCOP Jaclyn S. King, PharmD
20 Solid Organ Transplantation… 409

Benjamin Duhart, Jr, MS, PharmD
21 Gastrointestinal Diseases… 427

Christa M. George, PharmD, BCPS, CDE
22 Rheumatoid Arthritis, Osteoarthritis, Gout, and Lupus… 455

Kevin L. Freeman, PharmD, BCNSP
23 Pain Management and Migraines… 481

Elizabeth S. Miller, PharmD
24 Seizure Disorders… 507

Stephanie J. Phelps, PharmD, BCPS
25 Psychiatric Disease… 531

Jason Carter, PharmD
26 Common Dermatologic Disorders… 561

Shaunta' M. Ray, PharmD, BCPS
27 Nonprescription Medications… 585

Amanda Howard-Thompson, PharmD, BCPS
28 Asthma and Chronic Obstructive Pulmonary Disease… 613

Timothy H. Self, PharmD
29 Infectious Disease… 633

Joyce E. Broyles, PharmD, BCNSP
30 Anti-infective Agents… 649
Ronald L. Braden, PharmD W. Andrew Bell, PharmD
31 Human Immunodeficiency Virus and the Acquired Immune Deficiency Syndrome… 675
Camille W. Thornton, PharmD
32 Immunization… 701
Stephan L. Foster, PharmD
33 Pediatrics… 719
Catherine M. Crill, PharmD, BCPS, BCNSP
34 Geriatrics and Gerontology… 741

William Nathan Rawls, PharmD
35 Toxicology and Chem-Bioterrorism… 759

Peter A. Chyka, PharmD, FAACT, DABAT
36 Anemias… 785
Trevor McKibbin, PharmD, MS, BCPS
37 Thromboembolic Disease… 799

Gale Hamann, PharmD, BCPS, CDE
Appendixes… 823
Katie J. Suda, PharmD Anne M. Hurley, PharmD
A Normal Laboratory Values… 823
B Drugs in Renal Failure… 827
C Drugs in Hepatic Failure… 839
D Top 200 Prescription Drugs… 845
E Top 200 Over-the-Counter Products… 848
F Drugs Excreted in Breast Milk… 851
G Drugs That May Cause Photosensitivity… 853
H Drug Information Resources by Category… 857
I Drugs That Should Not Be Crushed… 860

J Use-in-Pregnancy Ratings… 867
K Sugar-Free Products… 879
L Alcohol-Free Products… 885
M Common Drug Interactions: Cytochrome P450 Interactions… 891
Notices
The authors, editors, and publisher have made every effort to ensure the accuracy and completeness
of the information presented in this book. However, the authors, editors, and publisher cannot be
held responsible for the continued currency of the information, any inadvertent errors or omissions,
or the application of this information. Therefore, the authors, editors, and publisher shall have no
liability to any person or entity with regard to claims, loss, or damage caused or alleged to be
caused, directly or indirectly, by the use of information contained herein.
The inclusion in this book of any product in respect to which patent or trademark rights may exist
shall not be deemed, and is not intended as, a grant of or authority to exercise any right or privilege
protected by such patent or trademark. All such rights or trademarks are vested in the patent or
trademark owner, and no other person may exercise the same without express permission, authority,
or license secured from such patent or trademark owner.
The inclusion of a brand name does not mean the authors, the editors, or the publisher has any
particular knowledge that the brand listed has properties different from other brands of the same
product, nor should its inclusion be interpreted as an endorsement by the authors, the editors, or the
publisher. Similarly, the fact that a particular brand has not been included does not indicate the
product has been judged to be in any way unsatisfactory or unacceptable. Further, no official
support or endorsement of this book by any federal or state agency or pharmaceutical company is
intended or inferred.
NAPLEX® is a trademark of the National Association of Boards of Pharmacy® (NABP®), and

NABP® in no way endorses, authorizes, or sponsors this guide.
Preface
It is indeed an honor to have again been asked to serve as editor-in-chief of The APhA Complete
Review for Pharmacy. We are now publishing the seventh edition and sincerely appreciate the
continued support of the American Pharmacists Association (APhA). The faculty of the University
of Tennessee College of Pharmacy and I appreciate the confidence that APhA has demonstrated by
allowing us this opportunity to assist pharmacy students in preparing for the NAPLEX examination.
This project is very important to pharmacy students across the United States, and we know they
appreciate the support of APhA.
As pharmacy students prepare to take the NAPLEX examination, it is imperative that they have
available to them the most up-to-date and relevant information concerning the practice of
pharmacy. The information explosion is such that facts change daily, and approximately 30 new
drugs are marketed each year. The amount of information that any student in pharmacy must master
is significant and doubles every two to three years.
The board examination is the culmination of at least six years of university work. It is impossible to
go back to the beginning and review all aspects of pharmacy education to prepare for it. Therefore,
we have developed a comprehensive review of pharmacy for students preparing to take the
NAPLEX examination.
In this new seventh edition, all chapters have been revised, and new information related to
medications, drug therapy management, and disease management has been added to the book.
This study guide has attempted to summarize the information in a user-friendly manner. Our faculty
and a panel of 10 pharmacy residents believe the information included to be the most important
information needed for the NAPLEX exam. The review includes educational material, which
synthesizes the most salient points; key points, which further delineate the most important factors;
references; and, finally, self-study questions.
This book is also an excellent review for practicing pharmacists as they continue to expand their
therapeutic knowledge and for foreign graduates interested in obtaining licensure in the United
States. The CD-ROM that accompanies this book contains case studies and more than 900
questions and annotated answers, and it will give students valuable practice exam experience.
It is highly recommended that any student preparing for the NAPLEX examination review the
instructions on the NABP Web site (www.nabp.net). Students should also read the current literature
in journals and review areas where they feel they have a weakness.
My thanks and appreciation go to my associate editor, James C. Eoff III, PharmD, executive
associate dean of the University of Tennessee College of Pharmacy.
DICK R. GOURLEY, PHARMD, FAPHA

DEAN AND PROFESSOR
UNIVERSITY OF TENNESSEE COLLEGE OF PHARMACY
MEMPHIS, TENNESSEE
November 2009
Acknowledgments
We would like to thank the faculty of the University of Tennessee College of Pharmacy, who
participated in preparing this comprehensive review, and Karin Ingram, executive assistant to the
dean, for coordinating the preparation of the review book. We also wish to thank APhA for
recognizing the need of pharmacy students for this review book. Working with Sandy Cannon and
Julian Graubart at APhA has been an absolute pleasure. APhA's willingness to provide this book to
all senior members of the Academy of Student Pharmacists who are pharmacy graduates in the
United States is a true service to the profession of pharmacy.
We also appreciate the efforts of the following contributors for the case studies and questions and
answers they prepared for the companion CD-ROM: Mollie Cannon, PharmD; L. Paige Clement,
PharmD; Amy B. Gamlin, PharmD; Tameka W. Lucas, PharmD; Kristi Nesler, PharmD; Laura
Pounders, PharmD; Kristie Ramser, PharmD; and Katie Wassil, PharmD.
About the Authors
Dick R. Gourley, PharmD, is Dean and Professor of Pharmacy at the highly rated University of
Tennessee College of Pharmacy, Memphis. He has coedited 10 books, including Textbook of
Therapeutics: Drugs and Disease Management, now in its 8th edition, and a preparation workbook
for the Pharmacy College Admission Test, PCAT Success.
James C. Eoff III, PharmD, is Executive Associate Dean and Professor in the Department of
Clinical Pharmacy and is responsible for recruitment, admissions, and student affairs in the College
of Pharmacy. The more than 40 chapter authors—all current or former faculty members at the
University of Tennessee College of Pharmacy—are top clinicians, scientists, and researchers whose
expertise spans the pharmacy curriculum.
Contributors
Hassan Almoazen, PhD

Assistant Professor, Department of Pharmaceutical
Sciences
W. Andrew Bell, PharmD

Assistant Professor, Department of Clinical
Pharmacy
Ronald L. Braden, PharmD

Associate Professor, Department of Clinical
Pharmacy
Lawrence M. Brown, PharmD, PhD

Associate Professor, Department of Pharmaceutical
Sciences
Rex O. Brown, PharmD, BCNSP

Professor and Executive Vice Chair, Department of
Clinical Pharmacy
Director of Experiential Education
Joyce E. Broyles, PharmD, BCNSP

Pharmacy
Jason Carter, PharmD

Pharmacy
Peter A. Chyka, PharmD, FAACT, DABAT

Professor, Department of Clinical Pharmacy
Executive Associate Dean, Knoxville Campus
Catherine M. Crill, PharmD, BCPS, BCNSP

Associate Professor, Departments of Clinical Pharmacy and
Pediatrics
University of Tennessee College of Pharmacy and
College of Medicine
L. Brian Cross, PharmD, CDE

Pharmacy
Benjamin Duhart, Jr, MS, PharmD

Pharmacy
Director, Transplant Pharmacy Services
Shannon Finks, PharmD, BCPS (AQ Cardiology)

Pharmacy
Walter L. Fitzgerald, Jr, BPharm, MS, JD

Dean, Pharmacy Education Program Development
South College, Knoxville, Tennessee
Stephanie A. Flowers, PharmD

Infectious Diseases Pharmacotherapy Fellow
Joni Foard, PharmD, CDE

Pharmacy
Stephan L. Foster, PharmD

Andrea S. Franks, PharmD, BCPS

Pharmacy
Kevin L. Freeman, PharmD, BCNSP

Pharmacy
Christa M. George, PharmD, BCPS, CDE

Pharmacy
Benjamin Gross, PharmD, BCPS

Pharmacy
Gale Hamann, PharmD, BCPS, CDE

Associate Professor, Departments of Clinical
Pharmacy and Medicine
College of Medicine
Amanda Howard-Thompson, PharmD, BCPS

Pharmacy
Joanna Q. Hudson, PharmD, BCPS, FASN
Associate Professor, Departments of Clinical
Pharmacy and Medicine (Nephrology)
College of Medicine
Anne M. Hurley, PharmD

Pharmacy
Jaclyn S. King, PharmD

Hematology/Oncology Pharmacy Resident
Walter Reed Army Medical Center, Washington, D.C.
Ram I. Mahato, PhD

Professor, Department of Pharmaceutical Sciences
Charles N. May, BSPh, MSHP

Assistant Professor, Department of Pharmaceutical
Sciences
Trevor McKibbin, PharmD, MS, BCPS

Pharmacy
Bernd Meibohm, PhD

Professor, Department of Pharmaceutical Sciences
Associate Dean for Graduate Programs and Basic
Research
Elizabeth S. Miller, PharmD

Pharmacy
Carrie S. Oliphant, PharmD, BCPS

Pharmacy
Stephanie J. Phelps, PharmD, BCPS

Associate Dean for Academic Affairs
Professor, Departments of Clinical Pharmacy and
Pediatrics
College of Medicine
William Nathan Rawls, PharmD

Shaunta' M. Ray, PharmD, BCPS

Assistant Professor, Departments of Clinical
Pharmacy and Family Medicine
College of Medicine
Kelly C. Rogers, PharmD

Pharmacy
P. David Rogers, PharmD, PhD, FCCP

First Tennessee Chair of Excellence in Clinical
Pharmacy
Associate Dean for Translational Research
Timothy H. Self, PharmD

Katie J. Suda, PharmD

Associate Professor and Director, Drug
Information Center
Department of Clinical Pharmacy
Laura A. Thoma, PharmD

Professor, Department of Pharmaceutical
Sciences
Director, Parenteral Medications Laboratories
Jeremy Thomas, PharmD, CDE

Pharmacy

Pharmacy
J. Aubrey Waddell, PharmD, FAPhA, BCOP

Associate Professor
Oncology Pharmacist
Blount Memorial Hospital, Maryville, Tennessee
G. Christopher Wood, PharmD, FCCP, BCPS with added qualifications in infectious diseases
Pharmacy
Charles R. Yates, PharmD, PhD

Associate Professor, Department of Pharmaceutical
Sciences
Eoff's NAPLEX Study Guide
Welcome to The APhA Complete Review for Pharmacy. With so many different academic
backgrounds, such a variety of learning experiences, and the increasing volume of information
taught at U.S. colleges of pharmacy, it is impossible to cover all materials from each course you
have taken while in pharmacy school. Therefore, the primary purpose of The APhA Complete
Review for Pharmacy is to provide a summary of therapeutics as well as other basic pharmaceutical
principles (dosage forms, math, biopharmaceutics, kinetics, basic and parenteral compounding,
among others) that will be valuable in your preparation for the NAPLEX and also be a resource as
you enter practice.
This review book is not an exhaustive discussion of the topics presented; it uses an abbreviated
outline format to enable you to review and organize the material in an efficient manner for easy
recall and recognition. The NAPLEX is a difficult exam, and it covers a tremendous amount of
material. In recent years, the NAPLEX has become even more relevant to professional practice,
with less emphasis on the basic sciences and more emphasis on drug therapy and pharmaceutical
care.
Your success in pharmacy school has been due to diligence and hard work. You should have
confidence that your pharmacy education has prepared you for the NAPLEX, and you should not
have anxieties about the exam. However, your self-confidence should not prevent you from being
meticulous about preparation for the NAPLEX. Realizing that approximately 10% of students fail
to achieve a passing score on their first attempt at the NAPLEX, do not take this exam lightly.
The following are helpful hints that will improve your success on this examination:
1. Positive attitude: You are encouraged to approach preparation for the NAPLEX with a positive
attitude. Study to learn and understand concepts, not just memorize enough facts to pass the
exam. Remember that in addition to being a minimum standard required for entry into pharmacy
practice, the NAPLEX is the comprehensive review, and an important benefit of taking the
NAPLEX is that it will make you a better pharmacy practitioner. Without the NAPLEX, few
pharmacy graduates would spend the time and effort to review the entire discipline immediately
prior to completing their studies. You should be confident that you have the knowledge to pass
the exam if you have prepared diligently.
2. Planning ahead: Do not delay your review and preparation for the NAPLEX until the last week
before your scheduled exam date. Although the total amount of time varies greatly from student
to student, it is recommended that you start a serious review no less than 4—6 weeks before you
plan to take the exam. However, if you have limited pharmacy work experience, you should start
much earlier, especially learning generic and trade names. Be conscientious about scheduling
specific times to prepare for the NAPLEX over this time period. Cramming the last few days
before the NAPLEX will potentially increase your anxiety and could also confuse you with such
a large volume of material. Read one or two chapters per day for 4 or 5 days per week, and
review the generic and trade names daily.
3. Generic and trade names: The first place to begin your preparation is to learn the generic and
trade names for the top 200 drugs. The importance of this basic recommendation cannot be
overemphasized. Without this base, you will experience tremendous difficulty on the NAPLEX,
which is traditionally over half trade names. In addition, you will also need to learn the generic
and trade names for unique drugs that may not be among the top 200 drugs (e.g., Cogentin and
Artane, which are used to manage the extrapyramidal side effects of psychotherapeutic agents;
Tofranil, which is used to treat enuresis; Tapazole, which is used to treat hyperthyroidism). Most
of the patient medication profiles contain numerous drugs that may be listed by either the generic
or the trade name. Therefore, knowledge of generic and trade names is essential to identify
therapeutic duplication (e.g., the patient who is prescribed Corgard who is already taking the ²-
blocker propranolol). You will also be expected to determine potential causes for adverse effects,
as well as screen for drug interactions and drug—disease interactions, from either drugs on the
profile or the new prescriptions. In some cases, drugs will be listed by their generic names, and in
other cases, by their trade names.
4. Math: Other than generic and trade names, pharmacy math is the most important single area to
review. You should practice working several examples of each type of math problem to be sure
you are comfortable and confident in your ability. Although some therapeutic topics may not be
covered extensively, the large number of math questions on the NAPLEX makes studying
pharmacy math a high priority. Many students struggle with math on the NAPLEX. Therefore, it
is recommended that you schedule several math study sessions. The metric system is emphasized,
but you must know the other systems and be able to make conversions. Although the apothecary
system is used infrequently, the avoirdupois system (sometimes called the household system) is
still used (e.g., prepare 1 pound of ointment). When apothecary or avoirdupois measures are
used, you should usually convert them to metric.
5. Competencies: You should review the areas of emphasis defined in the NAPLEX competency
statements that are available on the NABP Web site, www.nabp.net. As you review the top 200
drugs, you should ask yourself the following questions:
• What is the therapeutic category of this drug?

• What is the mechanism of action?
• What type of patient counseling information should be provided?
• What are the major adverse effects (side effects and toxic effects)?
• What is the dosage schedule (frequency)?
• What are the major drug interactions and disease contraindications?
These topics should also be the priority areas as you review each therapeutic class of agents.
6. Dosage schedules: Summary charts of the major categories of drugs are provided in each of the
therapeutic chapters of this book. You will find the generic as well as trade names, along with
commonly available dosage forms, dosage, and frequency of use. The frequency of use is
emphasized more on the NAPLEX than are the specific dosages. The following therapeutic lists
with multiple agents should also be emphasized in your studying: ²-blockers, calcium channel
blockers, angiotensin-converting enzyme inhibitors, benzodiazepines, cephalosporins,
quinolones, aminoglycosides, nonsteroidal anti-inflammatory drugs, H2 blockers, protease
inhibitors, oral antidiabetics, and statins. Be able to recognize the agents within these categories,
and know how to compare the differences within the category (e.g., duration of action, dosage
schedules, side effects, and distinct advantages in patients with certain diseases).
7. Appendixes: Many tables that can help you recall or recognize answers for NAPLEX questions
are included in the appendixes, such as the major drug—drug interactions, the drugs that should
not be crushed, and the top 200 over-the-counter agents. Other important tables are included
throughout the book, such as the table of common antidotes for poisons and overdosages in
Chapter 35, the toxicology chapter. By reviewing these therapeutic agents by categories and in
tables, you will increase your recall of them on the exam.
8. Chronic and common diseases: The NAPLEX emphasizes the more common and chronic
diseases and their therapy. Although it is a good idea to have a general knowledge of the disease
process, remember that the NAPLEX is heavily weighted toward drug therapy. Therefore, you
should not devote the majority of your study time to the disease process (e.g., etiology,
pathophysiology, diagnosis, and signs and symptoms) at the expense of the therapy (including
nondrug therapy). Although it is helpful to review your areas of strength, you should concentrate
more on your areas of weakness. The less familiar you are with a topic, the more time you should
give to reviewing the topic.
9. Priorities: Several areas should not be emphasized in your review: (1) the manufacturer of the
specific drug (e.g., Zithromax manufactured by Pfizer); (2) chemical structures; and (3)
identification or physical descriptions (e.g., color, shape). These areas are covered only
minimally on the NAPLEX.
10. Review questions: Reviewing sample exam questions is very helpful. However, to make your
learning experience more effective, study the explanations along with their answers. Do not look
only at the correct answer, but also at distractors and learn why they are incorrect. Therapeutics
reference texts may also be helpful in your NAPLEX review; they provide more detailed
information and may assist you with difficult or complex material. Studying such texts will also
reinforce learning points about material covered in your review.
11. Exam format: The NAPLEX consists of 185 multiple-choice questions in a computer adaptive
format that is individualized to each candidate's level of ability. The computer-adapted test
system selects your next questions depending on your response to previous questions; thus, each
question must be answered before you can proceed. The 150 questions that have been pretested
for validity are the basis for your evaluation. In addition, 35 questions that are being evaluated for
use in future exams are distributed throughout the exam.
12. Question format: You should log on to the NABP Web site (www.napb.net) to review the
format for exam questions and the patient profiles. NABP also offers a "pre-NAPLEX" test for a
fee. This pretest will allow you to practice with the computerized format. It will help allay your
anxiety and be especially beneficial if you are not comfortable with exams given in a computer
format.
All questions on the NAPLEX have five choices with only one "best" answer. You may not
continue the exam until you have answered the question. You may not skip the question and
come back. Therefore, you will be unable to leave any question blank. The question is
superimposed at the bottom of the screen below the patient medication record. After deciding on
the best answer, you will:
1. Highlight the answer.

2. Request the next question.
3. Confirm that you want the next question, which will finalize your answer.
You cannot go back to change an answer after step 3.
There are two types of multiple-choice questions:
1. The traditional single-answer type, as in the example below:
The agent of choice for the initial treatment of contact dermatitis, whether irritant or allergic, is
a
A. topical antihistamine
B. oral antihistamine
C. topical corticosteroid
D. local anesthetic
E. coal tar product
2. The combined-response ("K" type) question with one, two, or three components listed, as in
the example below:
The most common side effects of isotretinoin include which of the following?
I. Cheilitis
II. Acute depression
III. Decreased night vision
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III
13. Patient medication record: The patient medication record is usually followed by 10—15
questions. You must refer to the patient profile for many of the questions. However, some
questions may be answered as presented or "stand alone." You will not be able to see the entire
profile on the top of the screen without scrolling down to review the whole profile. You may
want to write down the significant points from the profile, such as allergies, age of the patient,
and preexisting diseases, on scrap paper. Note carefully if the patient has multiple diseases, and
for females, look for pregnancy or nursing, or for the likelihood of becoming pregnant. Some test
takers prefer to read the questions prior to reviewing the profile, but you could miss an important
fact like a drug allergy, a drug—disease contraindication, or an adverse effect being treated
currently that resulted from a previously prescribed drug. In such a case, you could answer the
question without all of the necessary information. Therefore, always conduct a quick review of
the profile prior to answering the questions.
14. Testing center location: If you are not familiar with the exact location of the testing center,
locate it no later than the day before the exam. Arrive at the testing site at least 30 minutes prior
to the scheduled time so that you are as calm as you can be. You do not want to be caught in
traffic or to get lost trying to find the testing center and panic immediately prior to taking the
exam.
15. The night before the exam: Do not study the night before the exam; last-minute cramming
will only add to your anxiety and will not improve your test score. I recommend that you take a
night off from study the evening before the exam. Go out for a relaxing dinner or a movie. Be
sure to get to bed early, especially if you are scheduled for a morning exam, so your ability to
reason, recognize, and recall information is sharp.
16. Afternoon exam: If your exam is scheduled in the afternoon, fatigue can dull your test-taking
abilities. Be on guard against fatigue by having a light lunch, preferably with coffee, tea, or some
caffeine-containing beverage, to be sure that you stay sharp for the afternoon session.
While you are taking the exam, keep these factors in mind:
1. Read all directions carefully. Read each question a minimum of two times to determine the
nature of the question and the point of asking the question. Note any modifying terms like
always, all, never, most, or usually; any double negatives; and anything else about the way the
question is worded that may change the meaning of the question. Modifiers like always and never
mean what they say.
2. Read all the choices thoroughly before you answer the question. Attempt to eliminate the
distractor choices or incorrect answers. Two or three answers can usually be eliminated for one
reason or another, and the final choice is between two answers. The more distractors you identify
and eliminate, the more you increase your probability of obtaining the best answer. Then select
the single best answer. Your first instinct is generally the best choice. Be cautious about reading
multiple possibilities into questions; the questions are straightforward and are not designed to
trick you.
3. If you are positive that you do not know the answer, eliminate any distractors and guess
intelligently, making the best choice of the remaining answers. If you can limit your guess to two
possible correct answers, your score will be much better than if you try to guess the correct
answer from five possible choices. By proceeding in this fashion over the course of the exam,
you can increase your success if you guess consistently. Although blind guessing is not
recommended, intelligent guessing is definitely recommended once you have narrowed the
possibilities.
4. Pace yourself, but do not rush through the exam. The 4 hours and 15 minutes scheduled for the
NAPLEX are more than adequate, and the majority of students have plenty of time to complete
the exam. You need to proceed at a reasonable pace and need to answer approximately 45—50
questions per hour to finish comfortably in the time available. A timer is visible at the corner of
the screen with your remaining exam time. If you notice that you have completed only 40
questions in the first hour, you should increase your speed.
5. Some of the math questions may be weighted more heavily, and some will take several minutes
to answer. Take the time to answer the math questions correctly. Incorrect answers may lead to
additional math questions (e.g., missing the first milliequivalent question could lead to more
milliequivalent questions on your exam). Use the scrap paper provided for your calculations. Be
sure to include units as you complete the math questions on your scrap paper.
6. It is important to remember that you cannot return to a previous question after you have
confirmed an answer. There is no need to get upset over a previous question that you realize you
have missed as you proceed through the exam. Do not get nervous during the exam or panic, or
you may lose your ability to recall or recognize common information. Remain calm and do the
best you can. Best of luck with the test!
JAMES C. EOFF III, PHARMD

EXECUTIVE ASSOCIATE DEAN AND PROFESSOR
UNIVERSITY OF TENNESSEE COLLEGE OF PHARMACY
MEMPHIS, TENNESSEE
November 2009
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Key Features
• Top 200 drugs. Begin your NAPLEX® preparation by learning the generic and trade names for the
top 200 drugs (Appendices).
• Math. After drug names, pharmacy math is the most important single area to review (Chapter 1).
• Drug therapy for chronic and common diseases. This is the heart of today's NAPLEX® and the
subject of more than half this study guide's 38 chapters.
• Review questions. All chapters end with 20 or more practice exam questions and answers, plus
explanations that reinforce key learning points.
• Seasoned advice on studying for and taking the NAPLEX® from James C. Eoff III, who has
coordinated the board review course at the University of Tennessee College of Pharmacy for
more than 30 years.
All Chapters Updated for 2010 Edition!
The NAPLEX® (North American Pharmacist Licensure Examination®) is the standard licensing
exam that all U.S. pharmacy students must pass to practice pharmacy. It's an arduous exam that
tests a daunting range of knowledge. Approximately 10% of students taking the exam for the first
time fail to achieve a passing score.
Preparing for the NAPLEX® by reviewing all the material from each of your pharmacy school
courses would be overwhelming. A far better approach would be to study only the information most
relevant to the exam, summarized in abbreviated bullet format, and that's what The APhA Complete
Review for Pharmacy contains.
An up-to-date, one-volume compilation of pharmacy knowledge, The APhA Complete Review for
Pharmacy is also a popular reference for busy practitioners wishing to stay current.
Companion CD-ROM
Includes 900 Practice Exam Questions and Answers with 3 options:
• Learning Mode, which allows you to customize the test-taking experience
• Certification Mode, which delivers the test as it was authored
• Flashcard Mode
Download Practice Exam Installer
System Requirements:
• Operating System: Windows XP, Vista, 7

• Disk Space: 90MB
1. Pharmacy Math - Hassan Almoazen, PhD
1-1. Units of Measure
Introduction
Calculations in pharmacy may involve four different systems of measure: the metric system, the
apothecaries' system, the avoirdupois system, and the household system.
Metric System
The fundamental units of the metric system are the gram, the liter, and the meter. Prefixes are used
extensively to express quantities much greater and much less than the fundamental units. Some of
the most commonly used prefixes are provided in
Table 1-1.
Apothecaries' System
Although the metric system is the official system of measure for pharmacy today, the apothecaries'
system is the traditional system, and some elements might sometimes be found in prescriptions.
Units of the apothecaries' system are presented in
Table 1-2.
Avoirdupois System
The avoirdupois system of measure for weight is used in ordinary commerce. Here, the ounce
corresponds to 437.5 grains. The avoirdupois grain unit is equal to the apothecaries' grain unit.
Sixteen ounces (7,000 grains) correspond to 1 pound. Note that the avoirdupois ounce (473.5
grains) and pound (7,000 grains) measures are not equal to the apothecaries' ounce (480 grains) and
pound (5,760 grains) measures.
Household Measures
A tablespoon is equivalent to 15 mL, and a teaspoon is equivalent to 5 mL.
Conversion Factors
A short list of convenient conversion factors follows:
1 inch = 2.54 cm
1 fl oz = 29.57 mL
1 g = 15.4 grains
1 kg = 2.20 lb (avoirdupois)
1 lb (avoirdupois) = 454 g
1 gal (U.S.) = 3,785 mL
1-2. Significant Figures
Introduction
All measured quantities are approximations. The accuracy of a given measurement is conveyed by
the number of figures that are recorded. The number of significant figures in a measurement
includes the first approximate figure. The last recorded digit to the right of a measured quantity is
taken to be an approximation. For example, the weight 13.24 g has four significant figures, and the
final digit, 4, is approximate. Calculations should be conducted so as to carry the correct numbers
of significant figures.
Frequently, the different quantities in a given calculation have different numbers of significant
figures. When that occurs, the following rules apply.
Addition and Subtraction
When adding or subtracting decimal numbers, round all measurements so that they have the same
number of decimal places as the least in the set. For example, 13.78 mL and 53.5 mL would be
added as 13.8 mL + 53.5 mL = 67.3 mL, using and retaining only one decimal place.
[Table 1-1. Metric System Prefixes]
Multiplication and Division
When multiplying or dividing decimal numbers, round the measurements to include the number of
significant figures contained in the least accurate number. For example, 25.678 mL × 1.24 g/mL
would be multiplied as 25.7 mL × 1.24 g/mL = 31.9 g, using and retaining three significant figures
in each number.
Handling Zero
The digit zero may or may not be counted as a significant figure, depending on where it appears in
the measured number. If zero occurs at an interior position in the number (e.g., 3,052 or 2.031), it is
significant. If zero occurs as the last digit to the right of the decimal (e.g., 44.50), it is significant. If
zero occurs as the first digit to the right of the decimal in a number that is less than 1, it is not
significant. For example, in 0.078 there are only two significant figures. If zero occurs as the last
digit, or digits, in a whole number (i.e., no decimal is expressed), its significance is unknown
without further information. For example, 3,500 might have two, three, or four significant figures.
[Table 1-2. Apothecaries' System of Measure]
1-3. Ratios and Proportions
The most frequently encountered calculations in pharmacy use ratios and proportions. In
mathematics, a ratio is the quotient of one quantity divided by another quantity of the same kind,
and a proportion is an equality between ratios. Thus, a proportion involves a relationship among
four quantities. You can always solve for one of those quantities when the other three are known. If
the ratio x/y is equal to the ratio a/b, then the proportion x/y = a/b exists, and x can be obtained by
algebraic manipulation (x = ay/b, etc.). Such problems frequently are encountered when adjusting
dosages.
One common source of error in proportion problems involves writing one of the ratios upside down
(e.g., writing x/y = b/a, when it should be written x/y = a/b). A disciplined approach to setting up
such problems can help. For example, you might establish a rule in which you express each ratio as
the quotient of like quantities. Then, when you equate the two ratios, if the numerator of one ratio is
smaller (or larger) than its denominator, the same should be true of the other ratio as well.
Another source of error involves using mixed units (e.g., using one number expressed in grams and
the other in milligrams). To guard against that kind of error, always write the units into the equation
along with the numbers. All unit expressions should cancel except those required for the quantity
being solved for (dimensional analysis).
Example: If 300 mL of a preparation contains 250 mg of drug, what weight of drug (x) is contained
in 1,800 mL of the preparation?
Equate the ratios x:250 mg and 1,800 mL:300 mL to solve for x:
Note that because the new volume is six times greater, the new weight should be six times greater
as well.
1-4. Specific Gravity and Density
At times, you will be required to convert a volume measure to a weight measure, or vice versa. To
do so, you will need to use either the specific gravity or the density of the material. The specific
gravity (SpGr) is a ratio of the weight of the material to the weight of the same volume of a
standard material. For liquids, the standard material is water, which has a density of 1 g/mL.
Specific gravity is unitless. Density is the quotient of any measure of the weight of a sample of the
material divided by any measure of the volume of the sample. The units must be explicitly
expressed (e.g., g/mL, lb/gal, etc.). When density is expressed in grams per milliliter, it is
numerically equal to specific gravity. Algebraically, density (weight/volume) is easier to work with
than the corresponding expression for specific gravity.
Example: What is the weight of 750 mL of concentrated hydrochloric acid (SpGr = 1.20)? From
the specific gravity definition, and using the volume of 750 mL,
Rearranging and noting that the density of H2O is 1 g/mL,

(SpGr)
weight of 750 mL HCl = × (weight of 750 mL H2O)
= 1.20 × 750 g = 900 g

Alternatively, specific gravity is numerically equal to density expressed in grams per milliliter.
Thus,
1-5. Percentage Error
Because all measurements are approximations, one must characterize the extent of error involved,
or percentage of error, which is defined as
The term error in the numerator indicates the maximum potential error in the measurement (error =
larger quantity - smaller quantity), while the term quantity desired in the denominator represents the
total amount measured. Percentage of error may be calculated for either a weight or a volume
measurement.
Example: A quantity of material weighs 5.810 g on a prescription balance. Using a much more
accurate analytical balance, the quantity weighs 5.893 g. What is the percentage of error for the
original weighing?
error = 5.893g - 5.810g = 0.083g
The quantity desired is 5.810 g. Thus,

Example: Suppose you wish to weigh out 75.0 mg of an ingredient but mistakenly weigh 65.0 mg
instead. Based on the quantity desired, what is the percentage of error?
1-6. Minimum Measurable
By regulation, weighings by a pharmacist cannot exceed a percentage of error greater than 5%,
which requires that the sensitivity of the balance be known and limits the smallest quantity that can
be weighed. Balance sensitivity is defined in terms of the sensitivity requirement (SR), which is the
weight of material that will move the indicator one marked unit on the index plate of the balance.
For a class A prescription balance, SR = 6 mg. The minimum weighable quantity for a given
balance can be calculated using the percentage of error formula: replace the "error" term with the
SR (e.g., 6 mg), replace the percentage of error term with 5%, and replace the "quantity desired"
term with "minimum weighable quantity" as follows:
Example: For a balance that has an SR of 4 mg, what is the minimum weighable quantity to ensure
a percentage of error no greater than 2%?
Example: What is the SR for a balance with a percentage of error of 5% when weighing 120 mg?
1-7. Patient-Specific Dosage Calculations
Introduction
Drugs with a narrow therapeutic range often are dosed on the basis of patient weight or body
surface area. For patients with renal impairment, some drugs are dosed on the basis of creatinine
clearance.
Dosing Based on Body Weight
Weight-based dosing might involve using the patient's actual body weight (ABW), ideal body
weight (IBW), or perhaps an adjusted ideal body weight that is a function of IBW and ABW. Those
weights are invariably expressed in kilograms.
Example: A patient weighing 180 lb is to receive 0.25 mg/kg per day amphotericin B (reconstituted
and diluted to 0.100 mg/mL) by intravenous (IV) infusion. What volume of solution is required to
deliver the daily dose?
A commonly used equation for calculating IBW is

(sex factor)
IBW (kg) =
+ (2.3 × height in inches over 5 feet),

where the sex factor for males is 50.0 and the sex factor for females is 45.5.
Example: The recommended adult daily dosage for patients with normal renal function for
tobramycin is 3 mg/kg IBW given in three evenly divided doses. What would each injection be for a
male patient who weighs 185 lb and is 5 feet, 9 inches tall?
= 50 + (2.3 × 9) = 50 + 21
IBW (kg)
= 71 kg (ignore ABW of 84 kg)

daily dose (tid) = 71 kg × 3 mg/kg = 213 mg (per day)
Thus, each injection = 213 mg/3 = 71 mg
In the absence of other information, the usual drug doses are considered generally suitable for 70-kg
individuals. Thus, in the absence of more specific information, an adjusted dosage for a notably
larger or smaller individual may be obtained by multiplying the usual dose by the ratio of patient
weight to 70 kg (Clark's rule).
Example: If the adult dose of a drug is 100 mg and no child-specific dosing information is
available, what would the weight-adjusted dose be for a child who weighs 40 kg?
Dosing Based on Body Surface Area
Dosing based on body surface area requires an estimation of the patient's body surface area (BSA)
expressed in square meters (m2). That parameter might be estimated from a nomogram using height
and weight or, for adults, by using one of several equations such as:
Example: What is the computed BSA for an adult who weighs 88 kg and is 5 feet, 10 inches tall?
The average adult BSA is taken to be 1.73 m2. That value can be used to obtain an approximate
child's dose, given the usual dose for an adult and the child's estimated BSA.
Example: If the adult dose of a drug is 50 mg, what would the BSA-adjusted dose be for a child
having an estimated BSA of 0.55 m2?
Dosing Based on Creatinine Clearance
For many drugs, the rate of elimination depends on kidney function. Creatinine clearance (CrCl) is
a measure of the volume of blood plasma that is cleared of creatinine by kidney filtration per
minute, and it is expressed in milliliters per minute. Creatinine clearance can be calculated using the
Cockcroft-Gault equation as a function of patient sex, age, body weight, and serum creatinine.
For males:
For females:
CrCl = 0.85 × CrCl for males
Example: Using the Cockcroft-Gault equation, calculate the creatinine clearance rate for a 76-year-
old female weighing 65 kg and having a serum creatinine of 0.52 mg/dL.
Alternatively, creatinine clearance may be estimated using the Jelliffe equations.
For males:
For females:
CrCl = 0.9 × CrCl for males
The normal value for creatinine clearance is taken to be 100 mL/min. Sometimes one must adjust
CrCl to the patient's BSA, which is calculated as:
The maintenance dose for some drugs is based on IBW and CrCl. See Chapter 6 for more detailed
information.
1-8. Using Batch Preparation Formulas
The relative amounts of ingredients in a pharmaceutical product are specified in a formula. A

pharmacist may be required to reduce or enlarge the formula to prepare a lesser or greater amount of
product. A given formula might specify either the actual amount (weight or volume) of each
ingredient for a specified total amount of product or just the relative amount (part) of each
ingredient. In the latter case, the ingredients must all be of the same measure (e.g., weight in
grams).
Example: From the following lotion formula, calculate the quantity of triethanolamine required to
make 200 mL of lotion.
Triethanolamine 10 mL

Oleic acid 25 mL

Benzyl benzoate 250 mL

Water to make 1,000 mL

Example: From the following formula, calculate the quantity of chlorpheniramine maleate required
to make 500 g of product.
Chlorpheniramine maleate 6 parts

Phenindamine 20 parts

Phenylpropanolamine HCl 55 parts

Note that the formula will give a total of 81 parts, which will correspond to the desired quantity of
500 g. Then,
1-9. Conventions in Expression of Concentration
Introduction
In pharmacy, one will encounter a diversity of conventions for expressing drug concentrations. One
must be prepared to calculate drug concentration units directly from their definitions and to
interconvert among them.
Percentage Strength
Percentage, strictly speaking, specifies the number of parts per 100 parts. In pharmacy, percentage
comes in three varieties:
• Percent weight-in-weight = %(w/w) = grams of ingredient in 100 grams of product (assumed for
mixtures of solids and semisolids)
• Percent volume-in-volume = %(v/v) = milliliters of ingredient in 100 milliliters of product

(assumed for solutions or mixtures of liquids)
• Percent weight-in-volume = %(w/v) = grams of ingredient in 100 milliliters of product (assumed

for solutions of solids in liquids)
Example: What is the concentration in %(w/v) for a preparation containing 250 mg of drug in 50
mL of solution? Note that %(w/v) is defined as g/100 mL. Thus,
Parts (Ratio Strength)
Concentrations may be expressed in "parts" or ratio strength when the active ingredient is highly
diluted. Assumptions concerning (w/w), (v/v), and (w/v) ratios are identical to those for
percentages.
Example: What is the concentration in %(v/v) of a solution that has a ratio strength of 1:2,500
(v/v)?
Millimoles
By definition, a 1 molar solution contains 1 gram molecular weight (1 GMW = 1 mole = weight in
grams of Avogadro's number of particles) per liter of solution. The molarity expresses the number
of moles per liter. The millimolarity (millimoles/liter) is 1,000 times the molarity of a solution.
Example: What is the millimolar concentration of a solution consisting of 0.90 g of sodium

chloride (GMW = 58.5) in 100 mL of water? The quantity of 0.9 g in 100 mL corresponds to 9.0 g
in 1,000 mL.
Milliequivalents
By definition, the equivalent weight of an ion is the atomic or formula weight of the ion divided by
the absolute value of its valence. Thus, the equivalent weight of ferric ion, Fe3+ (atomic weight
55.9, valence 3), is 18.6. A milliequivalent is 1,000th of an equivalent weight (i.e., 1,000
milliequivalent weights equal 1 equivalent weight). For a molecule, the equivalent weight is
obtained as the GMW (formula weight) divided by the total cation or the total anion charge. For
example, the equivalent weight of MgCl2 (atomic weight of Mg2+ = 24.3, with a valence of +2;
atomic weight of Cl1- = 35.5, with a valence of -1) is (24.3 + 2 × 35.5)/2 = 47.7 g. Its
milliequivalent weight is 0.0477 g, or 47.7 mg. In the case of a nondissociating (nonionizing)
molecule (e.g., dextrose or tobramycin), the equivalent weight is equal to the formula weight.
Example: What is the concentration, in milliequivalents per liter, of a solution containing 14.9 g of
KCl (GMW = 74.5 g) in 1 liter? Note that the valence of potassium is 1+, so the equivalent weight
equals the molecular weight. Accordingly,
Example: What weight of MgSO4 (GMW = 120) is required to prepare 1 liter of a solution that is
25.0 mEq/L in Mg2+? One must have 25.0 mEq of MgSO4 to obtain 25.0 mEq of Mg. The valence
of Mg (and total positive charge) is 2+; therefore, the equivalent weight of MgSO4 is 120/2 = 60 g.
Accordingly, 60 mg corresponds to 1 mEq of MgSO4. Then,
Example: How many milliequivalents of Ca2+ are contained in 100 mL of a solution that is
5.0%(w/v) in CaCl2 (GMW = 111, atomic weight of Ca2+ = 40, atomic weight of Cl- = 35.5)? Note
that the valence of calcium is 2+. The solution contains 5.0 g CaCl2 per 100 mL, which corresponds
to (5.0 g/111) × 2 = 0.090 equivalents of CaCl2, as well as Ca2+. Accordingly, 100 mL of the
solution contains 90 mEq of Ca2+.
Milliosmoles
Osmotic concentration is a measure of the total number of particles in solution and is expressed in
milliosmoles (mOsm). Thus, the number of milliosmoles is based on the total number of cations
and the total number of anions. The milliosmolarity of a solution is the number of milliosmoles per
liter of solution (mOsm/L), where:
mOsm/L = (moles/L) × number of species

× 1,000 moles

number of number of ionic species upon complete dissociation (e.g., dextrose = 1 specie,
species = NaCl = 2 species, MgCl2)

The total osmolarity of a solution is the sum of the osmolarities of the solute components of the
solution. When calculating osmolarities, in the absence of other information, assume that salts (e.g.,
NaCl, etc.) dissociate completely (referred to as the ideal osmolarity). You should be aware of the
distinction between the terms milliosmolarity (milliosmoles per liter of solution) and
milliosmolality (milliosmoles per kilogram of solution).
Example: What is the concentration, in milliosmoles per liter, of a solution that contains 224 mg of
KCl (GMW = 74.6 g) and 234 mg of NaCl (GMW = 58.5) in 500 mL? What is the number of
milliosmoles per liter of K+ alone?
Milligrams per 100 Milliliters and Milligrams per Deciliter

Traditionally, some lab test values are reported as the number of milligrams per 100 milliliters
(mg%) or, equivalently, milligrams per deciliter (mg/dL).
Example: What is the %(w/v) concentration of glucose in a patient with a blood glucose reading of
230 mg/dL? Note that 1 dL = 100 mL and that 230 mg = 0.230 g. Then,
"Units" and Micrograms per Milligram
The concentrations for some drugs whose production involves incomplete isolation from natural
sources might be expressed in terms of "units" of activity or micrograms per milligram (mcg/mg) as
determined by a standardized bioassay.
Example: A preparation of penicillin G sodium contains 2.2 mEq of sodium (atomic weight = 23,
valence = 1+) per 1 million units of penicillin. How many milligrams of sodium are contained in an
IV infusion of 5 million units? The 5 million unit dose will contain 5 × 2.2 mEq = 11.0 mEq.
mEq weight of sodium = 23 mg

= (23 mg/mEq) × 11.0 mEq
weight of sodium
= 253 mg

Parts per Million and Parts per Billion
Very low concentrations often are expressed in terms of parts per million (ppm) (the number of
parts of ingredient per million parts of mixture or solution) or parts per billion (ppb) (the number of
parts of ingredient per billion parts of mixture or solution). Thus, ppm and ppb are special cases of
ratio strength concentrations.
Example: Re-express 1:25,000 in terms of parts per million.
(i.e., the concentration is 40 ppm)
1-10. Dilutions and Concentrations
Simple Dilutions
In simple dilutions, a desired drug concentration is obtained by adding more solvent (or diluent) to
an existing solution or mixture. Mathematically, the key feature of this process is that the initial and
final amount of drug present remain unchanged. The amount of drug in any solution is proportional
to the concentration times the quantity of the solution. Thus, taking the initial concentration as C1,
the initial quantity of solution as Q1, the final concentration as C2, and the final quantity of solution
as Q2, one has the relationship: C1 × Q1 = C2 × Q2. When provided with values for any three of
those variables, the fourth variable can be calculated. (Because the equation can be rearranged to
C1/C2 = Q2/Q1, it sometimes is referred to as an inverse proportionality.)
Example: How much water should be added to 250 mL of a solution of 0.20%(w/v) benzalkonium
chloride to make a 0.050 %(w/v) solution?
Alcohol Solutions
The preceding treatment of dilutions assumes that solution and solvent volumes are reasonably
additive. For dilutions of concentrated ethyl alcohol in water, that is not the case, because a
contraction in volume occurs on mixing. Consequently, you cannot extend the calculation to
determine the exact volume of water to add to the initial alcohol solution. That is, the volume of
water to be added cannot be obtained simply as Q2 - Q1. Rather, you can specify only that sufficient
water be added to the initial concentrated alcohol solution (Q1) to reach the specified or calculated
final volume (Q2) of the diluted alcohol solution.
Example: How much water should be added to 100 mL of 95%(v/v) ethanol to make 50%(v/v)
ethanol?
Thus, to the 100 mL of 95%(v/v) ethanol add sufficient water to make 190 mL. The sufficient
quantity of water will be more than 90 mL because of the contraction that occurs when concentrated
alcohol is mixed with water.
Concentrated Acids
Concentrated mineral acids (hydrochloric, sulfuric, nitric, and phosphoric) are manufactured by
bubbling the pure acid gas into water to produce a saturated solution. The manufacturer specifies
the concentration as a %(w/w). However, when preparing diluted acids for compounding, the
pharmacist must express the concentration as a %(w/v), which requires use of the specific gravity of
the concentrated acid.
Example: What volume of 35%(w/w) concentrated HCl (SpGr 1.20) is required to make 500 mL of
5%(w/v) solution?
First, determine the weight of HCl required for the dilute solution. Because the dilute solution is
5%(w/v), it will contain 5 g in each 100 mL, or 25 g in 500 mL.
Next, one must determine what weight, x, of the 35%(w/w) solution contains 25 g of HCl. By
proportion,
Finally, use the specific gravity of the concentrated solution to convert the weight to volume. Here,
recall that specific gravity is numerically equal to density when the latter is expressed in grams per
milliliter. Thus,
density = 1.20 g/mL = weight/volume
Rearranging,
Triturations
Triturations are simply 10%(w/w) finely powdered (triturated) mixtures of a drug in an inert
substance.
Example: What weight of colchicine trituration is required to prepare 30 doses of 0.25 mg each of
colchicine?
For the trituration, 10 mg of the mixture contains 1 mg of drug. Thus,
Alligation Alternate Method
Sometimes a drug concentration is required that is in between the concentrations of two (or more)
stock solutions (or available drug products). In that case, the alligation alternate method may be
used to quickly obtain the relative parts of each of the stock solutions needed to yield the desired
concentration. If stock solutions of concentrations A% and B% (A% > B%) are to be used to make
a solution of concentration C%, one sets up the following diagram to obtain the relative parts of
solutions A and B.
A% (C% - B%) parts of A

C%

B% (A% - C%) parts of B

Example: In what proportion should 20%(w/v) dextrose be mixed with 5%(w/v) dextrose to obtain
15%(w/v) dextrose? How much of each is required to make 75 mL of 15%(w/v) solution?
20% 10 parts of 20%

15%

5% 5 parts of 5%

Thus, combine the stock solutions in the ratio of 10 parts of 20%(w/v) dextrose:5 parts of 5%(w/v)
dextrose (i.e., 2:1). Accordingly, to make 75 mL of 15% solution, mix 50 mL of 20% solution with
25 mL of 5% solution.
Alligation Medial Method
Sometimes one may need to know the final concentration of a solution obtained by mixing
specified volumes of two or more stock solutions. In that case, the alligation medial method may be
used.
Example: What is the concentration of a solution prepared by combining 100 mL of a 10%

solution, 200 mL of a 20% solution, and 300 mL of a 30% solution? Proceed as follows:
1-11. Isotonic Solutions
Introduction
In pharmacy, the preparation of many solutions requires attention to osmotic pressure, a colligative
property that is especially relevant for membrane transport. Other colligative properties include
freezing point depression and boiling point elevation. Those properties are a function of the total
number of particles dissolved in the solution, regardless of the identity of the particles. Here, the
term particles corresponds to cations, anions, and neutral undissociated molecules. A solution that
has the same osmotic pressure as bodily fluids (blood or tears) is said to be isotonic (and isosmotic).
As points of reference, 5.0%(w/v) dextrose, a nondissociating molecule, and 0.9%(w/v) sodium
chloride, a dissociating molecule, are isotonic.
Dissociating Solutes
Preparing solutions of specific tonicities requires knowledge of the dissociation properties of the
solutes involved. One must know if the solute in question dissociates and, if so, to what extent and
into how many particles. For example, in weak solutions, sodium chloride dissociates about 80%
into two particles, yielding a solution containing Na+ ions, Cl- ions, and undissociated NaCl
molecules. A measure of the extent of dissociation is provided by the dissociation factor, i, which is
defined as the ratio of the total number of particles following dissociation to the number of
molecules prior to dissociation. For example, 100 molecules of sodium chloride (prior to
dissociation) will dissociate 80% to produce 80 particles of Na+, 80 particles of Cl-, and 20 particles
of NaCl, or 180 particles in all. The dissociation factor, i, for NaCl, then, is 180/100 = 1.8. A
nondissociating molecule (such as dextrose or tobramycin) is assigned a dissociation constant of
1.0. If measured dissociation information is not available, one can assume approximately 80%
dissociation for weak solutions of salts. In that case, salts (including drugs) that dissociate into two
ions (such as sodium chloride and ephedrine hydrochloride) will have a dissociation factor of 1.8;
salts that dissociate into three ions (such as ephedrine sulfate) will have a dissociation factor of 2.6;
salts that dissociate into four ions (such as sodium citrate) will have a dissociation factor of 3.4.
Example: What is the dissociation factor (i) for a compound that dissociates 60% into three ions?
For each 100 undissolved molecules, one will obtain the following on dissolution:
60 × 3 = 180 particles of ions + 40 particles of undissociated molecules = a total of 220 particles

Thus, the dissociation factor = i = 220/100 = 2.2.
Example: What is the dissociation factor for dextrose, a nondissociating compound?
For each 100 undissolved molecules, one will obtain the following on dissolution:
0 particles of ions + 100 particles of undissociated molecules = a total of 100 particles
Thus, the dissociation factor = i = 100/100 = 1.0.
Sodium Chloride Equivalents or E value
When preparing isotonic drug solutions, one must take the tonicity contribution of the drug into
consideration. That can be accomplished by using the sodium chloride equivalent (E value) for the
drug, which is defined as the number of grams of sodium chloride that would produce the same
tonicity effect as 1 gram of the drug. If the value of the sodium chloride equivalent is not provided,
it can be calculated using the molecular weights (MWs) and dissociation factors of sodium chloride
and the drug in question:
Example: What is the sodium chloride equivalent of demecarium bromide (GMW = 717, i = 2.6)?
Thus, each gram of demecarium bromide is equivalent to 0.12 g sodium chloride. So how does one
proceed to prepare a drug solution that must be made isotonic? Using the total volume of isotonic
solution to be prepared, first calculate the hypothetical weight, x, of sodium chloride (alone) that
would be required to make that volume of water isotonic (0.9%). Next, using the weight of drug to
be incorporated in the solution and its sodium chloride equivalent, calculate the weight of sodium
chloride, y, that would correspond to the weight of the drug. Then, calculate the true weight of
sodium chloride, z, to be added to the preparation as z = x - y.
Example: What weight of sodium chloride would be required to prepare 50 mL of an isotonic

solution containing 500 mg of pilocarpine nitrate (sodium chloride equivalent = 0.23)?
Because isotonic saline requires 0.9 g/100 mL, 50 mL of isotonic saline will require 0.45 g (i.e., x =
0.45 g). The 500 mg of pilocarpine nitrate will correspond to 500 mg × 0.23 = 115 mg sodium
chloride (i.e., y = 0.12 g). Thus, the weight of sodium chloride needed to make an isotonic solution
= z = x - y = 0.45 g - 0.12 g = 0.33 g.
Example: A (fictitious) new drug, Utopical (MW = 175, dissociation factor i = 3.4), is to be
provided as 325 mg in 60 mL of solution made isotonic with sodium chloride. What is the required
weight of sodium chloride?
Here, the sodium chloride equivalent of the drug is not given and must be calculated from the
information provided.
Because isotonic saline requires 0.9 g/100 mL, 60 mL of isotonic saline will require 0.54 g (i.e., x =
0.54 g). The 325 mg of Utopical will correspond to 0.325 g × 0.63 = 0.20 g of sodium chloride (i.e.,
y = 0.20 g). Thus, the weight of sodium chloride needed to make an isotonic solution = z = (x - y) =
(0.54 g - 0.20 g) = 0.34 g.
1-12. Intravenous Infusion Flow Rates

A physician may specify the rate of flow of IV fluids in drops per minute, amount of drug per hour,
or the duration of time of administration of the total volume of the infusion. Therefore, to program
an infusion pump to give the medication at the correct rate, one may need to calculate the infusion
rate in per minute or per hour increments.
Example: If 250 mg of a drug is added to a 500-mL D5W bag, what should the flow rate be, in
milliliters per hour, to deliver 50 mg of drug per hour?
Example: If an infusion flow rate is 100 mL/h and the infusion set delivers 15 drops/mL, what is
the rate of flow in drops per minute?
15 drops/mL = × 100 mL/h = 1,500 drops/h

= 25 drops/min

Example: If 500 mL of an infusion is to be delivered using an IV administration set that delivers 10

drops/mL and the flow rate is set at 1.25 mL/min, how long will it take to deliver the 500 mL?
(The 10 drops/mL is superfluous information.)
1-13. Buffers
Buffer solutions are used to reduce pH fluctuations associated with introduction of small amounts
of strong acids or bases. Typical buffer solutions are composed of a weak acid or weak base plus a
salt of the acid or base. Solution pH in the presence of a buffer can be calculated using the
Henderson-Hasselbalch equations.
For weak acids, pH = pKa + log(salt/acid)

For weak bases, pH = pKw - pKb + log(base/salt)

where pKw = 14

Example: What is the pH of a buffer solution prepared to be 0.50 moles (M) in sodium acetate and
0.05 M in acetic acid (pKa of acetic acid = 4.76)?
Example: What is the pH of a buffer solution prepared to be 0.5 M in ammonia (pKb = 4.74) and
0.05 M in ammonium chloride?
Ammonia forms a base in aqueous solution.
pH = pKw - pKb + log(base/salt) = 14.00 -4.74 + log(0.50/0.05) = 14.00-4.74 + 1.00 = 10.26
1-14. Temperature
Frequently, one must convert temperature from Fahrenheit (F) to Centigrade (C), and vice versa.
The following formula can be used: 9°C = 5°F - 160.
Example: A patient has an oral temperature of 100°F. What is that temperature in °C?
1-15. Questions
If 100 capsules contain 340 mg of active ingredient, what is the weight of active ingredient in
75 capsules?
A. 453 mg
1.
B. 340 mg
C. 255 mg
D. 128 mg
E. 75 mg

What is the weight of 500 mL of a liquid whose specific gravity is 1.13?
A. 442 mg
2. B. 565 g
C. 442 g
D. 885 mg
E. 221 g

A pharmacist weighs out 325 mg of a substance on her class A prescription balance. When she
subsequently checks the weight on a more sensitive analytical balance, she finds it to be only
312 mg. What is the percentage of error in the original weighing?
3. A. 4%
B. 5%
C. 6%
D. 10%
E. 12%

What is the minimum weighable quantity for a maximum of 5% error using a balance with a
sensitivity requirement of 6 mg?
A. 80 mcg
4.
B. 100 mg
C. 120 mg
D. 150 mg
E. 240 mg

A patient weighing 175 lb is to receive an initial daily intramuscular (IM) dosage of
procainamide HCl (500 mg/mL vial) of 50 mg/kg (ABW) to be given in divided doses every 3
hours. How many milliliters should each injection contain?
5. A. 3.98 mL
B. 0.49 mL
C. 8.23 mL
D. 1.87 mL
E. 0.99 mL

What is the ideal body weight of a female patient whose height is 5 feet 8 inches?
A. 68 kg
6. B. 64 kg
C. 150 lb
D. 121 lb
E. 53 kg

What is the approximate BSA of an adult patient who weighs 154 lb and is 6 feet tall?
A. 1.73 m2
7. B. 3.15 m2
C. 1.89 m2
D. 0.70 m2
E. 2.67 m2

If the adult dose of a drug is 125 mg, what is the dose for a child whose BSA is estimated to be
0.68 m2?
A. 485 mcg
8.
B. 318 mg
C. 85 mg
D. 49 mg
E. 33 mg

What is the creatinine clearance for a 65-year-old female who weighs 50 kg and has a serum
creatinine level of 1.3 mg/dL?
A. 34 mL/min
9.
B. 40 mL/min
C. 26 mL/min
D. 82 mL/min
E. 100 mL/min

Using the formula that follows, determine how much zinc oxide is required to make 750 g of
10.
mixture:

Zinc oxide 150 g

Starch 250 g

Petrolatum 550 g

Coal tar 50 g

A. 200 g
B. 188 g
C. 413 g
D. 113 g
E. 38 g

Using the formula that follows, determine the weight of kaolin that would be required to
11.
produce 500 g of mixture:

Kaolin 12 parts

Magnesium oxide 3 parts

Bismuth subcarbonate 5 parts

A. 83 g
B. 300 g
C. 208 g
D. 333 g
E. 250 g

How much dextrose is required to prepare 500 mL of an aqueous 10% solution?
A. 250 mg
12. B. 500 mg
C. 10 g
D. 25 g
E. 50 g

What weight of hexachlorophene should be used in compounding 20 g of an ointment
containing hexachlorophene at a concentration of 1:400?
A. 25 mcg
13.
B. 50 mcg
C. 50 mg
D. 80 mg
E. 5 g

What weight of magnesium chloride (MgCl2, formula weight = 95.3) is required to prepare 200
mL of a solution that is 5.0 millimolar?
A. 191 mg
14.
B. 95.3 mg
C. 19.1 mg
D. 477 mcg
E. 95 g

What weight of magnesium chloride (MgCl2, formula weight = 95.3; Mg2+, atomic weight =
24.3; Cl1-, atomic weight = 35.5) is required to prepare 1,000 mL of a solution that contains 5.0
mEq of magnesium?
15. A. 238 mg
B. 4.76 g
C. 1.19 g
D. 60.7 mg
E. 476 mcg

What is the milliosmolarity (ideal) of normal saline (NaCl, formula weight = 58.5)?
A. 100 mOsm/L
16. B. 154 mOsm/L
C. 254 mOsm/L
D. 287 mOsm/L
E. 308 mOsm/L

How much water for injection should be added to 250 mL of 20% dextrose to obtain 15%
dextrose?
A. 333 mL
17.
B. 83 mL
C. 250 mL
D. 166 mL
E. 58 mL

What volume of a 5% dextrose solution should be mixed with 200 mL of a 20% dextrose
solution to prepare 300 mL of a 15% dextrose solution?
A. 150 mL
18.
B. 200 mL
C. 100 mL
D. 50 mL
E. 250 mL

What is the final concentration obtained by mixing 200 mL of 20% dextrose with 100 mL of
5% dextrose?
A. 10%
19.
B. 15%
C. 7.5%
D. 12.5%
E. 17.5%

Magnesium chloride (MgCl2) is a 3-ion electrolyte that dissociates 80% at the relevant
concentration. Calculate its dissociation factor (i).
A. 1.8
20.
B. 2.2
C. 2.4
D. 2.6
E. 3.2

Tobramycin (formula weight = 468) has a dissociation factor of 1.0. What is its sodium
chloride equivalent?
A. 0.069
21.
B. 0.0092
C. 0.117
D. 0.286
E. 0.782

What weight of sodium chloride should be used in compounding the following prescription for
22. ephedrine sulfate (formula weight = 429, dissociation factor = 2.6, sodium chloride equivalent
= 0.23)?

Ephedrine sulfate
0.25 g
Sodium chloride
qs
Purified water ad
30 mL
Make isoton. sol.

A. 1.22 g
B. 784 mcg
C. 212 mg
D. 527 mcg
E. 429 mg

A patient is to receive an infusion of 2 g of lidocaine in 500 mL D 5W at a rate of 2 mg/min.
What is the flow rate in milliliters per hour?
A. 2.0 mL/h
23.
B. 6.5 mL/h
C. 15 mL/h
D. 30 mL/h
E. 150 mL/h

What is the pH of a buffer solution prepared with 0.05 M disodium phosphate and 0.05 M
sodium acid phosphate (pKa = 7.21)?
A. 4.55
24.
B. 5.23
C. 6.18
D. 7.05
E. 7.21

Convert 104°F to Centigrade.
A. 22°C
25. B. 34°C
C. 40°C
D. 46°C
E. 54°C

Calculate the amount of water (in grams) in 100 mL of 65% (w/w) syrup that has a density of
1.313.
A. 30 g
26.
B. 75 g
C. 45.95 g
D. 65.25 g
E. 35 g

How much boric acid will be needed to prepare an isotonic solution of the following
27.
prescription?

Phenacaine HCl 1% E value for phenacaine HCl is 0.20

Chlorobutanol 0.5% E value for chlorobutanol is 0.24

Boric acid qs E value for boric acid is 0.52

Purified water ad 60mL

A. 0.55 g
B. 0.67 g
C. 0.75 g
D. 1.2 g
E. 2.2 g

How many milligrams of sodium chloride are required to make 30 mL of a solution of 1%
dibucaine HCl isotonic with tears?
Note: The freezing point depression of 1% dibucaine HCl solution is -0.08°C, and the freezing
point depression of an isotonic solution is -0.52°C.
28.
A. 1.2 g
B. 0.950 g
C. 0.450 g
D. 0.228 g
E. 0.850 g

29. How many milliequivalents of Na+ are contained in a 30 mL dose of the following solution?

Disodium hydrogen phosphate 18 g Na2HPO4 7H2O (MW 268)

Sodium biphosphate 48 g NaH2PO4 4H2O (MW 138)

Purified water ad 100 mL

A. 144.63 mEq
B. 104.34 mEq
C. 40.29 mEq
D. 100 mEq
E. 52 mEq

How many grams per liter are needed to prepare 2N (normality) of H2SO4?
A. 25 g
30. B. 35 g
C. 78 g
D. 49 g
E. 98 g

How many milliequivalents of magnesium sulfate are represented in 1 gram of anhydrous
magnesium sulfate (MgSO4) (MW 120)?
A. 122 mEq
31.
B. 16.67 mEq
C. 12 mEq
D. 10 mEq
E. 19 mEq

What is the concentration (g/mL) of a solution containing 4 milliequivalents of CaCl2 2H2O
per milliliter (MW 147)?
A. 0.345 g/mL
32.
B. 0.986 g/mL
C. 0.389 g/mL
D. 0.294 g/mL
E. 0.545 g/mL

Questions 33-37 are related to the following problem:
An IV infusion for a patient weighing 132 lb calls for 7.5 mg of drug/kg of body weight to be added
to 250 mL of 5% dextrose injection solution.
What is the patient's weight in kilograms?
A. 75 kg
33. B. 25 kg
C. 120 kg
D. 55 kg
E. 60 kg

How much drug is needed?
A. 250 mg
34. B. 350 mg
C. 150 mg
D. 450 mg
E. 900 mg

What is the total number of milliliters the patient receives per day if the IV solution runs at 52
mL/h?
A. 1,350 mL
35.
B. 1,248 mL
C. 256 mL
D. 1,000 mL
E. 1,500 mL

What is the infusion rate in drops per minute (1 mL = 20 drops)?
A. 25 drops/min
36. B. 22 drops/min
C. 17 drops/min
D. 30 drops/min
E. 15 drops/min

How many IV bags does the patient receive per day?
A. 10 bags
37. B. 12 bags
C. 2 bags
D. 5 bags
E. 8 bags

If 50 mg of drug X is mixed with enough ointment base to obtain 20 grams of mixture, what is
the concentration of drug X in ointment (expressed as a ratio)?
A. 1:300
38.
B. 1:400
C. 1:200
D. 1:600
E. 1:100

When 23 mL of water for injection are added to drug-lyophilized powder, the resulting
concentration is 200,000 units/mL. What is the volume of the dry powder if the amount of drug
in the vial was 5,000,000 units?
39. A. 2 mL
B. 4 mL
C. 1 mL
D. 5 mL
E. 9 mL

If 20 grams of salicylic acid are mixed with enough hydrophilic petrolatum to obtain a
concentration of 5%, how much ointment was used to prepare the prescription?
A. 400 g
40.
B. 380 g
C. 250 g
D. 480 g
E. 280 g

1-16. Answers
C.
1. x mg: 340 mg = 75 cap: 100 cap
x = 340 mg × 75 cap/100 cap = 255 mg

2. B. A specific gravity of 1.13 corresponds to a density of 1.13 g/mL.

density =
weight/volume; thus, weight

= density × volume = 1.13 g/mL

× 500 mL = 565 g

A.
3.

C.
4.

E.
5.

B.
6.
IBW = 45.5 + (2.3 × 8) = 64 kg

C.
7.

D.
8.

A.
9.

D. Note that the formula is designed to produce a total of 1,000 g of the mixture. Then, by
proportions:
10.

B. Note that the formula will produce a total of 20 parts of the mixture. Then, by proportions:
11.

E. Note that this will be a solution of a solid in a liquid; thus, the concentration will be %(w/v).
12.

C. By proportions, x g hexachlorophene: 20 g ung. = 1 part hexachlorophene: 400 parts ung.
13.

B. A 1.0 molar solution will contain 95.3 g in 1,000 mL. A 5.0 molar solution will contain 95.3
14. g × 5 = 477 g in 1,000 mL. A 5.0 millimolar solution will contain 477 mg in 1,000 mL. Thus,
200 mL of a 5 millimolar solution will contain 477 mg/5 = 95.3 mg in 200 mL.

A. Because magnesium has a valence of 2, a formula weight of MgCl2 will contain two
equivalent weights of magnesium (and chloride, for that matter). Thus, 5 equivalents of
15.
magnesium are contained in 5 × 95.3/2 g = 238 g MgCl2. Accordingly, 5 mEq of magnesium
are contained in 238 mg MgCl2.

E. Normal saline is 0.90%(w/v), or 0.90 g/100 mL = 9.0 g/1,000 mL.
16.
16.

B.
17.

18. C.

20% (concentration of stock A) 15 - 5 = 10 = parts of A

15% (desired concentration)

5% (concentration of stock B) 20 - 15 = 5 = parts of B

Relative volumes are 10:5, or 2:1. Thus, 200 mL of a 20% dextrose solution (A) will require

100 mL of a 5% dextrose solution (B) to produce 300 mL of a 15% dextrose solution.

B.
19.

D. Each 100 molecules will provide
80 Mg ions
160 Cl ions
20.
20 undissociated molecules
260 particles total
Thus, the dissociation factor = 260/100 = 2.6

A.
21.

C. Because 900 mg of sodium chloride in 100 mL is isotonic,
22.
which is the amount of sodium chloride alone needed to make 30 mL isotonic. But 1 g of
ephedrine sulfate is equivalent to 0.23 g of sodium, thus:

= 0.25 g × 0.23 = 0.058 g
y
= 58 mg of sodium chloride

Accordingly, the amount of sodium chloride to add (z = x - y)

is (270 mg - 58 mg) = 212 mg.

D. The bag contains 2,000 mg in 500 mL, or 4 mg/mL. Therefore, a rate of 2 mg/min
23.
corresponds to 0.5 mL/min, which corresponds to 30 mL/h.

E.
24.

C.
25.

C. Note that 65 %w/w means 65 g in 100 g syrup. The total weight of the 100 mL syrup is 100
mL × 1.313 (density) = 131.3 g. Every 100 g of syrup contains 35 g of water, so
26.

B. The 1% phenacaine HCl equals 0.6 g, and the 0.5% chlorobutanol equals 0.3 g. Because we
know the E value of phenacaine HCl, we can write the ratio:
Because we know the E value of chlorobutanol, we can write the ratio:
The amount of sodium chloride needed to make 60 mL of solution isotonic is calculated as

follows:
27.
amount of sodium chloride needed
= 0.54 g - (0.12g + 0.072g)
= 0.348 g NaCl
Because we know the E value for boric acid, we can write the ratio:

D. The weight of 1% of drug equals 0.3 g. The needed change in freezing point depression to
make the solution isotonic is 0.52°C - 0.08°C = 0.44°C, so the ratio is as follows:
28.
The amount of sodium chloride needed to make 30 mL of water isotonic is calculated as
follows:

A.
1 mEq of disodium hydrogen 1 mEq of disodium biphosphate
We can write the ratio as follows:
We can also write the ratio as follows:

29.
29.
To adjust for volumes, we can write the ratios as follows:
Thus, x1 = 40.29 mEq disodium hydrogen phosphate, and x2 = 104.34 mEq sodium
biphosphate. The total Na+ mEq = 104.34 + 40.29 = 144.63 mEq.

E. Normality is the number of equivalents in one liter of solvent. The expression "2N normal"
30. means two equivalents dissolved in one liter. Because one equivalent of sulfuric acid equals 49
g, 2N is equivalent to dissolving 98 g of sulfuric acid in 1 L of solvent.

B.
31.

D.
32.

E.
33.

D.
34.
7.5 mg/kg × 60 kg = 450 mg

B.
35.
52 ml/h × 1 h × 24 = 1,248 mL

C.
36.

D.
37.

B.
38.
, so X = 400

A.
39.
so x = 25 mL, and the volume of powder is 25 - 23 = 2 mL

B.
40.
, so x = 400g, and the amount of ointment is 400 - 20 = 380 g

1-17. References
Ansel HC, Stoklosa MJ. Pharmaceutical Calculations. 12th ed. Philadelphia: Lippincott Williams &
Wilkins; 2006.
Khan MA, Reddy IK. Pharmaceutical and Clinical Calculations. 2nd ed. Lancaster, Pa.: Technomic
Publishing Co; 2000.
O'Sullivan TA. Understanding Pharmacy Calculations. Washington, D.C.: American

Pharmaceutical Association; 2002.
2. Federal Pharmacy Law - Walter L. Fitzgerald, Jr, BPharm, MS, JD
Introduction
This study guide was developed for the purpose of assisting candidates for the National Association of
Boards of Pharmacy (NABP) Multistate Pharmacy Jurisprudence Examination (MPJE). Because
candidates will have been exposed, through the academic pharmacy degree program, to the federal and
state laws subject to inquiry on the MPJE, this study guide is not intended to be a comprehensive
collection or compilation of the text of those laws. Rather, it is a general overview of the relevant
federal laws with which the candidate should be familiar.
2-1. Resources to Assist in Preparing for the MPJE
Information from NABP
The body of federal and state law, which the MPJE candidate must be knowledgeable about, is quite
extensive. The candidate should begin the process of preparing for the MPJE by reviewing the MPJE
competency statements provided in the NABP Registration Bulletin for the NAPLEX and MPJE
exams. The bulletin is available on the NABP Web site at www.nabp.net . The MPJE statements are
very valuable in focusing the candidate on the body of federal law to be reviewed and understood.
As to the body of state law, NABP offers two resources that may be beneficial to the MPJE candidate.
More about each of these resources is available on the NABP Web site.
The first resource is the Survey of Pharmacy Law , published in CD-ROM format and available for
purchase from NABP. The Survey is revised annually and provides summary information for
individual states on various pharmacy law topics, including prescriptions (issuing, transmitting, and
dispensing requirements); patient counseling; and pharmacy technicians. The Survey is composed of
the following four sections.
• Organization
• Licensing law
• Drug law
• Census data
The second resource is NABPLAW Online. This resource is a searchable, electronic database of the
pharmacy practice act and board of pharmacy rules for each of the 50 states. A free NABPLAW demo
is available at the NABP Web site.
Candidates can purchase short-term access, varying from 1 day to 6 months. Time periods and prices
can be viewed at the NABP Web site.
Information from Electronic Databases of Federal Law
Of great assistance to the MPJE candidate are online, electronic databases of federal law. The
candidate is encouraged to use these databases as necessary during the review process. One of the
greatest advantages (in addition to being no cost) of these electronic databases is the ability, through
active links contained in the databases, to quickly retrieve and review cross-references to individual
sections of the laws as well as to other relevant laws.
Because the "pharmacy law course" is taught at different times at colleges and schools of pharmacy,
these electronic databases can be very beneficial. If the pharmacy law course was taught, for example,
during the first year of the 4-year PharmD curriculum, the candidate may not have been exposed to all
of the changes in federal pharmacy law that occurred over the following 3 years.
Because these databases are quite current, the candidate can achieve two objectives by reviewing the
federal law databases:
• First, the candidate will be refreshed on laws studied previously in the pharmacy law course.
• Second, the candidate will be exposed to changes that have occurred since completing the pharmacy
law course.
Accessing the Federal Food, Drug, and Cosmetic Act and the Federal Controlled Substances Act
Go to the U.S. Code Collection maintained by the Legal Information Institute of the Cornell
University Law School. The Web site address for this collection is www4.law.cornell.edu/uscode .
When the Web page appears, scroll down and select Title 21. From the Web page that will next
appear, you can access both the federal Food, Drug, and Cosmetic Act (FDCA) and the federal
Controlled Substances Act (CSA).
Federal Food, Drug, and Cosmetic Act
On the Web page that appears, select Chapter 9 , which is titled "Federal Food, Drug, and Cosmetic
Act ."
When the next Web page appears, you will see all nine subchapters that constitute the FDCA.
When you select a subchapter, you will then see on the next Web page the individual sections of the
act contained in that subchapter or, in some cases, the individual parts contained in that subchapter.
Where the subchapter contains individual parts, selecting one part leads to a Web page with the
individual sections contained in that part.
Federal Controlled Substances Act

The same Web page used to access the FDCA should be used to access the CSA, which is located at
Chapter 13 instead of Chapter 9 .
After selecting Chapter 13 , use the same process as described for the FDCA.
Accessing the Regulations of the U.S. Food and Drug Administration and the U.S. Drug
Enforcement Administration
Go to the electronic Code of Federal Regulations (CFR) maintained by the U.S. Government Printing
Office. The Web site address for this collection is www.gpoaccess.gov .
When the Web page appears, in the middle column under Executive Resources select "Code of
Federal Regulations."
When the next Web page appears, select "Browse and/or search the CFR," which will take you to the
CFR Titles. Scroll down and select "Title 21" and then select the most current date available. This will
take you to a Web page that lists the individual parts of Title 21. Parts 1-99 through 800-1299 contain
the regulations of the U.S. Food and Drug Administration (FDA). Beginning at Parts 1300 -1399, you
will find the regulations of the U.S. Drug Enforcement Administration (DEA).
The FDA regulations
The scope of the FDA regulations is significantly large, constituting literally thousands of pages.
Therefore, the sections of FDA regulations have not been included in this guide, and the MPJE
candidate should go to the GPO's CFR Web site, as described previously, for review.
The FDA regulations governing drugs begin at Part 200, which is found on the Web site at Parts 200-
299. Thus, the candidate should select Parts 200-299 in the column with the heading "Browse Parts."
When the next Web page appears, the individual parts will appear. When you select any of the parts,
the individual sections in that part will appear on the next Web page. FDA's regulations governing
drugs continue into the next set of parts, specifically, Parts 300-499.
The set of parts that follow (500-599) contains FDA's regulations governing animal drugs and should
be reviewed. The next set of parts (600-799) concerns two items, biologicals and cosmetics, and also
should be reviewed. The final set of parts (800-1299) contains FDA's regulations governing medical
devices and should be reviewed.
In reviewing these parts, the candidate need not read each word of every FDA regulation. To do so
would require an unreasonable and unnecessary time commitment. It is anticipated that the candidate
can recognize whether he or she needs to review the text of the section or move on to the next one.
The MPJE candidate can begin by opening Part 200 of the FDA regulations, as directed previously,
and open the first section of Part 200. Then the candidate should recognize from the section title
whether it contains (a) information about which the candidate is knowledgeable and does not require
review or (b) information that is not subject to inquiry on the MPJE. In the presence of either of these,
the candidate should move forward to the next section.
The DEA regulations
As with the FDA regulations, the scope of the DEA regulations is quite extensive, but fortunately the
DEA regulations are more manageable than the FDA regulations.
In addition, if the candidate has worked in pharmacy practice to any degree, the DEA regulations
likely will be more familiar to him or her than the FDA regulations, because the FDA regulations are
not as directly related to daily pharmacy practice as are the DEA regulations.
The MPJE candidate can review each section of the relevant DEA regulations using the process
described for the FDA regulations, beginning by opening Part 1300 and then each section in each part.
Information from Electronic Databases of State Law
Candidates for the MPJE are anticipated to have at least two resources for their study of relevant state
law. The first of these is the textbook or other compilation of state law that was used in the pharmacy
law course taught in the academic degree program. This first resource will, of course, be of value only
if the candidate is taking the MPJE and seeking licensure as a pharmacist in the same state where the
candidate completed the academic degree program.
The second is what is commonly referred to as the "state board of pharmacy law book." In many
states, on submission of an application for examination for licensure as a pharmacist, the applicant
will be provided a copy of the state board's pharmacy law book. The candidate may also have received
as a final-year pharmacy student the Survey of Pharmacy Law described in the section on resources
available from NABP.
In addition to these resources, as with federal law, a number of electronic databases are available for
accessing state law. Most directly related to preparing for the MPJE is NABPLAW, described in the
section on resources available from NABP. In addition to NABPLAW are various databases that are
accessible free of charge.
The candidate should first look to his or her state's Internet home page for resources on state law.
Although it is not possible to describe here how to find the relevant state law on each state's home
page, the candidate will likely be able to successfully navigate through the state's Web pages.
As an example, the candidate can search to see if the state's secretary of state has an individual home
page and, if it does, look on that home page for a link to state agency rules and regulations, such as
those of the state board of pharmacy.
Beyond the state home page are legal resource Web sites that the candidate can use for accessing state
law, again at no cost. The following Web sites may be useful to the candidate seeking additional
information on not only state law, but also federal and other law:
• Rominger Legal: www.romingerlegal.com
• FindLaw: www.findlaw.com
• Law.com: www.law.com
• AllLaw.com: www.alllaw.com
• Georgia State University Law School Meta-Index: http://gsulaw.gsu.edu/metaindex
Information from Federal Agencies
The value of information available online from federal agencies should not be overlooked in preparing
for the MPJE. Primary among these agencies are the FDA, the DEA, and the Consumer Product
Safety Commission (CPSC).
The FDA Web site (www.fda.gov ) contains many guides on pharmacy compounding, risk evaluation
and mitigation strategies, and many other topics. The MPJE candidate should look specifically at the
FDA Center for Drug Evaluation and Research Web site at www.fda.gov/cder .
The DEA Web site (www.dea.gov ) offers a variety of materials, but the DEA Office of Diversion
Control Web site (www.deadiversion.usdoj.gov ) provides more information of relevance to the MPJE
candidate. Included on the Diversion Control Web site is extensive information about registration
requirements and selling of scheduled listed chemical products such as pseudoephedrine.
Requirements for pharmacy with respect to child-resistant packaging may be found on the CPSC Web
site at www.cpsc.gov . The MPJE candidate should particularly review the CPSC publication "Poison
Prevention Packaging: A Guide for Healthcare Professionals," available at
www.cpsc.gov/CPSCPUB/PUBS/384.pdf .
Publications
At many colleges and schools of pharmacy, a textbook or other compilation of federal and state drug
and pharmacy law may have been used in the pharmacy law course. Thus, the MPJE candidate may
already have a resource that covers the laws subject to inquiry on the MPJE.
If not, other resources may be of assistance, including those from the reference list that follows. The
first two references provide a practical, easy-to-understand explanation of the federal law subject to
inquiry on the MPJE. The third reference provides a variety of state-specific (not all states are
available) study guides in comprehensive and condensed versions. Resources from this reference will
be particularly valuable to a candidate who earned the PharmD degree in a state different from the
state in which he or she seeks licensure.
All of these references contain sample questions that will help the MPJE candidate gain experience in
answering questions related to federal law and obtain a measure of knowledge prior to the MPJE.
References
Reiss BS, Hall GD. Guide to Federal Pharmacy Law . 6th ed. Boynton Beach, FL: Apothecary Press;
2009. Contact information: (888) 609-2665 or www.apothecarypress.com .
Strauss, S. Strauss' Federal Drug Laws and Examination Review . 5th ed. Boca Raton, FL: CRC Press;
2000. Contact information: (800) 272-7737 or www.crcpress.com .
State and federal pharmacy law study guides. Contact information: http://rxlaw.org .
2-2. The Comprehensive Drug Abuse Prevention and Control Act of 1970 and Regulations of
the U.S. DEA
Introduction
The Comprehensive Drug Abuse Prevention and Control Act, enacted by Congress in 1970, has as its
primary purpose preventing illicit manufacture, distribution, and use of controlled substances. This
purpose is achieved through numerous requirements in the act and DEA regulations.
The Comprehensive Drug Abuse Prevention and Control Act, more commonly known as the
Controlled Substances Act, establishes a "closed system" for distribution of drugs that are "controlled
substances." The term closed system means controlled substances can be distributed only by and
between persons registered with the DEA.
The DEA, a unit within the U.S. Department of Justice, was established in July 1973 by an executive
reorganization plan; it replaced the former Bureau of Narcotics and Dangerous Drugs.
The FDA has also promulgated regulations that affect the distribution of controlled substances. One
example is treatment programs for narcotic addicts. The FDA regulations contain medical guidelines
for such programs, and the DEA regulations contain requirements for dispensing and recordkeeping
activities for such programs.
Note that in 1988, Congress amended existing federal laws, including the CSA, with enactment of the
Chemical Diversion and Trafficking Act. This act establishes recordkeeping and reporting
requirements for persons who manufacture, distribute, import, or export a listed precursor or essential
chemical, as well as tableting and encapsulating machines.
When the MPJE candidate studies the CSA and DEA regulations, the text added as a result of this
1988 act is generally easily recognized. For example, the DEA regulation at 21 CFR 1300.02 is titled
"Definitions relating to listed chemicals."
The MPJE candidate needs to be attentive to how the CSA and DEA regulations govern commercially
available controlled substances versus chemicals.
Another very important amendment to the CSA occurred in 2005 with enactment of the Combat
Methamphetamine Epidemic Act (CMEA). The CMEA introduced a new category of substances
(scheduled listed chemical products) and new sale and recordkeeping requirements for those products.
Products in this category include ephedrine, pseudoephedrine, and phenylpropanolamine. DEA has
promulgated several regulations (see Part 1314 of the DEA regulations) to implement the CMEA.
Also in 2005, the CSA was amended to allow private practice physicians (subject to being certified) to
prescribe schedule III, IV, and V narcotic controlled substances for detoxification and maintenance
treatment of opioid dependency. Currently two products, Suboxone and Subutex, may be prescribed
for such treatment. For the MPJE candidate unfamiliar with the requirements for prescribing these
controlled substances, information is available on the Web site of the Substance Abuse and Mental
Health Services Administration at www.samhsa.gov .
Specific information about medication-assisted treatment may be found at www.dpt.samhsa.gov .
Several other developments have occurred in recent years, including DEA's promulgation of
regulations to allow practitioners to issue multiple prescriptions for schedule II controlled substances
and to allow electronic ordering (but not prescribing) of controlled substances. The MPJE candidate
should be familiar with these and other recent developments in the federal laws governing controlled
substances.
The CSA and DEA regulations are quite complex and technical, and they affect pharmacy practice
significantly; thus, they demand thorough study by the MPJE candidate.
Key Provisions of the CSA
Access the CSA at the Web link (www4.law.cornell.edu/uscode ) and follow the process listed earlier.
There are two subchapters:
• I. Control and Enforcement
• II. Import and Export
The MPJE candidate should be familiar with both subchapters, particularly the following provisions
from Subchapter I of the CSA. In addition, the MPJE candidate should review the sections in
Subchapter II on import and export.
Subchapter I. Control and enforcement
Part A—Introductory provisions

801. Congressional findings and declarations: controlled substances
This section sets forth the reasons Congress enacted the CSA. The MPJE candidate should be
generally familiar with these findings and declarations.
801a. Congressional findings and declarations: psychotropic substances

This section recognizes the international treaty—the Convention on Psychotropic Substances—that
the United States entered into in 1971 and sets forth the reasons Congress implemented the
convention. The MPJE candidate should be generally familiar with these findings and declarations.
802. Definitions
The MPJE candidate should be familiar with all terms defined in this section of the CSA, which will
aid in understanding the language of the sections that follow. Note the limitation in dispensing that
results from the relationship between the definition of dispense and the definition of ultimate user.
Note also that some of the definitions contain important substantive content, such as the definition of
a regulated transaction and its placing of "thresholds" on the retail sale of ephedrine, pseudoephedrine,
and phenylpropanolamine. Finally, note the definition of anabolic steroid as amended in 2004.
Part B—Authority to control; standards and schedules

811. Authority and criteria for classification of substances
This section gives the U.S. attorney general the authority to add a drug to a schedule, transfer a drug
between schedules, and remove a drug from a schedule. This section also contains the factors to
consider when determining whether a drug should be placed in or removed from a schedule. This
section also allows exclusion of a nonnarcotic substance from a schedule if the substance may be
lawfully sold, under the FDCA, without a prescription. Finally, this section provides that
dextromethorphan shall not be included in any schedule by reason of enactment of the CSA unless
controlled after October 27, 1970, on the basis of the factors in this section.
812. Schedules of controlled substances

This section establishes the five schedules (I-V) of controlled substances and the findings required for
each schedule. The MPJE candidate should be familiar with these findings, such as that a schedule I
controlled substance "has no currently accepted medical use in treatment."
813. Treatment of controlled substance analogues

This section provides that a controlled substance analogue, to the extent intended for human use, shall
be treated as a controlled substance in schedule I.
814. Removal of exemption of certain drugs

This section, among other things, allows the U.S. attorney general to remove from exemption—see
definition (39)(A)(iv) at section 802 concerning ephedrine, pseudoephedrine, and
phenylpropanolamine—a drug or group of drugs that is being diverted to obtain a listed chemical for
use in illicit production of controlled substances.
Part C—Registration of manufacturers, distributors, and dispensers of controlled substances

821. Rules and regulations
This section authorizes the U.S. attorney general to promulgate rules and regulations and to charge
reasonable fees relating to the registration and control of regulated persons and transactions.
822. Persons required to register
This section sets forth the registration requirements for persons who handle controlled substances. The
MPJE candidate should understand who is and who is not required to obtain a registration, that a
separate registration is required for separate locations, and that an inspection may be conducted prior
to granting a registration.
823. Registration requirements

This section provides specific detail regarding registration of practitioners, including pharmacies but
not pharmacists, and the factors to be considered in determining whether to grant a registration.
824. Denial, revocation, or suspension of registration

This section lists the grounds for denying, suspending, or revoking a registration. Note that a
suspension or revocation may be limited to a particular schedule or schedules and that the registration
can be revoked simultaneously with initiation of proceedings (issuing an "order to show cause") if
there is an imminent danger to public health or safety.
825. Labeling and packaging

This section establishes the labeling requirements for commercial containers of controlled substances.
826. Production quotas for controlled substances

This section authorizes the U.S. attorney general to determine and establish production quotas for
schedule I and II controlled substances to be manufactured each calendar year to provide for the
estimated medical, scientific, research, and industrial needs of the United States, for lawful export
requirements, and for the establishment and maintenance of reserve stocks.
827. Records and reports of registrants

This section establishes requirements for the biennial inventory (in relation to May 1, 1971) and for
the addition of any newly scheduled drug to the existing inventory. This section requires every
registrant to maintain a complete and accurate record of each controlled substance received, sold,
delivered, or otherwise disposed of, but it does not require a perpetual inventory. The MPJE candidate
should recognize the exceptions to the inventory requirement. Note also the recently added reporting
requirements for gamma hydroxybutyric acid.
828. Order forms

This section establishes the requirement that distribution of schedule I and II controlled substances
occur only pursuant to a form issued by the U.S. attorney general (the DEA 222 Form). It also lists
recordkeeping requirements for the form. As a related item, the MPJE candidate should be sure to
review the new DEA regulations on "electronic orders" for controlled substances in Parts 1305 and
1311 of the DEA regulations.
829. Prescriptions
This section sets forth the prescription requirements for each schedule of controlled substances and
notes that schedule V controlled substances, when not dispensed pursuant to a prescription, may be
sold only for a medical purpose.
830. Regulation of listed chemicals and certain machines
This section establishes the recordkeeping and reporting requirements for those engaged in activities
related to listed chemicals and tableting and encapsulating machines.
Part D—Offenses and penalties

841. Prohibited acts A
This section and the next two sections list unlawful acts and the penalties associated with these acts. It
is important for the MPJE candidate to recognize that some of the listed unlawful acts apply to all
persons, whereas others apply only to registrants. The MPJE candidate should recognize what acts are
unlawful and generally be familiar with the associated penalties.
842. Prohibited acts B

See note to section 841 .
843. Prohibited acts C

See note to section 841 .
844. Penalties for simple possession

This section makes possession by any person (including a registrant) of a controlled substance or
listed chemical unlawful unless allowed under the CSA. It also establishes penalties for unlawful
possession and defines what is meant by a "drug, narcotic, or chemical offense."
844a. Civil penalty for possession of small amounts of certain controlled substances
This section provides penalties for any person (including a registrant) for unlawful possession of
"personal use amounts" as specified by the U.S. attorney general by regulation.
846. Attempt and conspiracy

This section provides that persons who "attempt" or "conspire" to commit a controlled substance
offense are subject to the same penalties as prescribed for the offense.
847. Additional penalties

This section provides that any criminal penalties imposed for violation of the CSA do not preclude
other civil and administrative penalties, such as monetary fines under the federal Civil Monetary
Penalties Law or suspension or revocation of a DEA Certificate of Registration.
848. Continuing criminal enterprise

This section defines a continuing criminal enterprise and imposes very severe penalties—including
life imprisonment and the death penalty—for those convicted of engaging in such an enterprise. The
MPJE candidate should recognize that the text of this section includes other offenses that are not
considered a continuing criminal enterprise. For example, this section provides the penalty for any
person who during the commission of, in furtherance of, or while attempting to avoid apprehension,
prosecution, or service of a prison sentence for a felony violation of the CSA intentionally kills, or
counsels, commands, induces, procures, or causes the intentional killing of, any federal, state, or local
law enforcement officer engaged in, or on account of, the performance of such officer's official duties.
If such killing results, that person may be sentenced to any term of imprisonment, which shall not be
less than 20 years and may be up to life imprisonment, or he or she may be sentenced to death.
849. Transportation safety offenses

This section doubles the penalty for the first conviction and triples the penalty for subsequent
convictions of certain controlled substance offenses in a rest area or truck stop, as these terms are
defined in this section.
850. Information for sentencing

This section, unless provided otherwise in another federal law, establishes that no limitation be placed
on the information concerning the background, character, and conduct of a person convicted of a
controlled substance offense that may be received and considered for purposes of imposing an
appropriate sentence.
851. Proceedings to establish prior convictions

This section sets forth the process for establishing that a person has prior convictions of a controlled
substance offense or offenses.
852. Application of treaties and other international agreements

This section provides that no treaties and other international agreements entered into by the United
States shall limit the provision of treatment, education, or rehabilitation as alternatives to conviction
or criminal penalty for offenses involving any drug or other substance subject to a treaty or agreement.
853. Criminal forfeitures

This section provides that persons convicted of controlled substance offenses shall forfeit to the
United States all real and personal property constituting or derived from any proceeds the person
obtained, directly or indirectly, as the result of the offense and any of the person's property used, or
intended to be used, in any manner or part, to commit or to facilitate the commission of the offense.
854. Investment of illicit drug profits

This section makes it unlawful for a person to use or invest in certain enterprises, as defined in this
section, any income derived, directly or indirectly, from a violation of the CSA that is punishable by
imprisonment for more than 1 year, provided that the person participated as a principal in the
violation. It also provides penalties for making such investments.
855. Alternative fine

This section provides that, in lieu of a fine otherwise authorized by Part D , a defendant who derives
profits or other proceeds from an offense may be fined not more than twice the gross profits or other
proceeds.
856. Maintaining drug-involved premises

This section makes unlawful knowingly opening or maintaining any place for the purpose of
manufacturing, distributing, or using any controlled substance, as well as managing or controlling any
building, room, or enclosure, whether as an owner, lessee, agent, employee, or mortgagee, and
knowingly and intentionally renting, leasing, or making available for use, with or without
compensation, the building, room, or enclosure for the purpose of unlawfully manufacturing, storing,
distributing, or using a controlled substance. It also establishes penalties for a violation.
858. Endangering human life while illegally manufacturing controlled substance

This section provides that whoever, while unlawfully manufacturing a controlled substance or
attempting to do so, or while transporting or causing to be transported materials, including chemicals,
to do so, creates a substantial risk of harm to human life shall be subject to a fine and imprisonment.
859. Distribution to persons under age 21

This section provides enhanced penalties for first and second offenses of a person who is at least 18
years of age unlawfully distributing a controlled substance to a person under 21 years of age.
860. Distribution or manufacturing in or near schools and colleges

This section provides enhanced penalties for first and second offenses of any person who is unlawfully
distributing, possessing with intent to distribute, or manufacturing a controlled substance in or on, or
within 1,000 feet of, the real property comprising a public or private elementary, vocational, or
secondary school; a public or private college, junior college, or university; a playground; or a housing
facility owned by a public housing authority. The enhanced penalties also apply if the offense takes
place within 100 feet of a public or private youth center, public swimming pool, or video arcade
facility. This section also makes it an offense for any person at least 21 years of age to knowingly and
intentionally employ, hire, use, persuade, induce, entice, or coerce a person under 18 years of age to
violate this section or to knowingly and intentionally employ, hire, use, persuade, induce, entice, or
coerce a person under 18 years of age to assist in avoiding detection or apprehension for any offense
under this section by any federal, state, or local law enforcement official.
860a. Consecutive sentence for manufacturing or distributing, or possessing with intent to

manufacture or distribute, methamphetamine on premises where children are present or reside
This section provides additional penalties for anyone manufacturing or distributing methamphetamine
or its salts, isomers, or salts of isomers on premises in which an individual under 18 is present or
resides.
861. Employment or use of persons under 18 years of age in drug operations

This section makes it unlawful for any person at least 18 years of age to knowingly and intentionally
(a) employ, hire, use, persuade, induce, entice, or coerce a person under 18 years of age to violate any
provision of the CSA; (b) employ, hire, use, persuade, induce, entice, or coerce a person under 18
years of age to assist in avoiding detection or apprehension for any offense of the CSA by any federal,
state, or local law enforcement official; or (c) receive a controlled substance from a person under 18
years of age, other than an immediate family member, in violation of the CSA. This section also
establishes penalties for first and subsequent violations of this section. In addition, this section makes
it unlawful to knowingly provide or distribute a controlled substance or a controlled substance
analogue to a person under 18 years of age or to a pregnant person.
862. Denial of federal benefits to drug traffickers and possessors

This section provides for denial of federal benefits to drug traffickers and possessors, with differences
in denial based on whether the person is a drug trafficker or drug possessor.
862a. Denial of assistance and benefits for certain drug-related convictions
This section provides for denial of federal benefits and assistance to an individual convicted under
federal or state law of any offense that is classified as a felony by the law of the jurisdiction involved
and that has as an element of the offense the possession, use, or distribution of a controlled substance.
862b. Sanctioning for testing positive for controlled substances

This section provides that the federal government shall not prohibit states from testing welfare
recipients for use of controlled substances or from sanctioning welfare recipients who test positive for
use of controlled substances.
863. Drug paraphernalia

This section makes unlawful a number of activities with respect to drug paraphernalia, establishes
penalties for violations, and defines drug paraphernalia .
864. Anhydrous ammonia

This section makes unlawful the stealing of anhydrous ammonia or transporting stolen anhydrous
ammonia across state lines, knowing, intending, or having reasonable cause to believe that such
anhydrous ammonia will be used to manufacture a controlled substance in violation of this part.
865. Smuggling methamphetamine or methamphetamine precursor chemicals into the United

States while using facilitated entry programs
This section provides an enhanced prison sentence for a person convicted of an offense involving
methamphetamine when the person convicted was enrolled in, or acting on behalf of a person enrolled
in, any dedicated commuter lane, alternative or accelerated inspection system, or other facilitated entry
program into the United States, or when the person committed the offense while entering the United
States using such a lane, system, or program.
Parts E and F
The last two parts (Part E and Part F ) of Subchapter I contain a variety of sections, many of which are
not of interest to the MPJE candidate. As directed in the introduction to this study guide, the candidate
should open each part and from the titles of the sections in each part determine those that he or she
should review.
Subchapter II. Import and export
This subchapter of the CSA contains several sections governing the importation and exportation of
controlled substances, including requirements for registration of importers and exporters. The MPJE
candidate should review these sections and be generally knowledgeable about the content.
Regulations of the DEA
The DEA regulations may be found in Title 21 of the CFR. The body of DEA regulations is divided
into 17 parts.
The MPJE candidate should review relevant DEA regulations on the electronic database as described
in the introduction to this study guide. Following is a very basic summary of the content of each part.
Part 1300—Definitions
The DEA regulations begin at Part 1300 of Title 21 of the CFR. Part 1300 has two sections, both of
which contain definitions of terms related to controlled substances and to listed chemicals. Because
there are many definitions, they are not included here, but as noted previously for definitions
contained in the CSA, the MPJE candidate should retrieve and review all of the definitions contained
in the two sections of Part 1300 . Some of these definitions are quite extensive and contain very
important information for the MPJE candidate. For example, restrictions related to the sale of
scheduled listed chemical products are found in the definition of regulated transaction at 21 CFR
1300.02.
Part 1301—Registration of manufacturers, distributors, and dispensers of controlled substances
Part 1301 governs the many aspects of registration with the DEA. This part includes the sections
related to who is required to register, how one applies for registration, what exemptions exist to
registration, and what allowances are made for importation for personal use. Also included are
specific details about the DEA Certificate of Registration and the number assignment, procedure for
suspension or revocation of a registration, and modification or termination of a registration. A very
useful chart listing registration categories, fees, periods, and application form numbers is available at
www.deadiversion.usdoj.gov/drugreg/categories.htm . The MPJE candidate should be familiar with
each of these aspects of registration.
Very importantly, requirements for security, including the prohibition of employing certain
individuals, are included in this part. The MPJE candidate should study this part in detail, paying
particular attention to sections 1301.27 and 1301.28, both added in 2005. Although not included
specifically in the DEA regulations, the method for determining the legitimacy of a DEA registration
number is important for the MPJE candidate and thus is described immediately below.
Before October 1, 1985, DEA Certificate of Registration numbers for practitioners began with the
letter "A." Since that date, the DEA Certificate of Registration numbers for practitioners begin with
the letter "B." Further, a DEA Certificate of Registration number issued to a midlevel practitioner
begins with the letter "M." Following the first letter is a second letter, which is the first letter of the
registrant's last name. Following the two letters is a seven-digit computer-generated sequential
number. The number is constructed so that it can be tested for verification by using the following
formula:
• Step 1: Determine the sum of the first, third, and fifth digits.
• Step 2: Determine the sum of the second, fourth, and sixth digits, and then multiply the sum by two.
• Step 3: Determine the sum of the two numbers determined in steps 1 and 2.
• Step 4: The last digit of this third sum should be the same as the last digit of the seven-digit DEA
Certificate of Registration number.
Part 1302—Labeling and packaging requirements for controlled substances
Part 1302 contains the requirements for labeling of the "commercial container" of a controlled
substance. The MPJE candidate should be generally familiar with these requirements.
Part 1303—Quotas
Part 1303 contains the sections related to the establishment of production and procurement quotas for
schedule I and II controlled substances for the estimated medical, scientific, research, and industrial
needs. The MPJE candidate should be generally familiar with the sections in this part.
Part 1304—Records and reports of registrants
Part 1304 contains the many requirements associated with recordkeeping in relation to the various
aspects of handling controlled substances by practitioners, including narcotic treatment programs.
Also included in this part are the requirements associated with inventories of controlled substances,
including the "biennial inventory." The MPJE candidate should be very familiar with the sections in
this part.
Part 1305—Orders for schedule I and II controlled substances
Part 1305 includes the sections describing the DEA Form 222 for ordering schedule II controlled
substances. Also included in this part are the details associated with the granting of a power of
attorney to authorize individuals to execute order forms and electronic orders. The MPJE candidate
should be very familiar with the sections in this part and should be sure to review the regulations
added in 2005 regarding electronic orders for controlled substances.
Part 1306—Prescriptions
Part 1306 contains the sections concerning the many details of issuing, dispensing, and labeling of
prescriptions for controlled substances. Also included in this part in relation to prescriptions are the
requirements for electronic recordkeeping of prescription refills and for transfer of prescriptions
between pharmacies. Finally, this part includes the requirements for the sale of controlled substances
that are not "prescription drugs." The MPJE candidate should be very familiar with the sections in this
part and should be sure to review the new regulations added in 2005 regarding prescribing of some
controlled substances for narcotic treatment, as well as the requirements added more recently at
sections 1306.12(b) and 1306.14(e) regarding issuing of multiple prescriptions for a schedule II
controlled substance.
Part 1307—Miscellaneous
Part 1307 contains a few sections of interest to the MPJE candidate. Of particular note are the sections
on "distribution" by dispensers and disposal of controlled substances.
Part 1308—Schedules of controlled substances
Part 1308 describes the "Administration Controlled Substances Number" and its uses and lists
controlled substances in their respective schedules. Part 1308 also provides for "exempt" and
"excluded" substances, control of immediate precursors, and emergency scheduling. The MPJE
candidate should be generally familiar with controlled substances and the schedule into which they
have been placed, as well as those products that are exempt and excluded, as described in Part 1308 .
Part 1309—Registration of manufacturers, distributors, importers, and exporters of List I

chemicals
Part 1309 includes several provisions related to those engaged in activities with List I chemicals.
Although Part 1309 does not generally affect the practice of pharmacy, the MPJE candidate should
review these sections for familiarity.
Part 1310—Records and reports of listed chemicals and certain machines
Although some sections of Part 1310 also do not generally affect the practice of pharmacy, some
sections in Part 1310 relate to ephedrine, and thus this part deserves review by the MPJE candidate.
Part 1311—Digital certificates
Part 1311 was added in 2005. It governs digital certificates in association with electronic orders for
controlled substances, and the MPJE candidate should study it in detail.
Part 1312—Importation and exportation of controlled substances
Part 1312 includes several provisions related to those engaged in importing and exporting controlled
substances. Although this part does not generally affect the practice of pharmacy, the MPJE candidate
should review these sections for familiarity.
Part 1313—Importation and exportation of list I and list II chemicals
Part 1313 includes several provisions related to those engaged in importing and exporting precursors
and essential chemicals. Although this part does not generally affect the practice of pharmacy, the
MPJE candidate should review these sections for familiarity.
Part 1314—Retail sale of scheduled listed chemical products
Part 1314 is of importance to pharmacy because it sets forth the many requirements associated with
retail sales of scheduled listed chemical products. The MPJE candidate should be very familiar with
the details of selling these products at retail, including restrictions on quantity, recordkeeping
requirements, staff training requirements, and the annual self-certification process.
Part 1315—Importation and production quotas for ephedrine, pseudoephedrine, and
phenylpropanolamine
Part 1315 includes more provisions on scheduled listed chemical products, including a personal use
exemption. Although this part does not generally affect the practice of pharmacy, the MPJE candidate
should review these sections for familiarity.
Part 1316—Administrative functions, practices, and procedures
Part 1316 contains several sections that address inspections, probable cause, and other issues related
to warrants, matters related to research, procedures for hearings, burden of proof, and miscellaneous
other matters. The MPJE candidate should be generally familiar with these matters.
2-3. The Food, Drug, and Cosmetic Act of 1938 and Regulations of the U.S. FDA
Introduction
The Food, Drug, and Cosmetic Act, enacted by Congress in 1938, has as its primary purpose
preventing interstate distribution of foods, drugs, cosmetics, and devices that are adulterated or
misbranded. This purpose is achieved through numerous requirements in the act and FDA regulations.
The MPJE candidate should be familiar with the historical development of the FDCA, and its
predecessor, the Pure Food and Drug Act of 1906. The candidate should also be familiar with
amendments to the FDCA since 1938, including the following:
• Durham-Humphrey Amendment of 1951
• Kefauver-Harris Amendment of 1962
• Medical Device Amendment of 1976
• Orphan Drug Act of 1983
• Drug Price Competition and Patent Term Restoration Act of 1984
• Prescription Drug Marketing Act of 1987
• Safe Medical Devices Act of 1990
• Dietary Supplement Health and Education Act of 1994
• Food and Drug Administration Modernization Act of 1997
• Best Pharmaceuticals for Children Act of 2002

• Medical Device User Fee and Modernization Act of 2002
• Pediatric Research Equity Act of 2003
• Minor Use and Minor Species Animal Health Act of 2004
• Food Allergen Labeling and Consumer Protection Act of 2004
• Dietary Supplement and Nonprescription Drug Consumer Protection Act of 2006
• Food and Drug Administration Amendments Act of 2007
Key Provisions of the FDCA
The FDCA is located at Chapter 9 of Title 21 of the United States Code. Chapter 9 has the following
nine subchapters:
I. Short Title
II. Definitions
III. Prohibited Acts and Penalties
IV. Food
V. Drugs and Devices
VI. Cosmetics
VII. General Authority
VIII. Imports and Exports
IX. Miscellaneous
The MPJE candidate should be particularly familiar with Subchapters II, III, V (which is divided into
Subparts A through E), and VI and with the following sections within the subchapters of the FDCA.
Subchapter II. Definitions
321. Definitions; generally

The MPJE candidate should be familiar with all terms defined in this section of the FDCA, which will
aid in understanding the language of the sections that follow. The candidate also should be able to
distinguish between terms such as drug, counterfeit drug, new drug, device, dietary supplement, food,
and cosmetic .
Subchapter III. Prohibited acts and penalties
331. Prohibited acts

The MPJE candidate should be familiar with conduct that is prohibited by the FDCA, as set forth in
this section.
332. Injunction proceedings

This section provides that the U.S. district courts and all courts exercising jurisdiction in U.S.
territories have jurisdiction to enjoin violations of section 331 , with some exceptions as set forth in
this section. Furthermore, an alleged violation of an injunction or restraining order shall, upon demand
of the accused, be tried before a jury.
333. Penalties
The penalties for violation of the FDCA range from not very severe to very severe. The MPJE
candidate should be familiar with the penalties, and particularly those related to the prescription drug
marketing violations (i.e., drug samples) and distribution of human growth hormone. Notice the use of
the term knowingly, as defined in section 321 .
334. Seizure
This section describes the process related to seizure and disposition of adulterated and misbranded
foods, drugs, and cosmetics, a process with which the MPJE candidate should be familiar.
335. Hearing before report of criminal violation

This section provides that before any violation of this chapter is reported to a U.S. attorney for
criminal proceedings, the person against whom the proceeding is contemplated shall be given
appropriate notice and an opportunity to present his or her views, either orally or in writing.
335a. Debarment, temporary denial of approval, and suspension

This section describes the "debarment" from submitting or assisting in the submission of applications
for drug approvals of businesses and individuals based on prior misconduct related to the drug
approval process. The MPJE candidate should be able to distinguish the various characteristics of
mandatory and permissive debarments.
335b. Civil penalties

This section continues the matter of misconduct in the drug approval process. The MPJE candidate
should be familiar with the conduct prohibited and the associated penalties, together with the
provision concerning informants.
335c. Authority to withdraw approval of abbreviated drug applications

This section authorizes the withdrawal of approval of abbreviated drug applications if the approval
was obtained, expedited, or otherwise facilitated through bribery, payment of an illegal gratuity, or
fraud or material false statement. Withdrawal is also authorized if the manufacturer has repeatedly
demonstrated a lack of ability to produce the drug for which the application was submitted in
accordance with the formulations and manufacturing processes set forth in the application and has
introduced, or attempted to introduce, such adulterated or misbranded drug into commerce. This
section also provides procedures for withdrawals.
336. Report of minor violations

This section provides that the secretary of Health and Human Services (HHS) is not required to report
for prosecution, or for the institution of libel or injunction proceedings, minor violations of this
chapter whenever he or she believes that the public interest will be adequately served by a suitable
written notice or warning.
337. Proceedings in the name of United States; provision as to subpoenas
This section requires that legal proceedings for enforcement or restraint of violations be in the name of
the United States. However, this section also allows states to bring actions under the act, but only
upon notice being given to the HHS secretary as set forth in this section.
Subchapter IV. Food
Although this subchapter is titled "Food," the MPJE candidate should review select sections because
they contain requirements related to dietary supplements. The MPJE candidate should review the
portions addressing dietary supplements in the following sections: 341, 342, 343, 343-1, 343-2, and
350-b. In addition, the MPJE candidate should review section 350 on vitamins and minerals.
Subchapter V. Drugs and devices
Part A—Drugs and devices

351. Adulterated drugs and devices
A drug or device can be "adulterated" for several reasons, as listed in this section. The MPJE
candidate should be familiar with these reasons.
352. Misbranded drugs and devices

A drug or device can be "misbranded" for several reasons, as listed in this section. The MPJE
candidate should be familiar with these reasons.
353. Exemptions and consideration for certain drugs, devices, and biological products
A key section of the FDCA, this section, among other things, exempts legend drugs from the general
labeling requirements of the FDCA, including when sold when a prescription is presented. (Note the
label requirement of the "Rx Only symbol," which replaces the labeling requirement of "Caution:
Federal law prohibits dispensing without a prescription," a change created by the Food and Drug
Administration Modernization Act of 1997.) Also included in this section are the sales restrictions
imposed by the Prescription Drug Marketing Act of 1987 with respect to legend drug samples and
coupons for legend drugs, together with the wholesaler licensing requirements. Finally, this section
addresses drugs for veterinary use.
353a. Pharmacy compounding

This section was added to the FDCA by the Food and Drug Administration Modernization Act of
1997. However, in an April 29, 2002, opinion, the U.S. Supreme Court ruled the section
unconstitutional in the case of Thompson et al. v. Western States Medical Center et al ., 535 U.S. 357.
Other sections of the FDCA address pharmacy compounding, however. The MPJE candidate should
be very familiar with the federal law on pharmacy compounding. A good source for the U.S. Supreme
Court opinion and other materials, particularly the FDA Compliance Policy Guidance on pharmacy
compounding, is the FDA's Center for Drug Evaluation and Research at
www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/PharmacyCompounding/default.htm
. The MPJE candidate should be certain to review the FDA compliance guide on pharmacy
compounding, available at
www.fda.gov/downloads/AboutFDA/CentersOffices/CDER/UCM118050.pdf .
354. Veterinary feed directive drugs

This section defines what is meant by a veterinary feed directive drug and sets forth requirements in
relation to use and labeling of such drugs.
355. New drugs

This quite lengthy section sets forth the requirements and process for approval of a "new drug"
through filing of a new drug application or abbreviated new drug application. The MPJE candidate
should be familiar with the process for approval of drugs and note particularly in this section the
definition and use of the terms bioavailability and bioequivalent. The references listed in the
introduction to this study guide provide a good overview of the drug approval process.
355a. Pediatric studies of drugs

This section authorizes the HHS secretary to request pediatric studies, which are defined in this
section, from the holder of an approved application for a new or previously approved drug, where the
drug may produce health benefits in the pediatric population. If the holder of the approved application
completes the studies, the holder will be granted additional "market exclusivity," through extension of
patent life for the periods described in this section, for the drug. Finally, this section establishes
requirements relative to the conducting of pediatric studies.
355b. Adverse-event reporting

This section requires that the label of a prescription drug contain a toll-free number maintained by
HHS to receive reports of adverse events regarding drugs.
355c. Research into pediatric uses for drugs and biological products
This section contains several requirements in relation to assessing the safety and effectiveness of
drugs and biological products in pediatric patients and to support dosing and administration of drugs
and biological products in pediatric patients.
356. Fast-track products

This section authorizes the HHS secretary, at the request of the sponsor of a new drug, to facilitate the
development and expedite the review of the drug if it is intended for the treatment of a serious or life-
threatening condition and if it demonstrates the potential to address unmet medical needs for such a
condition, which serves as the definition of a fast-track product .
356a. Manufacturing changes

This section describes manufacturing changes and sets forth those changes that require filing of a
supplemental application and those that do not.
356b. Reports of postmarketing studies

This section establishes the requirements for postmarketing studies where the sponsor of a drug has
entered into an agreement with the HHS secretary to conduct such a study.
356c. Discontinuance of life-saving drug

This section creates the requirement that the sole manufacturer of a drug that has an approved
application and that was not originally derived from human tissue and was replaced with recombinant
product, and that is life supporting, life sustaining, or intended for use in the prevention of a
debilitating disease or condition, notify the HHS secretary of discontinuance of manufacture of the
product at least 6 months prior to the discontinuance date. Reduction in the 6-month notice
requirement is authorized in certain circumstances, as described in this section.
358. Authority to designate official names

This section authorizes the HHS secretary to designate an official name for a drug or device, except
where the official name infringes a valid trademark. It also contains a requirement that the HHS
secretary review official names in the United States Pharmacopoeia , the Homoeopathic
Pharmacopoeia , and the National Formulary to determine whether revision of those names is
necessary or desirable. Finally, in such reviews, the HHS secretary is required to make determinations
in relation to the designation of an official name on the basis of complexity, usefulness, multiplicity,
or lack of a name.
359. Nonapplicability of subchapter to cosmetics

As the title of this section states, nothing in this subchapter applies to cosmetics, unless the cosmetic
is also a drug or device or component of a drug or device.
360. Registration of producers of drugs or devices

This section establishes the registration and drug listing and National Drug Code requirements for
drug manufacturers. The MPJE candidate should be familiar with the National Drug Code system.
Significantly, this section, at (g)(1), exempts pharmacies and certain others from the registration and
drug listing requirements under the conditions stated.
360b. New animal drugs

As with drugs for human use, the MPJE candidate should be familiar with new animal drugs under the
FDCA, as described in this lengthy section.
360c. Classification of devices intended for human use

The MPJE candidate should be familiar with the FDCA provisions related to devices. This section
establishes three classes of devices, as follows.
• Class I: General controls
• Class II: Special controls
• Class III: Premarket approval
This section also sets forth the standards for determination of the safety and effectiveness of a device
and provides for classification panel organization and operation.
360d. Performance standards

This section establishes performance standards for class II—and in some cases class III—devices and
the procedures for establishing and recognizing the standards.
360e. Premarket approval

This section establishes the requirements and procedures for an application for premarket approval of
a class III device.
360f. Banned devices

This section authorizes the HHS secretary to promulgate regulations to ban certain devices, as
described in this section.
360g. Judicial review

This section sets forth the procedures for judicial review of decisions of the HHS secretary with regard
to devices.
360h. Notification and other remedies

This section provides that when a device presents an unreasonable risk of substantial harm and
notification is necessary to eliminate the risk of harm, the HHS secretary may issue an order to ensure
that adequate notification is provided, in an appropriate form, by the persons and means best suited
under the circumstances involved to all health professionals who prescribe or use the device and to
any other person (including manufacturers, importers, distributors, retailers, and device users) who
should properly receive such a notification to eliminate such a risk. This section also authorizes the
HHS secretary to order the manufacturer of a device to repair, replace, or make refund for the device.
Finally, this section gives the HHS secretary authority to order a recall of a device.
360i. Records and reports on devices

This section requires reports, as described in the section, from device manufacturers and device-user
facilities, such as hospitals. It also authorizes the HHS secretary to order a device manufacturer to
adopt a method for tracking certain class II and III devices.
360j. General provisions respecting control of devices intended for human use
This section contains a variety of requirements, including provisions for custom devices, restricted
devices, good manufacturing practice requirements, and exemption of devices for investigational use.
360k. State and local requirements respecting devices

This section establishes the relationship between the FDCA provisions on devices and any state laws
that may exist in relation to devices.
360l. Postmarket surveillance

This section authorizes the HHS secretary to impose on manufacturers of certain devices various
postmarketing surveillance requirements related to devices.
360m. Accredited persons

This section requires the HHS secretary to establish an accreditation program as described in the
section, for persons who review reports related to devices.
Part B—Drugs for rare diseases or conditions
360aa. Recommendations for investigations of drugs for rare diseases or conditions
This section provides that a sponsor of a drug for a disease or condition that is rare may request the
HHS secretary to provide written recommendations for the nonclinical and clinical investigations that
must be conducted with the drug before it may be approved for treatment of such a disease or
condition or, if the drug is a biological product, before it may be licensed for such disease or
condition.
360bb. Designation of drugs for rare diseases or conditions

This section allows a manufacturer or sponsor of a drug to request, prior to submission of an
application for approval, the HHS secretary to designate the drug as a drug for a rare disease or
condition. This section defines a rare disease or condition as any disease or condition that affects (a)
fewer than 200,000 persons in the United States or (b) more than 200,000 persons in the United States
provided that there is no reasonable expectation that the cost of developing and making available in
the United States a drug for such a disease or condition will be recovered from sales in the United
States. It also contains a requirement for notice to the HHS secretary for discontinuance of production
of the drug.
360cc. Protection for drugs for rare diseases or conditions

This section provides that if the HHS secretary approves an application for a drug designated for a rare
disease or condition, the HHS secretary may not approve another application for such a drug for such
a disease or condition for a person who is not the holder of the approved application until the
expiration of 7 years from the date of approval, unless (a) the holder of the approved application
cannot ensure the availability of sufficient quantities of the drug to meet the needs of people with the
disease or condition for which the drug was designated or (b) the holder provides the HHS secretary
written consent for the approval of other applications before the expiration of the 7-year period.
360dd. Open protocols for investigations of drugs for rare diseases or conditions
This section provides, under certain circumstances, for the HHS secretary to encourage the sponsor of
a drug designated for a rare disease or condition to design protocols for clinical investigations of the
drug that may be conducted to permit the addition to the investigations of people with the disease or
condition who need the drug to treat the disease or condition and who cannot be satisfactorily treated
by available alternative drugs.
360ee. Grants and contracts for development of drugs for rare diseases and conditions
This section authorizes the HHS secretary to make grants to and enter into contracts with public and
private entities and individuals to assist in defraying the costs of qualified testing expenses incurred in
connection with the development of drugs for rare diseases and conditions, of development of medical
devices for rare diseases or conditions, and of development of medical foods (a food formulated to be
consumed or administered enterally under the supervision of a physician) for rare diseases or
conditions.
Part D—Dissemination of treatment information

When sections 360aaa-360aaa-6 were enacted, Congress provided that they were to sunset (cease
effectiveness) in 2006. Related to this, the FDA has published a "guidance for industry" on good
reprint practices. The guidance is available at www.fda.gov/oc/op/goodreprint.html . Although the text
of the sections remains in the U.S. Code, rather than review the sections, the MPJE candidate should
review the FDA guidance to gain general understanding of requirements and limitations associated
with dissemination of treatment information.
Part E—General provisions relating to drugs and devices

360bbb. Expanded access to unapproved therapies and diagnostics
This section authorizes the HHS secretary to allow shipment of investigational drugs or
investigational devices for the diagnosis, monitoring, or treatment of a serious disease or condition in
emergency situations. Furthermore, an individual patient, acting through a physician, may request
from a manufacturer or distributor an investigational drug or device for the diagnosis, monitoring, or
treatment of a serious disease or condition if a number of conditions, as set forth in this section, are
fulfilled.
360bbb-1. Dispute resolution

This section requires the HHS secretary to establish a procedure for a sponsor, applicant, or
manufacturer to obtain a review, including by a scientific advisory panel, in situations in which there
is a scientific controversy with the HHS secretary.
360bbb-2. Classification of products

This section provides that a person submitting an application for a product may submit a request to the
HHS secretary with respect to the classification of the product as a drug, biological product, device, or
a combination or with respect to the component of the FDA that will regulate the product. In
submitting the request, the person shall recommend a classification for the product or a component to
regulate the product, as appropriate. This section also describes what action the HHS secretary shall
take in response to filing of such a request.
360bbb-3. Authorization for medical products for use in emergencies

This section provides for the use of unapproved drugs, devices, and biological products and for the use
of approved drugs, devices, and biological products for unapproved uses in the event of an emergency.
Part F—New animal drugs for minor use and minor species
360ccc. Conditional approval of new animal drugs for minor use and minor species
This section authorizes conditional approval of a new animal drug for a minor use or a minor species.
Included are the requirements associated with application for approval and limitations on seeking
approval.
360ccc-1. Index of legally marketed unapproved new animal drugs for minor species
This section requires the secretary of HHS to establish a list of (a) new animal drugs intended for use
in a minor species for which there is a reasonable certainty that the animal or edible products from the
animal will not be consumed by humans or food-producing animals and (b) new animal drugs
intended for use only in a hatchery, tank, pond, or other similar contained human-made structure in an
early, nonfood life stage of a food-producing minor species, where safety for humans is demonstrated.
360ccc-2. Designated new animal drugs for minor use or minor species
This section provides that the manufacturer or sponsor of a new animal drug for a minor use or use in
a minor species may request the secretary of HHS to declare that drug a designated new animal drug .
Subchapter VI. Cosmetics
The MPJE candidate should review the three sections (361-363) contained in this subchapter on
cosmetics.
The last three subchapters of Chapter 9 contain a variety of sections, many of which are not of interest
to the MPJE candidate. As directed in the explanation to the study guide, the candidate should open
each subchapter and from the titles of the parts and sections determine those that the MPJE candidate
should review.
Regulations of the U.S. FDA
The FDA regulations may be found in Title 21 of the CFR. The body of FDA regulations is divided
into subchapters as follows:
• Subchapter A—General (21 CFR Parts 1-99)
• Subchapter B—Food for Human Consumption (21 CFR Parts 100-199)
• Subchapter C—Drugs: General (21 CFR 200-299)
• Subchapter D—Drugs for Human Use (21 CFR Parts 300-499)
• Subchapter E—Animal Drugs, Feeds, and Related Products (21 CFR Parts 500-599)
• Subchapter F—Biologics (21 CFR Parts 600-699)
• Subchapter G—Cosmetics (21 CFR Parts 700-799)
• Subchapter H—Medical Devices (21 CFR Parts 800-899)
• Subchapter I—Mammography Quality Standards Act (21 CFR Parts 900-999)
• Subchapter J—Radiological Health (21 CFR Parts 1000-1099)
• Subchapter K—Reserved
• Subchapter L—Regulations under Certain Other Acts (21 CFR Parts 1200-1299)
The MPJE candidate should review relevant FDA regulations on the electronic database as described
in the introduction to this study guide.
2-4. The Poison Prevention Packaging Act of 1970 and Regulations of the U.S. CPSC
Introduction
The Poison Prevention Packaging Act (PPPA), enacted by Congress in 1970, has as its purpose
preventing poisonings in children under 5 years of age. This purpose is achieved through numerous
requirements in the act and CPSC regulations.
The PPPA establishes packaging requirements for certain household products. Included among these
products are both prescription and nonprescription drug products.
Key Provisions of the PPPA
The MPJE candidate should be familiar with the packaging requirements contained in the PPPA and
the regulations of the CPSC. The PPPA is located at Chapter 39A of Title 15 of the United States
Code. The MPJE candidate should retrieve and review the sections contained in Chapter 39A as
described in the introduction to this study guide.
Regulations of the U.S. CPSC
The CPSC regulations may be found at Part 1700 of Title 16 of the CFR. The MPJE candidate should
retrieve and review the sections contained in Part 1700 as described in the explanation to this study
guide.
As mentioned earlier, the MPJE candidate is encouraged to review the CPSC publication "Poison
Prevention Packaging: A Guide for Healthcare Professionals," available at
www.cpsc.gov/CPSCPUB/PUBS/384.pdf .
2-5. Miscellaneous Federal Laws
Omnibus Budget Reconciliation Act of 1990
The Omnibus Budget Reconciliation Act of 1990 (more commonly referred to as OBRA '90) required
the states to enact laws to require patient profiling, prospective drug use review, and patient
counseling by pharmacies. Although the federal mandate applied only to the provision of pharmacy
services to Medicaid beneficiaries, the states extended application of the requirements to all pharmacy
patients. The MPJE candidate should review state law on these requirements, and the federal
regulations may be found beginning at section 45 CFR 456.700.
Anti-Tampering Act of 1982
This act makes tampering with consumer products a federal offense and was passed as a result of a
series of incidents of intentional contamination of Tylenol capsules while held for sale in retail
establishments. Regulatory authority resides with the Federal Bureau of Investigation, U.S.
Department of Agriculture, and FDA. Regulations for specific types of products may be retrieved (as
described in the introduction to this study guide) and reviewed as follows:
• Over-the-counter drug products (21 CFR 211.132)
• Medical devices (21 CFR 800.12)
• Cosmetics (21 CFR 700.25)
Federal Law on Medicinal Use of Alcohol
Under federal law, retailers that sell alcohol are subject to an annual tax, and to handle any type of
alcohol, a license from the U.S. Bureau of Alcohol, Tobacco, and Firearms is required. Retailers
selling take-home liquors are required to obtain a federal retail liquor dealer's stamp. In a community
pharmacy, if the alcohol is sold only for medicinal purposes, a federal medicinal spirits dealer's stamp
may be obtained instead of the retail liquor dealer's stamp. Some pharmacies require much larger
volumes (usually obtained in 10- or 55-gallon drums) of alcohol, and the alcohol can be purchased tax
free. However, the use of tax-free alcohol is subject to a number of federal law restrictions.
• The alcohol must be used for medicinal or scientific purposes or for patient treatment.
• The alcohol must not be sold or loaned to other pharmacies or other practitioners.
• The alcohol, whether in pure form or in combination with other substances, must not be sold to
outpatients, with the exception of nonprofit clinics, as long as the patient is not charged.
• The alcohol must be kept in a secure, fire-resistant room.
• A perpetual inventory of the alcohol stock must be maintained.
For additional information, the MPJE candidate can review the sections beginning at 27 CFR 22.1, as
described in the explanation to this study guide.
2-6. Questions
Pharmacist Betty Jones decides to open her own community pharmacy. Which
of the following DEA forms will she use to apply for a DEA Certificate of
Registration for the new pharmacy?
1 . A. DEA Form 106

B. DEA Form 222
C. DEA Form 223
D. DEA Form 224
E. DEA Form 224a

You arrive at your community pharmacy one morning and discover that during
the night someone broke into the pharmacy and stole several commercial
containers of controlled substances. Within how many business day(s) must this
theft of controlled substances be reported to the field division office of the DEA
in your area?
2.
A. 1
B. 3
C. 7
D. 10
E. 30

As the owner of a community pharmacy, you recently employed a staff
pharmacist and granted the pharmacist a power of attorney to order controlled
substances. In addition to physically signing the DEA order form for schedule II
controlled substances, the staff pharmacist completed the steps necessary to
obtain authority from the DEA to place electronic orders for all schedules of
controlled substances. Today, this pharmacist resigned from your employment.
The pharmacist's resignation must be communicated to the DEA Certification
3.
Authority within what period?
A. 6 hours
B. 24 hours
C. 3 days
D. 7 days
E. 30 days

Which of the following is the federal agency that certifies private practice
physicians to prescribe schedule III, IV, or V narcotic controlled substances for
detoxification and maintenance treatment of opioid dependency?
4 . A. DEA
B. FDA
C. OIG
D. SAMHSA
E. FTC

Frank Wilson, a U.S. citizen, recently traveled outside the United States on
business. While outside the country, he became very ill with a gastrointestinal
infection and suffered severe nausea, vomiting, diarrhea, and dehydration. A
physician in the town where he was located prescribed medications, consisting
of an antibiotic and two controlled substances. A local pharmacy dispensed the
prescriptions, which were packaged, labeled, and dispensed in much the same
manner as if dispensed in the United States. On returning to the United States 2
days after receiving the prescriptions, he proceeded to U.S. Customs, where he
was asked if he was bringing any drugs into the country. He responded yes and
handed the Customs officer the prescriptions. As to the controlled substance
prescriptions, which of the following is true?
5.
A. If either or both of the prescriptions are for a schedule II controlled substance,
they will be seized by the Customs officer because federal law prohibits
importation of a schedule II controlled substance.
B. Mr. Wilson can legally bring a maximum of 50 dosage units of each of the
two controlled substances into the United States.
C. Mr. Wilson can legally bring a maximum total of 50 dosage units combined
of the two controlled substances into the United States.
D. Mr. Wilson can bring the antibiotic prescription into the United States but not
the prescriptions for controlled substances.
E. Both A and C.

A life-supporting or life-sustaining device that requires FDA approval before it
can be marketed in interstate commerce in the United States is a
A. class I device.
6.
B. class II device.
C. class III device.
D. class IV device.
E. class V device.

For purposes of classifying a drug as an orphan drug, a rare disease or condition
is defined as follows: a disease or condition that affects (a) fewer than ______
persons in the United States or (b) more than _____ persons in the United States
provided that there is no reasonable expectation that the cost of developing and
making the drug available will be recovered.
7.
A. 100,000
B. 200,000
C. 250,000
D. 500,000
E. 1,000,000

Which of the following is not one of the recognized "Official Compendia" in the
federal Food, Drug, and Cosmetic Act?
8 . A. United States Pharmacopeia

B. Homeopathic Pharmacopeia of the United States
C. National Formulary
D. Approved Drug Products with Therapeutic Equivalence Ratings

When a pharmacy orders schedule II controlled substances using the DEA
official triplicate order form, which copy (copies) of the form is (are) sent by the
pharmacy to the supplier?
9 . A. Copy 1
B. Copy 2
C. Copy 3
D. Copies 1 and 2
E. Copies 2 and 3

A quality control manager at Widget Pharmaceuticals has just discovered that a
batch sample of a Widget Pharmaceuticals brand of an intravenous solution has
tested positive for the presence of a bacterium toxin. If, in fact, the intravenous
10 solution contains a bacterium toxin that is harmful to humans, the solution
. would be
A. adulterated.
B. misbranded.

Pharmacies registered under the federal Controlled Substances Act are required
to take a complete inventory of all controlled substances every _____ months.
11 A. 6
. B. 12
C. 18
D. 24
E. 36

Dr. Marcia Wilson is a neurologist treating attention deficit disorder (ADD) and
attention deficit hyperactivity disorder (ADHD) patients. Among her treatments
for these patients, she prescribes Ritalin, Concerta, and Adderall. Her general
policy is that patients using these medications must be seen in her office every 3
months for evaluation. Because most of her patients prefer to obtain their
prescriptions locally and third-party prescription drug plans will reimburse for a
30-day supply only, Dr. Wilson is forced to issue 3 prescriptions to provide
adequate medication between office visits. According to the applicable DEA
12
regulation on issuing multiple prescriptions for a schedule II controlled
.
substance, for how many total days' supply of a schedule II controlled substance
may Dr. Wilson issue multiple prescriptions to a patient?
A. 60
B. 90
C. 120
D. 150
E. 180

According to the federal Food, Drug, and Cosmetic Act, which of the following
may not legally receive and possess prescription drug samples from a
manufacturer or authorized distributor of record?
13
A. Free-standing retail pharmacies
.
B. Pharmacies located within a hospital or other health care entity, at the written
request of a licensed practitioner
C. Osteopathic doctors
D. Dentists

One of your regular patients comes into your pharmacy and reports that he
developed a dry, hacking cough 2 days ago, and although he has been taking a
nonprescription liquid cough suppressant, it has been ineffective in controlling
the cough. He says that not too long ago another pharmacy sold him a
nonprescription cough suppressant containing codeine that was very effective.
He asks if you have such a product, and you reply that you do and agree to sell
him the product. Assuming that state law permits selling such a product without
a prescription, you may sell not more than 240 cc (8 oz) of a controlled
14 substance containing opium, nor more than 120 cc (4 oz) of any other controlled
. substance, nor more than 48 dosage units of a controlled substance containing
opium, nor more than 24 dosage units of any other controlled substance in any
given period of how many hours?
A. 24
B. 36
C. 48
D. 60
E. 72

According to the federal Food, Drug and Cosmetic Act, which of the following
is exempt from registration with the Food and Drug Administration as a
manufacturer?
15
A. A manufacturer of generic drug products
.
B. A manufacturer of brand-name drug products
C. A pharmacy compounding a product pursuant to a lawful prescription order
D. A pharmacy compounding a product to supply a physician for that physician
to use in dispensing prescription orders

"The rate and extent to which the active ingredient or therapeutic ingredient is
absorbed from a drug and becomes available at the site of drug action" is the
federal Food, Drug, and Cosmetic Act definition of which of the following?
16
. A. Bioavailability
B. Bioequivalency
C. Dissolution
D. Area under the curve

Under federal law, the daily sales limit of ephedrine base, pseudoephedrine base,
or phenylpropanolamine base is _____ grams per purchaser, regardless of the
number of transactions.
17
A. 1.8
.
B. 3.6
C. 7.2
D. 9.0
E. 14.4

At least how many days before introducing or delivering for introduction into
interstate commerce a dietary supplement that contains a new dietary ingredient
that has not been present in the food supply as an article used for food in a form
in which the food has not been chemically altered must the manufacturer or
distributor of that supplement, or of the new dietary ingredient, submit to the
U.S. Food and Drug Administration information, including any citation to
18 published articles, on which basis the manufacturer or distributor has concluded
. that the dietary supplement can reasonably be expected to be safe?
A. 30
B. 60
C. 75
D. 90
E. 120

With respect to pharmacy compounding of pharmaceutical products, which of
the following is not one of the factors considered by the U.S. Food and Drug
Administration in determining whether a pharmacy is "compounding" versus
"manufacturing" pharmaceutical products?
A. Compounding drugs in anticipation of receiving prescriptions, except in very

limited quantities in relation to the amounts of drugs compounded after
19 receiving valid prescriptions
. B. Using commercial-scale manufacturing or testing equipment for
compounding drug products
C. Offering compounded drugs at wholesale to other state-licensed persons or
commercial entities for resale
D. Setting prices for compounded drugs that are far higher than the prices for the
same or similar commercially available drugs
E. Compounding drugs that are commercially available in the marketplace or
that are essentially copies of commercially available drugs

The federal Food, Drug, and Cosmetic Act prohibits the selling, purchasing, or
trading of a prescription drug that was purchased by a public or private hospital
or other health care entity or donated or supplied at a reduced price to a
charitable organization. Which of the following is not one of the exceptions to
this prohibition?
A. The purchase or other acquisition by a hospital or other health care entity that
is a member of a group-purchasing organization of a drug for its own use
20 from the group-purchasing organization or from other hospitals or health care
. entities that are members of such an organization
B. A sale, purchase, or trade of a drug or an offer to sell, purchase, or trade a
drug among hospitals or other health care entities that are under common
control
C. A sale, purchase, or trade of a drug; an offer to sell, purchase, or trade a drug;
or the dispensing of a drug pursuant to a prescription
D. The sale, purchase, or trade of a drug or an offer to sell, purchase, or trade a
drug by a charitable organization to a nonprofit affiliate of the organization
E. A sale to a community pharmacy for non-emergency dispensing needs

A maximum of how many times may a prescription for a schedule III, IV, or V
controlled substance may be refilled?
21 A. 1
. B. 2
C. 3
D. 4
E. 5

Approximately 30 minutes ago, your community pharmacy received a
prescription for a schedule II controlled substance by facsimile transmission.
The patient for whom the prescription was issued has just arrived for the
prescription. You may dispense the prescription solely on the basis of the
22
facsimile prescription and use the facsimile prescription as the original
.
prescription for purposes of recordkeeping.
A. True
B. False

With respect to a prescription for a controlled substance, which of the following
may be maintained in an electronic database used for prescription dispensing
rather than having to be placed on the actual prescription form maintained in the
pharmacy's prescription files?
A. Physician's DEA number

23
B. Record of refills
.
C. Patient address
D. The word void or the word transfer required on issuing or receiving,
respectively, a transferred prescription for a controlled substance
E. A and B
F. B and C
G. B and D

William Wilson has just presented you two empty prescription vials and
requests that each be refilled. Both of the prescriptions are for solid, oral dosage
formulations. When dispensing the refills (and assuming neither Mr. Wilson nor
24 the prescriber has requested non-child-resistant packaging), you may reuse the
. prescription vials and closures when dispensing the refills.
A. True
B. False

The U.S. Food and Drug Administration regulations regarding medication
guides provide that where a medication guide is required for a particular
prescription drug product, the medication guide must be provided to the patient
25
on the initial dispensing of the drug but not on any refills thereafter.
.
A. True
B. False

2-7. Answers
D. DEA Form 224 is the application form for a new DEA Certificate of Registration. DEA Form
224a is the renewal application form that DEA mails to registrants approximately 60 days before
the expiration of a DEA Certificate of Registration. DEA Form 106 is used to report theft or loss
1.
of controlled substances. DEA Form 222 is used to order schedule II controlled substances. DEA
Form 223 is the number of the DEA Certificate of Registration that is displayed at the
registrant's location. The applicable DEA regulation is 21 CFR 1301.13.

A. Although notification is required within 1 business day, completion and submission of DEA
2. Form 106 is not required within 1 business day, but the form should be completed and submitted
promptly. The applicable DEA regulation is 21 CFR 1301.76.

A. Recognize that before electronic ordering of controlled substances was permitted, notifying
the DEA if a pharmacist with a power of attorney resigned or was terminated was not necessary.
The power of attorney was useless without physical access to DEA Form 222. But with
3.
electronic ordering of controlled substances, a DEA Form 222 is not needed, so notification
must be provided if the pharmacist had obtained the authority from DEA to submit electronic
orders. The applicable DEA regulation is 21 CFR 1311.45.

D. SAMHSA, not the DEA, certifies physicians to prescribe schedule III, IV, and V narcotic
controlled substances for detoxification and maintenance treatment of opioid dependency.
Prescriptions for the currently approved products Suboxone and Subutex for treatment of opioid
dependency must include the physician's DEA number and the physician's "X" number
4.
signifying certification to treat opioid dependency. Also, only physicians may be approved to
treat opioid dependency. Information about the medication-assisted treatment of opioid
dependency is available on the SAMHSA Web site at www.dpt.samhsa.gov . The applicable
DEA regulation is 21 CFR 1301.28.

C. The limitation associated with the exemption from import and export requirements for
5. personal medical use is a combined 50 dosage units and not 50 dosage units of each controlled
substance. The applicable DEA regulation is 21 CFR 1301.26.

C. The federal FDCA provides for three classes of medical devices: class I, class II, and class III.
Generally class I devices are not subject to premarket approval, and class II devices are subject
6. to performance standards. Class III devices are life-supporting or life-sustaining devices and
require premarket approval by FDA. The applicable section of the federal FDCA is 21 USC
360c.

7. B. The applicable section of the federal FDCA is 21 USC 360bb.

D. Although the Approved Drug Products with Therapeutic Equivalence Ratings (FDA Orange
8. Book) is an important publication for pharmacy, it is not one of the official compendia. The
official compendia are established by the federal FDCA at 21 USC 321.

D. The pharmacy keeps copy 3 and sends copies 1 and 2 to the supplier. The applicable DEA
9.
regulation is 21 CFR 1305.12.

10. A. The applicable section of the federal FDCA is 21 USC 351.

D. Pharmacies are required to conduct a "biennial" inventory of all controlled substances. The
11.
applicable DEA regulation is 21 CFR 1304.11.

12. B. The applicable DEA regulation is 21 CFR 1306.12.


14. C. The applicable DEA regulation is 21 CFR 1306.26.

C. Pharmacies are exempt from registration, provided that the compounding is "in the regular
15. course of their business of dispensing or selling drugs or devices at retail." The applicable
section of the federal FDCA is 21 USC 360.


17. B. The applicable DEA regulation is 21 CFR 1314.20.

18. C. The applicable section of the federal FDCA is 21 USC 3650b.

D. The other answer choices are contained in the FDA compliance guide on pharmacy
compounding, which is available at
19.
www.fda.goâ€‹v/downloadâ€‹s/AboutFDAâ€‹/CentersOfâ€‹fices/CDERâ€‹/UCM118050â€‹.pdf
.

20. E. The applicable section of the federal FDCA is 21 USC 353.

E. As provided in the DEA regulations, "No prescription for a controlled substance listed in
Schedule III or IV shall be filled or refilled more than 6 months after the date on which such
21.
prescription was issued and no such prescription authorized to be refilled may be refilled more
than five times." The applicable DEA regulation is 21 CFR 1306.22.

B. Although in some situations a facsimile prescription for a Schedule II controlled substance
22. can be dispensed and can be used as the original prescription for recordkeeping, it cannot be in
this situation of an ambulatory patient. The applicable DEA regulation is 21 CFR 1306.11.

B. All information required to be placed on a prescription for a controlled substance by either the
23. CSA or the DEA regulations must be placed on the prescription. The only exemption is the
record of refills. The applicable DEA regulation is 21 CFR 1306.22.

B. As stated by the CPSC in response to whether pharmacists may reuse prescription vials, "As a
general rule, no. This prohibition is based on the wear associated with a plastic vial, which could
compromise the package's effectiveness. Since such wear or undetected damage with a glass
container is negligible, the CPSC staff has indicated that it would have no objection to the reuse
24.
of a glass container, provided a new closure is used. This same consideration would be given to
any other package type that is not prone to wear." See the CPSC publication "Poison Prevention
Packaging: A Guide for Healthcare Professionals" available at
www.cpsc.gâ€‹ov/CPSCPUBâ€‹/PUBS/384.â€‹pdf .

B. Medication guides must be provided on each dispensing. The applicable FDA regulation is 21
25.
CFR 208.24.

3. Dosage Forms and Drug Delivery Systems - Ram I. Mahato, PhD
3-1. Introduction
Introduction
A pharmaceutical dosage form is the entity administered to patients so that they receive an effective
dose of a drug. Some common examples are tablets, capsules, suppositories, injections,
suspensions, and transdermal patches. Achieving an optimum response from any dosage form
requires delivery of a drug to its site of action at a rate and a concentration that both minimize its
side effects and maximize its therapeutic effects. The development of safe and effective
pharmaceutical dosage forms and delivery systems requires a thorough understanding of
physicochemical principles that allow a drug to be formulated into a pharmaceutical dosage form.
Design of the appropriate dosage form or delivery system depends on the
• Physicochemical properties of the drug, such as solubility, oil-to-water partition coefficient (Ko/w),
pKa value, molecular weight, and polymorphism
• Dose of the drug
• Route of administration
• Type of drug delivery systems desired
• Pathologic condition to be treated
• Desired therapeutic effect
• Drug release from the delivery system
• Bioavailability of the drug at the absorption site
• Pharmacokinetics and pharmacodynamics of the drug
How Drug Molecules Move across Barriers in the Body
Most drugs are absorbed from the site of their application by simple diffusion. Drug diffusion
through a barrier may occur by simple molecular permeation known as molecular diffusion or by
movement through pores and channels known as pore diffusion. In pore diffusion, drug release rate
is affected by degree of crystallinity and crystal size, degree of swelling, porous structure, and
tortuosity of polymers.
In passive molecular diffusion, a drug travels by passive transport (which does not require an
external energy source) from a region of high concentration to a region of low concentration.
However, other transport processes occur in the body as well. For example, active transport of
drugs can proceed from regions of low concentration to regions of high concentration through the
pumping action of one or more biologic transport systems. These active transport systems require
an energy source such as an enzyme or biochemical carrier to ferry the drug across the membrane.
Fick's law of diffusion is a mathematical expression that describes passive diffusion. Fick's first law
states that the amount of material (M) flowing through a unit cross-section (S) of a barrier in a unit
of time (t), which is known as the flux (J), is proportional to the concentration gradient (dc/dx).
where J = flux in g/cm2 × s; S = cross section of barrier in cm2; dM/dt = rate of diffusion in g/s; M
= mass in grams; and t = time in seconds.
The flux is proportional to the concentration gradient, dC/dx:
where D = diffusion coefficient of a penetrant in cm2/s; C = concentration in g/cm3 or g/mL; and x

= distance in centimeters of movement perpendicular to the surface of the barrier.
The diffusion coefficient, D, is a physicochemical property of the drug molecule. It is not constant
and can vary with changes in concentration, temperature, pressure, solvent properties, molecular
weight, and chemical nature of the diffusant. The larger the molecular weight is, the lower the
diffusion coefficient will be.
Fick's first law of diffusion describes the diffusion process under the condition of steady state when
the concentration gradient (dC/dx) does not change with time.
Figure 3-1 shows the diaphragm of thickness h and cross-sectional area S that separate the two
compartments of the diffusion cell. Equating both equations for flux, Fick's first law of diffusion
may be written as
in which (C1 - C2)/h approximates dC/dx. Concentrations C1 and C2 within the membrane can be
replaced by the partition coefficient multiplied by the concentration Cd in the donor compartment or
Cr in the receptor compartment. The partition coefficient, K, is given by K = C1/Cd = C2/Cr. Hence,
Under sink conditions, the drug concentration in the receptor compartment is much lower than the
drug concentration in the donor compartment.
[Figure 3-1. Concentration Gradient of Diffusant across a Diaphragm of a Diffusion Cell]
Therefore, Cr 0. The preceding equation can be simplified as

where D is the diffusion coefficient (in cm2/s); S is the surface area of the cross-section of the
barrier (in cm2); K is the partition coefficient; Cd is the concentration of drug in the donor
compartment (in g/mL); h is the barrier thickness (in cm); and P is the permeability coefficient (in
cm/s), where P = DK/h.
Transport of a drug by passive diffusion across a membrane such as the gastrointestinal (GI)
mucosa is represented by Fick's law:
where M is the amount of drug in the gut compartment at time t, Dm is drug diffusivity in the
intestinal membrane, S is the surface area of GI membrane available for absorption, K is the
partition coefficient between the membrane and aqueous medium in the intestine, h is the thickness
of the GI membrane, Cg is the drug concentration in the intestinal compartment, and Cp is the drug
concentration in the plasma compartment.
Because the gut compartment usually has a high drug concentration compared with the plasma
compartment, Cp may be omitted. Therefore, the preceding equation then becomes
This suggests that the rate of GI absorption of a drug by passive diffusion depends on the surface
area of the membrane available for drug absorption. The small intestine is the major site for drug
absorption because of the presence of villi and micro-villi, which provide an enormous surface area
for absorption.
pH Partition Theory and Its Limitation
The pH partition theory states that drugs are absorbed from the biological membranes by passive
diffusion, depending on the fraction of the un-ionized form of the drug at the pH of the fluids close
to that biological membrane. The degree of ionization of the drug depends on both the pKa and the
pH of the drug solution. The GI tract acts as a lipophilic barrier, and thus ionized drugs are more
hydrophilic than un-ionized ones and have minimal membrane transport. The solution pH affects
the overall partition coefficient of an ionizable substance. The pKa of the molecule is the pH at
which there is a 50:50 mixture of conjugate acid-base forms. The conjugate acid form predominates
at a pH lower than the pKa, and the conjugate base form is present at a pH higher than the pKa. The
extent of ionization of a drug molecule is given by the following Henderson-Hasselbalch equations,
which describe a relationship between ionized and nonionized species of a weak electrolyte:
where [HA] is the concentration of un-ionized acid, [A-] is the concentration of ionized base, [B] is
the concentration of un-ionized base, and [BH] is the concentration of ionized base. Although pH
partition theory is useful, it often does not hold true for certain experimental observations. For
example, most weak acids are well absorbed from the small intestine, which is contrary to the
prediction of the pH partition hypothesis. Similarly, quaternary ammonium compounds are ionized
at all pHs but are readily absorbed from the GI tract. These discrepancies arise because pH partition
theory does not take into consideration the following factors, among others:
• Large epithelial surface areas of the small intestine compensate for ionization effects.
• Long residence time in the small intestine also compensates for ionization effects.
• Charged drugs, such as quaternary ammonium compounds and tetracyclines, may interact with
opposite-charged organic ions, resulting in a neutral species that is absorbable.
• Some drugs are absorbed by means of active transport.
The Noyes-Whitney Equation of Dissolution
For most drugs, the rate at which the solid drug dissolves in a solvent (dissolution) is often the rate-
limiting step in the drug's bioavailability. The rate at which a solid drug of limited water solubility
dissolves in a solvent can be determined using the Noyes-Whitney equation:
where dM/dt is the rate of dissolution (in mass/time), k is the dissolution rate constant (in cm/s) (k
= D/h), S is the surface area of exposed solid (in cm2), D is the diffusion coefficient of solute in
solution (in cm2/s), h is the thickness of the diffusion layer (in cm), Cs is the drug solubility (in
g/mL), and C is the drug concentration in bulk solution at time t (in g/mL).
Under sink conditions, when C is much less than Cs, the Noyes-Whitney equation can be simplified
as follows:
where dC/dt is the dissolution rate (in concentration/time) and V is the volume of the dissolution
medium (in mL).
The following factors influence the dissolution rate:
• The physicochemical conditions in the GI tract affect the dissolution rate. For example, the
presence of foods that increase the viscosity of GI fluids decreases the diffusion coefficient, D, of
a drug and its dissolution rate.
• The thickness of the diffusion layer, h, is influenced by the degree of agitation experienced by
each drug particle in the GI tract. Hence, an increase in gastric or intestinal motility may increase
the dissolution rate of poorly soluble drugs.
• The removal rate of dissolved drugs attributable to absorption through the gastrointestinal-blood
barrier and the GI fluid volume affects drug concentration in the GI tract and thus also affects the
dissolution rate.
• The dissolution rate of a weakly acidic drug in GI fluids is influenced by the drug solubility in the
diffusion layer surrounding each dissolving drug particle. The pH of the diffusion layer
significantly affects the solubility of a weak electrolyte drug and its subsequent dissolution rate.
The dissolution rate of a weakly acidic drug in GI fluid (pH 1-3) is relatively low because of its
low solubility in the diffusion layer. If the pH in the diffusion layer could be increased, the
solubility (Cs) exhibited by the weak acidic drug in this layer (and hence the dissolution rate of
the drug in GI fluids) could be increased. The potassium or sodium salt form of the weakly acidic
drug has a relatively high solubility at the elevated pH in the diffusion layer. Thus, the dissolution
of the drug particles takes place at a faster rate.
• Particle size and the surface area of the drug significantly influence the drug dissolution rate. An
increase in the total effective surface area of drug in contact with GI fluids causes an increase in
its dissolution rate. The smaller the particle size is, the greater will be the effective surface area
exhibited by a given mass of drug and the higher the dissolution rate. However, particle size
reduction is not always helpful and may fail to increase the bioavailability of a drug. In the case
of certain hydrophobic drugs, excessive particle size reduction tends to cause reaggregation into
larger particles. Preventing formation of aggregates requires dispersion of small drug particles in
polyethylene glycol (PEG), polyvinylpyrrolidone (PVP), dextrose, or other agents. For example,
a dispersion of griseofulvin in PEG 4,000 enhances its dissolution rate and bioavailability.
Certain drugs, such as penicillin G and erythromycin, are unstable in gastric fluids and do not
dissolve readily in them. For such drugs, particle size reduction yields an increased rate of drug
dissolution in gastric fluid and also increases the extent of drug degradation.
• Amorphous or noncrystalline forms of a drug may have faster dissolution rates than crystalline
forms.
• Temperature also affects solubility. An increase in temperature will increase the solubility of a
solid with a positive heat of solution. The solid will therefore dissolve at a more rapid rate on
heating the system.
• Surface-active agents will increase dissolution rates by lowering interfacial tension, which allows
better wetting and penetration by the solvent. Weakly acidic and basic drugs may be brought into
solution by the solubilizing action of surfactants.
Interfacial Electrical Properties
Most dispersed substances in a solvent such as water acquire a surface electric charge by ionization,
ion adsorption, and ion dissolution.
• Ionization: Surface charge arising from ionization on the particles is the function of the pH of the
environment and the pKa of the drug. Proteins acquire charge through the ionization of carboxyl
and amino groups to obtain COO- and NH3+ ions. Ionization of these groups, as well as the net
molecular charge, depends on the pH of the medium. At a pH below its isoelectric point (PI), a
protein molecule is positively charged, -NH2 NH3+, and at a pH above its PI, the protein is
negatively charged, -COOH COO-. At the PI of a protein, the total number of positive charges
equals the total number of negative charges, and the net charge is zero. This state may be
represented as follows:
R-NH2-COO- Alkaline solution

R-NH3-COO- Isoelectric point (Zwitterion)

R-NH3-COOH Acidic solution

Often a protein is least soluble at its isoelectric point and is readily dissolved by water-soluble salts
such as ammonium sulfate.
• Ion adsorption: A net surface charge can result from the unequal adsorption of oppositely
charged ions. Surfaces that are already charged usually show a tendency to adsorb counterions.
Counterion adsorption can cause a reversal of charge. Surfactants strongly adsorb by hydrophobic
effect and thus will determine the surface charge when adsorbed.
• Ion dissolution: Ionic substances can acquire a surface charge by virtue of unequal dissolution of
the oppositely charged ions of which they are composed. For example, in a solution of silver
iodide with excess [I-], the silver iodide particles carry a negative charge; however, the charge is
positive if excess [Ag+] is present. The silver and iodide ions are referred to as potential-
determining ions because their concentrations determine the electric potential at the particle
surface.
Adsorption at solid interfaces
Adsorption of materials at solid interfaces may take place from either an adjacent liquid or a gas
phase. Adsorption is different from absorption: the process of absorption implies the penetration of
an entity through the organs and tissues. The degree of adsorption depends on the chemical nature
of the adsorbent (a material that is being adsorbed onto a substrate, called adsorbate), the chemical
nature of the adsorbate, the surface area of the adsorbent, the temperature, and the partial pressure
of the adsorbed gas. Adsorption can be physical or chemical in nature:
• Physical adsorption: Physical adsorption is rapid, nonspecific, and relatively weak. Furthermore,
it is associated with van der Waals attractive forces and is reversible. Removal of the adsorbate
from the adsorbent is known as desorption. A physically adsorbed gas may be desorbed from a
solid by increasing the temperature and reducing the pressure. Physical adsorption is an
exothermic process, and thus the amount of adsorption decreases with rise in temperature
• Chemical adsorption: Chemical adsorption or chemisorption is an irreversible process in which

the adsorbent is attached to the adsorbate by primary chemical bonds. Chemisorption is specific
and may require activation energy; therefore, the process is slow and only a monomolecular
chemisorbed layer is possible.
Factors affecting adsorption from solution
• Solubility of adsorbate: The extent of adsorption of a solute is inversely proportional to its

solubility in the solvent from which adsorption occurs.
• Solute concentration: An increase in the solute concentration causes an increase in the amount of
adsorption that occurs at equilibrium until a limiting value is reached.
• Temperature: An increase in temperature leads to decreased adsorption.
• pH: The influence of pH is through a change in the ionization and solubility of the adsorbate drug
molecule. For many simple small molecules, adsorption increases as the ionization of the drug is
suppressed; that is, the extent of adsorption reaches a maximum when the drug is completely un-
ionized. For amphoteric compounds, adsorption is at a maximum at the isoelectric point. Because
the un-ionized form of most drugs in aqueous solution has a low solubility, pH and solubility
effects act in concert.
• Surface area of adsorbent: An increased surface area, achieved by a reduction in particle size or
by the use of a porous adsorbing material, increases the extent of adsorption.
Rheology
Rheology is the study of flow properties of liquids and the deformation of solids under the influence
of stress. The flow of simple liquids can be described by viscosity, an expression of the resistance to
flow; however, other complex dispersions cannot be expressed simply by viscosity. Materials are
divided into two general categories, Newtonian and non-Newtonian, depending on their
characteristics. Rheological properties are useful for the formulation and analysis of emulsions,
suspensions, pastes, lotions, and suppositories. Pourability, spreadability, and syringeability of an
emulsion are determined by its rheological properties.
According to Newton's law of viscous flow, the rate of flow (D) is directly proportional to the
applied stress ( ). That is, = · D, where is the viscosity. Fluids that obey Newton's law of flow
are referred to as Newtonian fluids, and fluids that deviate are known as non-Newtonian fluids. The
force per unit area (F´/A) required to bring about flow is called the shearing stress (F):
where is the viscosity, dv/dr is the rate of shear = G (s-1), and F´/A units are in dynes per cm2. For
simple Newtonian fluids, a plot of the rate of shear against shearing stress gives a straight line (
Figure 3-2 A); thus, is a constant. In the case of Newtonian fluids, viscosity does not change with
increasing shear rate. Various types of water and pharmaceutical dosage forms that contain a high
percentage of water are examples of liquid dosage forms that have Newtonian flow properties.
Most pharmaceutical fluids (including colloidal dispersions, emulsions, and liquid suspensions) do
not follow Newton's law of flow, and the viscosity of the fluid varies with the rate of shear. There
are three types of non-Newtonian flow: plastic, pseudoplastic, and dilatant (Figure 3-2 B, C, and D).
Plastic flow
Substances that undergo plastic flow are called Bingham bodies, which are defined as substances
that exhibit a yield value (Figure 3-2 B). Plastic flow is associated with the presence of flocculated
particles in concentrated suspensions. Flocculated solids are light, fluffy conglomerates of adjacent
particles held together by weak van der Waals forces. The yield value exists because a certain
shearing stress must be exceeded to break up van der Waals forces. A plastic system resembles a
Newtonian system at shear stresses above the yield value. Yield value, f, is an indicator of
flocculation (the higher the yield value, the greater the degree of flocculation). The characteristics
of plastic flow materials can be summarized as follows:
• Plastic flow does not begin until a shearing stress, corresponding to a yield value, f, is exceeded.
• The curve intersects the shearing stress axis but does not cross through the origin.
• The materials are said to be "elastic" at shear stresses below the yield value.
• Viscosity decreases with increasing shear rate at shear stress below the yield value.
[Figure 3-2. Plots of Rate of Shear as a Function of Shearing Stress for (A) Newtonian, (B) Plastic,
(C) Pseudoplastic, (D) Dilatant, and (E) Thixotropic flow]
Pseudoplastic flow
Pseudoplastic flow is exhibited by polymers in solution. A large number of pharmaceutical

products, including natural and synthetic gums (e.g., liquid dispersions of tragacanth, sodium
alginate, methyl cellulose, and sodium carboxymethylcellulose), exhibit pseudoplastic flow
properties. The characteristics of pseudoplastic flow materials can be summarized as follows:
• Pseudoplastic substances begin flow when a shearing stress is applied: that is, there is no yield
value (it does cross the origin).
• The viscosity of a pseudoplastic substance decreases with increasing shear rate.
• With increasing shearing stress, the rate of shear increases; these materials are called shear-
thinning systems.
• Shear thinning occurs when molecules (polymers) align themselves along their long axes and slip
and slide past each other.
Dilatant flow
Certain suspensions with a high percentage of dispersed solids exhibit an increase in resistance to
flow with increasing rates of shear. Dilatant systems are usually suspensions with a high percentage
of dispersed solids that exhibit an increase in resistance to flow with increasing rates of shear.
Dispersions containing a high percentage ( 50%) of small, deflocculated particles may exhibit this
type of behavior. The characteristics of dilatant flow materials can be summarized as follows:
• Dilatant materials increase in volume when sheared.
• They are also known as shear-thickening systems (the opposite of pseudoplastic systems).
• When the stress is removed, the dilatant system returns to its original state of fluidity.
• Viscosity increases with increasing shear rate.
• Dilatant materials may solidify under conditions of high shear.
Thixotropy
Thixotropy is a nonchemical isothermal gel-sol-gel transformation. If a thixotropic gel is sheared

(by simple shaking), the weak bonds are broken and a lyophobic solution is formed. On standing,
the particles collide, flocculation occurs, and the gel is reformed. The advantage that thixotropic
preparations have is that the particles remain in suspension during storage, but when required for
use, the pastes are readily made fluid by tapping or shaking. The shearing force on the injection as it
is pushed through the needle ensures that it is fluid when injected; however, the rapid resumption of
the gel structure prevents excessive spreading in the tissues, and consequently a more compact
depot is produced than with nonthixotropic suspensions. Thixotropy is a desirable property in liquid
pharmaceutical preparations. A well-formulated thixotropic suspension will not settle out readily in
the container and will become fluid on shaking. Flow curves (rheograms) for thixotropic materials
are highly dependent on the rate at which shear is increased or decreased and the length of time a
sample is subjected to any one rate of shear.
Negative thixotropy
Negative thixotropy is also known as antithixotropy, which represents an increase rather than a
decrease in consistency on the down curve (an increase in thickness or resistance to flow with an
increased time of shear). It may result from an increased collision frequency of dispersed particles
(or polymer molecules) in suspension, which causes increased interparticle bonding with time.
Shelf-Life Stability of a Drug Product
The shelf life of a drug in a dosage form is the amount of time the product can be stored before it
becomes unfit for use because of chemical decomposition, physical deterioration, or both. Shelf-life
stability of a dosage form can be determined by the Arrhenius equation k = A × e-Ea/RT, which can
be rewritten as
k = A · e-Ea/RT, which can be written as
where k2 and k1 are the reaction rates at the absolute temperatures T2 and T1, respectively; R is the
gas constant (1.987 cal/kmol), Ea is the activation energy (in cal/mol), and A is the constant (based
on molecular weight and molar volume of liquid).
3-2. Surfactants and Micelles
Introduction
Surface-active agents, or surfactants, are substances that absorb to surfaces or interfaces to reduce
surface or interfacial tension. They may be used as emulsifying agents, solubilizing agents,
detergents, and wetting agents. Surfactants have two distinct regions in one chemical structure. One
area is hydrophilic (water liking); another is hydrophobic (water hating). The existence of two such
moieties in a molecule is known as amphipathy, and the molecules are consequently referred to as
amphipathic molecules or amphiphiles. Depending on the number and nature of the polar and
nonpolar groups present, the amphiphile may be predominantly hydrophilic, lipophilic, or
somewhere in between. For example, straight chain alcohols, amines, and acids are amphiphiles
that change from being predominantly hydrophilic to lipophilic as the number of carbon atoms in
the alkyl chain is increased. The hydrophobic portions are usually saturated or unsaturated
hydrocarbon chains or, less commonly, heterocyclic or aromatic ring systems.
Surfactants are classified according to the nature of the hydrophilic or hydrophobic groups. In
addition, some surfactants possess both positively and negatively charged groups and can exist as
either anionic or cationic, depending on the pH of the solution. These surfactants are known as
ampholytic compounds.
At low concentrations in solutions, amphiphiles exist as monomers. As the concentration is

increased, aggregation occurs over a narrow concentration range. These aggregates, which may
contain 50 or more monomers, are called micelles. Therefore, micelles are small spherical
structures composed of both hydrophilic and hydrophobic regions. The concentration of monomer
at which micelles are formed is called the critical micellization concentration, or CMC. Surface
tension decreases up to the CMC but remains constant above the CMC. The longer the hydrophobic
chain or the lower the polarity of the polar group, the greater the tendency for monomers to
"escape" from the water to form micelles and hence lower the CMC.
Types of Micelles
In the case of amphiphiles in water, in dilute solution (still above but close to the CMC), the
micelles are considered to be spherical in shape. At higher concentrations, they become more
asymmetric and eventually assume cylindrical or lamellar structures. Oil-soluble surfactants have a
tendency to self-associate into reverse micelles in nonpolar solvents, with their polar groups
oriented away from the solvent.
Factors Affecting CMC and Micellar Size
• Structure of hydrophobic group: An increase in the hydrocarbon chain length causes a

logarithmic decrease in the CMC.
• Nature of hydrophilic group: An increase in chain length increases hydrophilicity and the CMC.
In general, nonionic surfactants have very low CMC values and high aggregation numbers
compared with their ionic counterparts with similar hydrocarbon chains.
• Nature of counterions: Note that Cl- < Br- < I- for cationic surfactants, and Na+ < K+ for anionic
surfactants.
• Electrolytes: The addition of electrolytes to ionic surfactants decreases the CMC and increases
the micellar size. In contrast, micellar properties of nonionic surfactants are affected only
minimally by the addition of electrolytes.
• Temperature: At temperatures up to the cloud point, an increase in micellar size and a decrease
in CMC is noted for many nonionic surfactants but has little effect on that of ionic surfactants.
• Alcohol: CMCs are increased by the addition of alcohols.
Hydrophilic-Lipophilic Balance Systems
Griffin's method of selecting emulsifying agents is based on the balance between the hydrophilic
and lipophilic portions of the emulsifying agent, now widely known as the hydrophilic-lipophilic
balance (HLB) system. The higher the HLB value of an emulsifying agent, the more hydrophilic it
is. The emulsifying agents with lower HLB values are less polar and more lipophilic. The Spans
(i.e., sorbitan esters) are lipophilic and have low HLB values (1.8-8.6); the Tweens
(polyoxyethylene derivatives of the Spans) are hydrophilic and have high HLB values (9.6-16.7).
Surfactants with the proper balance of hydrophilic and lipophilic affinities are effective emulsifying
agents because they concentrate at the oil-in-water (o/w) interface. The type of an emulsion that is
produced depends primarily on the property of the emulsifying agent. The HLB of an emulsifier or
a combination of emulsifiers determines whether an o/w or water-in-oil (w/o) emulsion results. In
general, o/w emulsions are formed when the HLB of the emulsifier is within the range of about 9 to
12; w/o emulsions are formed when the range is about 3 to 6. The type of emulsion is a function of
the relative solubility of the supernatant. An emulsifying agent with high HLB is preferentially
soluble in water and results in the formation of an o/w emulsion. The reverse situation is true with
surfactants of low HLB value, which tend to form w/o emulsions.
Micellar Solubilization
Micelles can be used to increase the solubility of materials that are normally insoluble or poorly
soluble in the dispersion medium used. For example, surfactants are often used to increase the
solubility of poorly soluble steroids. The factors affecting micellar solubilization are the nature of
surfactants, the nature of solubilizates, and the temperature.
3-3. Dispersed Systems
Introduction
Dispersed systems consist of particulate matter, known as the dispersed phase, distributed
throughout a continuous or dispersion medium. The particulate matter, or dispersed phase, consists
of particles that range from 1 nanometer (nm) to 0.5 micrometer (10-9 m to 5 × 10-7 m). Depending
on the dispersed phase, dispersed systems are classified as follows:
• Molecular dispersions: Less than 1 nm, invisible under electron microscopy. Examples are
oxygen molecules, ions, and glucose.
• Coloidal dispersions: From 1 nm to 0.5 micrometer, visible under electron microscopy.

Examples are colloidal silver sols and natural and synthetic polymers.
• Coarse dispersions: Greater than 0.5 micrometer, visible under light microscopy. Examples are
grains of sand, emulsions, suspensions, and red blood cells.
Types of Colloidal Systems
On the basis of the interaction of the particles, molecules, or ions of the dispersed phase with the
molecules of dispersion medium, colloidal systems are classified into three groups: lyophilic,
lyophobic, and association colloids.
Lyophilic or hydrophilic colloids
Systems containing colloidal particles that interact with the dispersion medium are referred to as
lyophilic colloids. In the case of lipophilic colloids, organic solvent is the dispersion medium,
whereas water is used as the dispersion medium for hydrophilic colloids. Because of their affinity
for the dispersion medium, such materials form colloidal dispersions with relative ease. For
example, the dissolution of acacia or gelatin in water, or celluloid in amyl acetate, leads to the
formation of a solution. Most lyophilic colloids are polymers (e.g., gelatin, acacia, povidone,
albumin, rubber, and polystyrene).
Lyophobic or hydrophobic colloids
Lyophobic colloids are composed of materials that have little attraction for the dispersion medium.
Lyophobic colloids are intrinsically unstable and irreversible. Hydrophobic colloids are generally
composed of inorganic particles dispersed in water.
Association colloids
Association colloids (referring to amphiphilic colloids) are formed by the grouping or association of
amphiphiles (i.e., molecules that exhibit both lyophilic and lyophobic properties). At low
concentrations, amphiphiles exist separately and do not form a colloid. At higher concentrations,
aggregation occurs at around 50 or more monomers, leading to micelle formation. As with lyophilic
colloids, formation of association colloids is spontaneous if the concentration of the amphiphile in
solution exceeds the CMC.
Zeta Potential and Its Effect on Colloidal Stability
Zeta ( ) potential is defined as the difference in potential between the surface of the tightly bound
layer (shear plane) and the electroneutral region of the solution. The ¶ potential governs the degree
of repulsion between adjacent, similarly charged, dispersed particles. If ¶ potential is reduced below
a certain value, the attractive forces exceed the repulsive forces, and the particles come together.
This phenomenon is known as flocculation.
Stabilization is accomplished by providing the dispersed particles with an electric charge and a
protective solvent sheath surrounding each particle to prevent mutual adherence attributable to
collision. This second effect is significant only in the case of lyophilic colloids. Lyophilic and
association colloids are thermodynamically stable and exist in a true solution so that the system
constitutes a single phase. In contrast, lyophobic colloids are thermodynamically unstable but can
be stabilized by preventing aggregation or coagulation by providing the dispersed particles with an
electric charge, which can prevent coagulation through repulsion of like particles.
3-4. Pharmaceutical Ingredients
Turning a drug substance into a pharmaceutical dosage form or a drug delivery system requires
pharmaceutical ingredients. For example, in the preparation of tablets, diluents or fillers are
commonly added to increase the bulk of the formulation. Binders are added to promote adhesion of
the powdered drug to other ingredients. Lubricants assist the smooth tabletting process.
Disintegrants promote tablet breakup after administration. Coatings improve stability, control
disintegration, or enhance appearance. Similarly, in the preparation of pharmaceutical solutions,
preservatives are added to prevent microbial growth, stabilizers are added to prevent drug
decomposition, and colorants and flavorants are added to ensure product appeal. Thus, for each
dosage form, the pharmaceutical ingredients establish the primary features of the product and
control the physicochemical properties, drug-release profiles, and bioavailability of the product.
Table 3-1 lists some typical pharmaceutical ingredients used in different dosage forms.
3-5. Types of Commonly Used Dosage Forms
Solutions
Solutions are homogeneous mixtures of one or more solutes dispersed in a dissolving medium
(solvent). Aqueous solutions containing a sugar or sugar substitute with or without added flavoring
agents and drugs are classified as syrups. Sweetened hydroalcoholic (combinations of water and
ethanol) solutions are termed elixirs. Hydroalcoholic solutions of aromatic materials are termed
spirits. Tinctures are alcoholic or hydroalcoholic solutions of chemical or soluble constituents of
vegetable drugs. Most tinctures are prepared by an extraction process. Mouthwashes are solutions
used to cleanse the mouth or treat diseases of the oral membrane. Antibacterial topical solutions
(e.g., benzalkonium chloride and strong iodine) will kill bacteria when applied to the skin or
mucous membrane.
Solutions intended for oral administration usually contain flavorants and colorants to make the
medication more attractive and palatable to the patient. They may contain stabilizers to maintain the
physicochemical stability of the drug and preservatives to prevent the growth of microorganisms in
the solution. A drug dissolved in an aqueous solution is in the most bioavailable form. Because the
drug is already in solution, no dissolution step is necessary before systemic absorption occurs.
Solutions that are prepared to be sterile, that are pyrogen free, and that are intended for parenteral
administration are classified as injectables.
[Table 3-1. Typical Pharmaceutical Ingredients]
Some drugs, particularly certain antibiotics, have insufficient stability in aqueous solution to
withstand long shelf lives. These drugs are formulated as dry powder or granule dosage forms for
reconstitution with purified water immediately before dispensing to the patient. The dry powder
mixture contains all of the formulation components—that is, drug, flavorant, colorant, buffers, and
others—except for the solvent. Examples of dry powder mixtures intended for reconstitution to
make oral solutions include cloxacillin sodium, nafcillin sodium, oxacillin sodium, and penicillin V
potassium.
Sucrose is the sugar most frequently used in syrups; in special circumstances, it may be replaced in
whole or in part by other sugars (e.g., dextrose) or nonsugars (e.g., sorbitol, glycerin, and propylene
glycol). Most syrups consist of between 60% and 80% sucrose. Sucrose not only provides
sweetness and viscosity to the solution, but also renders the solution inherently stable (unlike dilute
sucrose solutions, which are unstable).
Compared with syrups, elixirs are usually less sweet and less viscous because they contain a lower
proportion of sugar, and they are consequently less effective than syrups in masking the taste of
drugs. In contrast to aqueous syrups, elixirs are better able to maintain both water-soluble and
alcohol-soluble components in solution because of their hydroalcoholic properties. These stable
characteristics often make elixirs preferable to syrups. All elixirs contain flavoring and coloring
agents to enhance their palatability and appearance. Elixirs containing over 10% to 12% alcohol are
usually self-preserving and do not require the addition of antimicrobial agents for preservation.
Alcohols precipitate tragacanth, acacia, agar, and inorganic salts from aqueous solutions; therefore,
such substances should either be absent from the aqueous phase or be present in such low
concentrations as not to promote precipitation on standing. Examples of some commonly used
elixirs include dexamethasone elixir USP, pentobarbital elixir USP, diphenhydramine
hydrochloride elixir, and digoxin elixir.
Tablets
Depending on the physicochemical properties of the drug, site and extent of drug absorption in the
GI tract, stability to heat or moisture, biocompatibility with other ingredients, solubility, and dose,
the following types of tablets are commonly formulated:
• Swallowable tablets are intended to be swallowed whole and then disintegrate and release their
medicaments in the GI tract.
• Effervescent tablets are dissolved in water before administration. In addition to the drug
substance, these tablets contain sodium bicarbonate and an organic acid such as tartaric acid.
These additives react in the presence of water, liberating carbon dioxide, which acts as a
disintegrator and produces effervescence.
• Chewable tablets are used when a faster rate of dissolution or buccal absorption is desired.
Chewable tablets consist of a mild effervescent drug complex dispersed throughout a gum base.
The drug is released from the dosage form by physical disruption associated with chewing,
chemical disruption caused by the interaction with the fluids in the oral cavity, and the presence
of effervescent material. For example, antacid tablets should be chewed to obtain quick
indigestion relief.
• Buccal and sublingual tablets dissolve slowly in the mouth, cheek pouch (buccal), or under the
tongue (sublingual). Buccal or sublingual absorption is often desirable for drugs subject to
extensive hepatic metabolism, often referred to as the first-pass effect. Examples are isoprenaline
sulfate (a bronchodilator), glyceryl trinitrate (a vasodilator), nitroglycerin, and testosterone
tablets. These tablets do not contain a disintegrant and are compressed lightly to produce a fairly
soft tablet.
• Lozenges are compressed tablets that do not contain a disintegrant. Some lozenges contain
antiseptics (e.g., benzalkonium) or antibiotics for local effects in the mouth.
• Controlled-release tablets are used to improve patient compliance and to reduce side effects.
Some water-soluble drugs are formulated as sustained-release tablets so that their release and
dissolution are controlled over a long period. A hydrophobic matrix composed of carnauba wax
and partially hydrogenated cottonseed oil were used to prepare sustained-release tablets of a
highly water-soluble drug, ABT-089, a cholinergic channel modulator for the treatment of
cognitive disorders. Theo-Dur is a controlled-release tablet of theophylline and consists of two
components: a matrix of compressed theophylline crystals and coated theophylline granules
embedded in the matrix. In contact with fluid, theophylline diffuses slowly through the wall of
the free granules, which dissolves with time. After oral administration of Theo-Dur 300 mg
tablets to human subjects, serum theophylline concentrations over 1 mg/mL were maintained
over 24 hours. Core-in-cup tablets, which provide a zero-order release of ibuprofen, were
developed by compressing the mixture of ethyl cellulose and carnauba wax, followed by
compression with core tablets containing ibuprofen. The combination of high- and low-viscosity
grades of hydroxypropyl methylcellulose (HPMC) was used as the matrix base to prepare
diclofenac sodium and zileuton sustained-release tablets. A ternary polymeric matrix system
composed of protein, HPMC, and highly water-soluble drugs such as diltiazem hydrochloride
was developed by the direct compression method. Xanthan gum was used for a hydrophilic
matrix for sustained-release ibuprofen tablets. Sustained-release tablets can also be prepared by
formulating inert polymers, such as polyvinyl chloride, polyvinyl acetate, and methyl
methacrylate. These polymers protect the tablet from disintegration and reduce the dissolution
rate of the drug inside the tablet. Examples of commonly used sustained-release drug delivery
products are listed in
Table 3-2.
• Coated tablets are used to prevent decomposition or to minimize the unpleasant taste of certain
drugs. Several types of coated tablets are made: film coated, sugar coated, gelatin coated (gel
caps), or enteric coated. Enteric coatings are resistant to gastric juices but readily dissolve in the
small intestine. These enteric coatings can protect drugs against decomposition in the acidic
environment of the stomach. Commonly used polymers for enteric coating are acid-impermeable
polymers, such as cellulose acetate trimellitate, HPMC
[Table 3-2. Examples of Sustained-Release Drug Delivery Products]
phthalate, polyvinyl acetate phthalate, cellulose acetate phthalate, and EUDRAGIT. Aspirin
formulated as enteric-coated sustained-release tablets has been shown to produce less gastric
bleeding than do conventional aspirin preparations. Film-coated tablets are compressed tablets
coated with a thin layer of a water-insoluble or water-soluble polymer, such as methylcellulose
phthalate, ethylcellulose, povidone, or polyethylene glycol. Abacavir is a capsule-shaped film-
coated tablet containing a nucleoside reverse transcriptase inhibitor, which is a potent antiviral
agent for the treatment of HIV infection.
Tablet formulation
In addition to the drug, the following materials are added to make the powder system compatible
with tablet formulation by the compression or granulation methods:
• Diluents or bulking agents are invariably added to very-low-dose drugs to bring overall tablet
weight to at least 50 mg, which is the minimum desirable tablet weight. Commonly used diluents
are lactose, dicalcium phosphate, starches, microcrystalline cellulose, dextrose, sucrose,
mannitol, and sodium chloride. Dicalcium phosphate absorbs less moisture than lactose and is
therefore used with hygroscopic drugs such as pethidine hydrochloride.
• Adsorbents are substances capable of holding quantities of fluids in an apparently dry state. Oil-
soluble drugs or fluid extracts can be mixed with adsorbents and then granulated and compressed
into tablets. Examples are fumed silica, microcrystalline cellulose, magnesium carbonate, kaolin,
and bentonite.
• Moistening agents are liquids that are used for wet granulation. Examples include water,
industrial methylated spirits, and isopropanol.
• Binding agents (adhesives) bind powders together in the wet granulation process. They also help
bind granules together during compression. Examples include starches, gelatin, PVP, alginic acid
derivatives, cellulose derivatives, glucose, and sucrose. Choice of binders affects the dissolution
rate. For example, the tablet formulation of furosemide with PVP as the binder has a t50 (time
required for 50% of the drug to be released during an in vitro dissolution study) of 3.65 minutes,
but with starch mucilage as the binder, the t50 of the tablets was 117 minutes.
• Glidants are added to tablet formulations to improve the flow properties of the granulations. They
act by reducing interparticle friction. Commonly used glidants are fumed (colloidal) silica, starch,
and talc.
• Lubricants have a number of functions in tablet manufacture. They prevent adherence of the
tablet material to the surfaces of the punch faces and dies, reduce interparticle friction, and
facilitate the smooth ejection of the tablet from the die cavity. Many lubricants also enhance the
flow properties of the granules. Commonly used lubricants are magnesium stearate, talc, stearic
acid and its derivatives, PEG, paraffin, and sodium or magnesium lauryl sulfate. Among these
lubricants, magnesium stearate is the most popular, because it is effective as both a die and a
punch lubricant. However, for many drugs (e.g., aspirin), magnesium stearate is chemically
incompatible; therefore, talc or stearic acid is often used. Most lubricants, with the exception of
talc, are used in concentrations below 1%.
• Disintegrating agents are added to the tablets to promote breakup or disintegration after
administration, which increases the effective surface area and promotes rapid release of the drug.
Disintegrants act either by bursting open the tablet or by promoting the rapid ingress of water into
the center of the tablet or capsule. Examples include starches, cationic exchange resins, cross-
linked PVP, celluloses, modified starches, alginic acid and alginates, magnesium aluminum
silicate, and cross-linked sodium carboxymethylcellulose. Among these agents, starch is the most
popular disintegrant because it has a great affinity for water and swells when moistened, thus
facilitating the rupture of the tablet matrix.
Disintegration, dissolution, and absorption
A solid drug product has to disintegrate into small particles and release the drug before absorption
can take place. Tablets that are intended for chewing or sustained release do not have to undergo
disintegration. The various excipients for tablet formulation affect the rates of disintegration,
dissolution, and absorption. Systemic absorption of most products consists of a succession of rate
processes, such as
• Disintegration of the drug product and subsequent release of drug
• Dissolution of the drug in an aqueous environment
• Absorption across cell membranes into the systemic circulation
In the process of tablet disintegration, dissolution, and absorption, the rate at which the drug reaches
the circulatory system is determined by the slowest step in the sequence. Disintegration of a tablet is
usually more rapid than drug dissolution and absorption. For the drug that has poor aqueous
solubility, the rate at which the drug dissolves (dissolution) is often the slowest step, and it
therefore exerts a rate-limiting effect on drug bioavailability. In contrast, for the drug that has a high
aqueous solubility, the dissolution rate is rapid, and the rate at which the drug crosses or permeates
cell membranes is the slowest or rate-limiting step.
Capsules
Capsules are the dosage forms in which unit doses or powder, semisolid, or liquid drugs are
enclosed in a hard or soft, water-soluble container or shell of gelatin. Coating of the capsule shell or
drug particles within the capsule can affect bioavailability. There are two types of capsules: hard
and soft capsules; hard gelatin capsules are more versatile for controlled drug delivery.
Hard gelatin capsules
A hard gelatin capsule consists of two pieces, a cap and a body, that fit one inside the other. They
are produced empty and are then filled in a separate operation. Hard gelatin capsules are usually
filled with powders, granules, or pellets containing the drug. After ingestion, the gelatin shell
softens, swells, and begins to dissolve in the GI tract. Encapsulated drugs are released rapidly and
dispersed easily, leading to high bioavailability. Capsules are supplied in a variety of sizes, and
high-speed filling machinery capable of filling approximately 1,500 capsules per minute is
available. The hard gelatin empty capsules are numbered from 000, the largest size, to 5, which is
the smallest. The approximate filling capacity of capsules ranges from 6,000 to 30 mg, depending
on the types and bulk densities of powdered drug materials.
Powder formulations for encapsulation into hard gelatin capsules require careful consideration of
the filling process, such as lubricity, compactibility, and fluidity. Additives present in the capsule
formulations, such as the amount and choice of fillers and lubricants, the inclusion of disintegrants
and surfactants, and the degree of plug compaction, can influence drug release from the capsule.
Formulation factors influencing drug release and bioavailability are as follows:
• Fillers (or diluents): Active ingredient is mixed with a sufficient volume of a diluent—usually
lactose, mannitol, starch, and dicalcium phosphate—to yield the desired amount of the drug in
the capsule when the base is filled with the powder mixture.
• Glidants: The flow properties of the powder blend should be adequate to ensure a uniform flow
rate from the hopper. Glidants such as silica, starch, talc, and magnesium stearate are used to
improve the fluidity. The optimal concentration of the glidant used to improve the flow of a
powder mixture is generally less than 1%.
• Lubricants: These ease the ejection of plugs by reducing adhesion of powder to metal surfaces
and friction between sliding surfaces in contact with the powder. Typical lubricants for capsule
formulations include magnesium stearate and stearic acid.
• Surfactants: These may be included in capsule formulations to increase wetting of the powder
mass and to enhance drug dissolution. The most commonly used surfactants in capsule
formulations are 0.1% to 0.5% sodium lauryl sulfate and sodium docusate.
• Wetting agents: Hydrophilic polymer is used as a wetting agent for improving the wettability of
poorly soluble drugs. Powder wettability and dissolution rate of several drugs, including
hexobarbital and phenytoin, from hard gelatin capsules have been shown to be enhanced if the
drug is treated with methylcellulose or hydroxyethyl-cellulose.
Vancomycin hydrochloride is a highly hygroscopic antibiotic. To achieve acceptable stability, Eli

Lilly has developed a hard gelatin capsule filled with a PEG 6,000 matrix of vancomycin
hydrochloride, which produces plasma and urine levels of the antibiotic similar to those obtained
with the solution of vancomycin hydrochloride. Controlled-release beads and minitablets are often
filled into gelatin capsules for convenient administration of an oral controlled-release dosage form.
For example, sustained-release antihistamines, antitussives, and analgesics are first preformulated
into extended-release microcapsules or microspheres and then placed inside a gelatin capsule.
Another example is enteric-coated lipase minitablets, which are placed in a gelatin capsule for more
effective protection and dosing of these enzymes.
Soft gelatin capsules
Soft gelatin capsules are prepared from plasticized gelatin by a rotary die process. They are formed,
filled, and sealed in a single operation. Soft gelatin capsules may contain a nonaqueous solution, a
powder, or a drug suspension, none of which solubilize the gelatin shell. In contrast to hard gelatin
capsules, soft gelatin capsules contain about 30% glycerol as a plasticizer in addition to gelatin and
water. The moisture uptake of soft gelatin capsules plasticized with glycerol is considerably higher
than that of hard gelatin capsules. Therefore, oxygen-sensitive drugs should not be inserted into soft
gelatin capsules, nor should emulsions, because they are unstable and crack the shell of the capsule
when water is lost in the manufacturing process. Extreme acidic and basic pH must also be avoided,
because a pH below 2.5 hydrolyzes gelatin, while a pH above 9.0 has a tanning effect on the gelatin.
Insoluble drugs should be dispersed with an agent such as beeswax, paraffin, or ethylcellulose.
Surfactants are also often added to promote wetting of the ingredients. Drugs that are commercially
prepared in soft capsules include declomycin, chlorotrianisene, digoxin, vitamin A, vitamin E, and
chloral hydrate.
Formulation of soft gelatin capsules involves liquid, rather than powder, technology. It requires
careful consideration of the composition of the gelatin shell and filling materials. The composition
of the soft capsule shell consists of two main ingredients: gelatin and a plasticizer. Water is used to
form the capsule, and other additives are often added as follows:
• Gelatin: Properties of gelatin shells are controlled by choice of gelatin grade and by adjustment of
the concentration of plasticizer in the shell.
• Plasticizers: The main plasticizer used for soft gelatin capsules is glycerol. Sorbitol and
polypropylene glycol are also used in combination with glycerol. Compared to hard gelatin
capsules and tablet film coatings, a relatively large amount (~30%) of plasticizers is added in soft
gelatin capsule formulation to ensure adequate flexibility.
• Water: The desirable water content of the gelatin solution used to produce a soft gelatin capsule
shell depends on the viscosity of the gelatin used and ranges between 0.7 and 1.3 parts of water
to each part of dry gelatin.
• Other additives: Preservatives are added to prevent mold growth in the gelatin shell. Potassium
sorbate and methyl, ethyl, and propyl hydroxybenzoate are commonly used as preservatives.
Emulsions
An emulsion is a thermodynamically unstable system that consists of at least two immiscible liquid
phases—one of which is dispersed as globules (dispersed phase) in the other, a liquid phase
(continuous phase)—that are stabilized by the presence of an emulsifying agent. Emulsified systems
range from lotions of relatively low viscosity to ointments and creams, which are semisolid in
nature.
Types of emulsions
One liquid phase in an emulsion is essentially polar (e.g., aqueous), whereas the other is relatively
nonpolar (e.g., an oil).
• Oil-in-water emulsion: When the oil phase is dispersed as globules throughout an aqueous
continuous phase, the system is referred to as an oil-in-water emulsion.
• Water-in-oil emulsion: When the oil phase serves as the continuous phase, the emulsion is
termed a water-in-oil emulsion.
• Multiple (w/o/w or o/w/o) emulsions: These are emulsions whose dispersed phase contains
droplets of another phase. Multiple emulsions are of interest as delayed-action drug delivery
systems.
• Microemulsions: These consist of homogeneous transparent systems of low viscosity that contain
a high percentage of both oil and water and high concentrations of emulsifier mixture.
Microemulsions form spontaneously when the components are mixed in the appropriate ratios
and are thermodynamically stable.
Externally applied emulsions may be o/w or w/o. The o/w emulsions use the following emulsifiers:
sodium lauryl sulfate, triethanolamine stearate, sodium oleate, and glyceryl monostearate. The w/o
emulsions are used mainly for external applications and may contain one or several of the following
emulsifiers: calcium palmitate, sorbitan esters (Spans), cholesterol, and wool fats.
Interfacial free energy and emulsification
Two immiscible liquids in emulsions often fail to remain mixed because of the greater cohesive
force between the molecules of each separate liquid, rather than the adhesive force between the two
liquids. These forces lead to phase separation, which is the state of minimum surface free energy.
When one liquid is broken into small particles, the interfacial area of the globules constitutes a
surface area that is enormous compared with that of the original liquid. The adsorption of a
surfactant or other emulsifying agent at the globule interface lowers the oil-to-water or water-to-oil
interfacial tension. In addition, the process of emulsification is made easier, and the drug's stability
may be enhanced.
Emulsifying agents
Preventing coalescence requires the introduction of an emulsifying agent that forms a film around
the dispersed globules. Emulsifying agents may be divided into three groups:
• Surface-active agents: Surfactants are adsorbed at oil-water interfaces to form monomolecular

films and to reduce interfacial tensions. Unless the interfacial tension is zero, the oil droplets
have a natural tendency to coalesce to reduce the area of oil-water contact. The presence of the
surfactant monolayer at the surface of the droplet reduces the possibility of collisions leading to
coalescence. To retain a high surface area for the dispersed phase, surface-active agents must be
used to decrease the surface free energy. Often a mixture of surfactants is used: one with
hydrophilic character and the other with hydrophobic character. A hydrophilic emulsifying agent
is needed for the aqueous phase, and a hydrophobic emulsifying agent is needed for the oil phase.
A complex film results that produces an excellent emulsion. Nonionic surfactants are widely
used in the production of stable emulsions. They are less toxic than ionic surfactants and are less
sensitive to electrolytes and pH variation. Examples include sorbitan esters and polysorbates.
• Hydrophilic colloids: A number of hydrophilic colloids are used as emulsifying agents. They
include gelatin, casein, acacia, cellulose derivatives, and alginates. These materials adsorb at the
oil-water interface and form multilayer films around the dispersed droplets of oil in an o/w
emulsion. Hydrated lyophilic colloids differ from surfactants because they do not appreciably
lower interfacial tension. Their action is caused by the strong multimolecular film's resistance to
coalescence. Additionally, they increase the viscosity of the dispersion medium. Hydrophilic
colloids are used for formation of o/w emulsions because the films are hydrophilic. Most
cellulose derivatives are not charged but can sterically stabilize the systems.
• Finely divided solid particles: These particles are adsorbed at the interface between two
immiscible liquid phases and form a film of particles around the dispersed globules. Finely
divided solid particles that are wetted to some degree by both oil and water can act as
emulsifying agents. They are concentrated at the interface, where they produce a film of particles
around the dispersed droplets that prevents coalescence. Finely divided solid particles that are
wetted by water form o/w emulsions; those that are wetted by oil form w/o emulsions. Examples
include bentonite, magnesium hydroxide, and aluminum hydroxide.
Types of instability in emulsions
The stability of an emulsion is characterized by the absence of coalescence of the internal phase, the
absence of creaming, and the maintenance of elegance with respect to appearance, odor, color, and
other physical properties. An emulsion becomes unstable because of creaming, breaking,
coalescence, phase inversion, and some other factors.
Creaming and sedimentation

Creaming is the upward movement of dispersed droplets relative to the continuous phase, whereas
sedimentation, the reverse process, is the downward movement of particles. Density differences in
the two phases cause these processes, which can be reversed by shaking. Creaming is undesirable,
however, because a creamed emulsion increases the likelihood of coalescence because of the
proximity of the globules in the cream. Factors that influence the rate of creaming are similar to
those involved in the sedimentation rate of suspension particles and are indicated by Stokes's Law
as follows:
where v is the velocity of creaming; d is the globule diameter; ‫ء‬s and ‫ء‬o are the densities of
dispersed phase and dispersion medium, respectively; ·o is the viscosity of the dispersion medium
(poise); and g is the acceleration of gravity (981 cm/s2). According to this equation, the rate of
creaming is decreased by
• A reduction in the globule size
• A decrease in the density difference between the two phases
• An increase in the viscosity of the continuous phase
This decrease may be achieved by homogenizing the emulsion to reduce the globule size and
increasing the viscosity of the continuous phase by the use of thickening agents such as tragacanth
or methylcellulose.
Creaming, breaking, coalescence, and aggregation

Creaming is a reversible process, whereas breaking is irreversible. When breaking occurs, simple
mixing fails to resuspend the globules in a stable emulsified form. Because the film surrounding the
particles has been destroyed, the oil tends to coalesce. Coalescence is the process by which
emulsified particles merge with each other to form large particles. The major factor preventing
coalescence is the mechanical strength of the interfacial barrier. Formation of a thick interfacial film
is essential for minimal coalescence. In aggregation, the dispersed droplets come together but do
not fuse. Aggregation is to some extent reversible.
Phase inversion
An emulsion is said to invert when it changes from an o/w to a w/o emulsion or vice versa.
Inversion can be caused by adding an electrolyte or by changing the phase-to-volume ratio. For
example, an o/w emulsion stabilized with sodium stearate can be inverted to a w/o emulsion by
adding calcium chloride to form calcium stearate.
Microbial growth
Growth of microorganisms in an emulsion can cause physical separation of the phases. Because
bacteria can degrade nonionic and anionic emulsifying agents, preservatives must be added to the
product in adequate concentrations to prevent bacterial growth.
Suspensions
Suspensions are dispersions of finely divided solid particles of a drug in a liquid medium in which
the drug is not readily soluble. Suspending agents are often hydrophilic colloids (e.g., cellulose
derivatives, acacia, or xanthan gum) added to suspensions to increase viscosity, inhibit
agglomeration, and decrease sedimentation. Highly viscous suspensions may prolong gastric
emptying time, slow drug dissolution, and decrease the absorption rate. A suspension that is
thixotropic as well as pseudoplastic should prove useful because it forms a gel on standing and
becomes fluid when disturbed.
Desired characteristics of suspensions
• Suspended material should settle slowly and should readily disperse on gentle shaking of the
container.
• Particle size of the suspension should remain fairly constant.
• The suspension should pour readily and evenly from its container.
Flocculation
The large surface area of the particles is associated with a surface free energy that makes the system
thermodynamically unstable. This instability makes particles highly energetic; they tend to regroup,
resulting in the decrease in total surface area and surface free energy. The particles in a liquid
suspension, therefore, tend to flocculate. Flocculation is the formation of light, fluffy conglomerates
held together by weak van der Waals forces. Aggregation occurs when crystals come together to
form a compact cake (growth and fusing together of crystals in the precipitate to form a solid
aggregate). Flocculating agents can prevent caking, whereas deflocculating agents increase the
tendency to cake. Surfactants can reduce interfacial tension, but they cannot reduce it to zero, so
suspensions of insoluble particles tend to have a positive finite interfacial tension, and particles tend
to flocculate.
Forces at the surface of a particle affect the degree of flocculation and agglomeration in a
suspension. Forces of attraction are of the London-van der Waals type, whereas repulsive forces
arise from the interaction of the electric double layers surrounding each particle. When the
repulsion energy is high, collision of the particles is opposed. The system remains deflocculated,
and when sedimentation is complete, the particles form a close-packed arrangement with the
smaller particles filling the voids between the larger ones. Those particles that are lowest in the
sediment are gradually pressed together by the weight of the ones above; the energy barrier is thus
overcome, allowing the particles to come into close contact with each other. Resuspending and
redispersing these particles requires that the high-energy barrier be overcome. Because agitation
does not easily achieve this, the particles tend to remain strongly attracted to each other and form a
hard cake. When the particles are flocculated, the energy barrier is still too large to be surmounted,
and so the approaching particles in the second energy minimum, which are at a distance of
separation of perhaps 1,000 to 2,000 A, are sufficient to form the loosely structural flocs.
Sedimentation of flocculated particles
Flocs tend to fall together, producing a distinct boundary between the sediment and the supernatant
liquid. The liquid above the sediment is clear because even the small particles present in the system
are associated with flocs. In deflocculated systems with variable particle sizes, by contrast, the large
particles settle more rapidly than the smaller particles, and no clear boundary is formed. The
supernatant remains turbid for a longer time.
Flocculation or deflocculation?
Whether a suspension is flocculated or deflocculated depends on the relative magnitudes of the

electrostatic forces of repulsion and the forces of attraction between the particles. Flocculated
systems form loose sediments that are easily redispersible, but the sedimentation rate is usually fast.
In contrast, a suspension is deflocculated when the dispersed particles remain as discrete units and
will settle slowly. This condition prevents the entrapment of liquid within the sediment, which leads
to caking—a serious stability problem encountered in suspension formulation.
Flocculating agents
If the charge on the particle is neutralized, flocculation will occur. If a high charge density is
imparted to the suspension particles, then deflocculation will be the result. The following
flocculating agents are often used to convert the suspension from a deflocculated to a flocculated
state:
• Electrolytes: The addition of an inorganic electrolyte to an aqueous suspension will alter the ¶
potential of the dispersed particles. If this value is lowered sufficiently, then flocculation may
occur. The most widely used electrolytes include sodium salts of acetates, phosphates, and
citrates.
• Surfactants: Ionic surfactants may also cause flocculation by neutralizing the charge on each
particle.
• Polymeric flocculating agents: Starches, alginates, cellulose derivatives, tragacanth, carbomers,
and silicates are examples of polymeric flocculating agents that can be used to control the degree
of flocculation. Their linear branched-chain molecules form a gel-like network within the system
and become adsorbed on the surfaces of the dispersed particles, thus holding them in a
flocculated state.
Formulation of suspensions
Physically stable suspensions can be formulated in two ways. One is to use a structured vehicle to
maintain deflocculated particles in suspension. However, the major disadvantage of deflocculated
systems is that when the particles eventually settle, they form a compact cake. The other is by
production of flocs, which may settle rapidly but are easily resuspended with a minimum of
agitation. Optimum physical stability is obtained when the suspension is formulated with
flocculated particles in a structured vehicle of hydrophilic colloid type.
Ointments, Creams, and Gels
Ointments, creams, and gels are semisolid preparations intended for topical applications. These
semisolid formulations are designed for local or systemic drug absorption.
Ointments are typically used as
• Emollients to make the skin more pliable
• Protective barriers to prevent harmful substances from coming in contact with the skin
• Vehicles in which to incorporate medication
Ointment bases are classified into four general groups: (1) hydrocarbon bases, (2) absorption bases,
(3) water-removable bases, and (4) water-soluble bases.
Hydrocarbon bases
Hydrocarbon (oleaginous) bases are anhydrous and insoluble in water. They cannot absorb or
contain water and are not washable in water.
Petrolatum is a good base for oil-insoluble ingredients. It forms an occlusive film on the skin and
absorbs less than 5% water under normal conditions. Wax can be incorporated to stiffen the base.
Synthetic esters are used as constituents of oleaginous bases. These esters include glycerol
monostearate, isopropyl myristate, isopropyl palmitate, butyl stearate, and butyl palmitate.
Absorption bases
Absorption bases are of two types: (1) those that permit the incorporation of aqueous solutions,
resulting in the formation of w/o emulsions (e.g., hydrophilic petrolatum and anhydrous lanolin),
and (2) those that are already w/o emulsions (emulsion bases) and thus permit the incorporation of
small additional quantities of aqueous solutions (e.g., lanolin and cold cream). These bases are
useful as emollients although they do not provide the degree of occlusion afforded by the
oleaginous bases. Absorption bases are also not easily removed from the skin with water. An
aqueous solution may be first incorporated into the absorption base, and then this mixture added to
the oleaginous base.
Water-removable bases
Emulsion, water-washable, or water-removable bases, commonly referred to as creams, represent

the most commonly used type of ointment base. The majority of dermatologic drug products are
formulated in an emulsion or cream base. Emulsion bases are washable and removed easily from
skin or clothing. An emulsion base can be subdivided into three component parts: the oil phase, the
emulsifier, and the aqueous phase. Drugs can be included in one of these phases or added to the
formed emulsion. The oil phase, also known as the internal phase, is typically made up of
petrolatum or liquid petrolatum together with cetyl or stearyl alcohol. Following are types of
emulsion bases:
• Hydrophilic ointment is an o/w emulsion that uses sodium lauryl sulfate as an emulsifying agent.
It is readily miscible with water and is removed from the skin easily. The aqueous phase of an
emulsion base contains the preservatives that are included to control microbial growth. The
preservatives in the emulsion include methylparaben, propylparaben, benzyl alcohol, sorbic acid,
or quaternary ammonium compounds. The aqueous phase also contains the water-soluble
components of the emulsion system, together with any additional stabilizers, antioxidants, and
buffers that may be necessary for stability and pH control.
• Cold cream is a semisolid white w/o emulsion prepared with cetyl ester wax, white wax, mineral
oil, sodium borate, and purified water. Sodium borate combines with free fatty acids present in
the waxes to form sodium soaps that act as the emulsifiers. Cold cream is used as an emollient
and ointment base. Eucerin cream is a w/o emulsion of petrolatum, mineral oil, mineral wax,
wool wax, alcohol, and Bronopol. It is frequently prescribed as a vehicle for delivery of lactic
acid and glycerin to treat dry skin.
• Lanolin is a w/o emulsion that contains approximately 25% water and acts as an emollient and
occlusive film on the skin, effectively preventing epidermal water loss.
• Vanishing cream is an o/w emulsion that contains a large percentage of water as well as a
humectant (e.g., glycerin or propylene glycol) that retards surface evaporation. An excess of
stearic acid in the formula helps to form a thin film when the water evaporates.
Water-soluble bases
Water-soluble bases may be anhydrous or may contain some water. They are washable in water and
absorb water to the point of solubility. Polyethylene glycol ointment is a blend of water-soluble
PEG that forms a semisolid base. This base can solubilize water-soluble drugs and some water-
insoluble drugs. It is compatible with a wide variety of drugs. It contains 40% PEG 4,000 and 60%
PEG 400. Another water-soluble base is the ointment prepared with propylene glycol and ethanol,
which form a clear gel when mixed with 2% hydroxypropyl cellulose. This base is a commonly
used dermatologic vehicle.
Incorporation of drugs into an ointment
Drugs may be incorporated into an ointment base by levigation and fusion. Normally, drug
substances are in fine powdered forms before being dispersed in the vehicle. Levigation of powders
into a small portion of base is facilitated by the use of a melted base or a small quantity of
compatible levigation aid, such as mineral oil or glycerin. Water-soluble salts are incorporated by
dissolving them in a small volume of water and incorporating the aqueous solution into a
compatible base. Fusion is used when the base contains solids that have higher melting points (e.g.,
waxes, cetyl alcohol, or glyceryl monostearate).
Suppositories
A suppository is a solid dosage form intended for insertion into body orifices (e.g., rectum, vagina,
or urethra). Once inserted, the suppository base melts, softens, or dissolves at body temperature,
distributing its medications to the tissues of the region. Suppositories are used for local or systemic
effects. Rectal suppositories intended for local action are often used to relieve the pain, irritation,
itching, and inflammation associated with hemorrhoids. Vaginal suppositories intended for local
effects are used mainly as contraceptives, as antiseptics in feminine hygiene, and to combat
invading pathogens. The suppository base has a marked influence on the release of active
constituents. Two main classes of suppository bases are in use: the glyceride-type fatty bases and
the water-soluble ones. The main water-soluble and water-miscible suppository bases are
glycerinated gelatin and polyethylene glycols. Polyethylene glycol suppositories do not melt at body
temperature but rather dissolve slowly in the body's fluids. Examples of rectal suppositories include
Thorazine (chlorpromazine) and Phenergan (promethazine).
Inserts, Implants, and Devices
Inserts, implants, and devices are used to control drug delivery for localized or systemic drug
effects. In these systems, drugs are embedded into biodegradable or nonbiodegradable materials to
allow slow release of the drug. The inserts, implants, and devices are inserted into a variety of
cavities (e.g., vagina, buccal cavity, cul de sac of the eye, or subcutaneous tissue).
Degradable inserts consist of polyvinyl alcohol, hydroxypropyl cellulose, PVP, and hyaluronic acid.
Nondegradable inserts are prepared from insoluble materials such as ethylene vinyl acetate
copolymers and styrene-isoprene-styrene block copolymers. The initial use of contact lenses was for
vision correction; however, they are becoming more useful as potential drug delivery devices by
presoaking them in drug solutions. The use of contact lenses can simultaneously correct vision and
release the drug.
A number of degradable and nondegradable inserts are currently available for ophthalmic delivery.
These ophthalmic inserts can be insoluble, soluble, or bioerodible. Insoluble inserts are further
classified as diffusional, osmotic, and contact lens (
Figure 3-3). Ocular inserts are no more affected by nasolacrimal drainage and tear flow than
conventional dosage forms; they can provide slow drug release and longer residence times in the
conjunctival cul de sac. Ocusert is an interesting device consisting of a drug reservoir (pilocarpine
hydrochloride in an alginate gel) enclosed by two release-controlling membranes made of ethylene
vinyl acetate copolymer and enclosed by a white ring, allowing positioning of the system in the eye.
Pilocarpine Ocusert has demonstrated slow release of pilocarpine, which can effectively control the
increased intraocular pressure in glaucoma. Other inserts (e.g., medicated contact lenses, collagen
shields, and mini-discs) have been shown to diminish the systemic absorption of ocularly applied
drugs as a result of decreased drainage into the nasal cavity. Lacrisert is a soluble insert composed
of hydroxypropyl cellulose and is useful in the treatment of dry eye syndrome. The device is placed
in the lower fornix, where it slowly dissolves over 6-8 hours to stabilize and thicken the tear film.
In addition to ophthalmic delivery, inserts are used for localized delivery of drugs to various other
tissues. For example, the Progestasert device is designed for implantation into the uterine cavity,
where it releases 65 mg progesterone per day to provide contraception for 1 year. Similarly,
Transderm relies on the rate-limiting polymeric membranes to control
[Figure 3-3. Different Types of Ophthalmic inserts]
drug release. Atridox, approved by the U.S. Food and Drug Administration (FDA), is a product
designed for controlled-release delivery of the antibiotic doxycycline for the treatment of
periodontal disease. When injected into the periodontal cavity, the formulation sets, forming a drug
delivery depot that delivers the antibiotic to the cavity.
An implant is a drug delivery system designed to deliver a drug moiety at a desired rate over a
prolonged period. Implants are available in many forms, including polymeric implants and
minipumps. Diffusional and osmotic symptoms contain a reservoir that is in contact with the inner
surface of a controller, to which it supplies the drug. The reservoir contains a liquid, a gel, a colloid,
a semisolid, a solid matrix, or a carrier that contains drug. Carriers consist of hydrophilic or
hydrophobic polymers.
ALZA Corporation (acquired by Johnson & Johnson in May 2001) developed ALZET miniosmotic
pumps, which permit easy manipulation of drug release rate over a range of periods (from 1 day to 4
weeks). ALZA Corporation also developed DUROS implants for continuous therapy for up to 1
year. The nondegradable, osmotically driven system is intended to enable delivery of small drugs,
peptides, proteins, and DNA (deoxyribonucleic acid) for systemic or tissue-specific therapy. Viadur
is a once-yearly implant for the palliative treatment of advanced prostate cancer.
One of the more commonly used devices is the oral osmotic pump, composed of a core tablet and a
semipermeable coating with a 0.3-4.0 mm diameter hole, produced by a laser beam, for drug exit.
This system requires only osmotic pressure to be effective, but the drug release rate depends on the
surface area, the nature of the membrane, and the diameter of the hole. When the dosage form
comes in contact with water, water is imbibed because of the resultant osmotic pressure of the core,
and the drug is released from the orifice at a controlled rate.
Transdermal Drug Delivery Systems
Transdermal drug delivery systems (often called transdermal patches) deliver drugs directly through
the skin and into the bloodstream. Percutaneous absorption of a drug generally results from direct
penetration of the drug through the stratum corneum. Once through the stratum corneum, drug
molecules may pass through the deeper epidermal tissues and into the dermis. When the drug
reaches the vascularized dermal area, it becomes available for absorption into the general
circulation. Among the factors influencing percutaneous absorption are the physicochemical
properties of the drug, including its molecular weight, solubility, and partition coefficient; the
nature of the vehicle; and the condition of the skin. Chemical permeation enhancers or
iontophoresis are often used to enhance the percutaneous absorption of a drug.
In general, patches are composed of three key compartments: a protective seal that forms the
external surface and protects it from damage, a compartment that holds the medication itself and
has an adhesive backing to hold the entire patch on the skin surface, and a release liner that protects
the adhesive layer during storage and is removed just prior to application. Examples of transdermal
patches include Estraderm (estradiol), Nicoderm (nicotine), Testoderm (testosterone), Alora
(estradiol), and Androderm (testosterone).
Aerosol Products
Aerosols are pressurized dosage forms designed to deliver drugs with the aid of a liquefied or
propelled gas (propellant). Aerosol products consist of a pressurizable container, a valve that allows
the pressurized product to be expelled from the container when the actuator is pressed, and a dip
tube that conveys the formulation from the bottom of the container to the valve assembly.
Inhalation devices broadly fall into three categories: pressurized metered dose inhalers (MDIs),
nebulizers, and dry powder inhalers. The most commonly used inhalers on the market are MDIs.
They contain active ingredient as a solution or as a suspension of fine particles in a liquefied
propellant held under high pressure. MDIs use special metering valves to regulate the amount of
formulation dispensed with each dose. Nebulizers do not require propellants and can generate large
quantities of small droplets capable of penetrating into the lung. Sustained release of drugs, such as
bronchodilators and corticosteroids for the treatment of asthma and chronic obstructive pulmonary
diseases, involves encapsulation of the drugs in slowly degrading particles that can be inhaled. For
accumulation in the alveolar zone of the lungs, which has a very large surface area, inhaled liquid or
dry powder aerosols should have particle sizes in the range of 1-5 micrometers. Inhaled drugs play a
prominent role in the treatment of asthma, because this route has significant advantages over oral or
parenteral administration. Azmacort (triamcinolone acetamide), Ventolin HFA (albuterol sulfate),
and Serevent (salmeterol) are examples of commercially available aerosols for the treatment of
asthma.
3-6. Targeted Drug Delivery Systems

Introduction
Targeted drug delivery systems are drug carrier systems that deliver the drug to the target or
receptor site in a manner that provides maximum therapeutic activity, prevents degradation or
inactivation during transit to the target sites, and protects the body from adverse reactions because
of inappropriate disposition. Design of an effective delivery system requires a thorough
understanding of the drug, the disease, and the target site (
Figure 3-4). Examples include macromolecular drug carriers (protein drug carriers); particulate
drug delivery systems (e.g., microspheres, nanospheres, and liposomes); monoclonal antibodies;
and cells. Plasma clearance kinetics, tissue distribution, metabolism, and cellular interactions of a
drug can be controlled by the use of a site-specific delivery system. Targeting of drugs to specific
sites in the body can be achieved by linking particulate systems or macromolecular carriers to
monoclonal antibodies or to cell-specific ligands (e.g., asialofetuin, glycoproteins, or
immunoglobulins) or by altering the surface characteristics so that they are not recognized by the
reticuloendothelial systems.
Macromolecular Carrier Systems
Both natural and synthetic water-soluble polymers have been used as macromolecular drug carriers.
The drug can be attached to the polymer chain either directly or via a spacer. Attachment of PEG to
proteins can protect them from rapid hydrolysis or degradation within the body, increase blood
circulation time, and lower the immunogenicity of proteins. PEGylated forms of interferons;
PegIntron and PEGASYS (for treatment of hepatitis C, to reduce dosing frequency from daily
injections to once-weekly injection dosing); adenosine deaminase; and L-asparaginase are currently
on the market. PEGylation improves macromole solubility and stability by minimizing the uptake
by the cells of the reticuloendothelial system. Because PEG drug conjugates are not well absorbed
from the gut, they are mainly used as injectables. The drug-polymer conjugate may also contain a
receptor-specific ligand to achieve selective access to, and interaction with, the target cells.
[Figure 3-4. Essential Components of Drug Delivery]
Particulate Drug Delivery Systems
Many particulate carriers have been designed for drug delivery and targeting. They include
liposomes, micelles, microspheres, and nanoparticles.
Liposomes
Liposomes are microscopic phospholipid vesicles composed of uni- or multilamellar lipid bilayers
surrounding compartments. Multilamellar vesicles have diameters in the range of 1.0-5.0
micrometers. Sonication of multilamellar vesicles results in the production of small unilamellar
vesicles with diameters in the range of 0.02-0.08 micrometers. Large unilamellar vesicles can be
made by evaporation under reduced pressure, resulting in liposomes with a diameter of 0.1-1.0
micrometer. The bilayer-forming lipid is the essential part of the lamellar structure, while the other
compounds are added to impart certain characteristics to the vesicles. Water-soluble drugs can be
entrapped in liposomes by intercalation in the aqueous bilayers, whereas lipid-soluble drugs can be
entrapped within the hydrocarbon interiors of the lipid bilayers. Liposomes can encapsulate low-
molecular-weight drugs, proteins, peptides, oligonucleotides, and genes. The use of the antifungal
agent amphotericin B formulated in liposomes has been approved by the FDA. Because
conventional liposomes are recognized by the immune system as foreign bodies, ALZA
Corporation developed STEALTH liposomes, which evade recognition by the immune system
because of their unique polyethylene glycol coating. Doxil is a STEALTH liposome formulation of
doxorubicin, used for the treatment of AIDS-related Kaposi's sarcoma.
Microparticles and nanoparticles
Microencapsulation is a technique that involves the encapsulation of small particles or the solution
of drugs in a polymer film or coat. Different methods of microencapsulation result in either
microcapsules or microspheres. For example, interfacial polymerization of a monomer usually
produces microcapsules, whereas solvent evaporation may result in microspheres or microcapsules,
depending on the amount of drug loading. A microcapsule is a reservoir-type system in which the
drug is located centrally within the particle, whereas a microsphere is a matrix-type system in which
the drug is dispersed throughout the particle. Microcapsules usually release their drug at a constant
rate (zero-order release), whereas microspheres typically give a first-order release of drugs. Low-
molecular-weight drugs, proteins, oligonucleotides, and genes can be encapsulated into
microparticles to provide their sustained release at disease sites.
The most commonly used method of microencapsulation is coacervation, which involves addition
of a hydrophilic substance to a colloidal drug dispersion. The hydrophilic substance, which acts as a
coating material, may be selected from a variety of natural and synthetic polymers, including
shellacs, waxes, gelatin, starches, cellulose acetate phthalate, and ethylcellulose, among others.
Following dissolution of the coating materials, the drug inside the microcapsule is available for
dissolution and absorption.
Biodegradable polylactide and its copolymers with glycolide [poly(lactic-co-glycolic acid), or

PLGA] are commonly used for preparation of microparticles from which the drug can be released
slowly over a period of a month or so. Microspheres can be used in a wide variety of dosage forms,
including tablets, capsules, and suspensions. Lupron Depot from TAP Pharmaceuticals is an FDA-
approved preparation of PLGA microspheres for sustained release of a small peptide luteinizing
hormone-releasing hormone agonist. More recently, PLGA microspheres of recombinant human
growth hormone have been developed and marketed successfully by Genentech under the trade
name Nutropin Depot.
3-7. Key Points
• Fick's first law of diffusion describes the diffusion process under steady-state conditions when the
drug concentration gradient does not change with time.
• Drug absorption depends not only on the fraction of un-ionized form of the drug but also on the
surface area available for absorption.
• The Noyes-Whitney equation can be used for determining the dissolution rate of a drug from its
dosage form, whereas the Arrhenius equation can be used for determining the shelf life of a drug
dosage form.
• Surfactants consist of hydrophilic and hydrophobic groups and can be used as emulsifying agents
to reduce interfacial tensions.
• The pharmaceutical dosage form contains the active drug ingredient in association with nondrug
(usually inert) ingredients (excipients). Together they form the vehicle, or formulation matrix.
• Water-soluble drugs are often formulated as sustained-release tablets so that their release and
dissolution rates can be controlled, whereas enteric-coated tablets are used to protect drugs from
gastric degradation.
• Capsules are solid dosage forms with hard or soft gelatin shells that contain drugs and excipients.
• Aerosols are pressurized dosage forms designed to deliver drugs to pulmonary tissues with the aid
of a liquefied or propelled gas.
• Inserts, implants, and devices allow slow release of the drug into a variety of cavities (e.g., vagina,
buccal cavity, cul de sac of the eye, and skin).
• Transdermal patches deliver drugs directly through the skin and into the bloodstream.
• The drug delivery system deals with the pharmaceutical formulation and the dynamic interactions
among the drug, its formulation matrix, its container, and the physiologic milieu of the patient.
These dynamic interactions are the subject of pharmaceutics.
• Macromolecular drug carriers, such as protein-polymer conjugates, and particulate delivery

systems, such as microspheres and liposomes, are commonly used for delivery of drugs with low
molecular weight, such as peptides and proteins, to different disease targets.
• Targeted (or site-specific) drug delivery systems are used for drug delivery to the target or receptor
site in a manner that provides maximum therapeutic activity, by preventing degradation during
transit to the target site while avoiding delivery to nontarget sites.
3-8. Questions
Which of the following is true for Fick's first law of diffusion?
A. It refers to the non-steady-state flow.

B. The amount of material flowing through a unit cross-section of a barrier in unit time is
1.
known as the concentration gradient.
C. Flux of material is proportional to the concentration gradient.
D. Diffusion occurs in the direction of increasing concentration.
E. All of the above are true.

Which equation describes the rate of drug dissolution from a tablet?
A. Fick's law
2. B. Henderson-Hasselbalch equation
C. Michaelis-Menten equation
D. Noyes-Whitney equation
E. All of the above

The pH of a buffer system can be calculated with
A. the Henderson-Hasselbalch equation.

3. B. the Noyes-Whitney equation.
C. the Michaelis-Menten equation.
D. Yong's equation.
E. all of the above.

Which of the following is not true for gas adsorption on a solid?
A. Chemical adsorption is reversible.

4. B. Physical adsorption is based on weak van der Waals forces.
C. Chemical adsorption may require activation energy.
D. Chemical adsorption is specific to the substrate.
E. All of the above.

What is bioavailability?
A. Bioavailability is the measurement of the rate and extent of active drug that reaches the
systemic circulation.
5. B. It is the relationship between the physical and chemical properties of a drug and its systemic
absorption.
C. It is the movement of the drug into body tissues over time.
D. It is dissolution of the drug in the GI tract.
E. All of the above describe bioavailability.

Which of the following may be used to assess the relative bioavailability of two chemically
equivalent drug products in a crossover study?
A. Dissolution test
6.
B. Peak concentration
C. Time-to-peak concentration
D. Area under the plasma-level time curve
E. All of the above

What condition usually increases the rate of drug dissolution for a tablet?
A. Increase in the particle size of the drug

7. B. Decrease in the surface area of the drug
C. Use of the ionized, or salt, form of the drug
D. Use of the free acid or free base form of the drug
E. Use of sugar coating around the tablet

The characteristics of an active transport process include all of the following except
A. active transport moves drug molecules against a concentration gradient.

8. B. active transport follows Fick's law of diffusion.
C. active transport is a carrier-mediated transport system.
D. active transport requires energy.
E. active transport of drug molecules may be saturated at high drug concentrations.

Which of the following dosage forms may use surface-active agents in their formulations?
A. Emulsions
9. B. Suspensions
C. Colloidal dosage forms
D. Creams
E. All of the above

Which of the following statements about lyophilic colloidal dispersions is true?
A. They tend to be more sensitive to the addition of electrolytes than do lyophobic systems.
10. B. They tend to be more viscous than lyophobic systems.
C. They can be precipitated by prolonged dialysis.
D. They separate rapidly.

Which of the following is not true for tablet formulations?
A. A disintegrating agent promotes granule flow.

11. B. Lubricants prevent adherence of granules to the punch faces of the tabletting machine.
C. Glidants promote flow of the granules.
D. Binding agents are used for adhesion of powder into granules.

The absorption rate of a drug is most rapid when the drug is formulated as
A. a controlled-release product.
12. B. a hard gelatin capsule.
C. a compressed tablet.
D. a solution.
E. a suspension.

The passage of drug molecules from a region of high drug concentration to a region of low
drug concentration is known as
A. active transport.
13.
B. simple diffusion or passive transport.
C. pinocytosis.
D. bioavailability.
E. biopharmaceutics.

Which equation is used to predict the stability of a drug product at room temperature from
experiments at increased temperatures?
A. Stokes's equation
14.
B. Arrhenius equation
C. Michaelis-Menten equation
D. Fick's equation
E. Noyes-Whitney equation

Choose which of the following statements is true.
A. Flocculation is desirable for pharmaceutical suspensions.

B. The diffusion rate of molecules of a smaller particle size is less than that of molecules of a
15.
larger particle size.
C. Particle size of molecular dispersions is larger than a coarse dispersion.
D. Pseudoplastic flow is shear-thickening type, and dilatant is shear-thinning type.

Choose which of the following statements is false.
A. The Henderson-Hasselbalch equation describes the effect of physical parameters on the

stability of pharmaceutical suspensions.
B. The passive diffusion rate of hydrophobic drugs across biological membranes is higher than
16. that of hydrophilic compounds.
C. When the dispersed phase in an emulsion formulation is heavier than the dispersion
medium, creaming can still occur.
D. Targeted drug delivery systems deliver the drug to the target or receptor site in a manner
that provides maximum therapeutic activity.

Which of the following is an emulsifying agent?
A. Sorbitan mono-oleate (Span 80)

17. B. Polyoxyethylene sorbitan mono-oleate (Tween 80)
C. Sodium lauryl sulfate
D. Gum acacia
E. All of the above

Which of the following surfactants is incompatible with bile salts?
A. Polysorbate 80
18. B. Potassium stearate
C. Sodium lauryl sulfate
D. Benzalkonium chloride
E. All of the above

Which of the following statements is false?
A. The partition coefficient is the ratio of drug solubility in n-octanol to that in water.
B. Absorption of a weak electrolyte drug does not depend on the extent to which the drug
19.
exists in its un-ionized form at the absorption site.
C. The drug dissolution rate can be determined using the Noyes-Whitney equation.
D. Amorphous forms of drug have faster dissolution rates than do crystalline forms.

Which of the following statements is true?
A. Most substances acquire a surface charge by ionization, ion adsorption, and ion dissolution.
B. The term surface tension is used for liquid-vapor and solid-vapor tensions
20.
C. At the isoelectric point, the total number of positive charges is equal to the total number of
negative charges.
D. All of the above.
E. None of the above.

Agents that may be used in the enteric coating of tablets include
A. hydroxypropyl methylcellulose.
21. B. carboxymethylcellulose.
C. cellulose acetate phthalate.
D. all of the above.
E. none of the above.

3-9. Answers
C. Fick's first law of diffusion states that the amount of material flow through a unit cross-
section of a barrier in unit time, which is known as the flux, is proportional to the
1.
concentration gradient. Fick's first law of diffusion describes the diffusion process under
steady-state conditions where the concentration gradient does not change with time.

D. The Noyes-Whitney equation describes the rate of drug dissolution from a tablet. Fick's first
law of diffusion is similar to the Noyes-Whitney equation in that both equations describe drug
2. movement attributable to a concentration gradient. The Michaelis-Menten equation involves
enzyme kinetics, whereas Henderson-Hasselbalch equations are used for determination of pH
of the buffer and the extent of ionization of a drug molecule.

A. The Henderson-Hasselbalch equation for a weak acid and its salt is represented as pH = pKa
3. + log [salt]/[acid], where pKa is the negative log of the dissolution constant of a weak acid, as
[salt]/[acid] is the ratio of the molar concentration of salt and acid used to prepare a buffer.

A. Chemical absorption is an irreversible process that is specific and may require activation
4.
energy, whereas physical adsorption is reversible and associated with van der Waals forces.

A. Bioavailability is the measurement of the rate and extent of systemic circulation of an active
5.
drug.

D. The plasma drug concentration versus time curve measures the bioavailability of a drug
from a product. The peak plasma drug concentration (Cmax) relates to the intensity of the
6.
pharmacologic response, while the time for peak plasma drug concentration (Tmax) relates to
the rate of systemic absorption.

C. The ionized, or salt, form of a drug is generally more water soluble and therefore dissolves
more rapidly than the nonionized (free acid or free base) form of the drug. According to the
7. Noyes-Whitney equation, the dissolution rate is directly proportional to the surface area and
inversely proportional to the particle size. Therefore, an increase in the particle size or a
decrease in the surface area slows the dissolution rate.

B. In passive transport, a drug travels from a high concentration to a low concentration,
8. whereas active transport moves drug molecules against a concentration gradient and requires
energy.

E. Surface-active agents facilitate emulsion formation by lowering the interfacial tension
9. between the oil and water phases. Adsorption of surfactants on insoluble particles enables these
particles to be dispersed in the form of a suspension.

B. Most lyophilic colloids are organic molecules (including gelatin and acacia); they
10. spontaneously form colloidal solutions and tend to be viscous. Dispersion of lyophilic colloids
is stable in the presence of electrolytes.

A. Disintegrating agents are added to the tablets to promote breakup of the tablets when placed
in the aqueous environment. Lubricants are required to prevent adherence of the granules to the
11. punch faces and dies. Glidants are added to tablet formulations to improve the flow properties
of the granulations. Binding agents are added to bind powders together in the granulation
process.

D. For a drug in solution, no dissolution is required before absorption. Consequently,
12. compared with other drug formulations, a drug in aqueous solution has the highest
bioavailability rate and is often used as the reference preparation for other formulations.

B. In simple diffusion or passive transport, a drug travels from a high concentration to a low
concentration, whereas active transport moves drug molecules against a concentration gradient
13.
and requires energy. Pinocytosis is a vesicular transport process of engulfment of small
particles or fluid volumes.

B. Stability at room temperature can be predicted from accelerated testing data by the
Arrhenius equation: log (k2/k1) = Ea(T2 - T1)/(2.303 RT2T1), where k2 and k1 are the rate
14. constants at the absolute temperatures T2 and T1, respectively; R is the gas constant; and Ea is
the energy of activation. Stokes's equation is used to determine the sedimentation rate of a
suspension, whereas the Noyes-Whitney equation is used to determine the dissolution rate.

A. Flocculation is the formation of light, fluffy conglomerates held together by weak van der
15. Waals forces and is a reversible process. Pseudoplastic flow is a shear-thinning process,
whereas dilatant is a shear-thickening type process.

A. The Henderson-Hasselbalch equation describes the relationship between ionized and
16.
nonionized species of a weak electrolyte.

E. Sorbitan mono-oleate (Span 80), polyoxyethylene sorbitan monooleate (Tween 80), sodium
17.
lauryl sulfate, and gum acacia are surfactants used as emulsifiers.

18. D. Benzalkonium chloride is a cationic surfactant and can interact with bile salts.

B. According to pH partition theory, absorption of a weak electrolyte drug depends on the
extent to which the drug exists in its unionized form at the absorption site. However, pH
19.
partition theory often does not hold true, because most weakly acidic drugs are well absorbed
from the small intestine, possibly because of the large epithelial surface areas of the organ.

D. Most substances acquire a surface charge by ionization, ion adsorption, and ion dissolution.
20. At the isoelectric point, the total number of positive charges is equal to the total number of
negative charges.

C. An enteric-coated tablet has a coating that remains intact in the stomach, but dissolves in
21. the intestine when the pH exceeds 6. Enteric-coating materials include cellulose acetate
trimellitate, polyvinyl acetate phthalate, and hydroxypropyl methylcellulose phthalate.

3-10. References
Ansel HC, Popovich NG, Allen LV, eds. Pharmaceutical Dosage Forms and Drug Delivery
Systems. 6th ed. Malvern, Pa.: Williams & Wilkins; 1995.
Aulton ME, ed. Pharmaceutics: The Science of Dosage Form Design. New York: Churchill
Livingstone; 1988.
Banker GS, Rhodes CT, eds. Modern Pharmaceutics. 3rd ed. New York: Marcel Dekker; 1995.
Block LH, Collins CC. Biopharmaceutics and drug delivery systems. In: Shargel L, Mutnick AH,
Souney PH, Swanson LN, eds. Comprehensive Pharmacy Review. New York: Lippincott
Williams & Wilkins; 2001:78-91.
Block LH, Yu ABC. Pharmaceutical principles and drug dosage forms. In: Shargel L, Mutnick AH,
Souney PH, Swanson LN, eds. Comprehensive Pharmacy Review. New York: Lippincott
Florence AT, Attwood D. Physicochemical Principles of Pharmacy. 3rd ed. Palgrave, N.Y.:
Macmillan; 1998.
Gennaro AR, Gennaro AL, eds. Remington: The Science and Practice of Pharmacy. Baltimore:
Lippincott, Williams & Wilkins; 2000.
Hillery AM. Advanced drug delivery and targeting: An introduction. In: Hillery AM, Lloyd AW,
Swarbrick J, eds. Drug Delivery and Targeting: For Pharmacists and Pharmaceutical Scientists.
New York: Taylor & Francis; 2001:63-82.
Mahato RI. Pharmaceutical Dosage Forms and Drug Delivery. New York: Taylor & Francis; 2007.
Martin A. Physical Pharmacy. 4th ed. Baltimore: Lippincott Williams & Wilkins; 1993.
Mathiowitz E, Kretz MR, Bannon-Peppas L. Microencapsulation. In: Mathiowitz E, ed.

Encyclopedia of Controlled Drug Delivery. New York: John Wiley & Sons; 1999:493-546.
Washington N, Washington C, Wilson CG. Physiological Pharmaceutics: Barriers to Drug

Absorption. 2nd ed. New York: Taylor & Francis; 2001.
4. Compounding - Charles N. May, BSPh, MSHP
4-1. Introduction
Pharmacists extemporaneously compound medications to provide patients and prescribers more

options for treatment and therapy than are provided by commercially available products. Patients
need individualized custom-prepared medications for many reasons, including the following: (1)
some therapeutic agents are not commercially manufactured; (2) some therapeutic agents are not
manufactured in the form or size needed; (3) some manufactured therapeutic agents contain
offending ingredients, such as dyes, preservatives, fillers, and binders; (4) some manufactured
therapeutic agents contain offending flavors, fragrances, or colors; and (5) some patients do not fit
into the standard categories that manufactured products treat. In addition, from time to time
commercially manufactured products are unavailable for a variety of reasons, such as (1) the drug is
recalled, (2) the manufacturing facility is closed down, (3) a strike or disaster occurs, (4) the
product is no longer commercially profitable, or (5) the manufacturer no longer supplies the product
for other corporate reasons. Several segments of the population are not properly served by
pharmaceutical manufacturers, including pediatric patients, geriatric patients, veterinary patients,
and patients with rare or very complicated disease states. Prescribers and pharmacists working very
closely with patients improve the quality of life for those patients as no other practice can.
4-2. Philosophy of Compounding
• Compounding is extemporaneous per patient.
• It fulfills needs for unique dosage forms and sizes.
• The pharmacist works as part of a three-member team—the patient, the pharmacist, and the
prescriber—to satisfy a patient's unique needs that cannot be satisfied by commercially available
products.
• The pharmacist follows up with the patient, the prescriber, or both to determine if the
compounded preparation needs further adjustment or refinement to completely satisfy the
patient's needs.
4-3. Compounding versus Manufacturing
Compounding
• Compounded preparations are patient specific in conjunction with the prescriber.
• They are regulated by the state board of pharmacy.
• Compounded preparations are not advertised.

• Compounded preparations have beyond-use dates.
• Compounded preparations are not prepared in advance except in the case of documented usage or
demand.
• Compounded preparations have no National Drug Code (NDC) number.
Manufacturing
• Products are subject to an approved New Drug Application (NDA).
• Products are subject to U.S. Food and Drug Administration (FDA)-approved labeling.
• Products are manufactured in FDA-approved plants in accordance with good manufacturing

practices.
• Products may be advertised.
• Products carry an expiration date.
• Products carry an NDC number.
• Products are regulated by the FDA.
4-4. Guidelines for Compounding
The following are published guidelines pharmacists use in designing and carrying out their
compounding activities. Pharmacists' compounding practices are regulated by the laws of the state
board of pharmacy of the state in which the pharmacist practices.
Allen LV Jr. Extemporaneous prescription compounding. In: Remington: The Science and Practice
of Pharmacy, 21st ed. Baltimore: Lippincott Williams & Wilkins; 2006:1903-12.
National Association of Boards of Pharmacy. Good Compounding Practices Applicable to State

Licensed Pharmacies. Park Ridge, Ill.: National Association of Boards of Pharmacy; 1993.
U.S. Food and Drug Administration. Pharmacy compounding. In: Compliance Policy Guide,
Compliance Policy Guidance for FDA Staff and Industry. Washington, D.C.; 2002. Section 460.
200.
U.S. Pharmacopeial Convention. Good compounding practices: chapter 1075. In: U.S.
Pharmacopeia 32/National Formulary 27. Rockville, Md.: U.S. Pharmacopeial Convention;
2009:523-26.
U.S. Pharmacopeial Convention. Pharmaceutical calculations in prescription compounding: chapter

1160. In: U.S. Pharmacopeia 32/National Formulary 27. Rockville, Md.: U.S. Pharmacopeial
Convention; 2009:674-83.
U.S. Pharmacopeial Convention. Pharmaceutical compounding-nonsterile preparations: chapter

795. In: U.S. Pharmacopeia 32/National Formulary 27. Rockville, Md.: U.S. Pharmacopeial
U.S. Pharmacopeial Convention. Prescription balances and volumetric apparatus: chapter 1176.
U.S. Pharmacopeia 32/National Formulary 27. Rockville, Md.: U.S. Pharmacopeial Convention;
2009:691-92.
U.S. Pharmacopeial Convention. Quality assurance in pharmaceutical compounding: chapter 1163.

In: U.S. Pharmacopeia 32/National Formulary 27. Rockville, Md.: U.S. Pharmacopeial
4-5. Requirements
Pharmacy
Space
• An appropriate amount is required; a dedicated area is ideal.
• Space should be properly arranged and maintained, with ingredients and equipment close at hand.
• A controlled atmosphere is necessary, with limited traffic flow and air flow away from operator.
• Separate areas are needed for sterile and nonsterile compounding.
• A source of potable water and purified water (i.e., sink) should be readily available.
• Facility should be constructed of materials that are as nonporous and seamless as possible; a well
lit space with bright fixtures, walls, and floors gives a clean, professional appearance.
Equipment
• Appropriate measuring devices are required (e.g., graduated cylinders, pharmacy graduates,
pipettes).
• Appropriate balances for weighing are necessary (e.g., an electronic balance or class A
prescription balance).
• Appropriate mixing devices are required (e.g., Wedgwood, porcelain, and glass mortars and
pestles, blenders).
• Appropriate counters and shelves are needed; sufficient countertop space must be available so that
compounding will not be cramped, and shelving must be sufficient and appropriately located so
that ingredients can be convenient and properly stored.
• Appropriate processing equipment is necessary (e.g., hot plates and magnetic stirrers, ointment
mills, electronic mortar and pestle, tablet pulverizers).
• Appropriate safety equipment must be available (e.g., rubber gloves, face masks, hair covers,
gowns, and goggles for personnel; devices that gently exhaust the air from the work area to keep
the air free of contamination with ingredients; and containment areas for personnel who are
working with light, fine, fluffy ingredients or ingredients that are irritating or foul smelling).
• Appropriate packaging equipment is required (e.g., capsule-filling machines, tube-sealing

equipment, calibrated measuring and filling devices)
• Appropriate computer equipment should be available (e.g., for processing labels, profiles, and
formulas and for maintaining required records regarding ingredients)
Formulas
Ingredient classification and quality
• USP/NF: United States Pharmacopeia/National Formulary (ingredients meet official standards and
are suitable for human use)
• FCC: Food Chemicals Codex (food grade)
• ACS: American Chemical Society (reagent grade)
• AR: analytical reagent (high purity)
• CP: chemically pure (uncertain quality)
• Tech: technical (industrial quality)
Supplies
• Supplies include weigh boats, weighing paper (parchment and glassine), filter paper, ointment
paper, spatulas (stainless steel and hard rubber), stirring rods (glass and polypropylene), rubber
scrapers, beakers, flasks, funnels, casseroles, and containers of all types and sizes to properly
package all the unique dosage forms and sizes patients require.
• Supplies also include all sizes of prescription bottles, powder jars, capsule vials, and ointment jars
as well as ointment tubes, troche molds, plastic suppository molds, powder paper boxes,
suppository boxes, "ride-up" tubes, and so forth.
Records
• An exact record of each compounded prescription must be made and maintained.
• A chronological record of each day's compounding activity should be made and kept for future
reference and use.
• A Master Formula card must be in place for each preparation compounded, and it must be
approved by and signed and dated by the pharmacist in charge.
Policies and procedures
• Standard operating procedures (SOPs)
• Material safety data sheets (MSDSs)
• Certificates of analysis (COAs)
• Quality assurance checks
• Other policies and procedures
The Pharmacist
• Interest: A distinct interest in being creative, solving difficult patient problems, working closely
with prescribers and patients, and formulating and compounding special customized medications
is very important.
• Education: The emphasis on compounding varies among colleges of pharmacy. Even graduates
of programs that require students to compound a wide variety of formulations may find that they
need more training.
• Training: Additional training is often obtained through continuing education courses, seminars,
professional development programs, or professional associations.
• Experience: Experience in compounding is perhaps the key to how effective a pharmacist can be
in creating special formulations that make a significant difference in a patient's life when
everything else up to that point has failed. It enables the pharmacist to suggest to the prescriber a
therapeutic agent in a unique dosage form that has a better chance of solving the patient's
problem. Conversely, a pharmacist with less-than-optimal experience and interest may compound
a medication that is not effective and thus not satisfy the patient's need—and perhaps may even
undermine the prescriber's confidence in all compounded medications. Pharmacists who
compound must be certain that they possess the appropriate requisites for the level of
compounding they perform.
• Compounding support: Compounding pharmacists should join professional organizations that
support compounding such as the International Academy of Compounding Pharmacists. They
should subscribe to journals that focus on compounding such as the International Journal of
Pharmaceutical Compounding or the U.S. Pharmacist. They should also use the professional
resources of the companies that fulfill their compounding needs.
Professional Considerations
• Is there a commercially available product in the exact dosage, size, form, and package needed?
• Is there an alternative product that will completely satisfy the patient's requirements?
• Can I do the required pharmaceutical calculations to make and package the preparation?
Quality Control Requirements
• Accurate calculations
• Accurate weights
• Accurate measurements
• Proper processing techniques
• Proper packaging
• Proper records
• Proper labeling, including beyond-use date
Beyond-Use Dates
• Pharmacists assign beyond-use dates to compounded preparations to provide patients with

guidance in the proper use of the preparation.
• The goal is to provide a beyond-use date that will allow the patient enough time to fully use the
amount of preparation dispensed, but not enough time to allow the preparation to degrade or lose
potency or be stored for future use.
• If the pharmacist does not have a reference on stability of the specific dosage form or if experience
with it is insufficient, the USP guidelines are followed.
4-6. Compounded Preparations

Solutions
• Definition: Solutions are chemically and physically homogenous mixtures of two or more
substances.
• Types: Solutions can be syrups, elixirs, aromatic waters, tinctures, spirits, nonaqueous, and so
forth.
• Properties: Solutions are hypertonic, isotonic, hypotonic, osmolar, osmolal, and so forth.
• Stability: Stability of solutions is enhanced by adjusting pH or adding preservatives, antioxidants,

and so forth.
• Rate of dissolution: The rate of dissolution is enhanced by stirring, heat, particle-size reduction,
and so forth.
• Beyond-use dates: Aqueous solutions have short beyond-use dates.
• Testing: Organoleptic, pH, and other testing is performed.
An example of an isotonic aqueous solution follows:
Ephedrine sulfate 1%

Sodium chloride qs

Purified water, qs ad 30 mL

M.ft. isotonic solution

Steps in compounding are as follows:
1. Calculate the required quantity of each ingredient (NaCl equivalent of ephedrine sulfate is 0.2).
2. Accurately weigh or measure each ingredient.
3. Dissolve the solid ingredients in about 25 mL of purified water.
4. Add sufficient purified water to measure 30 mL.
The following is an example of a nonaqueous solution:

Urea 10 g

Salicylic acid 5g

Coal tar solution 5 mL

Propylene glycol, qs ad 100 mL


2. Dissolve the urea and salicylic acid in about 75 mL of propylene glycol.
3. Add the coal tar solution and mix well.
4. Add sufficient propylene glycol to measure 100 mL.
Note: If using a mechanical stirrer, it may take significant time to dissolve the urea and salicylic
acid.
Suspensions
• Definition: A suspension is a two-phased system containing a finely divided solid in a vehicle.
• Requirement: Drug is uniformly dispersed throughout vehicle.
• Concentration: Suspending agents are typically used in a concentration of 0.5-6.0%.
• Viscosity: The vehicle has enough viscosity to keep drug particles suspended separately.
• Insolubility: The active ingredient is insoluble in vehicle.
• Tip: Wet insoluble powder with vehicle-miscible liquid.
• Advantage: A suspension allows the preparation of a liquid form of an insoluble drug.
• Stability: Stability is enhanced by adding a preservative.
• Testing: Organoleptic, pH, and other testing is performed.
Categories of suspending agents
• Natural hydrocolloids: Acacia, alginic acid, gelatin, guar gum, sodium alginate, tragacanth,
xanthan gum
• Semisynthetic hydrocolloids: Ethylcellulose, methylcellulose, sodium carboxymethylcellulose
• Synthetic hydrocolloids: Carbomers (Carbopol), poloxamers (Pluronic), polyvinyl alcohol,

polyvinylpyrrolidone
• Clays: Bentonite, magnesium aluminum silicate (Veegum)
An example of an oral suspension follows:
Progesterone, micronized 1.2 g

Glycerin 3 mL

Methylcellulose 2% solution 30 mL

Flavored syrup, qs ad 60 mL


2. In a glass mortar, wet the progesterone with the glycerin, making a thick paste.
3. Slowly add the methylcellulose solution while triturating.
4. When mixed thoroughly, pour into a graduate.
5. Add small amounts of syrup in mortar, mix, and add to graduate until the desired volume is
reached.
Emulsions
• Definition: An emulsion is a two-phase system of two immiscible liquids, one of which is

dispersed throughout the other as small droplets.
• Components: An emulsion has a dispersion medium or external or continuous phase, an internal

or discontinuous or dispersed phase, and an emulsifying agent.
• Type: Types are oil in water (o/w) and water in oil (w/o), depending on which is the internal and
which is the external phase
• Emulsifying agents: Emulsifying agents can be natural gums (acacia, agar, chondrus, pectin,
tragacanth) or hydrophilic or lipophilic agents (the esters of sorbitan)
• Lipophilic agents: Trade names for lipophilic agents include Arlacel and Span
• Hydrophilic agents: Trade names for hydrophilic agents include Myrj and Tween
• Hydrophilic-lipophilic balance: A lower hydrophilic-lipophilic balance (HLB) value favors a

w/o emulsion; a higher HLB value favors an o/w emulsion. Agents with an HLB value of 1-9 are
considered to be lipophilic; agents with an HLB value of 10 and above are considered to be
hydrophilic.
• Other agents: Other agents include bentonite, cholesterol, gelatin, lecithin, methylcellulose,
soaps of fatty acids, sodium docusate, sodium lauryl sulfate, and triethanolamine.
• Equipment: Equipment includes mortar and pestle, homogenizers, colloid mill, mechanical
mixers, agitators, and ultrasonic vibrators.
• Solids: Solid ingredients should be dissolved before they are incorporated into the emulsion, or if
a sizable quantity is added, a levigating or wetting agent may be needed.
• Flavors: Flavors should be incorporated into the external phase.
• Preservatives: Preservatives should be added in the aqueous phase; they may also be added in the
oily phase, if necessary.
• Stability: Emulsions either cream or crack.
• Continental method: The Continental or dry gum method of preparing an emulsion nucleus
involves using the oil:water:dry gum emulsifier in a 4:2:1 ratio.
• Advantages: An emulsion can be used to mask taste, improve palatability, increase absorption,
and enhance bioavailability.
• Testing: Organoleptic testing is performed.
An example of preparing an emulsion by the Continental or dry gum or 4:2:1 method follows:
Cod liver oil 50 mL

Acacia 12.5 g

Syrup 10 mL

Flavor oil 0.4 mL



2. Place the cod liver oil in a dry mortar.
3. Add the acacia and give it a very quick mix.
4. Add 25 mL of purified water and immediately triturate rapidly to form the thick, white,
homogenous emulsion nucleus.
5. Add the flavor and mix thoroughly.
6. Add the syrup and mix thoroughly.
7. Add sufficient purified water to measure 100 mL.
Capsules
• Definition: This dosage form incorporates ingredients into a shell called a capsule.
• Procedure: Triturate powders to reduce particle size, mix powders by geometric dilution,
incorporate diluent by geometric dilution, calculate total weight to fit a certain size capsule, and
clean the outside of the filled capsules.
• Advantages: Capsules mask unpleasant taste; allow the mixture of ingredients that could not be
mixed in other vehicles; alter the release rate of ingredients; incorporate several ingredients into
one dosage form; provide an accurate dosage size for liquids, semisolids, and powders; and
provide a dosage form that is easier to swallow and more acceptable to the patient.
• Methods of filling: Hand punch from powder on pill tile; use a capsule-filling machine.
• Sizing: Determining the size of capsule to use for a particular dosage size involves assessing the
density or fluffiness of the powder, comparing it to known weights of various reference powders
with published capsule size capacities, and then actually weighing the capsule. If the requested
dosage does not fill a specific size capsule, a filler should be added.
• Testing: Organoleptic, weight percent error, weight variance, and other testing is performed.
An example of an altered-release capsule follows:
Progesterone, micronized 25 mg

Methocel E4M 50%

Lactose, qs ad

M.ft. capsules Make 15 doses

1. Select capsule size and calculate the required quantity of each ingredient.
2. Accurately weigh each ingredient.
3. If necessary, reduce particle size, and mix thoroughly.
4. Fill capsules.
5. Weigh capsules, calculate average weight, and determine percentage of error.
Tablet Triturates (Sublingual or Molded Tablets)
• Definition: A tablet triturate is a small tablet that is made in a mold and intended for sublingual
administration. It usually weighs about 30-250 mg.
• Advantages: A tablet triturate rapidly dissolves under the tongue, is rapidly absorbed, avoids first
pass through liver, and provides a rapid therapeutic response.
• Components: Tablet triturates consist of an active ingredient and a base, which may consist of
lactose, sucrose, dextrose, mannitol, and so forth.
• Formulation: On the basis of the size of the mold cavities, mix the active ingredient with the
base, which often consists of four parts lactose and one part sucrose. Thoroughly triturate
powders, mix by geometric dilution, and then moisten with a solution containing four parts
alcohol and one part purified water until the powder mixture is adhesive. Press into mold.
• Tip: Tablets may be flavored and colored by adding flavor and color to the wetting solution.
An example of a tablet triturate follows:

Testosterone 3 mg

Base, qs ad

M.ft. tabs

1. The base may consist of a 1:4 mixture of sucrose and lactose.

2. The wetting solution may consist of a 1:4 mixture of water and alcohol.
3. On the basis of the size mold and the number of tablets it makes, calculate the required quantity
of each ingredient.
5. Reduce particle size and mix ingredients by geometric dilution.
6. In a glass mortar, gradually moisten the powder mixture until it becomes adhesive. Note: Drop
the wetting solution onto the powder a few drops at a time and triturate after each addition until
powder becomes moist and adhesive.
7. Press moist powder evenly into all holes in the tablet triturate mold plate.
8. Place the mold plate on the base plate and press down until the tablets rest on top of the pegs.
9. Let tablets air dry.
10. Very gently remove dried tablets from pegs.
Troches, Lozenges, and Lollipops (Suckers)
• Definition: Troches, lozenges, and lollipops are solid dosage forms intended to be slowly
dissolved in the mouth for local or systemic effects.
• Formulation: Troches, lozenges, and lollipops are composed of an active ingredient and a base
that may consist of (1) sugar and other carbohydrates that produce a hard candy troche, (2)
polyethylene glycols and other ingredients that produce a softer troche, or (3) a glycerin-gelatin
combination that produces a chewable troche.
• Formulations made in a sucker mold complete with sticks are called lollipops or suckers.
• Formulations must be calculated to fit the size mold that will be used.
• Flavors and colors are added just before the molds are filled.
• Advantages: Troches, lozenges, and lollipops are easy to administer, are convenient for patients
who cannot swallow oral dosage forms, maintain a constant level of drug in the oral cavity and
throat, and have a pleasant taste.
An example of a troche follows:
Gelatin 4.68 g

Glycerin 16.70 mL

Purified water 2.30 mL

Acacia 0.50 g

Bentonite 0.50 g

Benzocaine 0.30 g

Citric acid 0.66 g

Saccharin sodium 0.17 g

Flavor and color qs

1. Depending on the size of the mold to be used and the number of troches to be made, calculate the
required quantity of each ingredient.
3. Heat the glycerin in a boiling water bath for several minutes.
4. Add the water and heat for a few more minutes.
5. While stirring, very slowly add the gelatin. Note: Gelatin must be lump free; the mixture must be
homogeneous.
6. Triturate and thoroughly mix the powders.
7. Add the powders to the warm liquid and mix thoroughly.
8. Add flavor and color, mix, pour into the mold, and let cool.
Transdermal Gels
• Definition: Transdermal gels move medications through the skin in quantities sufficient to
produce a therapeutic effect.
• Components: Transdermal gels have the following components:
• Active ingredient or ingredients
• Gelling agents: the carbomers (e.g., Carbopol 934P); methylcellulose; the poloxamers (e.g.,
Pluronic F-127); sodium carboxymethylcellulose; and so forth
• Wetting or levigating agents: propylene glycol, glycerin, and so forth
• Penetration-enhancing agents: water, alcohol, lecithin, dimethyl sulfoxide, isopropyl myristate,

isopropyl palmitate, propylene glycol, polyethylene glycol, and so forth
• Suspending or dispersing agents: bentonite, silica gel, and so forth
• Advantages: Transdermal gels are convenient and effective, have great acceptability to patients,
and avoid problems other dosage forms have such as gastrointestinal irritation from oral dosages,
pain from injections, and undesirability of suppositories
• Formulation: Use proper techniques for creating the gel, adjust the pH for carbomer gels, respect
the temperature for poloxamer gels, use small amounts of nonaqueous solvents, and if possible
keep electrolyte ingredients to a minimum.
• Tip: Do not use transdermal gels for the systemic use of antibiotics, and do not try to get large
molecules such as proteins through the skin via transdermal gels.
An example of a transdermal gel using carbomer as the base follows:
Ketoprofen 5%

Carbomer 934P 2%

Alcohol qs

Trolamine 2 mL


1. Calculate the required quantity of each ingredient.

3. Triturate the carbomer 934P in a glass mortar.
4. While triturating, gradually add about 18 mL of purified water.
5. Be sure the carbomer and water are thoroughly mixed and the mixture is homogenous.
6. Dissolve the ketoprofen in about 10 mL of alcohol.
7. While triturating, add this solution to the carbomer-water mixture, and mix thoroughly.
8. If necessary, add purified water to make about 28 mL and pour into the ointment jar.
9. Add trolamine and stir quickly with a stirring rod until the gel is thoroughly formed.
Note: A trade name for carbomer 934P is Carbopol 934P.
An example of a transdermal gel using organogel (PLO) as the base follows:
Ketoprofen 5%

Propylene glycol 10%

Lecithin isopropyl palmitate liquid 20%

Poloxamer 407 20% gel, qs ad 100 mL


3. In a glass mortar, triturate the ketoprofen with the propylene glycol.
4. Make a smooth uniform paste.
5. Add the lecithin isopropyl palmitate liquid and mix well.
6. Add sufficient poloxamer 407 20% gel to measure 100 mL.
7. Triturate until a high-quality gel is produced.
8. Package in a light-resistant container.
Note: The lecithin isopropyl palmitate liquid and the poloxamer 407 20% gel should be prepared
ahead of time so that they are ready for use.
The lecithin isopropyl palmitate liquid may be prepared as follows:

Soy lecithin, granular 10.0 g

Isopropyl palmitate 10.0 g

Sorbic acid 0.2 g


2. Add the soy lecithin granules and the sorbic acid to the isopropyl palmitate, mix well, and allow
to set overnight at room temperature.
3. The next morning, very gently stir to ensure complete mixing.
Note: Isopropyl myristate may be used in place of isopropyl palmitate.
The poloxamer 407 20% gel may be prepared as follows:
Poloxamer 407 20.0 g

Potassium sorbate 0.2 g



2. Add the poloxamer 407 and the potassium sorbate to a portion of the purified water, mix well,
and add purified water to make 100 mL.
3. Mix thoroughly, ensuring that the poloxamer 407 is completely wet.
4. Allow to set overnight in the refrigerator.
5. The next morning, stir slowly to be sure mixing is complete.
6. Store in the refrigerator.
Note: A trade name for poloxamer 407 is Pluronic F-127.
Suppositories
• Definition: Suppositories are solid dosage forms for insertion into the rectum, vagina, or urethra
to provide localized therapy or systemic therapy.
• Sizes: Rectal suppositories are approximately 2 g, vaginal suppositories are 3-5 g; and urethral
suppositories are 2 g (female) or 4 g (male). Note: Urethral suppositories were formerly called
bougies.
• Formulation: Suppositories are usually made by fusion with either a fatty or water-miscible base.
They can also be hand molded or made by compression.
• Suppositories are usually made in a metal or plastic mold.
• The active ingredients in powder form should be triturated (comminuted) to reduce particle size
and should be levigated with a levigating or wetting agent before incorporation into the melted
base.
• The melted formulation should be poured continuously into the mold to prevent layering.
• Calculations: The capacity in grams of the suppository mold must be known to determine the
quantity of base needed. (If this capacity is not known, the capacity must be determined by filling
the mold with the suppository base and weighing the resulting suppositories.) The space in the
suppository occupied by the active ingredient or ingredients must calculated using the density
factor of each active ingredient. (If the density factor is not known, it can be calculated by
making a suppository containing a known amount of the active ingredient.)
• Advantages: Suppositories deliver medication for local or systemic effects. (The systemically
absorbed medication avoids the first pass through the liver.) They can be used when patients
cannot take medication orally or by injection.
An example of a rectal suppository follows:
Progesterone, micronized 25 mg

Polyethylene glycol base qs

M.ft. supp dtd #12

Use the following formula for the polyethylene glycol base:
Polyethylene glycol 300 50%


1. On the basis of the size of the mold, calculate the required amount of each ingredient.
3. Carefully heat the polyethylene glycol 6000 until it melts.
4. Add the polyethylene glycol 300 and mix well.
5. Very slowly add the micronized progesterone and mix thoroughly.
6. Pour the mixture into the suppository mold.
Note: When using the plastic molds (shells), the liquid mixture must not be too hot.
Powders
• Definition: Powders are fine particles that result from the comminution of dry substances. Particle
sizes are usually determined by the size sieve they will pass through and may be described as
very coarse, coarse, moderately coarse, fine, and very fine.
• Mixtures: Mixtures of powders should have the same size or similar size particles, and mixing
should be accomplished by geometric dilution.
• Preparation: Comminution is the process of reducing particle size in powders. It is accomplished

manually by trituration, levigation, or pulverization by intervention and mechanically by grinders
and various types of mills.
• Uses: Powders taken by mouth may provide systemic effects. Powders are applied topically for
local effects. Powders that contain mucoadhesive ingredients, when insufflated into body
cavities, will adhere to moist body surfaces.
• Advantages: Because they are dry, powders often have greater stability, and they may not react
with ingredients with which they are otherwise incompatible (except explosive mixtures). Once
in the gastrointestinal tract, they are ready to be absorbed, and they tend to have longer beyond-
use dates.
An example of a powder for external use follows:

Calamine

Zinc oxide, of each 8%

Red mercuric oxide 1%

Magnesium oxide, heavy, qs ad 60 g

M.ft. powder

1. Calculate the required amount of each ingredient.

3. Thoroughly mix the powders by geometric dilution.
4. If using a mortar and pestle, use a porcelain mortar and begin with the ingredient having the
smallest weight.
5. Use the "spread test" to determine when the mixture is totally homogeneous.
Powder Papers (Charts)
• Definition: Powders or mixtures of powders are enfolded in papers containing one dose each and
dispensed in an appropriate box or container.
• Preparation: Powders are finely subdivided (comminuted) and mixed by geometric dilution, and
a dose of the appropriate size is placed on a powder paper and properly folded. The appropriate
size can be obtained by weighing. An alternate method is to place all the powder on a pill tile and
to "block and divide" the powder into the proper number of doses, placing one dose on each
powder paper.
• Advantages: For patients who cannot swallow, those who have difficulty swallowing certain
tablets or capsules, and those who have indwelling nasogastric tubes, powder papers provide an
ideal dosage form. Several medications can be given as one dose. The medication is in powder
form and ready to be absorbed once it is in the gastrointestinal tract. For patients who have many
medications to take each day, they may be combined into a smaller number of powder papers.
Powder papers have longer beyond-use dates than many other compounded dosage forms.
An example of a powder paper (chart) follows:

Aspirin 3.5 grains

Acetaminophen 2.5 grains

Caffeine 0.5 grains

M.ft. chart dtd #12


3. Triturate each ingredient separately to reduce particle size.
4. Thoroughly mix the ingredients by geometric dilution.
5. Weigh the correct amount for each chart on a separate paper.
6. Properly fold each paper and place it in the powder box.
Ointments and Creams
• Definition: Ointments and creams are semisolid dosage forms for external application. Properties
are typically characteristic of the base selected (e.g., white petrolatum, hydrophilic petrolatum,
cold cream, hydrophilic ointment, polyethylene glycol ointment). Ointments and creams protect
the skin and mucous membranes, moisturize the skin, and provide a vehicle for various types of
medications. Types and classifications include oleaginous or hydrocarbon, absorption, emulsion,
and water soluble.
• Characteristics of an oleaginous or hydrocarbon ointment base: Such a base
• Is occlusive—white petrolatum
• Is greasy—white ointment
• Is an emollient—vegetable shortening
• Is not water washable
• Will not absorb water
• Is insoluble in water
• Characteristics of an absorption ointment base: Such a base

• Is occlusive—hydrophilic petrolatum
• Is greasy—lanolin, USP (anhydrous)
• Is an emollient—Aquaphor
• Is not water washable—Aquabase
• Can absorb water
• Is insoluble in water
• Characteristics of an emulsion, w/o ointment base: Such a base
• Is occlusive—cold cream
• Is greasy—rose water ointment
• Is an emollient—Eucerin
• Is not water washable—hydrous lanolin
• Will absorb water—hydrocream
• Is insoluble in water—Nivea
• Characteristics of an emulsion, o/w ointment base: Such a base
• Is nonocclusive—hydrophilic ointment
• Is nongreasy—acid mantle cream
• Is water washable—Cetaphil
• Will absorb water—Dermabase
• Is insoluble in water—Keri lotion, Lubriderm, Neobase, Unibase, vanishing cream, Velvachol
• Characteristics of water-soluble ointment bases
• Is nonocclusive—polyethylene glycol ointment
• Is nongreasy—Polybase
• Is water washable
• Will absorb water
• Is water soluble
• Preparation: Ointments are typically prepared by fusion or levigation. Powders should be

comminuted to fine particles; some powders may be dissolved. If using the fusion method, use
only enough heat to melt the ingredient with the highest melting point. For the levigation method,
an ointment slab and metal spatula usually work well. Levigating agents should be carefully
selected, considering both the ingredient or ingredients to be incorporated and the base.
Table 4-1 shows commonly used levigating agents grouped by type and matched with the
appropriate group of ointment base classifications.
• Uses: Ointments or creams are an effective dosage form for treating skin and mucous membranes.
On occasion, an ointment or cream will move sufficient quantities of medication through the skin
to produce a systemic effect. Some formulations provide effective protection for the skin and
mucous membranes.
[Table 4-1. Levigating Agents by Type and Ointment Base Classification]
• Packaging: Typically, ointments and creams are packaged in ointment jars. The tube is often an
ideal alternative package because it protects the preparation until it is squeezed out and used.
• Testing: Organoleptic, homogenicity, and other testing is performed.
An example of a nongreasy ointment follows:
Benzoyl peroxide 10%

Sulfur 1%

Polyethylene glycol base, qs ad 30 g

1. Calculate the required quantity of each ingredient. Benzoyl peroxide, hydrous, USP contains
about 26% water. The polyethylene glycol base consists of


3. Triturate each powder to a fine particle size.
4. Melt the polyethylene glycol 3350 and remove it from the heat source.
5. Add the polyethylene glycol 400 and mix thoroughly.
6. Add the powders and mix thoroughly.
7. Before the preparation begins to harden, stir thoroughly and pour into the ointment jar.
An example of a greasy ointment follows:
Salicylic acid 3%

White petrolatum, qs ad 30 g


3. Triturate the salicylic acid to reduce particle size.
4. Levigate with a small quantity of mineral oil.
5. By geometric dilution, incorporate the levigated salicylic acid into the white petrolatum.
The following is an example of a cream:
Almond oil 56.0 g

White wax 12.0 g

Light mineral oil 10.0 g

Cetyl esters wax 2.5 g

Sodium borate 0.5 g

Purified water 19.0 g

Total 100.0 g

M.ft. cream, S.A.


2. Melt the white wax.
3. Add the cetyl esters wax, almond oil, and light mineral oil.
4. Bring to a temperature of 70°C.
5. Dissolve the sodium borate in the purified water.
6. Bring to a temperature of 70°C.
7. With both liquids at 70°C, mix and stir.
8. Stir until the cream is completely formed.
9. Package in a tube or jar.
Sticks
• Definition: This topical dosage form is made in the shape of a rod or stick or variation thereof and
packaged in a container that allows it to be advanced upward as it is used or consumed.
• Advantages: Sticks are an effective, convenient method of applying a topical agent exactly in the
location desired. They can deliver a variety of agents—including those that are therapeutic,
protective, and cosmetic—and they are very portable.
• Preparation: Select a semisolid vehicle from a variety of polyethylene glycols, waxes, and oils
that will produce the consistency desired. Triturate solid ingredients, wet them with an
appropriate wetting or levigating agent, and add them along with any liquid ingredients to the
melted vehicle. Mix thoroughly. Pour into an appropriate "ride-up" container.
• Tip: Sticks can usually be considered a stable dosage form and assigned a corresponding beyond-
use date.
An example of a stick follows:

Menthol 1.00%

Camphor 0.50%

Phenol 0.25%

Flavor qs

Color qs

Polyethylene glycol 400 7 g

Polyethylene glycol 4500 3 g

Steps in compounding:

3. Melt the polyethylene glycol 4500.
4. Remove from heat source.
5. Add the polyethylene glycol 400 and mix thoroughly.
6. Mix the menthol, camphor, and phenol together; they will liquefy, forming a eutectic mixture.
7. Add the eutectic mixture and the other ingredients and mix thoroughly.
8. Pour into a "ride-up" lip balm tube and let cool.
4-7. Quality Assurance and Preparation Testing
The assurance of high quality influences every facet of compounding. The atmosphere, the area
design, the fixtures, the equipment and apparatus, the components, the containers, the expertise and
experience of the personnel, the policies and procedures, and many other factors play important
roles for achieving the highest quality possible in the compounding of individualized, customized
preparations. Perhaps the most important element is commitment—the commitment of each
individual who plays any role in the compounding process. This commitment must be of such
intensity that the individual will not vary from the correct way of performing every function every
time in everything.
Preparation testing must be in place for every compounded preparation. Chapter 1163 in the U.S.
Pharmacopeia 32/National Formulary 27 has a table that shows what types of tests can be
performed on every type of compounded preparation. The compounding process of each type of
dosage form should include all applicable tests that must be performed each time the dosage form is
compounded.
The ultimate test of quality for a compounded preparation consists of having the preparation
analyzed by a competent analytical laboratory. The typical goal is to have the contents of the
preparation vary no more than plus or minus 5% of the potency stated on the label.
An indicator that the compounding pharmacy is committed to a high-quality practice is

accreditation by the Pharmacy Compounding Accreditation Board (PCAB). The PCAB is national
in scope, and it very carefully evaluates all aspects of the pharmacy operation and ensures that
policies and procedures are in place and operational for a very high-quality practice.
PCAB accreditation is currently the only benchmark available to attest to the quality of a
compounding pharmacy. PCAB accreditation should be the goal of every pharmacy that provides
compounded preparations.
4-8. Key Points
• Each extemporaneously compounded prescription is for a specific patient.
• Three parties are involved in extemporaneous compounding: the prescriber, the patient, and the
pharmacist.
• A thorough knowledge of and proficiency in pharmacy math is required for the extemporaneous
compounding of prescriptions.
• The sensitivity of the pharmacy balance must be determined, and the minimum weighable quantity
calculated for that particular balance.
• All weighing and measuring must be accurate. Avoid errors of 5% or more.
• Once an ingredient is removed from the stock container, it may not be returned to the stock
container.
• Trituration is used to reduce the particle size of powders so that a greater surface area will be
available, to uniformly mix powders using geometric dilution, and to dissolve solutes in solvents.
• Levigation is the process of mixing or triturating a powder with a liquid in which it is insoluble to
reduce particle size and aid in incorporating the powder into the ointment base.
• The pharmacist must choose a levigating agent that is miscible with the ointment base.
• Mineral oil is an appropriate levigating agent for a hydrophobic ointment base such as white
petrolatum.
• Up to 5% of levigating agent is usually sufficient unless the amount of powder is large.

• Heat should be used sparingly in compounding. Use only enough heat to melt ingredients, effect
solution, enhance a reaction, and so forth—never any extra.
• Use of a water bath normally prevents overheating ingredients when compounding.
• Care must be taken to never lose or waste any ingredients in the preparation process because doing
so can alter the concentration of active ingredients in the finished preparation and produce a
subpotent or superpotent preparation.
• To promote accuracy in the compounding process, place all unused stock containers on the left
side of the workstation. As each one is used, place it on the right side.
• The dry gum (or Continental) method of preparing an emulsion uses oil, purified water, and gum
(e.g., acacia) in a ratio of 4:2:1, respectively.
• The extemporaneously compounded preparation has no NDC number.
4-9. Questions
When water is an ingredient in a nonsterile compounded preparation and the type of water is
not specified, the pharmacist is correct to use
A. tap water.
1.
B. potable water.
C. purified water.
D. water for injection.
E. sterile water for injection.

When alcohol is an ingredient in a nonsterile compounded preparation and the type and percent
alcohol is not specified, the pharmacist is correct to use
A. ethyl alcohol 100%.

2.
B. ethyl alcohol 95%.
C. ethyl alcohol 70%.
D. ethyl alcohol 50%.
E. isopropyl alcohol 70%.

Ingredients that soften the skin and make it more flexible when applied topically are called
A. keratolytics.
3. B. emollients.
C. rubefacients.
D. counterirritants.
E. astringents.

To increase the stability of potassium iodide oral solution (SSKI),____________________
may be used as an antioxidant to prevent the release of free iodine.
A. sodium alginate
4.
B. sodium borate
C. sodium glycinate
D. sodium succinate
E. sodium thiosulfate

In preparing diluted hydrochloric acid, the pharmacist notes a temperature change. The reaction
is called
A. hypothermic.
5.
B. hyperthermic.
C. endothermic.
D. exothermic.
E. isothermic.

Ingredients that tend to tighten or shrink tissues when applied topically are called
A. astringents.
6. B. emollients.
C. keratolytic agents.
D. occlusive agents.
E. suspending agents.

A solution expressed as 35% w/w has the following:
A. 35 mg of solute dissolved in 100 mL of solution

7. B. 35 g of solute dissolved in 100 g of solvent
C. 35 mg of solute dissolved in 100 g of solvent
D. 35 g of solute dissolved in 100 g of solution
E. 35 mL of solute dissolved in 100 mL of solution

When dissolving potassium iodide in purified water, the pharmacist notes a temperature
change. The reaction is called
A. hypothermic.
8.
B. hyperthermic.
C. endothermic.
D. exothermic.
E. isothermic.

A solution expressed as 35% w/v has the following:
A. 35 mg of solute dissolved in 100 mL of solvent

9. B. 35 g of solute dissolved in 100 mL of solution
C. 35 mg of solute dissolved in 100 mL of solution
D. 35 g of solute dissolved in 100 mL of solvent
E. 35 mL of solute dissolved in 100 g of solution

Hydrophilic ointment, USP, is an o/w type of ointment base; therefore, it possesses the
property of being
A. emollient.
10.
B. greasy.
C. occlusive.
D. water washable.
E. anhydrous.

When compounding an emulsion that contains a flavoring agent, the flavoring agent should be
in
A. the continuous (external) phase.

11.
B. the discontinuous (internal) phase.
C. the aqueous phase.
D. the oil phase.
E. the emulsifier.

The next four questions pertain to the following compounded prescription:
Mineral oil 60 mL

Acacia qs

Syrup 12 mL

Flavor qs


M.ft. emulsion using dry gum method
Mineral oil is in the
I. internal phase.
II. external phase.
III. discontinuous phase.
12.
A. I only
B. II only
C. I and III only
D. II and III only
E. I, II, and III

Acacia is the
A. primary active ingredient.

13. B. preservative.
C. emulsifying agent.
D. wetting agent.
E. coloring agent.

How much acacia is needed for this preparation?
A. 5 g
14. B. 10 g
C. 15 g
D. 30 g
E. 35 g

How much purified water is needed to make the initial emulsion?
A. 5 mL
15. B. 10 mL
C. 15 mL
D. 30 mL
E. 48 mL

When cocoa butter is used as a suppository base, its melting point can pose a problem. To
overcome this problem, the compounding pharmacist can replace _____________ of the cocoa
butter with white wax.
16. A. 5%
B. 10%
C. 15%
D. 20-25%
E. 30%

When cocoa butter is used as a suppository base, its melting point can pose a problem. To
overcome this problem, the compounding pharmacist can replace ______________ of the
cocoa butter with cetyl esters wax.
17. A. 5%
B. 10%
C. 15%
D. 20-25%
E. 30%

Hydrophilic petrolatum, USP, is used as an ointment base. It possesses the characteristic or
characteristics of being
I. emollient.
II. occlusive.
III. greasy.
18.
A. I only
B. II only
C. I and III only
D. II and III only
E. I, II, and III

When lime water and olive oil are processed together to form an emulsion, a reaction occurs
that produces the emulsifying agent, which is
A. lime oil.
19.
B. lime oxide.
C. calcium oxide.
D. calcium oleate.
E. olive oxide.

The advantage or advantages of sublingual tablets as a dosage form are
I. quick absorption into the bloodstream.

II. rapid onset of action.
III. avoidance of the first pass through the liver.
20.
A. I only
B. II only
C. I and III only
D. II and III only
E. I, II, and III

The next question pertains to the following compounded prescription:
Camphor 1.0%

Menthol 1.0%

Thymol 0.5%


M.ft. oint

To prepare this compounded prescription, the pharmacist should
A. dissolve the camphor, menthol, and thymol in alcohol and incorporate them into the white
petrolatum by geometric dilution.
B. dissolve the camphor, menthol, and thymol in glycerin and incorporate them into the white
21.
petrolatum by geometric dilution.
C. dissolve the camphor, menthol, and thymol in propylene glycol and incorporate them into
the white petrolatum by geometric dilution.
D. form a eutectic mixture and incorporate it into the white petrolatum by geometric dilution.
E. alter the formula to avoid incompatibilities.

The advantage or advantages of capsules as a dosage form are that they
I. provide an accurate dose.

II. mask unpleasant tastes.
III. provide an immediate therapeutic response.
22.
A. I only
B. II only
C. I and II only
D. II and III only
E. I, II, and III

The next question pertains to the following compounded prescription:
Salicylic acid 5%


The pharmacist has on hand 2% salicylic acid ointment to use in preparing this prescription.
When using it, the pharmacist should
A. weigh 0.5 g of salicylic acid powder and qs to 30 g with 2% salicylic acid ointment,
incorporating the salicylic acid powder by geometric dilution.
B. weigh 0.5 g of salicylic acid powder, levigate it with 5 mL of alcohol, and qs to 30 g with
23. 2% salicylic acid ointment, incorporating the salicylic acid by geometric dilution.
C. weigh 1.5 g of salicylic acid powder, levigate it with 6 mL of mineral oil, and qs to 30 g
with 2% salicylic acid ointment, incorporating the salicylic acid by geometric dilution.
D. weigh 1.5 g of salicylic acid powder and qs to 30 g with 2% salicylic acid ointment,
incorporating the salicylic acid powder by geometric dilution.
E. weigh 1 g of salicylic acid powder, levigate it with 4.5 mL of mineral oil (SpGr 0.89), and
incorporate it into 25 g of 2% salicylic acid ointment by geometric dilution.

The advantage or advantages of a transdermal gel as a dosage form is/are
I. convenience of administration or application.

II. quick therapeutic response.
III. patient acceptance.
24.
A. I only
B. II only
C. I and II only
D. II and III only
E. I, II, and III

One gram of iodine is soluble in 3,000 mL of water. In Lugol's solution (strong iodine
solution), 1 g of iodine is dissolved in 20 mL of solution. Lugol's solution contains 5% iodine
and 10% potassium iodide. The phenomenon by which the potassium iodide increases the
solubility of iodine is known as
25.
A. alligation.
B. coalescence.
C. comminution.
D. complexation.
E. diffusion.

4-10. Answers
1. C. For nonsterile compounding, the USP specifies that purified water be used.

B. When type or percentage of alcohol is not specified, alcohol, USP, is used, and it is 95%
2.
ethyl alcohol.

3. B. Ingredients that make the skin soft and pliable when applied locally are called emollients.

E. Sodium thiosulfate is the antioxidant that prevents the iodide ion from oxidizing to form
4.
free iodine.

D. When diluted hydrochloric acid is prepared, heat is generated, and the reaction is called
5.
exothermic.

6. A. Ingredients that shrink or tighten the skin when applied locally are called astringents.

D. W/w means weight in weight. Consequently, 35 g of solute must be contained in 100 g of
7.
solution to have a 35% w/w solution.

C. When potassium iodide is dissolved in purified water, the solution becomes distinctively
8.
cold and the reaction is called endothermic.

B. W/v means weight in volume. Consequently, 35 g of solute must be contained in 100 mL of
9.
solution to have a 35% w/v solution.

10. D. Hydrophilic ointment is water washable but does not possess the other properties listed.

11. A. For the flavoring agent to be tasted, it must be in the external or continuous phase.

12. C. Mineral oil is in the internal or discontinuous phase and should not be tasted.

13. C. Acacia is the emulsifying agent forming an oil-in-water emulsion.

14. C. Given the 4:2:1 ratio, the 1 part or 15 g is the acacia.

15. D. Given the 4:2:1 ratio, the 2 parts or 30 mL is the water for the initial emulsion.

A. Five percent cocoa butter replaced by white wax will overcome the low melting point
16.
problem.

D. Twenty to twenty-five percent cocoa butter replaced by cetyl esters wax will overcome the
17.
low melting point problem.

18. E. Hydrophilic petrolatum is greasy, occlusive, and emollient.

D. The lime water is calcium hydroxide solution and the olive oil contains oleic acid. The two
19. react together to form calcium oleate, which is the emulsifying agent that forms a water-in-oil
emulsion.

20. E. All three items are advantages of sublingual tablets as dosage forms.

D. Camphor, menthol, and thymol are three ingredients that, when mixed together, will
21. liquefy, forming what is called a eutectic mixture. This liquid mixture is then gradually
incorporated into the white petrolatum by geometric dilution.

C. Capsules do not provide an immediate therapeutic response; the other two choices are
22.
correct.

E. Your compounded preparation must contain 1.5 g of salicylic acid. Twenty-five grams of
your 2% ointment contain 500 mg. You must weigh out 1 g of salicylic acid powder. The
23.
remaining ingredients must not contain any salicylic acid. The remaining weight can be made
up with the levigating agent or a combination of the levigating agent and white petrolatum.

24. E. All three choices are correct.

D. In solution, potassium iodide ionizes into potassium and the iodide ion. The iodide ion
25.
complexes with elemental iodine to form the soluble I3 complex.

4-11. References
The following are references that should be available in the compounding pharmacy to provide
assistance as the pharmacist formulates the variety of dosage forms that customized medications
require:
Allen LV Jr. The Art, Science, and Technology of Pharmaceutical Compounding. 3rd ed.
Washington, D.C.: American Pharmacists Association; 2008.
Ansel HC, Allen LV Jr, Popovich NG. Ansel's Pharmaceutical Dosage Forms and Drug Delivery
Systems. 8th ed. Baltimore: Lippincott Williams & Wilkins; 2005.
Ansel HC, Stoklosa MJ. Pharmaceutical Calculations. 11th ed. Baltimore: Lippincott Williams &
Wilkins; 2001.
Hendrickson R, ed. Remington: The Science and Practice of Pharmacy. 21st ed. Baltimore:
Lippincott Williams & Wilkins; 2006.
O'Neil MJ, ed. The Merck Index. 14th ed. Whitehouse Station, N.J.: Merck & Co.; 2006.
Shrewsbury R. Applied Pharmaceutics in Contemporary Compounding. Englewood, Colo.: Morton;

2001.
Sweetman SC, ed. Martindale: The Complete Drug Reference. 36th ed. London: Pharmaceutical
Press; 2009.
Thompson JE, Davidow LW. A Practical Guide to Contemporary Pharmacy Practice. 2nd ed.
Baltimore: Lippincott Williams & Wilkins; 2004.
Trissel LA. Stability of Compounded Formulations. 4th ed. Washington, D.C.: American
Pharmacists Association; 2009.
U.S. Pharmacopeial Convention. U.S. Pharmacopeia 32/National Formulary 73. Rockville, Md.:
U.S. Pharmacopeial Convention; 2009.
U.S. Pharmacopeial Convention. USP Pharmacists' Pharmacopeia. 2nd ed. Rockville, Md.: U.S.
Pharmacopeial Convention; 2008.
5. Sterile Products - Laura A. Thoma, PharmD
5-1. Parenteral Products
Introduction
Parenteral products are products that are administered by injection and that, therefore, bypass the
gastrointestinal tract. Parenteral products must be sterile and free of pyrogens and particulate
matter. Drugs that are destroyed, are inactivated in the gastrointestinal tract, or are poorly absorbed
can be given by a parenteral route. Parenteral routes of administration may also be used when the
patient is uncooperative, unconscious, or unable to swallow. This route is also used when rapid
drug absorption is essential, such as in emergency situations.
Parenteral Routes of Administration
Intravenous route
An intravenous (IV) medication is administered directly into the vein. The IV route gives a rapid
effect with a predictable response. It is used for irritating medications because the medication is
rapidly diluted. This route does not have as much volume restriction as other parenteral routes.
A bolus is an injection of solution into the vein over a short period of time. A bolus is used to
administer a relatively small volume of solution and is often written as "IV push" (IVP).
An infusion refers to the introduction of larger volumes of solution given over a longer period of
time. A continuous infusion is used to administer a large volume of solution at a constant rate.
Intermittent infusions are used to administer a relatively small volume of solution over a specified
amount of time at specific intervals.
Intramuscular route
An intramuscular (IM) medication is injected deep into a large muscle mass, such as the upper arm,
thigh, or buttocks. The medication is absorbed from the muscle tissue, acting more quickly than
when given by the oral route, but not as quickly as when given by the IV route. Up to 2 mL may be
administered intramuscularly as a solution or suspension given in the upper arm, and 5 mL may be
given in the gluteal medial muscle of each buttock. A sustained-release-type action can be achieved
with certain drugs that have low solubility because they are released from muscle tissue at a slow
rate. IM injections are often painful, and reversing adverse effects from medications given by this
route is very difficult. Antibiotics are often given by this route.
Subcutaneous route
Subcutaneous (SC) injections of solution or suspension are given beneath the surface of the skin.
Medications administered by this route are not absorbed as well as and have a slower onset of
action than medications given by the IV or IM route. The volume of solution or suspension that can
be injected subcutaneously is 2 mL or less. Drugs often given by this route include epinephrine,
heparin, insulin, and vaccines.
Intradermal route
An intradermal injection is injected into the top layer of the skin. The injection is not as deep as an
SC injection. Medications used for diagnostic purposes, such as a tuberculin test or an allergy test,
are often administered by this route. The volume of solution that can be administered intradermally
is limited to 0.1 mL. The onset of action and the rate of absorption of medication from this route are
slow.
Intra-arterial route
An intra-arterial injection is injected directly into an artery. It delivers a high drug concentration to
the target site with little dilution by the circulation. Generally, this route is used only for radiopaque
materials and some antineoplastic agents.
Other routes
• Intracardiac: An injection is made directly into the heart.
• Intra-articular: Administration by injection is made into a joint space. Corticosteroids are often
administered by this route for the treatment of arthritis.
• Intrathecal: An injection is made into the lumbar intraspinal fluid sacs. Local anesthetics are
frequently administered by this route during surgical procedures. Preservative-free drugs should
be used for intrathecal administration.
5-2. Definitions for Compounding of Sterile Preparations
Introduction
• Admixture: Parenteral dosage forms that are combined for administration as a single entity.
• Antearea: An International Organization for Standardization (ISO) Class 8 or better area where
personnel hand hygiene and garbing procedures, sanitizing of supplies, and other particulate-
generating activities are performed. The area contains a line of demarcation separating the clean
side from the dirty side.
• Aseptic processing: The separate sterilization of a product and its components, containers, and
closures, which are then brought together and assembled in an aseptic environment. The primary
objective of aseptic processing is to create a sterile preparation.
• Aseptic technique: Performance of a procedure or procedures under controlled conditions in a

manner that will minimize the chance of contamination. Contaminants can be introduced from
the environment, equipment and supplies, or personnel (see the section on ISO classification).
• Buffer area: The area where the primary engineering control is located.
• Compounding aseptic containment isolator (CACI): An isolator that protects workers from
exposure to undesirable levels of airborne drugs while providing an aseptic environment during
the compounding of sterile preparations.
• Compounding aseptic isolator (CAI): An isolator that maintains an aseptic compounding

environment within the isolator throughout the compounding and material transfer process during
the compounding of sterile preparations.
• Critical site: Any opening or surface that can provide a pathway between the sterile product and
the environment.
• Hypertonic: A solution that contains a higher concentration of dissolved substances than the red
blood cell, thereby causing the red blood cell to shrink.
• Hypotonic: A solution that contains a lower concentration of dissolved substances than the red
blood cell, thereby causing the red blood cell to swell and possibly burst.
• Isotonic: A solution that has an osmotic pressure close to that of bodily fluids, thus minimizing
patient discomfort and damage to red blood cells. Dextrose 5% in water and sodium chloride
0.9% solutions are approximately isotonic.
• Primary engineering control (PEC): A device or room that provides an ISO Class 5
environment for the exposure of critical sites when producing compounded sterile preparations
(CSPs). These devices could include a laminar airflow workbench, a biological safety cabinet,
CAIs, and CACIs.
• Sterilizing filter: A filter that, when challenged with the microorganism Brevundimonas diminuta
at a minimum concentration of 107 organisms per cm2 of filter surface, will produce a sterile
effluent. A sterilizing filter has a nominal pore size rating of 0.20 or 0.22 micron.
• Tonicity: Osmotic pressure exerted by a solution from the solutes or dissolved solids present.
• Validation: Establishment of documented evidence providing a high degree of assurance that a

specific process will consistently produce a product meeting predetermined specifications and
quality attributes.
ISO Classification
The ISO Classification of Particulate Matter in Room Air is the standard for clean rooms and
associated environments. Limits are expressed in particles 0.5 micron and larger per cubic meter. In
contrast, the limits from Federal Standard 209E are expressed in particles 0.5 micron and larger per
cubic foot (1 cubic meter = 35.31 cubic feet).
ISO class 5 area
The air in an ISO class 5 area has a count of no more than 3,520 particles 0.5 micron or larger per
cubic meter of air. This area is equivalent to a class 100 area under Federal Standard 209E, where
the air has a count of no more than 100 particles 0.5 micron or larger per cubic foot of air. This
class is the quality of air provided by the PEC and required for sterile product preparation.
ISO class 7 area
The air in an ISO class 7 area has a count of no more than 352,000 particles 0.5 micron or larger per
cubic meter. This area is equivalent to a class 10,000 area under Federal Standard 209E, where the
air has a count of no more than 10,000 particles 0.5 micron or larger per cubic foot of air. This class
is the quality of air usually required in the buffer area.
ISO class 8 area
The air in an ISO class 8 area has a count of no more than 3,520,000 particles 0.5 micron or larger
per cubic meter. This area is equivalent to a class 100,000 area under Federal Standard 209E, where
the air has a count of no more than 100,000 particles 0.5 micron or larger per cubic foot of air. The
antearea should have ISO class 8 air or better.
5-3. Sterile Product Preparation Area
Introduction
The following are examples of PECs that provide the ISO class 5 area for compounding of CSPs.
Horizontal Laminar Flow Workbench
The horizontal laminar flow workbench (HLFW) works by drawing air in through a prefilter. The
prefiltered air is pressurized in the plenum for consistent distribution of air to the high-efficiency
particulate air (HEPA) filter (
Figure 5-1).
The prefilter protects the HEPA filter from prematurely clogging. Prefilters should be checked
regularly and changed as needed. A record of these checks and changes of the prefilter must be
kept.
[Figure 5-1. Horizontal Laminar Flow Workbench]
The plenum of the hood is the space between the prefilter and the HEPA filter. Air is pressurized
here and distributed over the HEPA filter.
Laminar flow is the air in a confined space moving with uniform velocity along parallel lines. The
term unidirectional flow has taken the place of laminar flow in more recent publications.
Unidirectional flow is airflow moving in a single direction in a robust and uniform manner and at
sufficient speed to sweep particles away from the critical processing area. Inside the HLFW is an
ISO class 5 area (class 100 area).
Vertical Laminar Flow Workbench
The vertical laminar flow workbench (VLFW) works like a HLFW in that the air is drawn in
through the prefilter and is pressurized in the plenum for distribution over the HEPA filter.
However, the air is blown down from the top of the workstation onto the work surface, not across it
(
Figure 5-2).
Working in vertical laminar flow requires different techniques than does working in horizontal
laminar flow. In vertical laminar flow, an object or the hands of the operator must not be above an
object in the hood. In horizontal laminar flow, an object or the hands of the operator must not be in
back of another object. The hands of the operator must never come between the HEPA filter and the
object.
A biological safety cabinet, CAI, and CACI also use vertical unidirectional airflow to provide an
ISO class 5 environment and are other examples of PECs.
[Figure 5-2. Vertical Laminar Flow Workbench]
The HEPA Filter
The HEPA filter consists of a bank of filter media separated by corrugated pleats of aluminum.
These pleats act as baffles to direct the air into laminar sheets. The HEPA filter is 99.97% efficient
at removing particles 0.3 micron and larger.
Certification of the HEPA filter
The velocity of air from the HEPA filter is checked with a velometer or hot wire anemometer. ISO
14644 recommends that the average air velocity should be > 0.2 m/second.
Integrity of the HEPA filter: The dioctyl phthalate (DOP) test
The integrity of the HEPA filter is checked by introducing a high concentration of aerosolized
Emery 3004 (a synthetic hydrocarbon) upstream of the filter on a continuous basis, while
monitoring the penetration on the downstream side of the HEPA filter.
The aerosol has an average particle size of 0.3 micron. An aerosol photometer is used to check for
leaks by passing the wand slowly over the filter and the gasket. None of the surfaces shall yield
greater than 0.01% of the upstream smoke concentration. Any value greater than 0.01% indicates
that a serious leak is present and must be sealed. All repaired areas must be retested for compliance.
At one time, DOP was used to generate the aerosol. However, because DOP is a carcinogen, Emery
3004 is now used. An electronic particle counter cannot be used to certify the integrity of the HEPA
filter. The particle counter is used to determine room classification.
Buffer Area (Controlled Area)
The PEC is the cleanest area and provides an ISO class 5 (class 100) area. It must be located in a
controlled environment, away from excess traffic, doors, air vents, or anything that could produce
air currents greater than the velocity of the airflow from the HEPA filter. Air currents greater than
the velocity of the airflow from the HEPA filter may introduce contaminants into the hood. It is
very easy to overcome air flowing at 90 feet per minute.
The buffer area should be enclosed from other pharmacy operations. Floors, walls, ceiling, shelving,
counters, and cabinets of the controlled area must be of nonshedding, smooth, and nonporous
material to allow for easy cleaning and disinfecting. All surfaces shall be resistant to sanitizing
agents. Cracks, crevices, and seams shall be avoided, as should ledges or other places that could
collect dust. The floor of the buffer area shall be smooth and seamless with coved edges up the
wall.
The walls of the buffer area can be sealed panels caulked with silicone or, if drywall is used,
painted with epoxy paint, which is nonshedding. The corners of the ceiling and the walls shall be
sealed to avoid cracks. A solid ceiling may be painted with epoxy paint, or nonshedding washable
ceiling tiles that are caulked into place may be used.
Light fixtures shall be mounted flush with the ceiling and sealed. Anything that penetrates the
ceiling or walls shall be sealed.
Air entering the room shall be fresh, HEPA filtered, and air conditioned. The room must be
maintained in positive pressure (0.02-0.05 inches of water column) in relation to the adjoining
rooms or corridors. If the buffer area is used for compounding of cytotoxic drugs, 0.01 inches of
water column negative pressure is required. At least 30 air changes per hour shall occur, with the
PECs allowed to provide up to 15 of the 30 required air changes per hour.
People entering the buffer area shall be properly scrubbed and gowned. Access to the buffer area
shall be restricted to qualified personnel only.
Controlling the traffic in the buffer area is a critical factor in keeping the area clean. Only items
required for compounding shall be brought into the buffer area. These items must be cleaned and
sanitized before being taken into the buffer area. Items may be stored in the buffer area for a limited
time. However, the number of items stored in the buffer area shall be kept to a minimum. All
equipment used in the buffer area should remain in the room except during calibration or repair.
Because they can harbor many organisms, refrigerators and freezers should be located out of the
buffer area. Computers and printers should be located outside of the buffer area because they
generate many particles. However, if they are required to be in the buffer area, monitor the
environment and evaluate their effect on the environment. Cardboard boxes shall not be stored in
the buffer area. The items shall be removed from the boxes on the dirty side of the antearea and
sanitized and transferred to the clean side of the antearea or to the buffer area for storage. Vials
stored in laminated cardboard may be stored in the buffer area. Sinks or floor drains shall not be in
the buffer area because potable water contains many organisms and endotoxins.
Preparation of Operators
An operator must be trained and evaluated to be capable of properly scrubbing and garbing before
entering the buffer area. This requirement is critical to the maintenance of asepsis. The greatest
source of contamination in a clean room is the people in the area. A seated or standing person
without movement releases an average of 100,000 particles greater than 0.3 micron in diameter per
minute. A person standing with full body movement releases an average of 2,000,000 particles per
minute greater than 0.3 micron in diameter, and if moving at a slow walk, he or she releases an
average of 5,000,000 particles. The garb is designed to help contain the particles that are being
shed.
Before entering the antearea, an operator must remove all cosmetics and all hand, wrist, and other
visible jewelry or piercings. Artificial nails or extenders are prohibited while working in the sterile
compounding environment, and natural nails must be kept neat and trimmed. Garb is donned in an
order proceeding from that considered dirtiest to that considered cleanest. Shoe covers, head and
facial hair covers, and facemask or eye shields are donned before performing hand hygiene. Hands
and forearms are then washed for 30 seconds with soap and water in the antearea, and hands and
forearms are dried using a lint-free disposable towel or an electric hand dryer. While still in the
antearea, an operator must don a nonshedding gown that zips or buttons up to the neck, falls below
the knees, and has sleeves that fit snugly around the wrists. After entering the buffer area, an
operator must use a waterless alcohol-based surgical hand scrub with persistent activity to again
cleanse the hands before putting on sterile gloves. Sterile contact agar plates must be used to sample
the gloved finger tips of compounding personnel after garbing to assess garbing competency. For
successful completion of this competency, no colony-forming units can be found on any of the agar
plate samples. Three consecutive, successful garbing and gloving exercises must be completed
before sterile compounding is allowed. Routine application of sterile 70% isopropyl alcohol (IPA)
must occur throughout the compounding process and whenever nonsterile surfaces are touched.
After this initial evaluation, the entire process is repeated at least once a year for low- and medium-
risk compounding and semiannually for high-risk compounding during any media-fill test
procedure. The colony-forming unit action level for gloved hands will be based on the total number
of colony-forming units on both gloves, not per hand.
Validation of the Operator
A media fill or media transfer is when a growth promotion media is used instead of the drug
product, and all the normal compounding manipulations are done. It is critical that the process
mimic the actual compounding process as closely as possible and represent worst-case conditions.
Usually, the medium used is soybean-casein digest, which is also known as trypticase soy broth.
This medium will support the growth of organisms that are likely to be transmitted to CSPs from
the compounding personnel and environment. A media fill is used to check the quality of the
compounding personnel's aseptic technique. It is also used to verify that the compounding process
and the compounding environment is capable of producing sterile preparations.
Initially, before an operator can compound low- or medium-risk sterile injectable products, he or
she must successfully complete one media fill using sterile fluid culture media such as soybean-
casein digest medium. Media fill units must be incubated at 20-25°C for a minimum of 14 days or
at 20-25°C for a minimum of 7 days and then at 30-35°C for a minimum of 7 days. A successful
media fill is indicated by no growth in any of the media fill units. The media fill shall closely
simulate the most challenging or stressful conditions encountered during the compounding of low-
and medium-risk preparation. The compounding personnel shall perform a revalidation at a
minimum of once a year by successfully completing one media fill. The media fills shall be
designed to mimic the most challenging techniques the operator will use during a normal day.
Validation for high-risk compounding focuses on ensuring that both the process and the
compounding personnel are capable of producing a sterile preparation with all its purported quality
attributes. Revalidation must be done on at least a semiannual basis. An example of a high-risk
operation is the compounding of a sterile preparation from nonsterile drug powder. To mimic this
operation, the compounder must use commercially available soybean-casein digest medium made
up to a 3% concentration and perform normal processing steps, including filter sterilization. All
media fills must occur in an ISO class 5 environment and must be completed without interruption.
5-4. Working in the Laminar Flow Workbench
Items not in a protective overwrap shall be wiped with a lint-free wipe soaked with sterile 70% IPA
before being placed in the hood. Containers and packages should be inspected for cracks, tears, or
particles as they are decontaminated and placed in the hood. Items in a protective overwrap, such as
bags, should be taken from the overwrap at the edge of the hood (within the first 6 inches of the
hood) and placed in the hood with the injection port facing the HEPA filter. The overwrap should
not be placed in the hood, because doing so would introduce particles and organisms into the hood.
When working in the HLFW, an operator shall arrange supplies to the left or right of the direct
compounding area (DCA). The critical site must be in uninterrupted unidirectional airflow at all
times. The compounder must be careful not to place an object or hand between the HEPA filter and
the critical site because doing so would interrupt the airflow to the critical site. and potentially
cause particles to be washed from the hand or object onto the critical site.
All work performed in the HLFW must be done at least 6 inches inside the hood. The unidirectional
airflow is blowing toward the operator, who acts as a barrier to the airflow, causing it to pass
around the body and create backflow. This turbulence can cause room air to be carried into the front
of the hood.
Items placed in the HFLW disturb the unidirectional airflow. The unidirectional airflow is disturbed
downstream of the item for approximately three times the diameter of the object. If the item is
placed next to the sidewall of the hood, the unidirectional airflow is disturbed approximately six
times the diameter of the object. Air downstream from the nonsterile objects is no longer bathed in
unidirectional airflow and may become contaminated with particles. For these reasons, it is very
important that a direct path exists between the HEPA filter and the area where the manipulations
will occur.
With the VLFW, supplies in the hood should be placed so that the operator may work without
placing a hand or object above the critical site. An operator can place many more items in the
VLFW and still work without compromising the unidirectional airflow. One must remember that
within 1 inch of the work surface the air is turbulent. The unidirectional air, which is coming down
from the HEPA filter, strikes the work surface and changes direction to move horizontally across
the work surface. Therefore, all work in the VLFW should be done at least 1 inch above the work
surface. During the compounding of sterile preparations, all movements into and out of the hood
must be minimized to decrease the risk of carrying contaminants into the DCA. This can be
achieved by introducing all items needed for the aseptic manipulation into the work area at one time
and by waiting until the procedure is completed before removing used syringes, vials, and other
supplies from the PEC.
5-5. Syringes, Needles, Ampuls, and Vials
Syringes
The basic parts of the syringe are the barrel, plunger, collar, rubber tip of the plunger, and tip of the
syringe. Syringes are sterile and free of pyrogens. They are packaged either in paper or in a rigid
plastic container. Syringe packages must be inspected to ensure that the wrap is intact and the
syringe is still sterile. Syringes have either a Luer-Lok tip, in which the needle is screwed tightly
onto the threaded tip, or a slip tip, in which the needle is held on by friction (
Figure 5-3). Syringes are supplied with and without needles attached and are available in a variety
of sizes. Care must be taken not to let the syringe tip touch the surface of the hood.
Calibration marks are on the barrel of the syringe. These marks are accurate to one-half the interval
marked on the syringe. The critical sites on the syringe are the tip of the syringe and the ribs of the
plunger. The ribs of the plunger go back inside the syringe on injection of the fluid from the syringe
and could potentially contaminate the syringe.
[Figure 5-3. Types of Syringes]
Needles
The basic parts of a needle include the hub, needle shaft, bevel, bevel heel, and tip of the needle (
Figure 5-4).
Needles are sterile and are wrapped either in plastic with a twist-off top or in paper. This wrap must
be inspected for integrity before the needle is used. The gauge of the needle refers to its outer
diameter. The larger the number, the smaller the bore of the needle. The smallest is 27 gauge, and
the largest is 13 gauge. The length of the needle is measured in inches, and some common lengths
are 1.0-1.5 inches.
The critical sites on the needle are the hub of the needle, the entire needle shaft, and the tip of the
needle.
[Figure 5-4. Needle]
Ampuls
Ampuls are single-dose containers. Once ampuls are broken, they are an open-system container; air
can pass freely in and out of the ampul. Any solution taken from an ampul must be filtered with a 5-
micron filter needle or filter straw, because glass particles fall into the ampul when it is broken.
Before breaking the ampul, one shall wipe the neck of the ampul with a sterile 70% IPA prep pad.
Vials
A vial is a molded glass or plastic container with a rubber closure secured in place with an
aluminum seal. It may contain sterile solutions, dry-filled powders, or lyophilized drugs, or it may
be an empty evacuated container. Vials may be single-dose or multiple-dose containers.
A single-dose container usually contains no preservative system to prevent the growth of

microorganisms if they are accidentally introduced into the container. A single-dose vial punctured
in an environment worse than ISO class 5 air must be used within 1 hour. A single-dose vial
continuously exposed to ISO class 5 air may be used up to 6 hours after initial needle puncture.
When the vial is first used, it should be labeled with the date, time, and initials of the person using
the vial so the length of time that the vial has been in the hood can be determined.
A multidose vial contains preservatives, and these vials can be entered more than once. The
pharmaceutical manufacturer has done studies to prove that the preservative system will remain
effective and the closure will reseal after penetration by the needle. Therefore, the beyond-use date
for opened or entered multidose containers is 28 days, unless otherwise specified by the
manufacturer.
5-6. Biological Safety Cabinets
Introduction
A class II biological safety cabinet (BSC) should be used to prepare cytotoxic and other hazardous
drugs. Four different types of class II BSCs exist. Types A1 and A2 exhaust 30% of HEPA-filtered
air either into the room or to the outside through a canopy connection. Type A1 mixes the supply air
in a common plenum and may have ducts and plenum under positive pressure. Type A2 has all
contaminated ducts and plenum under negative pressure or surrounded by negative pressure. Type
B1 exhausts 70% of total air through a dedicated exhaust duct and must be hard ducted. Type B2
exhausts 100% of total air to the outside without any recirculation and must be hard ducted also.
With types B1 and B2, all the ducts and the plenum are under negative pressure and are surrounded
by negative pressure.
Preparation of Hazardous Drugs
When working with hazardous drugs, personnel must wear appropriate protective equipment,
including gowns, face masks, eye protection, hair and shoe covers, and double sterile
chemotherapy-type gloves. Personnel must handle all hazardous drugs with caution at all times,
using appropriate chemotherapy gloves, not only during preparation, but also during receiving,
distribution, stocking, inventorying, and disposal.
It is imperative that positive pressure not be allowed to build up in the vial. Proper training on the
use of a chemotherapy-venting device, which uses a 0.2 micron hydrophobic filter or the negative
pressure technique to prevent the build up of positive pressure within the vial, must be done before
preparing hazardous drugs and on an annual basis. When a closed system transfer device (one that
allows no venting or exposure of hazardous substance to the environment) is used, it shall be used
within the ISO class 5 environment of a BSC or CACI.
When compounding, syringes and IV sets with Luer-Lok fittings must be used if possible. Use a
large enough syringe so that the plunger does not separate from the barrel of the syringe when filled
with solution. Syringes should be filled with no more than 75% of their total volume. When
possible, attach IV sets and prime them before adding the hazardous drug. Wipe the outside of the
bag or bottle to remove any inadvertent contamination. The use of nonshedding plastic-backed
absorbent pads is also conducive to keeping the BSC as clean as possible.
The PEC shall be located in an ISO class 7 area physically separated from other preparation areas
and maintained under negative pressure of not less than 0.01 inch water column to the surrounding
area.
5-7. Overview of the Standard of Practice Related to Sterile Preparations: The United States
Pharmacopeia (USP) 32/National Formulary (NF) 27
Introduction
Chapter 797, Pharmaceutical Compounding—Sterile Preparations in USP 32/NF 27, became

official June 2008. Chapter 797 has three microbial risk levels of compounded sterile preparations.
The risk levels are determined on the basis of the potential for the introduction of microbial,
chemical, or physical contamination into the product. The chapter covers topics such as validation
of sterilization and of the aseptic process, environmental control and sampling, end-product testing,
bacterial endotoxins, training, and a quality assurance program.
Low-Risk Compounding
Compounding is classified as low risk when all of the following conditions prevail:
• Commercially available sterile products, components, and devices are used in compounding
within air quality of ISO class 5 or better.
• Compounding involves few aseptic manipulations, using not more than three commercially
manufactured sterile products and not more than two entries into any one sterile container.
• Closed-system transfers are used. Withdrawal from an open ampul is classified as a closed system.
• In the absence of passing a sterility test, the storage periods for the compounded sterile
preparations cannot exceed the following time periods before administration:
• Storage for not more than 48 hours at controlled room temperature
• Storage for not more than 14 days at a cold temperature of 2-8°C
• Storage for not more than 45 days in a solid frozen state between -25°C and -10°C.
Medium-Risk Compounding
Medium-risk CSPs are those compounded under low-risk conditions when one or more of the
following conditions exist:
• Compounding involves pooling of additives for the administration to either multiple patients or to
one patient on multiple occasions.
• Compounding involves complex manipulations other than a single volume transfer.
• The compounding process requires a long time period to complete dissolution or homogeneous
mixing.
• In the absence of passing a sterility test, the storage periods for the CSPs cannot exceed the
following time periods before administration:
• Exposure for not more than 30 hours at controlled room temperature
• Storage for not more than 9 days at a cold temperature
High-Risk Compounding
High-risk compounds are compounded under any of the following conditions and are either
contaminated or at high risk to become contaminated with infectious microorganisms:
• A sterile preparation is compounded from nonsterile ingredients.

• Sterile ingredients or components are exposed to air quality inferior to ISO class 5 for more than 1
hour, including storage in environments inferior to ISO class 5 of opened or partially used
packages of manufactured sterile products with no antimicrobial preservative system.
• Nonsterile water containing preparations are exposed for more than 6 hours before being
sterilized.
• No examination of labeling and documentation from suppliers or direct determination that the
chemical purity and content strength of ingredients meet their original or compendia specification
occurs.
• Compounding personnel are improperly garbed and gloved.
• In the absence of passing a sterility test, the storage periods for the CSPs cannot exceed the
following time periods before administration:
• Storage for not more than 24 hours at controlled room temperature
• Storage for not more than 3 days at a cold temperature
5-8. Sterilization Methods
Filtration
Filtration works by a combination of sieving, adsorption, and entrapment. Care must be taken to
choose the correct filter to sterilize the preparation. Membrane filters generally are compatible with
most pharmaceutical solutions, but interactions do occur—often because of sorption or leaching.
Sorption is the binding of drug or other formulation components to the filter, which can occur with
peptide or protein formulations. There are filters that have little or no affinity for peptides or
proteins. Leaching is the extracting of components of the filter into the solution. Surfactants are
often added to the filter to make it hydrophilic, and they may leach into the product. Large-
molecular-weight peptides may be affected by filtration. Their passage through a filter with a small
pore size may cause shear stress and alter the three dimensional structure of the peptide. Solvents in
the parenteral formulation may also affect filters. All filter manufacturers have compatibility data
on their membrane type and can be a great source of information when choosing a membrane.
Filter choice
Choose the appropriate size and configuration of filtration device to accommodate the volume
being filtered and permit complete filtration without clogging of the membrane. A 25 mm syringe
disk filter should filter no more than 100 mL of solution. If the solution being filtered has a heavy
particulate load, a 5 micron filter should be used before the 0.2 micron filter to decrease the
particulate load to the 0.2 micron filter. The filter membrane and housing must be physically and
chemically compatible with the product to be filtered and capable of withstanding the temperature,
pressures, and hydrostatic stress imposed on the system.
A pharmacy may rely on the certificate of quality provided by the vendor. Certification shall include
microbial retention testing with Brevundimonas diminuta at a minimum concentration of 107
organisms per cm2, as well as testing for membrane and housing integrity, nonpyrogenicity, and
extractables.
Hydrophobic and hydrophilic filters
Hydrophilic membranes wet spontaneously with water. They are used for filtration of aqueous
solutions and aqueous solutions containing water-miscible solvents. Hydrophobic filters do not wet
spontaneously with water. They are used for filtering gases and solvents.
Filter integrity
A sterilizing filter assembly should be tested for integrity after filtration has occurred. The bubble
point is a simple, nondestructive check of the integrity of the filtration assembly, including the filter
membrane. The basis for the test is that liquid is held in the capillary structure of the membrane by
surface tension. The minimum pressure required to force the liquid out of the capillary space is a
measure of the largest pores in the membrane.
A bubble point test is performed by wetting the filter with water, increasing the pressure of air
upstream of the filter, and watching for air bubbles downstream to indicate passage of air through
the filter capillaries. The typical water bubble point pressure of a sterilizing filter with a pore size
rating of 0.2 micron is > 50 pounds per square inch gauge (psig). As pore size decreases, the bubble
point increases. Remember that the bubble point given on the certificate of quality from the filter
manufacturer is usually the water bubble point. Many drug formulations have a lower surface
tension than water and will have a lower bubble point. Bubble points are also often given for 70%
IPA and water. Use the alcohol test for a hydrophobic filter.
After the solution is filtered and before the integrity of the filter membrane is checked, the filter
should be flushed with water to wash as much of the product off the membrane as possible. The
integrity test may then be performed.
Heat Sterilization
Moist-heat sterilization (autoclave)
Moist-heat sterilization is one of the most widely used methods of sterilization. Saturation of steam
at high pressure is the foundation for the effectiveness of moist-heat sterilization. When steam
makes contact with a cooler object, it condenses and loses latent heat to the object. The amount of
energy released is ~524 kcal/g at 121°C. Most sterilization cycles are at 121°C at 15 psig for a
minimum of 15 minutes. Moist-heat sterilization is faster and does not require as high a temperature
as dry-heat sterilization. Biological indicators of Bacillus stearothermophilus and temperature-
sensing devices shall be used to verify the effectiveness of the steam sterilization cycle.
Dry-heat sterilization
Dry-heat sterilization is usually done as a batch process in an oven designed for sterilization. It
provides heated filtered air that is evenly distributed throughout the chamber by a blower. The oven
is equipped with a system to control the temperature and exposure period. Dry-heat sterilization
requires higher temperatures and longer exposure times than does moist-heat sterilization. Typical
sterilization cycles are 120-180 minutes at 160°C or 90-120 minutes at 170°C. Biological indicators
of Bacillus subtilis and temperature-sensing devices shall be used to verify the effectiveness of the
dry-heat sterilization cycle.
Depyrogenation by dry heat
Dry heat can also be used for depyrogenation of glass and stainless steel equipment and of vials.
The pyrogens are destroyed when the equipment is kept at 250°C for 30 minutes. The effectiveness
of the dry-heat depyrogenation cycle shall be verified by using endotoxin challenge vials to
determine whether the cycle is adequate to achieve a 3-log reduction in endotoxins.
Beyond-Use Date
Each compounded sterile preparation must have a label that specifies the correct names and amount
of ingredients, the total volume, the storage requirements, route of administration, and beyond-use
date (BUD). The BUD is the date after which a compounded preparation is not to be used and is
determined from the date the preparation is compounded. In the absence of passing the sterility test,
the CSPs must comply with the microbial BUD. If the lot of CSP has met the requirements of the
sterility test, then the BUD may be based on chemical and physical stability. When assigning a
BUD, compounding personnel should consult and apply drug-specific and general stability
documentation and literature where available. They should consider the nature of the drug, its
degradation mechanism, the container in which it is packaged, the expected storage conditions, and
the intended duration of therapy.
5-9. Stability
Introduction
Stability refers to physical, chemical, and microbial stability.
Instability usually refers to chemical reactions that are incessant and irreversible and result in
distinctly different chemical entities. These new chemical entities can be therapeutically inactive
and possibly exhibit greater toxicity.
Incompatibility usually refers to physicochemical phenomena such as concentration-dependent

precipitation and acid-base reactions that occur when one drug is mixed with others to produce a
product unsuitable for administration to the patient. An incompatibility could cause the patient not
to receive the full therapeutic effect, or it could cause toxic decomposition products to form. A
precipitated incompatibility may irritate the vein or cause occlusion of vessels.
There are three categories of incompatibilities: therapeutic incompatibility, physical

incompatibility, and chemical incompatibility.
Therapeutic Incompatibility
Therapeutic incompatibility occurs when two or more drugs administered at the same time result in
undesirable antagonistic or synergistic pharmacologic action.
Physical Incompatibility
Physical incompatibility is the combination of two or more drugs in solution, resulting in a change
in the appearance of the solution, a change in color, the formation of turbidity or a precipitate, or the
evolution of a gas. Physical incompatibilities are related to solubility changes or container
interactions rather than to molecular change to the drug entity itself.
Six major areas of concern about physical incompatibility
Compatibility or incompatibility of two or more drugs mixed in the same syringe

For example, preoperative medications—a combination of a narcotic, an analgesic, an antiemetic,
and an anticholinergic—are mixed in the same syringe to save the patient from multiple IM
injections.
Compatibility of two or more drugs given through the same IV administration line
This concern is common in intensive care units, where patients are often on a number of IV
medications and could also be fluid restricted. For example, dopamine HCl 800 mg in 500 mL D5W
(5% dextrose in water) is prescribed. The nurse wants to push 2 amps of sodium bicarbonate
through the IV line. The pH of dopamine is 3.0-4.5, and that of NaHCO3 is approximately 8.0. If
this push is done, a color change occurs because of decomposition of the product. The pH of the
bicarbonate is too high for dopamine stability.
Compatibility of two or more drugs placed in the same bottle or bag of IV fluid
KCl, the most common additive, is a neutral salt composed of monovalent ions that are not likely to
produce compatibility problems. Therefore, if a drug is compatible in a neutral salt, it is probably
compatible in KCl.
Parenteral nutrition solutions can be especially difficult. The number of components, the long
duration of contact time, and exposure to ambient temperature and light enhance the potential for an
adverse compatibility interaction to occur. The interaction of Ca and PO4 to form CaPO4, which
appears as fine white particles that create a milky solution, is a problem.
Some ways to decrease the risk of injury follow:

• Calculate the solubility of the added calcium from the volume at the time when calcium is added.
Flush the line in between the addition of any potentially incompatible components.
• Add the calcium before the lipid emulsion. Therefore, if a precipitate forms, the lipid will not
obscure its presence.
• Periodically agitate the admixture, and check for precipitates. Train patients and caregivers to
visually inspect for signs of precipitation and to stop the infusion if precipitation is noted.
The following factors enhance formation of precipitate of calcium and phosphate:
• High concentrations of calcium and phosphate
• Increases in solution pH
• Decreases in amino acid concentrations
• Increases in temperature
• Addition of calcium before phosphate
• Lengthy time delay or slow infusion rates
• Use of the chloride salt of calcium.
Do not exceed 15 mEq of Ca with up to 15 mL PO4 per 1000 mL of solution.
Compatibility of the additive with the composition of the IV container itself

Nitroglycerin readily migrates into many plastics, especially polyvinylchloride (PVC). Insulin
adsorbs to IV tubing, filters, and both glass and plastic containers.
Compatibility of the additive with the additional equipment used to prepare or administer the
IV admixture
Cisplatin interacts with aluminum by forming a black precipitate when coming in contact with it.
Stability of the drug after admixture

Ampicillin sodium is stable for 72 hours when refrigerated and 24 hours at room temperature in
normal saline. However, if it is added to D5W, it is stable for only 4 hours when refrigerated and 2
hours at room temperature.
Other potential sources of physical incompatibilities
Concentration
A drug will remain in aqueous solution as long as its concentration is less than its saturation
solubility.
Cosolvent system
Drugs that are poorly water soluble are often formulated using water-miscible cosolvents. Examples
of water-miscible cosolvents include ethanol, propylene glycol, and polyethylene glycol. Dilution of
drugs that are in a cosolvent system often causes precipitation of the drug. A good example is
diazepam injection. Dilution of the drug results in precipitation in some concentrations, but
sufficient dilution to a point below diazepam's saturation solubility results in a physically stable
admixture.
pH
The greatest single factor in causing an incompatibility is a change in acid-base environment.
Solubility of drugs that are weak acids or bases is a direct function of solution pH. The drug's
dissociation constant and pH control the portion of drug in its ionized form and the solubility of the
un-ionized form. A drug that is a weak acid may be formulated at a pH sufficient to yield the
desired solubility. Sodium salts of barbiturates, phenytoin, and methotrexate are formulated at high
pH values to achieve adequate solubility.
Sodium salts of weak acids precipitate as free acids when added to IV fluids having an acidic pH. If
the pH of these drugs is lowered, the drug's solubility at the final pH may be exceeded, resulting in
possible precipitation. Drugs that are salts of weak bases may precipitate in an alkaline solution.
Ionic interactions
Large organic anions and cations may also form precipitates, such as the precipitation that occurs
when heparin (anionic) and aminoglycoside antibiotics (cationic) are mixed. These heparin salts of
the cationic drug are relatively insoluble in water.
Sorption phenomena
The intact drug is lost from the solution by adsorption to the surface or absorption into the matrix of
container material, administration set, or filter.
Adsorption to the surface can result from interactions of functional groups within the drug's
molecule to binding sites on the surfaces.
Absorption of lipid-soluble drugs into the matrix of plastic containers and administration sets,
especially those made from PVC, does occur. The substantial amount of phthalate plasticizer used
to make the PVC bag pliable and flexible allows the lipid-soluble drugs to diffuse from the solution
into the plasticizer in the plastic matrix. Plastics such as polyethylene and polypropylene, which
contain little or no phthalate plasticizer, do not readily absorb lipid-soluble drugs into the polymer
core. Leaching of the phthalate plasticizer into the solution may also occur, especially if surface-
active agents or a large amount of organic cosolvent is present in the formulation.
Chemical Incompatibility
Chemical incompatibilities are interactions resulting in molecular changes or rearrangements to

different chemical entities. Most chemical interactions are not observable by the unaided eye.
Chemical degradation pathways
Hydrolysis is a common mode of chemical decomposition. Water attacks labile bonds in dissolved
drug molecules. Functional groups labile to hydrolysis are carboxylic acid and phosphate esters,
amides, lactams, and imines.
Oxidation is an electron loss that causes a positive increase in valence. Many drugs are in the
reduced form, and oxygen creates stability problems. Steroids, epinephrine, and tricyclic
compounds are sensitive to oxygen. For control of the stability problem, oxygen can be excluded,
pH can be adjusted, and chelating agents or antioxidants can be added.
Reduction is when an electron is gained, causing a decrease in valence and the addition of halogen
or hydrogen to the double bond. -lactam antibiotics can produce reducing aldehydes on hydrolysis.
Photolysis is the catalysis by light of degradation reactions such as oxidation or hydrolysis.

Examples of drugs that are light sensitive are amphotericin B, furosemide, and sodium
nitroprusside. The reaction rate depends on the intensity and wavelength of light. Sodium
nitroprusside in D5W has a faint brownish cast, but exposure to light causes deterioration, which is
evident by a change in color to blue caused by the reduction of the ferric to ferrous ion.
Extreme pH can be a catalysis of drug degradation. Drug reaction rates are generally less at
intermediate pH values than at high or low ranges. A buffer system is often used to ensure the
maintenance of the proper pH.
Effects of temperature may be evident. Usually, but not always, an elevation in temperature may
increase reaction rates.
An increase in drug concentration will usually increase the degradation rate exponentially.
However, this rule does not always apply. Some drugs appear to have a lower rate of decomposition
at a high concentration, such as the reduced hydrolysis of nafcillin in the presence of aminophylline.
Greater buffer concentration at higher nafcillin concentrations protects the drug from
aminophylline's high pH and slows the hydrolysis.
Expiration dates and removal of the IV bag overwrap are important. The overwrap protects against
evaporation of the solution, desiccation of the container, drug oxidation, and photochemical
inactivation of the drug. Substantial moisture loss may occur, increasing drug concentration. With
ready-to-use dopamine or dobutamine injections, removal of the overwrap can allow oxygen to
enter the container, thereby reducing drug stability. After removal of the overwrap, the expiration
date should be changed at once.
5-10. Sterile Products Compounded from Nonsterile Drugs
Introduction
When a sterile preparation is compounded from a nonsterile component, several concerns arise:
how to sterilize the drug, how to sterilize the container and closure, and how to ensure that the drug
and components are sterile. Every sterilization process must be verified, whether it is terminal
sterilization of the CSP in the final container or aseptic processing of the CSP. Sterility testing must
be done on all high-risk compounded sterile preparations if they are prepared in groups of more
than 25 single-dose packages or in multidose vials for administration to multiple patients. Such
testing must also be done if prior to sterilization the preparations are exposed longer than 12 hours
to temperatures of 2-8°C or longer than 6 hours to temperatures warmer than 8°C. If the high-risk
CSPs are dispensed before the results of the sterility test are known, a method must be in place
requiring daily observation of the test specimens and immediate recall of the CSP if there is
evidence of microbial growth in the test sample.
Sterility Testing
There are two methods of sterility testing: direct inoculation and membrane filtration. The USP
states that, when possible, membrane filtration should be performed and that two culture media are
required: fluid thioglycollate medium (FTM) and trypticase soy broth (TSB), which is also known
as soybean-casein digest medium.
Media suitability test
Before beginning the test, one must confirm that the medium being used is sterile and will support
the growth of microorganisms.
Sterility
Confirm the sterility of each sterilized batch of medium (1) by incubating a portion of the batch at
the specified incubation temperature (TSB, 20-25°C; FTM, 30-35°C) for 14 days or (2) by
incubating uninoculated containers as negative controls during a sterility test procedure. When
purchasing a new batch of sterile media from a vendor, one should incubate a portion for several
days to ensure that it did not become contaminated during shipment.
Growth promotion test

Each lot of ready-prepared medium and each batch of dehydrated medium bearing the
manufacturer's lot number must be tested for its growth-promoting qualities. Separately inoculate,
in duplicate, containers of each medium with fewer than 100 viable microorganisms of each of the
strains listed in the next paragraph. If visual evidence of growth appears in all inoculated media
containers within 3 days of incubation in the case of bacteria and 5 days of incubation in the case of
fungi, the test media is satisfactory. The test may be conducted simultaneously with testing of the
media for sterility.
The organisms to be used for the growth promotion test of FTM are Staphylococcus aureus
(Bacillus subtilis may be used instead), Pseudomonas aeruginosa (Micrococcus luteus may be used
instead), and Clostridium sporogenes (Bacteroides vulgatus may be used instead). The test
organisms for soybean-casein digest media are Bacillus subtilis, Candida albicans, and Aspergillus
niger. Soybean-casein digest media are incubated at 20-25°C, and FTM are incubated at 30-35°C,
both under aerobic conditions for a minimum of 14 days.
Validation test: Bacteriostasis and fungistasis test

The bacteriostasis and fungistasis test must be done on each product to determine if the product
itself will inhibit the growth of microorganisms. This test needs to be done only once for each
product tested. The organisms used are the same as those used for growth promotion. The test uses
two sets of containers. One set is inoculated with the drug product and microorganisms, and the
other set is inoculated with just the microorganisms. Both sets will be incubated at the appropriate
temperature for no more than 5 days. The same amount of growth should be seen in both sets. If the
drug is inhibiting the growth of the microorganisms, the conditions of the test must be modified so
the drug will not inhibit growth. The modifications made will now become the method for
performing the sterility test on the drug preparation.
Number of articles to test
The minimum number of articles to be tested in relation to the number of articles in the batch are as
follows:
• For up to 100 articles, test 10% or 4 articles, whichever is greater.
• For more than 100 but not more than 500 articles, test 10 articles.
Interpretation of results
No growth
At days 3, 5, 7, 10, and 14, examine the media visually for growth. If no microbial growth is seen,
the article complies with the test for sterility. Lack of growth of the media does not prove that all
units in the lot are sterile.
Observed growth
When microbial growth is observed and confirmed microscopically, the article does not meet the
requirements of the test for sterility. If there is no doubt that the microbial growth can be ascribed to
faulty aseptic techniques or materials used in conducting the testing procedure, the test is invalid
and must be repeated.
An investigation must occur, and the organism must be identified down to the species. All records
must be reviewed, including all employee training procedures and records, aseptic gowning
practices, equipment maintenance records, component sterilization data, and environmental
monitoring data.
Visual inspection
Every unit compounded in the pharmacy should be subjected to a physical inspection against a
white background and a black background. Any container whose contents show evidence of
contamination with visible foreign material must be rejected.
Pyrogens
A pyrogen is a substance that produces fever. An endotoxin is a type of pyrogen.
Gram-negative bacteria produce more potent endotoxins than do Gram-positive bacteria and fungi.
The lipopolysaccharide (LPS) portion of the cell wall causes the pyrogenic response. The LPS can
be sloughed off, and the bacteria do not have to be living for the LPS to be pyrogenic.
Some of the effects caused by pyrogens in the body are an increase in body temperature, chills,
cutaneous vasoconstriction, a decrease in respiration, an increase in arterial blood pressure, nausea
and malaise, and severe diarrhea.
The official endotoxin limits are 5 endotoxin units (EU)/kg per hour or 350 EU/total body per hour
for drugs and biologicals. Drugs for intrathecal use have a much lower endotoxin limit of 0.2
EU/kg.
Water is the primary source of endotoxins because Pseudomonas, a Gram-negative bacterium,

grows readily in water. Other sources of endotoxins or pyrogens are raw material, equipment,
processing, and human contamination. It is very important to use good-quality raw materials and
request a certificate of analysis with each lot of material when compounding. Endotoxins can be
destroyed by dry heat. Three to five hours at 200°C will depyrogenate glass vials and beakers. The
endotoxin concentration can be reduced by rinsing with sterile water for injection. When a sterile
preparation is compounded from a nonsterile product, any equipment that can withstand the heat of
200°C should be depyrogenated. An article that is depyrogenated is also sterile. Endotoxins are not
completely removed by filtration, and steam sterilization reduces endotoxin levels by only a small
amount.
Pyrogen test (rabbit test)
The pyrogen test is designed to limit, to an acceptable level, the patient's risk of febrile reaction in
the administration—by injection—of the product concerned. The test involves measuring the rise in
temperature of rabbits following the IV injection of a test solution, and it is designed for products
that can be tolerated by the test rabbit in a dose—not to exceed 10 mL/kg—injected intravenously
within a period of no more than 10 minutes.
The rabbit test has several limitations. It is an in vivo method, it is an expensive and time-
consuming test, and it is not a very sensitive test. Drugs that have pyretic side effects or that are
antipyretics cannot be tested using the rabbit test. The test is not quantitative, and the pyrogenic
response is dose dependent, not concentration dependent.
Bacterial endotoxin test (limulus amebocyte lysate test)
The bacterial endotoxin test (BET) provides a method for estimating the concentration of bacterial
endotoxins that may be present in, or on the sample of, the article to which the test is applied using
limulus amebocyte lysate (LAL) reagent. Because the blood cells of the horseshoe crab are sensitive
to endotoxin and form a gel in its presence, LAL reagent is made from the lysate of amebocytes
from the horseshoe crab.
There are two types of techniques for this test: the gel-clot technique, which is based on the
formation of the gel, and the photometric technique, which is based on either the development of
turbidity or the development of color in the test sample.
The routine gel-clot test requires 0.1 mL of test sample to be mixed with 0.1 mL of LAL reagent.
This mixture is incubated for 1 hour at 37°C. A positive reaction is confirmed by formation of a
firm gel that remains intact when the tube is slowly inverted 180 degrees.
The BET is 5-50 times more sensitive, more simple and rapid, and less expensive than the pyrogen
test. However, the clotting enzyme is heat sensitive, pH sensitive, and chemically related to trypsin.
It is dependable for detection of only pyrogens originating from Gram-negative bacteria. Also, some
drugs can inhibit the reaction, and other drugs can enhance the reaction. The BET does not
determine the fever-producing potential of the bacterial endotoxins.
The photometric technique requires the establishment of a standard regression curve. The endotoxin
content of the test material is determined by interpolation from the curve. The test can be either an
endpoint determination, in which the reading is made immediately at the end of the incubation
period, or a kinetic test, in which the absorbance is measured throughout the reaction period.
All high-risk CSPs (except those for inhalation and ophthalmic use) that are prepared in groups of
25 or more individual single-dose units or in multidose vials for administration to multiple patients,
or that are exposed longer than 12 hours to temperatures of 2-8°C and longer than 6 hours to
temperatures warmer than 8°C before sterilization, must comply with the BET.
5-11. Key Points
• A sterilizing filter (0.2 micron) is required to filter sterilize a CSP. The integrity of the filter must
be tested before the preparation may be released. The test is often referred to as the bubble point
test.
• The high-efficiency particulate air filter is 99.97% efficient at filtering out particles 0.3 micron
and larger. Certification of the HEPA filter involves testing the velocity of airflow from the filter
and the integrity of the filter.
• The air in an ISO class 5 area has no more than 3,520 particles 0.5 micron and larger per cubic
meter of air. The laminar flow workbench provides an ISO class 5 area.
• The critical site is any opening or pathway between the CSP and the environment. The larger the
critical site is and the longer it is exposed to the environment, the greater the risk of
contamination of the preparation.
• The bacterial endotoxin test is designed to detect the level of bacterial endotoxin from Gram-
negative organisms in the CSP. All bacterial endotoxins are pyrogens, but not all pyrogens are
bacterial endotoxins.
• The sterility test and the BET should be performed on all high-risk compounded sterile
preparations intended for administration by injection into the vascular or central nervous system
that are prepared in groups of more than 25 identical individual single-dose packages or in
multidose vials for administration to multiple patients. The BET must be performed before the
CSP can be dispensed.
• Any pharmacist preparing CSPs must have training in aseptic technique. One way to validate
aseptic technique is by performing media fills. The growth medium most often used is trypticase
soy broth, also known as soybean-casein digest medium in the USP.
• The laminar airflow in a horizontal laminar flow workbench flows toward the operator. The
operator must never put his or her hands in back of an object, between the HEPA filter and the
critical site. Never break first air.
• The laminar airflow in a vertical laminar flow workbench flows down onto the work surface.
• A biological safety cabinet should always be used for preparing cytotoxic drugs. All biological
safety cabinets have vertical laminar airflow.
• The hot air oven is used to depyrogenate items used in compounding and to sterilize compounded
preparations that cannot be sterilized by steam.
• Moist-heat sterilization is a common way to sterilize equipment used in the compounding process.
Only items that can be moistened by steam can be sterilized by autoclaving.
5-12. Questions
Which of the following tests does not have to be completed on a high-risk compounded sterile
preparation that will be administered by intravascular injection and is prepared in a lot size of
30 single-dose vials before release to a patient?
1. A. Bacterial endotoxin test

B. Visual inspection
C. Sterility test
D. Verification of the sterilizing filter integrity
E. LAL test

Which of the following is correct concerning certification of a laminar flow workbench?
A. The particles introduced into the plenum of the hood must be approximately 0.5 micron.
B. Airflow from the HEPA filter must be 120 ft/min.
2.
C. A leak greater than 0.01% of the upstream smoke concentration through the filter is
considered a serious leak.
D. A total particle counter can be used to check the integrity of the HEPA filter.
E. If a HEPA filter leaks, it cannot be patched; it must be replaced.

The bacterial endotoxin test is used to determine
A. the amount of pyrogens.

3. B. the level of pyrogens from Gram-negative bacteria.
C. the fever-producing potential of bacterial endotoxins from Gram-negative bacteria.
D. the level of bacterial endotoxin from Gram-positive bacteria.
E. the amount of live bacteria present in the drug solution.

Which of the following is correct concerning USP media transfers?
A. An operator must successfully complete one media fill before compounding any CSPs.
B. An operator who passes a written exam may compound sterile preparations until the chief
pharmacist finds time to watch his or her aseptic technique.
4.
C. An operator who has successfully completed a media fill must requalify semiannually if he
or she is preparing low-risk CSPs.
D. When an operator successfully completes one media fill for high-risk compounding, he or
she needs to revalidate quarterly by completing one media fill.
E. Fluid thioglycollate media are used for media transfers.

For a transfer of product into the controlled area,
A. bottles, bags, and syringes must be removed from brown cardboard boxes before being
brought into the buffer area.
B. vials stored in laminated cardboard may not be brought into the controlled area.
5.
C. stainless steel carts may be used to transfer items into the controlled area directly from the
storage area.
D. large-volume parenteral bags of IV solution must be removed from their protective
overwrap before being brought into the controlled area.
E. the refrigerator should be placed next to the laminar flow hood for easy access.

Which of the following is correct concerning a vertical laminar flow hood?
A. It is always a biological safety cabinet.

6. B. In vertical laminar flow, the hands of the operator must not be behind an object.
C. A vertical laminar flow hood has turbulent airflow within 1 inch of the work surface.
D. A vertical laminar flow hood has the laminar airflow blowing at the operator.
E. The operator works in a vertical flow hood and a horizontal flow hood in the same manner.

Certain factors may increase the risk of microbial contamination of a CSP. Which of the
following would not be a risk factor?
A. Very complex compounding steps

7.
B. Lengthy exposure of a critical site during compounding
C. Use of appropriate aseptic technique
D. Batch compounding without preservatives for multiple patients
E. Preparation of a CSP from nonsterile powders

Which of the following is correct concerning the USP risk levels of compounded sterile
preparations?
A. Preparations intended for administration over 3 days would be classified as low risk.
B. A high-risk sterile preparation that has met the requirements of the sterility test can be
8. stored for not more than 24 hours at a controlled room temperature.
C. The storage time for a medium-risk preparation under refrigeration is no longer than 9 days.
D. A CSP that will be administered to multiple patients or to a single patient multiple times is
classified as a high-risk CSP.
E. After meeting the requirements of the sterility test, a sterile preparation can be stored
indefinitely.

Which of the following is correct?
A. For work done in a horizontal laminar flow workbench, arrange items in the hood so that
your hand is never between the HEPA filter and an object.
B. For work done in a horizontal laminar flow workbench, vials that are not being used should
9.
be stacked up along the side of the hood to increase workspace in the hood.
C. Before each shift, 70% isopropyl alcohol is used to sterilize the laminar flow workbench.
D. An object placed in the horizontal laminar flow workbench disturbs the airflow downstream
of the object equal to two times the diameter of the object.
E. Syringes and IV bags are placed in the hood in their protective overwrap.

Which of the following is correct concerning the necessity that operators in the buffer area be
properly gowned?
A. Operators don gowns because they shed particles, and the nonshedding gowns keep them
sterile.
B. Sterile gloves are used to avoid contamination of the CSP in case the operator accidentally
10.
touches a critical site during compounding of the preparation.
C. Frequent sanitization with sterile 70% isopropyl alcohol is essential to keep the operators'
hands sterile during the compounding process.
D. Nonshedding garb and sterile gloves help to contain the particles shed from the operators.
E. Operators must don gowns before working at the laminar flow workbench but not before
entering the buffer area.

Which of the following is correct concerning placement of items and work performed in the
laminar flow workstation?
A. Items should be placed in a horizontal flow hood to the right or left of the work area.
B. Items in a vertical laminar flow hood should be placed so that an operator's hand never goes
11. over the top of a critical site while the operator is working in the hood.
C. An object placed in a horizontal laminar flow hood disturbs the airflow downstream of the
object equal to three times the diameter of the object.
D. When working in a horizontal laminar flow workstation, an operator must perform all work
at least 6 inches inside the hood.
E. All of the above are correct.

Which parts of the syringe are considered critical sites?
I. The ribs of the plunger

II. The collar of the syringe
III. The tip of the syringe
12.
A. I only
B. II only
C. I and III only
D. II and III only
E. I, II, and III

Which parts of the needle are considered critical sites?
I. The hub
II. The needle shaft
III. The bevel and bevel tip of the needle
13.
A. I only
B. II only
C. I and III only
D. II and III only
E. I, II, and III

Which of the following are correct concerning ampuls?
I. Ampuls are single-dose containers.

II. Ampuls must have the neck wiped with a sterile alcohol pad before being broken.
III. Ampuls can be left in the hood and used for several days once opened.
14.
A. II only
B. I and III only
C. I and II only
D. I, II, and III
E. None of the above

Which of the following are correct concerning the steps taken to protect an operator when
working with cytotoxic agents?
I. Preparation of cytotoxic drugs must occur in a biological safety cabinet.

II. Syringes with Luer-Lok tips should be used when compounding cytotoxic CSPs.
III. It is very important that positive pressure not be allowed to build up inside the vial when
15. one is working with cytotoxic preparations.
A. I only
B. II only
C. I and III only
D. II and III only
E. I, II, and III

A. Filter integrity testing of the filter membrane is done to determine at what pressure the filter
will break.
B. The manufacturer of the filter membrane determines the bubble point of the membrane; this
16. value is always the same, no matter what solution has been filtered.
C. As the pore size of the filter membrane decreases, the pressure at which the air can be
pushed from the largest pore increases.
D. The bubble point test is a destructive test.
E. It is not necessary to perform the bubble point test if a certificate of quality from the filter
manufacturer is provided.

Which of the following factors should be considered when choosing a sterilizing filter?
A. The volume of solution to be filtered

17. B. The compatibility of the membrane with the solution to be filtered
C. Whether the solution to be filtered is hydrophobic or hydrophilic
D. The compatibility of the filter housing with the product to be filtered
E. All of the above

Which of the following is correct concerning the USP sterility test?
A. The validation test must be done on each CSP to determine if the article to be tested
adversely affects the reliability of the test.
B. The growth promotion test does not require that the test organisms listed in the USP be
18. used.
C. After inoculation, the media must be incubated for 14 days or fewer at the appropriate
temperature.
D. No growth on the sterility test proves that the aseptically produced product is sterile.
E. Trypticase soy broth is incubated at 30-35°C, and fluid thioglycollate is incubated at 20-
25°C.

A. Gram-negative bacteria must be alive to cause a pyrogenic response.

B. The lipopolysaccharide portion of the cell wall of Gram-negative bacteria causes the
19.
pyrogenic response.
C. Endotoxin can be removed by a 0.2 micron filter.
D. Steam sterilization will depyrogenate an object just as well as the hot air oven.
E. An article that is depyrogenated is not necessarily sterile.

A. The rabbit test and the LAL test are the same test.
B. LAL reagent will determine the fever-producing potential of the pyrogens.
20.
C. There are two types of techniques for the BET: the gel-clot technique and the photometric
technique.
D. The CSP being tested has no effect on the test.
E. All CSPs may be tested using the rabbit test.

A. The rabbit test is the most sensitive because it can detect pyrogens from all sources.
21. B. The rabbit test is an in vitro test.
C. Some drugs may inhibit the formation of a gel in the BET.
D. No drug will enhance the formation of the gel in the BET.
E. The pyrogen test is a quantitative test.

The plenum in a laminar flow workbench is the area
A. where the air is prefiltered.

22. B. where air is pressurized for distribution over the HEPA filter.
C. where compounding takes place.
D. that serves no purpose.
E. directly above the HEPA filter in a horizontal laminar flow hood.

Calcium and phosphate can interact to form a precipitate in parenteral nutrition solutions. Of
the following situations that could enhance precipitate formation, which one would not do so?
A. High concentration of calcium and phosphate

23.
B. Increase in solution pH
C. Decrease in temperature
D. Use of the chloride salt of calcium
E. A slow infusion rate

Of the following potential sources of physical or chemical incompatibilities, which is not a
source?
A. Dilution of a drug in a cosolvent system into an aqueous system

24. B. Addition of a drug solution with a high pH into a solution with a low pH
C. Adsorption of a lipid-soluble drug into the matrix of a polypropylene container
D. A photosensitive drug such as sodium nitroprusside in 5% dextrose in water exposed to
light
E. Leaching of phthalate plasticizer into the solution from a polyvinyl chloride container

5-13. Answers
C. The bacterial endotoxin test (LAL test), visual inspection test, and bubble point test should
all be completed before the CSP is dispensed. Because the sterility test takes 14 days, the
1.
preparation may be dispensed before the results are known. However, a system to recall the
CSP must be in place if it does not meet the test's requirement.

C. Any leak greater than 0.01% of upstream smoke concentration is a serious leak. The smoke
particles are 0.3 microns. The airflow from the HEPA filter should be 90 ft/min, plus or minus
2.
20%. A total particle counter is used to classify the environment, not to certify the integrity of
the HEPA filter. The HEPA filter can be patched.

B. The BET determines the level of bacterial endotoxin from Gram-negative bacteria only. The
3. BET cannot determine fever-producing potential of the endotoxins. The Gram-negative
bacteria do not have to be alive for the endotoxin to produce an effect.

A. The operator must successfully complete one media fill before compounding a sterile
preparation. Once validated for low- or medium-risk compounding, the operator must
4. revalidate annually. For high-risk compounding, the operator must revalidate semiannually.
Passing only a written exam does not allow the operator to compound a CSP. Trypticase soy
broth is the medium most often used in media fills.

A. Cardboard must be kept out of the buffer area. Vials stored in laminated cardboard may be
stored in the buffer area. No items should be brought into the buffer area without being
5. sanitized. Large-volume parenteral bags should be removed from their overwrap just before
being used. The refrigerator should not be in the buffer room because it is a source of
contamination.

C. There are several types of vertical laminar flow hoods, of which the biological safety
6. cabinet is one. The operator must never work over the top of items in the hood, and all work
should be done at least 1 inch above the work surface.

7. C. Use of good aseptic technique is one way to ensure a good preparation.

C. A medium-risk CSP may not be stored longer than 9 days at cold temperature. USP 797
does not address administration at all; it applies only up to the time of administration. Once a
CSP has met the requirement of the sterility test, the storage periods specified under the risk
8.
levels no longer apply. However, the beyond-use date based on chemical stability always
applies. A CSP that will be administered to multiple patients or to a single patient multiple
times is a medium-risk CSP.

A. In an HLFW, never put your hand behind an object, and in a VLFW, never put your hand
above an object. In an HLFW, a vial disturbs the laminar airflow equal to three times the
9. diameter of the object. If the vial is next to the side wall, the airflow is disturbed equal to six
times the diameter of the object. Syringes and IV bags should be taken from their overwrap at
the edge of the hood.

D. Operators in the buffer area should wear clean, nonshedding gowns and gloves to help
10. contain the particles that they shed. The sterile gloves are no longer sterile once they are out of
the package. Proper aseptic technique must always be used.

E. All of the statements are correct concerning placement of items and work performed in the
11.
laminar flow workstation.

12. C. The ribs of the plunger and the tip of the syringe are critical sites of the syringe.

13. E. The hub, the needle shaft, and the bevel and bevel tip of the needle are all critical sites.

14. C. Once an ampul is opened, it must be used immediately.

E. When working with cytotoxic agents, an operator must take the following steps for
15. protection: (1) preparation must occur in a biological safety cabinet, (2) syringes with Luer-Lok
tips must be used, and (3) positive pressure must not be allowed to build up inside the vial.

C. The bubble point test is not a destructive test, and the value depends on the solution being
16. filtered. When a CSP is filter sterilized, the bubble point test must be done before the
preparation may be dispensed.

17. E. All of the factors should be considered.

A. The validation (bacteriostasis and fungistasis test) must be completed one time for each
18. CSP. The growth promotion organisms listed in the USP are used for the validation test and for
the growth promotion test.

B. Endotoxin will pass through a 0.2 micron filter. Steam sterilization will not depyrogenate an
19.
article. Bacteria do not have to be alive to be pyrogenic.

C. The pyrogen test, also known as the rabbit test, determines the fever-producing potential of
20. the pyrogens. The BET is also known as the LAL test. The drug product can inhibit or enhance
the gel formation in the BET.

C. The pyrogen (rabbit) test is an in vivo test and is not as sensitive as the BET. It is not a
21.
quantitative test.

B. The plenum is the area behind the HEPA filter in an HFLW that allows air to be pressurized
22.
for even distribution over the filter.

23. C. An increase in temperature could enhance precipitate formation.

C. Absorption of a lipid-soluble drug into the matrix of polyvinylchloride containers does
24.
occur. Polypropylene and polyethylene contain little or no phthalate plasticizer.

5-14. References
Akers MJ, Larrimore D, Guazzo D. Parenteral Quality Control: Sterility, Pyrogen, Particulate and
Package Integrity Testing. 3rd ed. New York: Marcel Dekker; 2003.
American Society of Health-System Pharmacists. ASHP guidelines on quality assurance for
pharmacy-prepared sterile products. Am J Hosp Pharm. 2000;57:1150-69.
Anderson RA. The status of environmental control: Practical approaches to the safe handling of
anticancer products. Proceedings of a symposium in Mayaguez, Puerto Rico, November 2-5,
1983.
Buchanan C, McKinnon B, Scheckelhoff D, Schneider P. Principles of Sterile Product Preparation.

Bethesda, Md.: American Society of Health-System Pharmacists; 2002:50.
General Services Administration. Federal standard 209e: Clean room and work station
requirements, controlled environments. Washington, D.C.: U.S. Government Printing Office;
1992.
McKinnon B, Avis K. Membrane filtration of pharmaceutical solutions. Am J Hosp Pharm. 1993;

50:1021-36.
Trissel LA. Handbook on Injectable Drugs. 15th ed. Bethesda, Md.: American Society of Health-
System Pharmacists; 2009.
United States Pharmacopeial Convention. Bacterial endotoxin test. In: United States Pharmacopeia,
32nd Revision: National Formulary. 27th ed. Rockville, Md.: United States Pharmacopeial
United States Pharmacopeial Convention. Compounded sterile preparations. In: United States
Pharmacopeia, 32nd Revision: National Formulary. 27th ed. Rockville, Md.: United States
Pharmacopeial Convention; 2009: 318-41.
United States Pharmacopeial Convention. Pyrogen test. In: United States Pharmacopeia, 32nd
Revision: National Formulary. 27th ed. Rockville, Md.: United States Pharmacopeial
Convention; 2009: 124-25.
United States Pharmacopeial Convention. Sterility tests. In: United States Pharmacopeia, 32nd
Revision: National Formulary. 27th ed. Rockville, Md.: United States Pharmacopeial
Convention; 2009: 80-86.
6. Pharmacokinetics, Drug Metabolism, and Drug Disposition - Bernd Meibohm, PhD, Charles
R. Yates, PharmD, PhD
6-1. Introduction
Introduction
Pharmacokinetics is the science of a drug's fate in the body. A drug's therapeutic potential is
intimately linked to its pharmacokinetic profile. For example, a drug's pharmacologic response may
be severely diminished by poor absorption, rapid elimination from the body, or both. The most
important factors contributing to drug disposition include absorption, distribution, metabolism, and
excretion.
Absorption
The rate and extent of drug absorption is referred to as bioavailability. The fraction of drug
absorbed (fa), an important determinant of the extent of bioavailability (represented by F), is
affected not only by the drug's physicochemical properties but also by physiologic barriers at the
site of absorption. For example, intestinal expression of the drug efflux transporter P-glycoprotein
is known to limit oral drugs.
Distribution
Many drugs circulate in the body bound to plasma proteins (e.g., human serum albumin). The
fraction of drug not bound to protein (fup) is responsible for the pharmacologic effect. A drug may
also bind significantly to tissue proteins (f ut). Drugs with a large f up-to-fut ratio have a large volume
of distribution, whereas drugs with a small fup-to-fut ratio are largely confined to the vascular space.
Volume of distribution is directly related to half-life (t 1/2), the time required to eliminate half the
drug from the body.
Metabolism
Approximately 50% of drugs undergo some form of hepatic metabolism. The cytochrome P450
(CYP450) family of drug-metabolizing enzymes is primarily responsible for drug inactivation in the
liver. Hepatic clearance depends on liver blood flow and the extraction ratio (ER). Hepatic ER can
be used to estimate the fraction of drug escaping first-pass metabolism (F*), which is an important
determinant of oral bioavailability. Intestinal inactivation of drugs by CYP450 enzymes in the gut is
responsible for reduced F of a number of drugs.
Excretion
The primary purpose of hepatic metabolism is to increase a drug's water solubility to facilitate its
renal elimination. The kidneys also serve as the primary eliminating organ for drugs that do not
undergo hepatic metabolism. Renal clearance comprises three main physiologic processes:
glomerular filtration, reabsorption, and secretion. Filtration clearance is the product of fup and
glomerular filtration rate (a physiologic parameter that diminishes with age). Renal reabsorption is a
predominantly passive process dependent on physicochemical drug properties and on urine drug
concentration and pH, whereas secretion is an active process facilitated by various transport
mechanisms. The net of filtration, reabsorption, and secretion determines a drug's total renal
clearance.
Interindividual differences in drug pharmacokinetics can at least partially explain variability in drug
response. Thus, a thorough understanding of the physiologic processes affecting drug disposition is
essential to drug individualization and optimization.
6-2. Absorption and Disposition
Drug Input
Drugs are administered to the body by one of two routes, intravascular or extravascular. For
intravascular administration, drugs are usually administered as in intravenous (IV) infusion
(continuous, short term, or bolus). The concentration C is given by the following expressions.
IV bolus
(rate of change in plasma concentration)

= (rate of drug elimination, or output rate)

K = elimination rate constant = CL/V

CL = clearance = Dose/AUC

V = Volume

IV infusion
For drugs that are administered extravascularly (by mouth, intramuscularly, or subcutaneously) and
act systemically, absorption must occur. See section 6-4.
First-order absorption
where ka = first-order rate constant for drug absorption; absorption half-life = 0.693/ka; K = first-
order rate constant for drug elimination (CL/V); CL = F × Dose/AUC, oral clearance = CL/F =
Dose/AUC; and F = bioavailability, or fraction of drug absorbed. F refers to the rate and extent of
absorption.
6-3. Constant Rate Regimens
Introduction
For many drugs to be therapeutically effective, drug concentrations of a certain level have to be
maintained at the site of action for a prolonged period (e.g., ²-lactam antibiotics, antiarrhythmics),
whereas for others, alternating plasma concentrations are more preferable (e.g., aminoglycoside
antibiotics such as gentamicin).
Two basic approaches to administering the drug can be applied to continuously maintain drug
concentrations in a certain therapeutic range over a prolonged period:
• Drug administration at a constant input rate
• Sequential administration of discrete single doses (multiple dosing)
Drug Administration as Constant Rate Regimens
At any time during the infusion, the rate of change in drug concentration is the difference between
the input rate (infusion rate R0/volume of distribution V) and the output rate (elimination rate
constant K × concentration C):
Rate of change = input rate - output rate
In concentrations:
In amounts:
R0 = infusion rate (in amount/time, e.g., mg/h)

V = volume of distribution

CL = clearance

K = first-order rate constant for drug elimination (CL/V)

Hence, the steady-state concentration Css is determined only by the infusion rate R0 and the
clearance CL.
Drug concentration at steady state:
Drug concentration before steady state:
Time to Reach Steady State
For therapeutic purposes, knowing how long after initiation of an infusion reaching the targeted
steady-state concentration Css will take is often of critical.
Concentration during an infusion before steady state:
Concentration during an infusion at steady state:
The fraction of steady-state f is then

After a duration of infusion of
1.0 t1/2 50% of steady state is reached
3.0 t1/2 87.5% of steady state is reached
The following conclusions can be drawn:
• The approach to the steady-state concentration Css is exponential in nature and is controlled by the
elimination process (elimination rate constant K), not the infusion rate R0.
• Only the value of the steady-state concentration Css is controlled by the infusion rate R0 (and of
course by the clearance CL).
• Assuming for clinical purposes that a concentration of > 95% of steady state is therapeutically
equivalent to the final steady-state concentration Css, approximately five elimination half-lives
t1/2 are necessary to reach steady state after initiation of an infusion.
Concentration-Time Profiles Postinfusion
The plasma concentration postinfusion cannot be distinguished from giving an IV bolus dose.
Because the drug input has been discontinued, the rate of change in drug concentration is
determined only by the output rate. If the drug follows one-compartment characteristics, then the
plasma concentration profile can be described by
C = C´ × e-K×tpi
where C´ is concentration at the end of the infusion and tpi is time postinfusion (i.e., time after the
infusion has stopped).
Thus, a general expression can be used to calculate the plasma concentration during and after a
constant rate infusion:
where t is the elapsed time after the beginning of the infusion and t pi is the postinfusion time—that
is, the difference between the duration of the infusion (infusion time Tinf) and t: t pi = t - Tinf. For
describing concentrations during the infusion, t pi is set to zero. For describing concentrations
postinfusion, t is set to Tinf.
Four different cases can be distinguished:
1. During the infusion, but before steady state is reached:
2. During the infusion at steady state:
3. After cessation of the infusion before steady state:
4. After cessation of the infusion at steady state:
Determination of Pharmacokinetic Parameters
The elimination rate constant K and the elimination half-life t1/2 can be determined from
• The terminal slope after the infusion has been stopped
• The time to reach half of Css
• The slope of the relationship of ln(Css - C) vs. t, based on
C = Css × (1 - e-K × t)
and the resulting ln(Css - C) = ln Css - K × t
The clearance CL from the relationship can be determined from
The volume of distribution from the relationship can be determined from

Loading Dose and Maintenance Dose
The loading dose LD is supposed to immediately (t = 0) reach the desired target concentration
Ctarget. It is administered as an IV bolus injection or, more frequently, as a short-term infusion.
Following is an expression of target concentration calculated for a drug with one-compartment
characteristics:
The maintenance dose MD is intended to sustain Ctarget. It is administered as a constant rate

infusion. The maintenance dose is the infusion rate necessary to sustain the target concentration:
6-4. Multiple Dosing
Introduction
Continuous drug concentrations for a prolonged therapy can be maintained either by administering
the drug at a constant input rate or by sequentially administering discrete single doses of the drug.
The latter is the approach more frequently used and can be applied for extravascular as well as
intravascular routes of administration.
Multiple-dose regimens are defined by two components, the dose D that is administered at each
dosing occasion, and the dosing interval , which is the time between the administrations of two
subsequent doses. Dose and dosing interval can be summarized in the dosing rate DR:
Concentration-Time Profiles during Multiple Dosing
The multiple-dose function MDF can be used for calculating drug concentrations before steady state
has been reached during a multiple-dose regimen:
where K is the respective rate constant of the drug, ‫ ؤ‬is the dosing interval, and n is the number of
the dose.
Once steady state has been reached, n approaches infinity, and MDF simplifies to the accumulation
factor AF:
Multiple-Dosing Regimens: Instantaneous Input (IV Bolus)
For an IV bolus multiple-dose regimen, the concentrations during the first dosing interval, the nth
dosing interval, and at steady state are described by the relationships shown in
Table 6-1.
The peak and trough concentrations at steady state can thus be expressed as the peak and trough
after the first dose multiplied by the accumulation factor AF:
Average steady-state concentration
By definition, the average drug input rate is equal to the average drug output rate at steady state.
Whereas the average input rate is the drug amount entering the systemic circulation per dosing
interval, the average output rate is equal to the product of clearance
[Table 6-1. IV Bolus Multiple Dose Regimen]
CL and the average plasma concentration within one dosing interval Css,av:
Thus, the average steady-state concentration Css,av during multiple dosing is determined only by the
dose, the dosing interval (or both together as dosing rate DR = D/ ), and the clearance CL:
The area under the curve resulting from administration of a single dose AUCsingle is equal to the
area under the curve during one dosing interval at steady state AUCss if the same dose is given per
dosing interval ‫ؤ‬:
Thus,
AUCsingle = AUCss
Extent of accumulation
The extent of accumulation during multiple dosing at steady state is determined by the dosing
interval and the half-life of the drug t1/2 (or the elimination rate constant K):
Thus, the extent of accumulation is dependent not only on the pharmacokinetic properties of a drug
but also on the multiple-dosing regimen chosen.
Fluctuation
The degree of fluctuation between peak and trough concentrations during one dosing interval—that
is, Css,max and Css,min—is determined by the relationship between elimination half-life t1/2 and
dosing interval ‫ؤ‬.
Multiple-Dosing Regimens: First-Order Input (Oral Dosing)
The average steady-state concentration Css,av is now determined by the bioavailable fraction F of
the dose D administered per dosing interval ‫ ؤ‬and the clearance CL:
The concentration-time profile after a single oral dose is given by
Hence, the concentration at any time within a dosing interval during multiple dosing at steady state
is determined by
Thus, the trough concentration is readily available, assuming that the absorption is completed:
The peak concentration is assessable via the time-to-peak tmax, which is dependent on the rate of
absorption and has to be determined through
6-5. Volumes of Distribution and Protein Binding
Introduction
Drug distribution means the reversible transfer of drug from one location to another within the
body. After the drug has entered the vascular system, it becomes distributed throughout the various
tissues and body fluids. However, most drugs do not distribute uniformly and in a similar manner
throughout the body, as reflected by the difference in their volumes of distribution. Thus, the
following material focuses on the factors and processes determining the rate and extent of
distribution and the resulting consequences for pharmacotherapy.
Factors affecting distribution are
• Binding to blood or tissue elements
• Blood flow (i.e., the delivery of drug to the tissues)
• Ability to cross biomembranes
• Physicochemical properties of the drug (lipophilicity, extent of ionization) that determine

partitioning into tissues
Protein Binding
The fraction unbound in plasma varies widely among drugs. Drugs are classified as follows:
• Highly protein bound:

fu 0.1 ( 10% unbound, 90% bound)
• Moderately protein bound:
fu = 0.1 - 0.4(10 - 40% unbound, 60 - 90% bound)
• Low protein bound:
fu = 0.4 ( 40% unbound, 60% bound)
Factors Determining the Degree of Protein Binding
The reversible binding of a drug to proteins obeys the law of mass action,
where the expressions in brackets represent the molar concentrations of the components, and k1 and
k2 are rate constants for the forward and reverse reactions, respectively. The equilibrium association
constant Ka is defined as k1/k2.
This reaction results in the following relationship for the fraction unbound:
where N is the number of available binding sites and Cu is the unbound concentration.
Binding Proteins
Human plasma contains more than 60 proteins. Of these, three proteins account for the binding of
most drugs. Albumin, which comprises approximately 60% of total plasma protein, fully accounts
for the plasma binding of most anionic drugs and many endogenous anions (high-capacity, low-
affinity binding site). Many cationic and neutral drugs bind appreciably to ±1-acid glycoprotein
(high-affinity, low-capacity binding site) or lipoproteins in addition to albumin. Other proteins, such
as transcortin, thyroid-binding globulin, and certain antibodies have specific affinities for a small
number of drugs.
Volumes of Distribution
Volume of distribution at steady-state Vss
The volume of distribution at steady state is by definition the sum of the pharmacokinetic volumes
of distribution for the different pharmacokinetic compartments. It is the theoretical
where Vp is the volume of plasma (3 L); Vt is the volume of tissue water (total body water minus
plasma volume: 42 - 3 = 39 L based on a "standard" person); and fu and fu,t are the fraction unbound
for the drug in plasma and in tissue, respectively.
Besides physicochemical properties of the drug, the relationship for Vss shows that the extent of
distribution is largely determined by the differences in protein binding in plasma and tissue,
respectively:
Unbound steady-state concentrations
The average steady-state concentration during a multiple-dose regimen or during a constant rate
infusion is determined by
The free steady-state concentration Css,u is given by
Css,u = fu × Css
Thus, the unbound steady-state concentration Css,u is determined by
6-6. Bioavailability and Bioequivalence
Introduction
The FDA (21 Code of Federal Regulations 320) defines bioavailability as "the rate and extent to
which the active ingredient or active moiety is absorbed from a drug product and becomes available
at the site of action." Because, in practice, drug concentrations can rarely be determined at the site
of action (e.g., at a receptor site), bioavailability is more commonly defined as "the rate and extent
that the active drug is absorbed from a dosage form and becomes available in the systemic
circulation."
Following are factors affecting bioavailability:
• Drug product formulation
• Properties of the drug (salt form, crystalline structure, formation of solvates, and solubility)
• Composition of the finished dosage form (presence or absence of excipients and special coatings)
• Manufacturing variables (tablet compression force, processing variables, particle size of drug or
excipients, and environmental conditions)
• Rate and site of dissolution in the gastrointestinal tract
• Physiology
With respect to physiology, the following factors affect bioavailability:
• Contents of the gastrointestinal tract (fluid volume and pH, diet, presence or absence of food,
bacterial activity, and presence of other drugs)
• Rate of gastrointestinal tract transit (influenced by disease, physical activity, drugs, emotional
status of subject, and composition of the gastrointestinal tract contents)
• Presystemic drug metabolism or degradation (influenced by local blood flow; condition of the
gastrointestinal tract membranes; and drug transport, metabolism, or degradation in the
gastrointestinal tract or during the first pass of the drug through the liver)
Absolute Bioavailability
Absolute bioavailability is the fraction (or percentage) of a dose administered nonintravenously (or
extravascularly) that is systemically available as compared to an intravenous dose. If given orally,
absolute bioavailability (F) is
Relative Bioavailability
Relative bioavailability refers to a comparison of two or more dosage forms in terms of their
relative rate and extent of absorption:
Bioequivalence
Two dosage forms that do not differ significantly in their rate and extent of absorption are termed
bioequivalent. In general, bioequivalence evaluations involve comparisons of dosage forms that are
• Pharmaceutical equivalents: Drug products that contain identical amounts of the identical active
drug ingredient (i.e., the same salt or ester of the same therapeutic moiety, in identical dosage
forms)
• Pharmaceutical alternatives: Drug products that contain the identical therapeutic moiety, or its
precursor, but not necessarily in the same amount or dosage form or as the same salt or ester
Biopharmaceutics Classification System
With minor exceptions, the FDA requires that bioavailability and bioequivalence of a drug product
be demonstrated through in vivo studies. However, the Biopharmaceutics Classification System
(BCS) can be used to justify the waiver of the requirement for in vivo studies for rapidly dissolving
drug products containing active moieties or active ingredients that are highly soluble and highly
permeable (Class 1 drugs).
The BCS divides drugs into classes on the basis of their solubility and permeability:
• Class 1: high solubility and high permeability
• Class 2: low solubility and high permeability
• Class 3: high solubility and low permeability
• Class 4: low solubility and low permeability
6-7. Elimination and Clearance Concepts
Clearance is defined as the irreversible removal of drug from the body by an organ of elimination.
Because the units of CL are flow (e.g., mL/minute or L/h), CL is often defined as the volume of
blood irreversibly cleared of drug per unit of time.
CL by the eliminating organ (CL organ) is defined as the product of blood flow (Q) to the organ and
the extraction ratio (ER) of that organ:
CLorgan = Q × ER
Individual organ clearances are additive. For the majority of drugs used clinically, the liver is the
major—and sometimes only—site of metabolism; the kidneys are the major site of excretion for
drugs and metabolites. Thus, the equation for total clearance can be written to include renal
clearance (CLR) and hepatic clearance (CLH):
CL = CLR + CLH
The fraction of drug excreted unchanged by the kidneys (f e) indicates what fraction of the drug
administered will be excreted into the urine:
6-8. Renal Clearance
Introduction
Drugs may undergo three processes in the kidney. Two act to remove drug from the body: filtration
and secretion. The other acts to return drug to the body: reabsorption. Thus, one may express renal
clearance of a drug as follows:
CLR = [CLfiltration + CLsecretion] × (1-freabsorbed)
Calculating Filtration Clearance of Creatinine
Normal serum concentrations of creatinine are 0.8-1.3 mg/dL for men and 0.6-1.0 mg/dL for
women.
Creatinine is a useful marker of renal function because it is an endogenous by-product of muscle

breakdown. The kidney eliminates creatinine at a rate approximately equal to the glomerular
filtration rate (GFR). A number of formulas have been developed that allow creatinine clearance
(CLcr) to be estimated from serum creatinine concentrations. The most widely used clinically is the
Cockroft-Gault equation:
where Scr is the serum creatinine concentration in mg/dL, and IBW is the ideal body weight.
IBWmales (kg) = 50 + (2.3 × height in inches > 5 ft)
IBWfemales (kg) = 45.5 + (2.3 × height in inches > 5 ft)
Secretion Clearance
Drug in blood may also be secreted into the kidney tubule. This process occurs against a
concentration gradient (concentration of drug in kidney tubule is very high because of water
reabsorption) and therefore is an active process.
Cellular processes (e.g., presence of active transporters) exist to facilitate tubular secretion. The two
most well characterized of these processes include transporters responsible for the secretion of basic
(anionic) and acidic (anionic) drugs.
Reabsorption
Passive reabsorption of many drugs also occurs in the kidneys. Because reabsorption is a passive
process (i.e., diffusion), reabsorption will depend on the physicochemical properties of the drug
(e.g., molecular weight, polarity, and acid disassociation content pKa).
Weak bases: B + H+ BH+
Low urine pH = more ionized, less reabsorption
High urine pH = less ionized, more reabsorption
Thus, only weak bases with pKa between 6 and 12 show changes in the extent of reabsorption (and
thus CLR) with changes in urine pH.
Weak acids: HA A- + H+
Low urine pH = less ionized, more reabsorption
High urine pH = more ionized, less reabsorption
Thus, only weak acids with pKa in the range of 3.0 to 7.5 show changes in the extent of
reabsorption (and thus CLR) with changes in urine pH.
All drugs that are not bound to plasma proteins are filtered; therefore, filtration clearance is
CLfiltration = fup × GFR = 125mL/minute
Some drugs are secreted or reabsorbed, or both. One can determine the net process a drug
undergoes by calculating the excretion ratio (Eratio):
6-9. Hepatic Clearance
Introduction
The fraction of drug escaping first-pass metabolism (F*) can be described in terms of the hepatic
extraction ratio:
F* = 1 - ER
The overall oral bioavailability (F) of a drug is dependent on the fraction absorbed (fa), the fraction
escaping metabolism in the intestinal wall (fg), and the fraction escaping hepatic first-pass
metabolism (F*).
F = fa × fg × F*
Venous Equilibrium Model for Hepatic Clearance
The venous equilibrium model relates hepatic extraction ratio ER to its determinants as follows:
and (remembering that CLH = QH × ERH)
The fraction of drug escaping hepatic first-pass metabolism using the venous equilibrium model is
Drugs undergoing hepatic metabolism can be divided into three broad categories:
1. Low-extraction drugs: ER < 0.3 and thus F* > 0.7

2. Intermediate-extraction drugs: 0.3 < ER < 0.7 and thus 0.3 < F* < 0.7
3. High-extraction drugs: ER > 0.7 and thus F* < 0.3
Determinants of Hepatic Clearance
Thus, the determinants of hepatic extraction ratio, hepatic clearance, and the fraction escaping
hepatic first-pass metabolism are liver blood flow (Q), protein binding (fup), and CLint.
For some drugs, hepatic clearance is limited or restricted to the unbound or free drug (ER < f up).
This is known as restrictive clearance. Because clearance is limited to unbound drug, changes in
protein binding will alter the concentration of drug that is available for elimination.
Some drugs defy this principle so that the hepatic extraction ratio is greater than the fraction of drug
unbound in plasma (ER > f up). When this occurs, it suggests that drug clearance is not restricted to
unbound drug. Drugs behaving in this manner are said to undergo nonrestrictive clearance. Because
nonrestrictive clearance is not limited to the fraction unbound in plasma, changes in protein binding
will not alter the concentration of drug that is available for elimination (i.e., all drug is available for
elimination regardless of whether it is bound or unbound).
Intrinsic clearance (CLint) is defined as the intrinsic ability of the hepatic enzymes to eliminate drug
when blood flow or protein binding causes no limitations. CLint is a measure of the capacity and
affinity of drug-metabolizing enzymes (e.g., CYP450s) for the drug. The determinants of CLint can
be explained using the Michaelis-Menten equation:
where is the rate of drug metabolism (amount/time), Vmax is the maximal rate of metabolism for a
given metabolic pathway (amount/time), Km is the concentration of the drug at which the rate of
metabolism is half-maximal (amount/volume), and Cu is the unbound drug concentration
(amount/volume).
Physiologically, Vmax describes the quantity (capacity) of a drug-metabolizing enzyme to

metabolize drug. Km describes the interaction between the drug-metabolizing enzyme and the drug.
Factors that affect CLint are
• Enzyme induction: Enzyme induction refers to an increased number (capacity) of drug-

metabolizing enzymes, which results in an increase in clearance. An increased number (capacity)
of drug-metabolizing enzymes results in an increase in Vmax and CLint.
• Enzyme inhibitors: Competitive inhibition of the drug-metabolizing enzyme by another drug

increases the apparent Km (i.e., a higher concentration of drug will be required to achieve a half-
maximal rate of metabolism). Increase in apparent Km results in decrease in CL int.
An extensive list of potential P450 inducers and inhibitors can be found at www.drug-
interactions.com.
6-10. Drug, Disease, and Dietary Influences on Absorption, Distribution, Metabolism, and
Excretion
Introduction
Pharmacokinetics is the science of a drug's fate in the body. Typical reported pharmacokinetic
parameters are determined in healthy individuals. However, drugs are prescribed to individuals with
one or more altered physiological or pathological conditions. Clinical pharmacokinetics focuses on
tailoring therapeutic dosing regimens to individuals on the basis of these altered physiological and
pathological states. Thus, it is important to consider patient-specific factors that potentially
contribute to drug interactions: drug-drug, drug-disease, and drug-dietary factors.
Drug interactions alter the effects of a drug by reaction with another drug or drugs, with foods or
beverages, or with a preexisting medical condition. Drug interactions can be broadly classified as
• Drug-drug
• Drug-disease
• Drug-dietary
Drug-Drug Interactions
• Induction of CYP450 enzymes
• An increased number (Vmax) of drug-metabolizing enzymes leads to increased clearance.
• Example: Rifampin increases clearance of warfarin.
• Inhibition of cytochrome P450 enzymes
• Competitive inhibition of the drug-metabolizing enzyme by another drug leads to increase in

apparent Km, which leads to decreased clearance.
• Example: Cimetidine decreases the clearance of warfarin.
• Inhibition of drug efflux transporter P-glycoprotein
• Competitive inhibition of P-glycoprotein occurs.
• Decreased renal clearance for drugs undergoing net secretion
• Example: Quinidine inhibits the renal secretion of digoxin.
• Increased fa and F
• Example: Ketoconazole increases the oral absorption of cyclosporine.
• Protein-binding displacement
• A drug or drugs is displaced from major binding proteins.
• Increased fup
• Increased volume of distribution

• Increased clearance for restrictively cleared drugs
• Example: Aspirin displaces warfarin from albumin, leading to an increased distribution and
clearance for warfarin.
Drug-Disease Interactions
Cardiovascular disease
Reduced cardiac output associated with congestive heart failure leads to reduced perfusion of key
eliminating organs such as the liver and kidney. The following pharmacokinetic effects have been
reported:
• Decreased absorption rate (e.g, digoxin, hydrochlorothiazide, procainamide, and quinidine)
• Prolonged hepatic clearance for high extraction (E > 0.7) drugs (e.g., lidocaine and theophylline)
• Reduced volume of distribution (e.g., digoxin)
Renal disease
Creatinine clearance is commonly used to assess renal function, and the CLR of many drugs is
known to vary in proportion to CLcr. Thus, renal impairment can be inferred from changes in CLcr.
CLcr is most often estimated by measuring serum creatinine concentration, using the Cockroft-Gault
equation, as discussed previously.
Serum creatinine concentrations remain relatively constant (about 1 mg/dL) in adults over age 20.
However, patients with compromised renal function may exhibit higher concentrations.
Renal function RF in a patient may be estimated by comparing the patient's creatinine clearance to
what CLcr would be in a normal individual (i.e., fup × GFR or 125 mL/minute).
Use of this equation to estimate RF assumes the intact nephron hypothesis (i.e., that renal disease
results in the dysfunction of a certain fraction of nephrons but allows the remaining nephrons to
remain intact).
To individualize drug treatment in patients with renal impairment, you need to know the drug
clearance in your patient. This knowledge will allow you to calculate the dose rate of the drug that
will maintain an individualized Ctarget. Clearance in your patient with renal impairment will be
designated CL*. Three parameters are needed to calculate CL*:
• CL of the drug and fe in normal subjects. These values can be found in textbooks, primary
literature, or package inserts.
• RF in your patient is usually estimated using a recent serum creatinine concentration and the
equations presented above.
You can then calculate clearance in your patient with renal impairment using the following
equation:
CL* = CL × [1 - fe × (1 - RF)]
CL* represents total clearance in the renally impaired individual.
Liver disease
Hepatic disease results in numerous pathophysiologic changes in the liver that may influence drug
pharmacokinetics, including the following:
• Reduction in liver blood flow
• Decreased clearance for high-extraction drugs
• Reduction in number and activity of hepatocytes
• Decreased first-pass metabolism for high-extraction drugs
• Decreased clearance for low-extraction drugs
• Impaired production of human serum albumin
• Increased distribution of drugs
Drug-Diet Interactions
• Drug-food interactions
• Type I: Ex vivo bioinactivation
• Type II: Interactions affecting oral absorption
• Type III: Interactions affecting systemic disposition
• Type IV: Interactions affecting either renal or hepatic clearance

• Ex vivo bioinactivation
• It typically occurs in the delivery device before drugs enter body.
• Interaction occurs between the drug and the nutritional element or formulation through
biochemical or physical reactions.
• Interaction examples include hydrolysis, oxidation, neutralization, precipitation, and

complexation.
• High ethanol content may precipitate inorganic salts present in enteral feeding formulas.
• Syrups are acidic solvents and may cause precipitation of inorganic salts.
• Interactions affecting absorption
• This type of interaction affects drugs and nutrients delivered by mouth only.
• It may result in either an increase or a decrease in oral bioavailability.
• The interacting agent may alter function of either the metabolizing enzyme (e.g., CYP3A4) or
the active transport protein (e.g., P-glycoprotein).
• Meal intake alters oral absorption through mechanisms involving altered (1) gastric pH, (2)
gastrointestinal transit time, and (3) dissolution of solid dosage forms.
• Grapefruit juice inactivates gut CYP3A4, enhancing oral absorption of CYP3A4 substrates
(e.g., cyclosporine, midazolam, and nifedipine).
• Interactions affecting systemic disposition
• These interactions occur after drug or nutrient has entered the systemic circulation.
• They involve alteration in tissue disposition or response.
• Example: Foods high in vitamin K (e.g., broccoli) can alter systemic clotting factors, reducing
effectiveness of warfarin.
• Interactions affecting either renal or hepatic clearance
• These interactions arise from modification of drug elimination mechanisms in liver, kidney, or
both.
• Acute ethanol ingestion may potentiate central nervous system effects of benzodiazepines (e.g.,
alprazolam).
6-11. The Pharmacokinetic-Pharmacodynamic Interface
Pharmacokinetics (PK) establishes the relationship between dose and concentration.

Pharmacodynamics (PD) establishes the relationship between concentration and effect. When
individualizing pharmacotherapy, it is important to account for both PK and PD variability. For a
number of drugs, the PK variability is much larger than the PD variability. Thus, concentration-
based therapeutic drug monitoring is useful for a number of drugs (e.g., theophylline). However, for
some drugs, PD variability exceeds PK variability.
Linking the PK and PD allows a more thorough understanding of the effect of dosage adjustments
on pharmacologic response.
The simple Emax model represents the most widely used model to describe the relationship between
drug concentration and effect:
where Emax is the maximum effect possible (intrinsic activity) and EC50 is the concentration
achieving 50% maximal effect (potency).
Figure 6-1 illustrates the three concentration-dependent phases as follows:
• Linear phase (1)
• Drug concentration is much smaller than EC50 (C << EC50).
• A linear relationship exists between concentration C and effect E:
• Constant phase (3)
• Drug concentration much larger than EC 50 (C >> EC50).
• Effect E is independent of concentration:
E = Emax
• Log-linear phase (2)
• A log-linear relationship exists between C and E when E is between 20% and 80% of Emax.
Emax/4 is the slope describing this relationship:
6-12. Hysteresis
Response is linked to concentration and time. In other words, a given concentration may have a
different effect depending on time. Therefore, the concentration-effect relationship is described by a
hysteresis loop, which may be either clockwise or counterclockwise.
• Counterclockwise hysteresis
• Distributional delay to effect site
• Indirect response mechanism
• Active metabolite (agonism)
• Sensitization
[Figure 6-1. The Three Concentration-Dependent Phases]
• Clockwise hysteresis
• Functional tolerance
• Active metabolite (antagonism)
6-13. Clinical Examples
Clinical Example 1
A patient (55 years old, weighing 73 kg) was started on a multiple-dose regimen with gentamicin 80
mg every 8 hours given as IV short-term infusion over 30 minutes. Because his infection is serious,
it is decided to target for a peak concentration of 10 mg/L and a trough concentration of 1 mg/L.
Three blood samples were drawn 30 minutes prior to the third dose and 30 minutes and 7 hours
after the end of the infusion of the third dose, respectively. The measured plasma concentrations are
1.73, 5.96, and 1.80 mg/L, respectively.
Optimize the gentamicin dosing regimen on the basis of the individual pharmacokinetic parameters
of the patient to achieve the therapeutically targeted concentrations.
• Step 1: Calculate the elimination rate constant K:

• Step 2: Calculate volume of distribution V:
• Step 3: Calculate recommended dosing interval ‫ؤ‬:
The practically reasonable, recommended dosing interval is 12 hours.
• Step 4: Calculate recommended dose D:
The recommended dosing regimen is 140 mg every 12 hours.

• Step 5: Check expected peak Css,max and trough Css,min:
Clinical Example 2
A 70-year-old white male weighing 95 lbs is 5 feet tall and has a serum creatinine of 1.1 mg/dL. He
is admitted to the hospital complaining of shortness of breath; he denies chest pain. Digoxin is
prescribed for him. You are asked to design a dosage regimen using tablets for him to achieve and
maintain a Ctarget,ss of 1 ng/mL. The PK parameters for digoxin are as follows: CL = 2.7
mL/minute/kg (total body weight, or TBW); f e = 0.68; Vss = 6.7 L/kg (IBW); F of tablet = 0.75.
• Step 1: Estimate CL, CLcr, RF, and CL* of digoxin in this patient.
IBW = 45.5 kg; TBW = 43 kg. Therefore, use TBW for all calculations.
CL for a normal 43 kg patient = 116 mL/minute.
CLcr and RF are
• Step 2: Estimate CL*, clearance of digoxin in this patient with renal impairment:
CL* = 116 mL/minute × [1 - 0.68 (1 - 0.304)]

= 61.1 mL/minute

• Step 3: Calculate Dose Rate*:

• Step 4: Determine dosing interval * by estimating the half-life of digoxin:
Vss (Vd) for digoxin from PK tables is 6.7 L/kg, or 289 L in this patient. Thus,
Digoxin is normally administered every 24 hours (‫ = ؤ‬24 h); it could be administered 0.25 mg
every 48 hours ( = 48 h). Here, however, changing the dosing interval is not recommended,
because 24 hours is very convenient, and the resultant peak:trough ratio would be lower with ‫= ؤ‬
24 h as compared with ‫ = ؤ‬48 h.
Clinical Example 3
A. M. is a 61-year-old white male, 6 feet tall, weighing 195 lbs. He has a diagnosis of pneumonia.
His serum creatinine is 2.3 mg/dL. Design a dosage regimen of gentamicin to achieve Cpeak and
Ctrough values of 8 mg/L and 1 mg/L, respectively. Vd = 0.2 L/kg IBW.
• Step 1: The CL of gentamicin is 85 mL/minute and the fe = 1.0. Calculate the degree of renal
impairment:
• Step 2: Calculate the CL of gentamicin in this patient:
= 85 mL/minute × [1 - 1 × (1 - 0.296)]
CL*
= 25.2 mL/minute = 1.5 L/h

• Step 3: Calculate the elimination rate constant in this patient:

• Step 4: Calculate the infusion rate and dosing interval:
Clinical Example 4
Patient D. M. is a 50-year-old white male (74.1 kg) who is being treated for seizure control with
phenytoin (Vd = 0.6 L/kg), 300 mg/d, using the capsule formulation. He has been taking phenytoin
for 2 weeks. He experienced a seizure on day 14 of treatment. His blood level was 5.2 mg/L. His
dose rate was increased to 400 mg/d of the capsule formulation. Three weeks later his blood level
was 11.8 mg/L.
• Phenytoin capsules and parenteral solution = sodium phenytoin
• Phenytoin tablets and suspension = phenytoin acid
• 100 mg phenytoin sodium = 92 mg phenytoin acid
• Step 1: The Vmax (mg/d) for phenytoin in patient D. M. is
a. 491
b. 499
c. 542
d. 590
e. 614
Because D. M. is using capsules, you need to multiply the original dose rate by 0.92.
Dose rate (mg/day) Css (mg/L) Dose rate/Css (L/day)

300 × 0.92 = 276 5.2 53.08

400 × 0.92 = 368 11.8 31.19

Y-intercept = Vmax = 499 mg/d phenytoin slope = - Km = - 4.2 mg/L; therefore
Km = 4.2 mg/L
• Step 2: What dosage regimen would you recommend to achieve an average steady-state phenytoin
concentration of 15 mg/L in patient D. M. using the capsule formulation?
a. 100 mg q6h
b. 100 mg q8h
c. 200 mg q6h
d. 200 mg q8h
390 mg/d phenytoin = 424 mg/d sodium phenytoin
Recommend 400 mg Dilantin Kapseals in three or four divided doses (e.g., 100 mg q6h).
• Step 3: Estimate the time required to achieve steady-state levels of phenytoin in patient D. M. at
the dosage regimen if it were changed to 100 mg capsule q6h.
a. 1 day
b. 5 days
c. 9 days
d. 13 days
e. 17 days
About 9 days are needed to reach 90% of new steady-state plasma concentration.
• Step 4: Calculate the loading dose of phenytoin in this patient that would be needed to achieve a
phenytoin blood level of 12 mg/L. (Assume that blood levels of phenytoin = 0 at time of
administration of the loading dose.)
a. 491 mg
b. 535 mg
c. 580 mg
d. 603 mg
LD = Css,target × Vss = 12 mg/L phenytoin × 0.6 L/kg

× 74.1 kg = 534 mg of phenytoin

= 580 mg of phenytoin sodium (parenteral)

Clinical Example 5
To treat her asthma exacerbation, L. Y., a 68-year-old woman who weighs 55 kg, has received a
continuous infusion of aminophylline (infusion rate 0.45 mg/kg/h) for 5 days. This morning, she
suffers from theophylline toxicity indicated by tachycardia, headache, and dizziness. A blood
sample is drawn, and the theophylline plasma concentration is 24.3 mg/L. The therapeutic range is
10-20 mg/L; the population average of the volume of distribution is 0.5 L/kg.
• Step 1: What is the theophylline clearance in this patient under the assumption that steady state
had already been reached at the time the blood sample was obtained?
a. 0.81 L/h
b. 0.95 L/h
c. 1.35 L/h
d. 2.15 L/h
e. 2.80 L/h
• Step 2: To what aminophylline infusion rate should the infusion be reduced to achieve a steady-
state concentration in the middle of the therapeutic range, that is, 15 mg/L?
a. 0.17 mg/kg/h
b. 0.18 mg//kg/h
c. 0.20 mg/kg/h
d. 0.22 mg/kg/h
e. 0.28 mg/kg/h
= Ctarget × CL = 15 mg/L × 0.81 L/h
MD = 12.15 mg/h theophylline
= 15.2 mg/h aminophylline

Because the patient weighs 55kg, MD = 0.28 mg/kg/h.
• Step 3: How long does it take approximately to achieve the new steady state after the infusion rate
has been changed?
a. 26 hours
b. 68 hours
c. 118 hours
d. 156 hours
e. 192 hours
Estimated V = 55 kg × 0.5 L/kg = 27.5 L
Time to new steady state approximately 5 t 1/2 118 hour
• Step 4: The pharmacist suggests that the new target concentration can be achieved faster if the
first infusion with the higher infusion rate is completely stopped and the second infusion with the
lower infusion rate is not initiated until the plasma concentration has decreased to 15 mg/L, the
target concentration. Calculate the time the therapy has to pause (i.e., the time one waits after
cessation of the first infusion before the second infusion is started).
a. 14.7 hours
b. 16.4 hours
c. 20.7 hours
d. 36.1 hours
e. 55.1 hours
6-14. Key Points
• The clearance CL can be determined from the relationship
• The volume of distribution can be determined from the relationship
• The average steady-state concentration Css,av during multiple dosing is determined only by the
dose, the dosing interval (or both together as dosing rate DR = D/ ) and the clearance CL:
• The area under the curve resulting from administration of a single dose AUCsingle is equal to the
area under the curve during one dosing interval at steady-state AUCss, provided that the same
dose is given per dosing interval ‫ؤ‬:
• The volume of distribution at steady state is by definition the sum of the pharmacokinetic volumes
of distribution for the different pharmacokinetic compartments. It is the theoretical
where Vp is the volume of plasma (3 L), Vt is the volume of tissue water (total body water minus
plasma volume: 42 - 3 = 39 L based on a "standard" person), and fu and fu,t are the fraction
unbound for the drug in plasma and tissue, respectively.
• Clearance is defined as the irreversible removal of drug from the body by an organ of elimination.
CL by the eliminating organ (CL organ) is defined as the product of blood flow to the organ (Q)
and the extraction ratio of that organ (ER). The fraction of drug escaping first-pass metabolism
(F*) can be described in terms of the hepatic ER (F* = 1 - ER).
• The venous equilibrium model relates hepatic ER to hepatic blood flow Q, unbound drug fraction
fup, intrinsic clearance CL int:
• The venous equilibrium model can be simplified for drugs with low ER (< 0.3) and high ER (>
0.7). For low-ER drugs, CL H fup * CLint. For high-ER drugs, CL H Q.
• Bioavailability is the fraction (or percentage) of a dose administered nonintravenously (or

extravascularly) that is systemically available as compared to an intravenous dose. The overall
oral bioavailability (F) of a drug is dependent on the fraction absorbed (fa), the fraction escaping
metabolism in the intestinal wall (fg), and the fraction escaping hepatic first-pass metabolism
(F*).
• Drugs may undergo three processes in the kidney. Two act to remove drug from the body:
filtration and secretion. The other acts to return drug to the body: reabsorption. The net process a
drug undergoes can be determined by calculating the excretion ratio (Eratio) using total renal
clearance (CLR) and filtration clearance (CLF):
6-15. Questions
A pediatric patient receives an immunosuppressive therapy with oral cyclosporine solution.

His concentration-adjusted dosing regimen is 85 mg every 12 hours. Because of a recent
change in his insurance coverage, he needs to be switched from the drug product he is
currently using to a generic solution dosage form of cyclosporine that is covered by his
insurance. The bioavailability of the dosage form he previously used is 43%; the
bioavailability of the generic dosage form is 28%. What is the appropriate dosage regimen for
the generic dosage form to maintain the same systemic exposure as obtained from the
1.
previously used dosage form?
A. 25 mg every 12 hours
B. 55 mg every 12 hours
C. 184 mg every 12 hours
D. 130 mg every 12 hours
E. 305 mg every 12 hours

A drug is administered via continuous infusion at a rate of 60 mg/h, resulting in a steady-state
plasma concentration of 5 mcg/mL. If the plasma concentration is intended to be doubled to
10 mcg/mL, the infusion rate must be
2. A. left the same.

B. increased by 30 mg/h.
C. increased by 60 mg/h.
D. increased by 120 mg/h.
E. decreased by 30 mg/h.

Jonathan R. (72 kg, 23 years old) has been admitted to the emergency room with acute asthma
symptoms. He will be started on a continuous infusion of aminophylline with a target
theophylline concentration of 12 mg/L (therapeutic range 10-20 mg/L). To achieve the target
concentration more rapidly, medical personnel will administer an additional loading dose as a
3.
short-term infusion over 30 minutes. The population mean values for clearance and volume
of distribution of theophylline are 2.7 L/h and 34 L, respectively. What aminophylline loading
and maintenance dose should be given? (Select practically useful doses. Remember that
aminophylline contains 80% theophylline.)

Loading dose:
A. 400 mg
3a. B. 450 mg
C. 500 mg
D. 550 mg
E. 600 mg

Maintenance dose:
A. 35 mg/h
3b. B. 40 mg/h
C. 45 mg/h
D. 50 mg/h
E. 55 mg/h

Lidocaine will be given as a constant rate infusion for the treatment of ventricular arrhythmia.
A plasma concentration of 3 mcg/mL was decided on as the therapeutic target concentration.
The concentration of the infusion solution is 20 mg/mL lidocaine. The average volume of
distribution of lidocaine is 90 L; the elimination half-life is 1.1 hours. What infusion rate (in
mL/minute) has to be set on the infusion pump to achieve the desired target concentration?
4.
A. 5 mL/h
B. 8.5 mL/h
C. 14 mL/h
D. 23.5 mL/h
E. 194 mL/h

After termination of an intravenous constant rate infusion, the plasma concentration of a drug
declines monoexponentially (C = C0 × e-k × t). Concentrations measured at 2 hours and 12
hours after the end of the infusion are 12.9 mcg/mL and 6.0 mcg/mL, respectively. Calculate
the initial concentration at the end of the infusion, and predict the concentration 24 hours
after termination of the infusion.
5.
A. 13.5 and 2.9 mcg/mL
B. 16.5 and 3.8 mcg/mL
C. 16.5 and 1.3 mcg/mL
D. 15 and 2.4 mcg/mL
E. 15 and 1.3 mcg/mL

Margaret Q. (100 kg, 26 years old) presents to the emergency room with acute symptoms of
asthma. She recently started smoking again and has been taking oral theophylline for several
years. The immediate determination of her theophylline plasma concentration results in a
level of 4 mg/L.
Theophylline population pharmacokinetic parameters: CL 0.04 L/h/kg; V 0.5 L/kg

Therapeutic range: 10-20 mg/L
6.
What is the appropriate intravenous loading dose of aminophylline for Margaret to achieve a
target concentration of 12 mg/L?
A. 300 mg
B. 400 mg
C. 500 mg
D. 600 mg
E. 750 mg

For a drug product in clinical drug development, an oral dosing regimen needs to be
established for a phase III study that maintains an average steady-state concentration of 50
ng/mL. In single-dose studies, an oral dose of 80 mg resulted in an AUC of 962 ng h/mL and
an elimination half-life of 10.3 hours. What dosing regimen should be used?
7.
A. 35 mg every 12 hours
B. 50 mg every 12 hours
C. 72 mg every 12 hours
D. 95 mg every 12 hours
E. 125 mg every 12 hours

Mary D. (47 years old, 68 kg) has recently received her first 0.25 mg dose of digoxin. Plasma
digoxin concentrations 12 and 24 hours following oral administration of this dose are 0.72
and 0.33 mcg/L, respectively. The therapeutic plasma concentration range is 0.8-2.0 mcg/L.
Predict Mary's digoxin trough concentration at steady state, assuming that oral digoxin
therapy is continued at a dose rate of 0.25 mg once daily.
8.
A. 0.62 mcg/L
B. 0.93 mcg/L
C. 1.32 mcg/L
D. 1.57 mcg/L
E. 1.95 mcg/L

The population average values for the clearance and volume of distribution of nifedipine have
been reported as 0.41 L/h/kg and 1.2 L/kg. What would be the maximum dosing interval you
can use for a multiple-dose regimen with an immediate-release oral dosage form of nifedipine
if peak-to-trough fluctuation should not exceed 100%?
9.
A. 2 hours
B. 4 hours
C. 6 hours
D. 8 hours
E. 12 hours

Beth R. (63 years old, 58 kg) is suffering from symptomatic ventricular arrhythmia. She will
be started on an oral multiple-dose regimen with the antiarrhythmic mexiletine. The
population average values of mexiletine for clearance and volume of distribution are CL = 0.5
L/h/kg and V = 6 L/kg, respectively. Although a therapeutic range of 0.5-2.0 mg/L has been
described, avoiding large peak-to-trough fluctuations is recommended. The available oral
dosage forms are 150, 200, and 250 mg capsules with an oral bioavailability of F = 0.9.
Design an appropriate and practically reasonable oral dosing regimen that keeps the plasma
10. concentrations at an average concentration of approximately 1 mg/L, with a peak-to-trough
fluctuation 100% (e.g. with concentrations within the limits of 0.75 and 1.5 mg/L).
A. 150 mg q6h
B. 200 mg q6h
C. 200 mg q8h
D. 250 mg q8h
E. 375 mg q12h

Edgar W. (20 years old, 58 kg) is receiving 80 mg of gentamicin as IV infusion over a 30-
minute period q8h. Two plasma samples are obtained to monitor serum gentamicin
concentrations as follows: one sample 30 minutes after the end of the short-term infusion and
one sample 30 minutes before the administration of the next dose. The serum gentamicin
concentrations at these times are 4.9 and 1.7 mg/L, respectively. Assume steady state.
Develop a practically reasonable dosing regimen that will produce peak and trough
11. concentrations of approximately 8 and 1 mg/L, respectively.
A. 120 mg q8h
B. 160 mg q8h
C. 140 mg q12h
D. 180 mg q12h
E. 280 mg q24h

A patient who is receiving chronic phenytoin therapy is hospitalized for an elective surgical
procedure. Admission labs note that the patient has a phenytoin concentration of 8 mcg/mL
(therapeutic range: 10-20 mcg/mL) and an albumin concentration of 3.0 g/dL. Phenytoin: F =
0.2-0.9, CL-variable, < 1% excreted unchanged in the urine, 88-93% bound to plasma
proteins (primarily albumin). Given this information and the therapeutic range of phenytoin,
you would recommend that the physician
A. decrease the dose of phenytoin, because high-extraction drugs (e.g., phenytoin) exhibit
12. increased unbound concentrations with increases in fraction unbound in the plasma.
B. increase the dose rate of phenytoin, because low-extraction drugs (e.g., phenytoin) exhibit
increased CL with increases in fraction unbound in the plasma.
C. not change the dose rate of phenytoin because low-extraction drugs (e.g., phenytoin) do
not exhibit changes in unbound concentrations with increases in fraction unbound in the
plasma.
D. not change the dose rate of phenytoin because low-extraction drugs (e.g., phenytoin)
exhibit equal and offsetting changes in CL and F with increases in fraction unbound in
plasma.

Which of the following conditions indicate the possibility of renal clearance of a weakly
acidic drug being sensitive to changes in urine pH?
I. It is secreted and not reabsorbed.

II. It has a pKa value of 5.0.
III. It has a small volume of distribution.
13. IV. All of the drug is excreted unchanged by the kidneys (i.e., fe = 1).
A. Only item I is correct.

B. Only item II is correct.
C. Only item III is correct.
D. Items II and III are correct.
E. Items II and IV are correct.

A young man (age 28, 73 kg, creatinine clearance 124 mL/minute) receives a single 200 mg
oral dose of an antibiotic. The following pharmacokinetic parameters of the antibiotic are
reported in the literature:
• F = 90%
• Vd = 0.31 L/kg
• t1/2 = 2.1 h
• fup = 0.77
14.
• 67% of the antibiotic's absorbed dose is excreted unchanged in the urine.
Determine the renal clearance of the antibiotic. What is the probable mechanism for renal
clearance of this drug?
A. 84 mL/minute, glomerular filtration and tubular reabsorption

B. 98 mL/minute, glomerular filtration and tubular reabsorption
C. 112 mL/minute, glomerular filtration
D. 167 mL/minute, glomerular filtration and tubular reabsorption
E. 236 mL/minute, glomerular filtration and tubular secretion

The pharmacokinetic parameters for captopril in healthy adults are
• Clearance: 800 mL/minute
15. • fe = 0.5
• Vss: 0.81 L/kg
• Plasma protein binding: 75%

Captopril is a weakly basic drug that is used in the treatment of hypertension. Assume a
glomerular filtration rate of 125 mL/minute. What is (are) the mechanism(s) for renal
clearance of captopril?
15a. A. Filtration only

B. Reabsorption only
C. Secretion only
D. Filtration and net secretion
E. Filtration and net reabsorption

When cimetidine (a highly lipid soluble weak base that is highly secreted in the renal
proximal tubules) and captopril are coadministered, the renal clearance of captopril is reduced
to approximately 125 mL/minute. What is the most likely mechanism to account for this
reduction in renal clearance?
15b.
A. Cimetidine reduces the filtration clearance of captopril.
B. Cimetidine enhances the reabsorption of captopril.
C. Cimetidine increases the unbound fraction of captopril.
D. Cimetidine blocks the renal secretion of captopril.

One of the most severe drug interactions is that between digoxin and quinidine.
Administration of quinidine to patients taking digoxin results in a two- to threefold increase
in digoxin Css and AUC after oral and intravenous administration of digoxin. Digoxin and
quinidine are substrates for the multidrug resistance transporter, P-glycoprotein. According to
the following pharmacokinetic data for digoxin, what is the most likely mechanism to explain
this drug-drug interaction?
CL: 125 mL/minute
16. Vss: 1.2 L/kg (IBW)
fe: > 0.99
fup: 0.25
A. Quinidine reduces the digoxin fraction escaping first-pass metabolism.

B. Quinidine inhibits renal secretion of digoxin by blocking P-glycoprotein.
C. Quinidine decreases digoxin fraction reabsorbed in the kidney tubule.
D. Quinidine reduces the fraction of digoxin absorbed.

The drug transporter P-glycoprotein is involved in numerous processes in drug disposition. P-
glycoprotein activity is directly responsible for the following processes:
I. Glomerular filtration
II. Transport of drug from hepatocytes into the bile
III. Transport of drug from the small intestine into the systemic circulation (i.e., bloodstream)
IV. Degradation of drug in the lumen of the duodenum
17.
V. Maintenance of the integrity of the blood-brain barrier by transport of drug out of the brain
A. Only V
B. II and V
C. II and III
D. I, II, and V
E. All of the above

A 59-year-old white female is hospitalized for a ruptured duodenal diverticulum. She is 5 feet
6 inches, weighs 65 kg, and has a serum creatinine of 1.5 mg/dL. Design a dosage regimen to
achieve Cpeak and Ctrough values of 8.0 and 0.5 mg/L with an infusion time = 30 minutes.
Assume Vd of gentamicin of 0.2 L/kg IBW in this patient. The typical population value of CL
for gentamicin is 85 mL/minute/70 kg.
18. Which of the following dosage regimens would you recommend for this patient?
A. 100 mg q8h
B. 100 mg q18h
C. 100 mg q24h
D. 160 mg q12h
E. 160 mg q24h

J. D. is a 47-year-old white male who has been prescribed codeine for lower back pain. The
pharmacist dispensing the medication remembers reading a study in which patients who took
codeine with grapefruit juice experienced an enhanced analgesic effect. The study found that
grapefruit juice enhanced oral bioavailability (F) of codeine. Interestingly, there was no effect
on codeine hepatic clearance or volume of distribution. Thus, the pharmacist counseled the
patient not to take his codeine with grapefruit juice. Based on the pharmacokinetic data for
codeine (listed below), what is the most likely explanation for the enhanced oral
bioavailability of codeine?
CL: 1,350 mL/minute

19.
fe: 0.10
Vss: 3.3 L/kg
Plasma protein binding: 35%
A. Grapefruit juice increases the absorption (fa) of codeine.

B. Grapefruit juice decreases the fraction escaping first-pass metabolism (F*).
C. Grapefruit juice increases renal secretion of codeine.
D. Grapefruit juice increases the fraction escaping first-pass metabolism (F*).

The pharmacokinetic parameters for codeine in healthy adults are as follows:
Oral F: 50%
fe < 0.01
Vss: 2.6 L/kg
20. Plasma protein binding: 7%
Codeine is well absorbed (f a = 1, fg = 0.8). You may assume that hepatic blood flow in a 70
kg adult is 1,350 mL/minute. The hepatic clearance of codeine is
A. 851 mL/minute.
B. 1,350 mL/minute.
C. 500 mL/minute.
D. 675 mL/minute.

6-16. Answers
D. The systemic exposure or average steady-state concentration for an oral dosing regimen is
given by
where DR is the dose rate and F the oral bioavailability of the respective dosing regimens. If
Css,av should be maintained constant, if follows that
1.
where the subscript denotes the different dosing regimens. Thus DR2, the dose rate for the
generic dosage form, can be calculated as

C. Steady-state plasma concentration of a constant-rate infusion is directly proportional to the
infusion rate R0 through
2.
Thus, R0 has to be doubled from 60 mg/h to 120 mg/h to increase Css from 5 to 10 mcg/mL,
that is, an increase of infusion rate by 60 mg/h.

3a. C. 500 mg for the loading dose.

B. 40mg/h for the maintenance dose.
3b.
The loading dose and maintenance dose can be calculated from target concentration and
volume of distribution or clearance:

LD = Ctarget × V = 12 mg/L × 34 L

= 408 mg theophylline

= 510 mg aminophylline

MD = Ctarget × CL = 12 mg/L × 2.7 L/h

= 32.4 mg/h theophylline

= 40.5 mg/h aminophylline

B. The infusion rate R0 or maintenance dose MD needed to achieve and maintain a steady-
sate concentration of 3 mcg/mL is given by
4.
The infusion pump setting can then be calculated as

D. The first step is to calculate the elimination rate constant k from the measured plasma
concentrations:
The initial concentration C0 at the end of the infusion can then be back-extrapolated by
solving the following relationship for C0:
5.
The concentration 24 hours after termination of the infusion can be predicted by
C24 h = 15 mcg/mL × e-0.077 h-1 × 24 h = 2.4 mcg/mL

C. The loading dose can be determined on the basis of the target concentration to be achieved
and the volume of distribution. The predose level of 4 mg/L needs to be subtracted from the
6.
target concentration, because the loading dose only has to account for the concentration
difference. The calculated theophylline dose needs to be converted to aminophylline:

LD
(C -C ) × Vd
= target predose

= (12 - 4) mg/L × 0.5 L/kg

× 100 kg = 400 mg theophylline

A loading dose of 400 mg theophylline is equivalent to 500 mg aminophylline.

B. The maintenance dose MD required to achieve an average steady-state concentration of 50
ng/mL for an oral dosing regimen is given by
MD = Css,av × CL/F
The oral clearance CL/F can be determined from the relationship between dose and area
under the plasma concentration-time curve AUC:
7.
7.
Thus, the required MD can be calculated as
This corresponds to a dosing regimen of 50 mg (4.16 mg/hour × 12 hours) given every 12

hours.

D. Because trough concentrations after the first dose are known (0.33 mcg/L), trough
concentrations during multiple dose at steady state can be predicted by multiplying the trough
after the first dose with the accumulation factor
The dosing interval ‫ ؤ‬is 24 hours; k can be calculated from

8.
Thus,

A. For immediate-release formulations, upper limits for peak concentrations (Css,max) and
lower limits for trough concentrations (Css,min) can be estimated by assuming immediate drug
absorption. If fluctuation is equal to 100%, Css,min is exactly one-half of Css,max. This is the
case when the dosing interval is equal to the elimination half-life t1/2 of the drug. A
population average half-life for nifedipine can be calculated as
9.
Thus, has to be smaller than 2.03 hours to avoid peak-to-trough fluctuation exceeding
100%.

D. Calculate necessary dose rate DR to maintain Css,avg = 1 mg/L:
10. Determine the maximum dosing interval:
Practical dosing interval: 8 hours

= DRnecessary × = 32.22 mg/h × 8h
D
= 257.8 mg

Recommended dosing regimen: 250 mg every 8 hours

C. Calculate the elimination rate constant k:
Calculate the volume of distribution assuming steady state:

11.
Calculate the recommended dosing interval:
Recommended dosing interval: 12 hours
Calculate the recommended dose:

Recommended dosing regimen: 140 mg every 12 hours

C. Phenytoin has to be a low-extraction drug because its bioavailability is as high as 90%.
The large range in F is due to variability in the absorption of the drug. You know it is not high
extraction because if it were, you could never get an F of 90%. Assume ER < 0.1, fup = 0.07-
0.12. Low-extraction drug and restrictively cleared (assume all low-ER drugs are restrictively
cleared for the purposes of this course). Normal albumin range: 3.5-5 gm/dL. Thus, patient
probably has increased fup because of decreased albumin. Fup (according to the following
equation) would be 0.14 (slightly elevated).
12.
Because phenytoin is a low-extraction drug, CL is dependent on fup and CLint. Increased fup
would lead to increased CL and decreased total plasma concentrations (thus Cp of 8, which is
below therapeutic range). However, unbound concentrations would be predicted to be normal
(therapeutic) even though total concentration is low. You would not recommend an increase
in patient's phenytoin dose because it may result in toxic concentrations. Obtaining free
phenytoin plasma concentration, if available from the hospital's lab, may be reasonable to
document therapeutic concentrations.

B. Only item II is correct. Item I is incorrect. No pH sensitivity in CLR is expected unless the
drug is reabsorbed (i.e., Eratio << 1). Item II is possible. Weakly acidic drugs with pKa values
between 3.0 and 7.5 can be highly un-ionized in the range of urine pH (5-8) and can thus
undergo significant reabsorption if the unionized form is nonpolar. Item III is incorrect.
13. Clearance and volume have nothing to do with a drug's likelihood of being affected by
changes in urine pH. Item IV is incorrect. The fraction excreted unchanged says nothing
about the mechanisms of renal elimination. However, it is important to note that for drugs
with high fe values that are susceptible to changes in urine pH, large changes in the PK of the
drug (i.e., CLR) may be observed.

A. The antibiotic's total clearance can be determined from the reported Vd and t1/2:
14.
Renal clearance CLR is then given by total clearance and the fraction excreted fe:

CLR = fe × CL = 0.67 × 7.47 L/h = 5.00 L/h

= 83.3 mL/minute

The predominant renal clearance mechanism can be estimated by determining the Eratio:
The Eratio < 1 indicates that glomerular filtration and net reabsorption are the probable renal
clearance mechanisms.

D.
15a.

D. The most likely mechanism to account for this reduction in renal clearance is that
15b.
cimetidine blocks the renal secretion of captopril.

B.
16.
16.

B. The drug transporter P-glycoprotein is directly responsible for the transport of drug from
17. hepatocytes into the bile and maintenance of the integrity of the blood-brain barrier by
transport of drug out of the brain.

C. Calculation of CL: IBW = 59.3 kg:
CL of gentamicin is 85 mL/minute/70 kg TBW (1.2 mL/minute/kg). CL of gentamicin in this

patient if she did not have renal impairment would be
18.
Calculate the dosing interval (‫ )ؤ‬that you would recommend:

Calculate the dose of gentamicin that will maintain Cpeak and Ctrough of 8 and 0.5 mg/L:
Administration of 100 mg of gentamicin infused over 30 minutes given every 24 hours will
provide Cpeak and Ctrough of approximately 8.0 and 0.5 mg/L.

A.
19.

C.
20.
6-17. References
Atkinson A, Daniels C, Dedrick R, et al. Principles of Clinical Pharmacology. Academic Press, San
Diego, Calif.; 2001.
Ensom MH, Davis GA, Cropp CD, Ensom RJ. Clinical pharmacokinetics in the 21st century: Does
the evidence support definitive outcomes? Clin Pharmacokinet. 1998;34:265-79.
Levy RH, Bauer LA. Basic pharmacokinetics. Ther Drug Monit. 1986;8(1):47-58.
Meibohm B, Derendorf H: Basic concepts of pharmacokinetic/pharmacodynamic (PK/PD)

modelling. Int J Clin Pharmacol Ther. 1997;35:401-13.
Rolan, PE. Plasma protein binding displacement interactions: Why are they still regarded as
clinically important? Br J Clin Pharmacol. 1994;37: 125-8.
Rowland M, Tozer T. Clinical Pharmacokinetics. 3rd ed. Media, Pa.: Williams & Wilkins; 1995.
Saitoh A, Jinbayashi H, Saitoh AK, et al. Parameter estimation and dosage adjustment in the
treatment with vancomycin of methicillin-resistant Staphylococcus aureus ocular infections.
Ophthalmologica. 1997;211(4):232-35.
Sawchuk RJ, Zaske DE, Cipolle RJ, et al. Kinetic model for gentamicin dosing with the use of
individual patient parameters. Clin Pharmacol Ther. 1977;21:362-69.
Tod MM, Padoin C, Petitjean O. Individualising aminoglycoside dosage regimens after therapeutic
drug monitoring: Simple or complex pharmacokinetic methods? Clin Pharmacokinet. 2001;
40:803-14.
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Pharmacol Ther. 1975;18:377-90.
7. Biotechnology and Pharmacogenomics - Stephanie A. Flowers, PharmD, P. David Rogers,
PharmD, PhD, FCCP
7-1. Introduction
Introduction
Since the discovery of the DNA (deoxyribonucleic acid) double helix half a century ago, significant
use of biotechnology has been made for the improvement of human health (
Table 7-1). Accompanying these advances is a number of biological products with therapeutic
applications. With the arrival of the postgenomic era, the field of pharmacogenomics has emerged
and shows great promise to revolutionize the way in which pharmacy and medicine are practiced.
This chapter highlights key concepts relevant to the practicing pharmacist in the areas of
biotechnology and pharmacogenomics.
Biotechnology has revolutionized the pharmaceutical industry by imparting the ability to mass
produce safe and pure versions of chemicals produced naturally in the body. A multitude of disease
states have been affected by therapeutic agents derived through biotechnology, including AIDS
(acquired immune deficiency syndrome), anemia, cancer, congestive heart failure, cystic fibrosis,
diabetes, growth hormone deficiency, hemophilia, hepatitis B and C, and multiple sclerosis, to
name a few.
Biotechnology is defined by the Merriam-Webster's Dictionary as "the manipulation (as through

genetic engineering) of living organisms or their components to produce useful usually commercial
products (as pest resistant crops, new bacterial strains, or novel pharmaceuticals)."
Key Terms
• Antibody (immunoglobulin): A protein produced by -lymphocytes in response to antigen

molecules determined to be nonself. Antibodies recognize and bind to antigens, resulting in their
inactivation or opsonization for phagocytosis or complement-mediated destruction. A number of
immunoglobulin (Ig) G products have been developed for therapeutic use in various immune
disorders.
• Antigen: A molecule that elicits an antibody-mediated immune response.
• Bioinformatics: The application of computer sciences and information technology to the

management and analysis of biological information.
• Biotherapy: Any treatment involving the administration of a microorganism or other biologic

material.
• Clotting factor (blood factor): Chemical blood constituents that interact to cause blood
coagulation.
• Combinatorial chemistry: A drug development strategy that uses nucleic acids and amino acids
in various combinations to synthesize vast libraries of oligonucleotide or peptide compounds for
high-throughput lead compound screening.
• Cytokine: An extracellular signaling protein that mediates communication between cells.
• DNA (deoxyribonucleic acid): A polynucleotide molecule consisting of covalently linked nucleic

acids. DNA serves as the genetic material.
• Enzyme: A protein that catalyzes a chemical reaction.
• Gene: A region of DNA that encodes a specific RNA (ribonucleic acid) or protein responsible for
a specific hereditary characteristic.
• Gene therapy: Therapeutic technologies that directly target human genes responsible for disease.
• Genome: The complete set of genetic information for a given organism.
[Table 7-1. Milestones in Biotechnology]
• Genomics: The scientific discipline of mapping, sequencing, and analyzing genomes. It

encompasses structural genomics, functional genomics, and pharmacogenomics.
• Hormone: A chemical substance imparting specific cellular effects that is transmitted by the
bloodstream to cells distant from its physiologic source.
• Hybridoma: A cell line generated by the fusion of antibody-producing ²-lymphocytes with

lymphocyte tumor cells for the production of monoclonal antibodies.
• Interferon: A member of a group of cytokines that prevents viral replication and slows the
growth and replication of cancer cells.
• Interleukin: A member of a group of cytokines involved in orchestration and regulation of the

immune response.
• Liposome: A microscopic, sphere-like lipid droplet that functions as a therapeutic carrier.
• Monoclonal antibody: An antibody derived from a hybridoma cell line.
• Pharmacogenomics: The scientific discipline of using genomewide approaches to understand the

inherited basis of differences between individuals in the response to drugs. This field is an
expansion of the field of pharmacogenetics, which traditionally considered such inherited
differences on a gene-by-gene basis.
• Plasmid: A small, circular, extrachromosomal DNA molecule capable of replication independent
of that of the genome.
• Polymerase chain reaction (PCR): A molecular biologic technique for amplification of specific
DNA molecules.
• Protein: A functional product of a specific gene consisting of amino acids linked together through
peptide bonds in a specific sequence.
• Proteomics: The scientific field of the study of sequencing and analyzing the expression,
modification, and function of proteins on a genomewide or global scale.
• Recombinant DNA (rDNA) technology: The application of DNA molecules derived by joining
two DNA molecules from different sources.
• Restriction endonucleases: An enzyme capable of cleaving a DNA molecule in a site-specific

manner.
• Ribozymes: RNA molecules with intrinsic enzymatic activity.
• RNA (ribonucleic acid): A polynucleotide molecule consisting of covalently linked ribonucleic

acids. Messenger RNA (mRNA) serves as the template for protein synthesis. Transfer RNA
(tRNA) serves as the adaptor molecules between amino acids and mRNA during protein
synthesis. Ribosomal RNA serves as a component of the ribosome and participates in protein
synthesis.
• Small molecule chemistry: The field of drug development focusing on small organic nucleotide-
or peptide-based molecules derived through either combinatorial chemistry or rational drug
design.
• Single nucleotide polymorphism: Common DNA sequence variations among individuals

involving a single nucleotide substitution.
• Vaccine: A preparation of antigenic material administered to stimulate the development of

antibodies conferring active immunity against a particular pathogen or disease.
Biological Products
Many FDA-approved biological products are currently on the market, including blood factors,
cytokines, enzymes, growth factors, hormones, interferons, monoclonal antibodies, and vaccines. A
list of such biological products is provided in
Table 7-2.
[Table 7-2. Approved Biological Products]

Gene Expression and Protein Synthesis
Proteins are the major macromolecular component of the cell and are responsible for conducting
most of a cell's biological activity. Proteins consist of a linear polymer of amino acids linked
together in a specific sequence. This specific sequence is responsible for a protein's structure and
function. The initial code for the synthesis of a given protein is stored in a gene on a sequence of
DNA that is part of a chromosome within the nucleus of a cell.
The central dogma of molecular biology is that DNA encodes RNA, which, in turn, encodes
protein. A given amino acid within a protein is encoded by a triplet of nucleic acid base pairs within
the gene encoding the protein. This triplet is called a codon. There are 64 codons encoding 20
different amino acids as dictated by the genetic code.
An overview of transcription, translation, and post-translational modification is shown in

Figure 7-1.
Recombinant DNA Technology
Recombinant DNA (rDNA) technology uses several molecular biological tools to insert a desired
DNA fragment with a specific purpose in proximity to other DNA fragments within a DNA
molecule. Most often, a gene encoding a desired protein is isolated through screening of the
genomic library or by use of the viral enzyme reverse transcriptase to generate complementary
DNA (cDNA) from the mRNA transcript of the gene. Enzymes called restriction endonucleases
allow
[Figure 7-1. Gene Expression: The Synthesis of Proteins]
the cleavage of DNA in the plasmid at very specific locations. The gene is then ligated into a vector,
such as a plasmid, for gene cloning or for control of the expression of the encoded protein.
An expression vector is a plasmid designed to allow inducible expression of the inserted gene
within a host cell (such as the bacterium Escherichia coli or the yeast Saccharomyces cerevisiae).
This mechanism permits production of large quantities of the desired protein. The protein must then
be isolated and purified for further use. Such techniques, used on an industrial scale, mass produce
therapeutically useful biological products such as cytokines, enzymes, hormones, blood factors, and
vaccines (
Figure 7-2).
[Figure 7-2. Summary of Typical rDNA Production of a Protein from Either Genomic DNA or
cDNA]
Cytokines (i.e., molecules secreted by cells) orchestrate the immune response and activate immune
cells such as lymphocytes, monocytes, macrophages, and neutrophils. Therapeutically useful
recombinant cytokines include interferons, interleukins, and colony-stimulating factors. Examples
of these include interferon beta-1b (Betaseron), which is used to treat acute relapsing-remitting
multiple sclerosis; aldesleukin (IL-2) (Proleukin), which aids in the management of metastatic renal
cell carcinoma and melanoma; and oprelvekin (IL-11) (Neumega), which treats thrombocytopenia
caused by chemotherapy.
An enzyme is a protein that catalyzes a specific chemical reaction. Numerous different enzymes
with therapeutic use have been produced using rDNA technology. Alteplase (Activase), for
example, treats acute myocardial infarction, pulmonary embolism, and stroke. Dornase alfa
(Pulmozyme) treats respiratory complications that develop in cystic fibrosis. Eptifibatide
(Integrelin) is used to treat acute coronary syndromes.
Hormones—chemical substances transmitted through the bloodstream—are designed to impart

specific cellular effects to cells distant from their physiologic source. Since the introduction and
success of recombinant human insulin in 1982, many other recombinant hormones have been
developed, such as human growth hormone, which treats growth hormone deficiency in pediatric
patients, and follitropin alfa and beta (Gonal-F and Follistim, respectively), which are used to
remedy ovulatory failure.
Clotting or blood factors are chemical blood constituents that interact to cause blood coagulation.
Patients suffering from hemophilia A (caused by factor VIII deficiency) and hemophilia B (caused
by factor IX deficiency) have benefited greatly from rDNA technology. Factors VII, VIII, and IX are
available in recombinant forms for clinical use.
Vaccines—preparations of antigenic material administered to stimulate the development of

antibodies—confer active immunity against a particular pathogen or disease. Vaccine development
has also benefited from advances in rDNA technology. Traditional vaccine production used killed
or non-virulent organisms, microbial toxins, or actual microbial components to elicit long-term
immune protection. Safer and more specific vaccine antigens have been devised as recombinant
proteins. This technology has led to the very successful recombinant hepatitis B vaccine.
Monoclonal Antibodies
Antibodies, proteins produced by the immune system's ²-lymphocytes, use specific methods to
recognize foreign molecules within the body. Subsets of ²-lymphocyte clones produce identical
antibodies that recognize the same antigen. These identical antibodies are monoclonal. Fusing ²-
lymphocytes with lymphocyte tumor cells produces a hybridoma. This fused cell type is immortal
and can be cultured in large quantities for the mass production of a given monoclonal antibody.
Monoclonal antibodies that bind to and inactivate their targets can be developed and have great
therapeutic utility (
Figure 7-3). Nomenclature of monoclonal antibodies is highly structured. The first component of
the name is product specific. The second component indicates its therapeutic use: ci for
cardiovascular use, li for use in inflammation, and tu for use in cancer. The third component
indicates the type of monoclonal antibody: mo for murine, xi for chimeric, and zu for humanized.
The fourth component, mab, represents monoclonal antibody. An example of a monoclonal
antibody used clinically is abciximab (ReoPro), which prevents blood clots following percutaneous
transluminal coronary angioplasty (PTCA) and prevents unstable angina prior to PTCA. Another
example, infliximab (Remicade), is used to treat Crohn's disease and rheumatoid arthritis.
Gene Therapy
Gene therapy is an excellent example of the therapeutic application of biotechnology. This

technology holds promise for the treatment of inherited disorders, as well as acquired illnesses such
as infectious diseases and cancer.
The molecular goal of gene therapy is to repair or correct a dysfunctional gene by selectively
introducing recombinant DNA into cells or tissues, thereby allowing the expression of a functional
gene product.
Novel drug delivery strategies must be used to introduce exogenous DNA into the cell to treat
retroviruses, lentiviruses, and adeno-associated viruses. These novel drug delivery strategies also
have applications for nonviral delivery systems (e.g., liposomes or uncomplexed plasmid DNA).
Alternative approaches using ribozymes (e.g., RNA repair) may prove effective. The enzymatic
activity of these RNA molecules can be used to repair defective mRNAs.
[Figure 7-3. Production of Monoclonal Antibodies]
Chimeric RNA and DNA oligonucleotides make use of the cell's DNA mismatch repair apparatus
to correct mutations at the genomic level. Antisense oligonucleotides for gene inactivation have
proved clinically useful. Fomivirsen (Vitravene), one such agent, targets the mRNA of human
cytomegalovirus (CMV). This agent is indicated for the treatment of CMV retinitis in patients with
AIDS.
Drug Delivery
Biotechnology has facilitated the development of novel drug delivery strategies. The use of
liposomes has had a positive effect on drug delivery. Drugs can be formulated into liposomes (i.e.,
microscopic, spherical lipid droplets). The outer membrane of the liposome fuses with the
membrane of the target cell, thereby facilitating highly targeted drug delivery. Such technology has
greatly improved the therapeutic index of the antifungal drug amphotericin B. Lipid-based
formulations now allow greater quantities of the drug to be delivered with substantially less toxicity
to the patient.
Another promising approach is the use of immunotoxins. These delivery agents combine a
monoclonal antibody with a toxin such as an anticancer or antimicrobial agent, thereby allowing
targeted drug delivery with minimal toxicity.
Another novel strategy is the use of PEGylation—that is, the addition of polyethylene glycol (PEG)
to therapeutic proteins to minimize the deleterious immune response to an individual protein.
Pharmacogenomics
Pharmacogenomics is the scientific discipline of using genomewide approaches to understand the

inherited basis of differences between individuals in the response to drugs. This field is an
expansion of the field of pharmacogenetics, which traditionally considered such inherited
differences on a gene-by-gene basis.
Genetic differences in drug metabolism, drug disposition, and drug targets have a large effect on
efficacy and toxicity. Comprehension of the relationships between specific genetic factors and drug
response can be used to predict drug response and optimize drug therapy in any given individual.
Of particular significance are single nucleotide polymorphisms (SNPs). SNPs are differences in a
single nucleotide base that occur at a significant frequency (usually > 5%) within the population. An
SNP may or may not promote change in the encoded amino acid of a codon, or it may change the
encoded amino acid but yield no change in the function of the encoded protein. When a SNP causes
amino acid substitution, a phenotypic difference that carries clinical relevance may result. Even
when the SNP results in no change in the encoded amino acid, it may be associated with a
phenotypic change, thereby serving as a predictive marker of that change.
Examples of significant genetic polymorphisms that can influence drug response are shown in
Tables 7-3 and
7-4.
Examples of significant genetic polymorphisms in drug-metabolizing enzymes are shown in

Tables 7-5 and
7-6.
7-2. Key Points
• Biotechnology, as defined by Merriam-Webster's Dictionary, is "the manipulation (as through

genetic engineering) of living organisms or their components to produce useful usually
commercial products (as pest resistant crops, new bacterial strains, or novel pharmaceuticals)."
• The central dogma of molecular biology is that DNA encodes RNA, which, in turn, encodes
protein.
• Recombinant DNA technology makes use of several molecular biological tools that allow for the
placement of a desired DNA fragment in proximity to other DNA fragments within a DNA
molecule for a specific purpose.
• Cytokines are molecules secreted by cells that orchestrate the immune response. They activate
immune cells such as lymphocytes, macrophages, monocytes, and neutrophils.
• An enzyme is a protein that catalyzes a specific chemical reaction.

• Hormones are chemical substances transmitted by the bloodstream to cells distant from their
physiologic source that impart specific cellular effects.
• Clotting or blood factors are chemical blood constituents that interact to cause blood coagulation.
• Vaccines are preparations of antigenic material administered to stimulate the development of

antibodies for the purpose of conferring active immunity against a particular pathogen or disease.
• Subsets of -lymphocyte clones produce identical antibodies that recognize the same antigen.
These identical antibodies are said to be monoclonal. Fusing ²-lymphocytes with lymphocyte
tumor cells produces a hybridoma that can be cultured in large quantities for the mass production
of a given monoclonal antibody.
[Table 7-3. Genetic Polymorphisms in Drug Target Genes That Can Influence Drug Response a]
[Table 7-4. Genetic Polymorphisms in Disease-Modifying or Treatment-Modifying Genes That

Can Influence Drug Responsea]
[Table 7-5. Pharmacogenomics of Phase I Drug Metabolisma]
• Gene therapy, an application of biotechnology, has great potential therapeutic benefit.
• Biotechnology has facilitated the development of novel drug delivery strategies, including
liposomal technology, immunotoxins, and PEGylation.
• Pharmacogenomics is the scientific discipline of using genomewide approaches to understand the

inherited basis of differences between individual responses to drugs.
• Single nucleotide polymorphisms are differences in a single nucleotide base occurring at a

significant frequency (usually > 5%) within the population. They may result in no change in the
encoded amino acid of a codon or a change in the encoded amino acid with no change in the
function of the encoded protein. However, when the amino acid substitution attributable to a SNP
results in a phenotypic difference, it may carry clinical relevance.
[Table 7-6. Pharmacogenomics of Phase II Drug Metabolisma]
7-3. Questions
The process whereby the ribosome in the cytoplasm reads mRNA codons and matches them
with the appropriate tRNAs (which, in turn, carry amino acids responsible for protein
synthesis) is referred to as
1. A. transcription.
B. translation.
C. transformation.
D. transfection.
E. transduction.

How many nucleotide triplets (or codons) exist for the encoding of the 20 possible amino acids
specified by the genetic code?
A. 4
2.
B. 12
C. 20
D. 61
E. 64

Which of the following refers to a plasmid designed to allow for the expression of an inserted
gene within a host cell for the production of the specified protein?
A. Cloning vector
3.
B. Expression vector
C. Transcription factor
D. Translation initiation factor
E. Transposable genetic element

Which of the following is an example of a recombinant DNA-generated cytokine used for the
management of acute relapsing-remitting multiple sclerosis?
A. Interferon beta-1b (Betaseron)

4.
B. Aldesleukin (IL-2) (Proleukin)
C. Eptifibatide (Integrelin)
D. Bivalirudin (Angiomax)
E. Abciximab (ReoPro)

Alteplase (Activase) is a recombinant DNA protein of which of the following types?
A. Hormone
5. B. Enzyme
C. Clotting factor
D. Chemokine
E. Cytokine

Which of the following biological agents is indicated for treatment of ovulatory failure?
A. Ganirelix (Antagon)
6. B. Glucagon (GlucaGen)
C. Follitropin alfa (Gonal-F)
D. Eptifibatide (Integrelin)
E. Thyrotropin (Thyrogen)

Which of the following recombinant blood factors is available in recombinant form for clinical
therapeutic use?
A. Factor III
7.
B. Factor V
C. Factor VI
D. Factor VII
E. Factor X

Recombinant DNA technology has led to the development of vaccines for which of the
following diseases?
A. Hepatitis B
8.
B. Hepatitis A
C. Haemophilus influenzae type B infection
D. Malaria
E. AIDS

As dictated by the nomenclature for monoclonal antibodies, which of the following is a
chimeric monoclonal antibody therapeutically used for inflammatory disease?
A. Abciximab
9.
B. Infliximab
C. Palivizumab
D. Rituximab
E. Trastuzumab

Which of the following is best described as the repair or correction of a dysfunctional gene by
selectively introducing recombinant DNA into cells or tissues (ultimately leading to the
expression of a functional gene product)?
10. A. Monoclonal antibody therapy

B. Gene therapy
C. Antiviral therapy
D. Cell therapy
E. Recombinant DNA therapy

Fomivirsen (Vitravene) is an example of which of the following biological products?
A. A liposomal formulation
11. B. An antisense oligonucleotide
C. An siRNA molecule
D. A recombinant DNA-produced protein
E. A monoclonal antibody

The use of liposomal technology has favorably affected the therapeutic index of which of the
following drugs?
A. Cyclosporine
12.
B. Itraconazole
C. Amphotericin B
D. Cisplatin
E. Propofol

Which of the following is best described as the scientific discipline of using genomewide
approaches to understand the inherited basis of differences between individuals in their
response to drugs?
13. A. Pharmacogenomics
B. Functional genomics
C. Comparative genomics
D. Pharmacodynamics
E. Molecular genetics

A single nucleotide polymorphism (SNP) always results in a change in which of the following?
A. The nucleotide sequence in the genome

B. The nucleotide sequence of a codon
14.
C. The encoded amino acid of the codon
D. The encoded amino acid of the codon, with no change in function of the encoded protein
E. The encoded amino acid of the codon, with a clinically relevant change in the function of
the encoded protein

Which of the following is best described as "the manipulation (as through genetic engineering)
of living organisms or their components to produce useful usually commercial products (as
pest resistant crops, new bacterial strains, or novel pharmaceuticals)"?
15. A. Biology
B. Biotechnology
C. Biotherapy
D. Bioinformatics
E. Nanotechnology

Which of the following is a drug discovery strategy that uses nucleic acids and amino acids in
various combinations to synthesize vast libraries of oligonucleotide or peptide compounds for
high-throughput lead compound screening?
16. A. Whole cell screening

B. Natural product screening
C. Gene therapy
D. Combinatorial chemistry
E. rDNA technology

Which of the following is best defined as the application of computer sciences and information
technology to the management and analysis of biological information?
A. Biometrics
17.
B. Biotherapy
C. Bioinformatics
D. Biostatistics
E. Biotechnology

Which of the following best outlines the central dogma of molecular biology?
A. RNA DNA Protein

18. B. DNA RNA Protein
C. Protein’RNA’DNA
D. DNA Protein RNA
E. Protein’DNA’RNA

Which of the following biotechnology agents is indicated for treating anemia caused by chronic
renal disease?
A. Epoetin alfa
19.
B. Becaplermin
C. Filgrastim
D. Alemtuzumab
E. Sargramostim

Which of the following products is indicated for prevention of blood clots post-PTCA?
A. Abciximab
20. B. Basiliximab
C. Infliximab
D. Trastuzumab
E. Becaplermin
7-4. Answers

7-4. Answers
B. Transcription is the process by which RNA polymerase copies a strand of DNA into
complementary RNA. Transformation refers to the alteration of the heritable properties of a
1. eukaryotic cell. Transfection is the introduction of foreign DNA into a eukaryotic cell.
Transduction can refer to the transfer of DNA from one bacterium to another through a
bacteriophage.

D. There is degeneracy in the genetic code. Some amino acids may be encoded by as many as
2. six codons, whereas others may be encoded by only one. Of the 64 possible codons, three are
stop codons (UAA, UGA, and UAG).

B. A cloning vector is used to carry a fragment of DNA into a cell for cloning. A transcription
factor is a protein that regulates transcription in eukaryotic cells. A translation initiation factor,
3.
as its name implies, is involved in the initiation of translation. A transposable genetic element,
or transposon, is a portion of DNA that can move from one part of the genome to another.

A. Aldesleukin (IL-2) (Proleukin) is a recombinant cytokine indicated for the treatment of
metastatic renal cell carcinoma and melanoma. Eptifibatide (Integrelin) is a recombinant
enzyme indicated for treatment of acute coronary syndromes. Bivalirudin (Angiomax) is an
4.
enzyme indicated for use in coronary angioplasty and unstable angina. Abciximab (ReoPro) is
a monoclonal antibody indicated for prevention of blood clots post-PTCA and unstable angina
prior to PTCA.

5. B. Alteplase (Activase) is a recombinant DNA protein of the enzyme type.

C. Ganirelix (Antagon) is a recombinant hormone indicated for the treatment of luteinizing
hormone surge during fertility therapy. Glucagon (GlucaGen) is a recombinant hormone
6. indicated for treatment of hypoglycemia. Eptifibatide (Integrelin) is a recombinant enzyme
indicated for the treatment of acute coronary syndromes. Thyrotropin (Thyrogen) is a
recombinant hormone indicated for the treatment of thyroid cancer.

7. D. The other factors listed are not clinically available in recombinant form.

A. Although promising, this technology has not yet yielded vaccines for hepatitis A, malaria,
8.
AIDS, or infections caused by Haemophilus influenzae type B.

B. Nomenclature of monoclonal antibodies is highly structured. The first component of the
name is product specific; the second component indicates its therapeutic use (ci for
9. cardiovascular use, li for use in inflammation, tu for use in cancer); the third component
indicates the type of monoclonal antibody (mo for murine, xi for chimeric, zu for humanized);
and the fourth component (mab) represents monoclonal antibody.

B. The repair or correction of a dysfunctional gene by selectively introducing recombinant
10. DNA into cells or tissues, ultimately leading to the expression of a functional gene product, is
called gene therapy.

11. B. Fomivirsen (Vitravene) is the first product based on this technology to come to market.

C. Formulation of this antifungal agent as a liposomal preparation (Ambisome) has
12.
significantly reduced the nephrotoxicity and other adverse effects associated with this drug.

A. The scientific discipline of using genomewide approaches to understand the inherited basis
13. of differences between individuals in their response to drugs best describes
pharmacogenomics.

A. An SNP may occur outside of an open reading frame (coding region), it may induce a
14. mutation where no change in encoded amino acid occurs, and it may or may not cause a
functional change in an encoded protein.

15. B. This definition by the Merriam-Webster's Dictionary best describes biotechnology.

D. A drug discovery strategy that uses nucleic acids and amino acids in various combinations
16. to synthesize vast libraries of oligonucleotide or peptide compounds for high-throughput lead
compound screening is called combinatorial chemistry.

C. The application of computer sciences and information technology to the management and
17.
analysis of biological information best defines bioinformatics.

18. B. DNA is transcribed into mRNA, which is translated ultimately to protein.

A. Becaplermin is indicated for the management of diabetic foot ulcers. Filgrastim is indicated
for treatment of neutropenia. Alemtuzumab is indicated for treatment of chronic lymphocytic
19. leukemia. Sargramostim is indicated for myeloid reconstitution after bone marrow transplant;
after bone marrow transplant failure, as an adjunct to chemotherapy in acute myelogenous
leukemia; and in peripheral blood progenitor cell transplant.

A. Basiliximab is indicated for management of acute organ transplant rejection. Infliximab is
indicated for the treatment of Crohn's disease and rheumatoid arthritis. Trastuzumab is
20.
indicated for the management of metastatic breast cancer. Becaplermin is indicated for the
treatment of diabetic foot ulcers.

7-5. References
Adams VR, Karlix JL. Monoclonal antibodies. In: Koeller J, Tami J, eds. Concepts in Immunology
and Immunotherapeutics. 3rd ed. Bethesda, Md.: American Society of Health-System
Pharmacists' Production Office; 1997:269-99.
Alberts B, Bray D, Lewis J, et al., eds. Molecular Biology of the Cell. 3rd ed. New York: Garland;
1994.
Carrico JM. Human Genome Project and pharmacogenomics—implications for pharmacy. J Am

Pharm Assoc. 2000;40:115-16.
Evans WE, McLeod HL. Pharmacogenomics: Drug disposition, drug targets, and side effects. N
Engl J Med. 2003;348:538-49.
Glick BR, Pasternak JJ, eds. Molecular Biotechnology: Principles and Applications of Recombinant
DNA. 2nd ed. Washington, D.C.: ASM Press; 1998.
Hollinger P, Hoogenboom H. Antibodies come back from the brink. Nature Biotech. 1998;16:1015-
16.
Regan JW. Biotechnology and drug discovery. In: Delgado JN, Remers WA, eds. Textbook of
Organic Medicinal and Pharmaceutical Chemistry. 10th ed. Philadelphia: Lippincott-Raven;
1998:139-52.
Rogers CS, Sullenger BA, George AL Jr. Gene therapy. In: Hardman JG, Limbird LE, eds.
Goodman and Gilman's The Pharmacological Basis of Therapeutics. 10th ed. New York:
McGraw-Hill; 2001: 81-112.
Sindelar RD. Pharmaceutical biotechnology. In: Williams DA, Lemke TL, eds. Foye's Principles of
Medicinal Chemistry. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2002:982-1015.
U.S. Food and Drug Administration (FDA). Center for Biologics Evaluation and Research Web
page: www.fda.gov/cber.
U.S. Food and Drug Administration (FDA). Center for Drug Evaluation and Research Web page:
www.fda.gov/cder/.
Vaughan TJ, Osbourn JK, Tempest PR. Human antibodies by design. Nature Biotech. 1998;16:535-
39.
Weinshilboum R. Inheritance and drug response. N Engl J Med. 2003;348:529-37.

8. Hypertension - Benjamin Gross, PharmD, BCPS, L. Brian Cross, PharmD, CDE
8-1. Disease Overview
Introduction
• Hypertension is defined as a systolic blood pressure >140 mm Hg, a diastolic blood pressure > 90
mm Hg, or a condition in any patient requiring antihypertensive therapy.
• In the United States, 65 million people are affected by hypertension. In approximately 64% of
those affected, it is controlled (
Table 8-1).
• Incidence increases with age.
• Its onset most commonly occurs in the third to fifth decades of life, and the lifetime risk of
hypertension is 90% for those surviving to age 80.
• Prevalence differs by ethnic group (

Table 8-2), socioeconomic group, and geographic region.
Classification
Classification of hypertension is based on the Seventh Report of the Joint National Committee on
Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VII).
Table 8-3 shows the JNC-VII classification.
Clinical Presentation and Complications
Cardiovascular effects
• Left ventricular hypertrophy
• Congestive heart failure (CHF)
• Peripheral arterial disease
• Angina pectoris
• Myocardial infarction
• Sudden death
Renal effects
• Nephropathy
• Renal failure
• Requirements for dialysis
Cerebrovascular effects
• Transient ischemic attacks
• Stroke
Ophthalmologic effects
• Retinal hemorrhage
• Retinopathy
• Blindness
Pathophysiology and Etiology
• Blood pressure = (stroke volume × heart rate) × peripheral resistance (

Figure 8-1)
Sympathetic nervous system activation
Central activation
• Presynaptic 2 stimulation is a negative feedback mechanism, leading to decreased norepinephrine

release.
• Presynaptic stimulation leads to increased norepinephrine release.
[Table 8-1. Trends in Awareness, Treatment, and Control of High Blood Pressure in Adults Ages
18-74]
Peripheral activation
• 1 Stimulation leads to increased heart rate and contractility, causing increased cardiac output.
• 2 Stimulation leads to arterial vasodilation.
• Stimulation also causes increased renin release, causing increased angiotensin II production.
• 1 Stimulation leads to arterial and venous vasoconstriction.
Renin-angiotensin-aldosterone system
• Decreased renal perfusion pressure causes increases in renin levels.
• Renin reacts with angiotensinogen to produce angiotensin I (AT-I).
• Angiotensin-converting enzyme (ACE) causes AT-I to become angiotensin II (AT-II).
• AT-II is a potent vasoconstrictor and stimulates aldosterone release, which increases sodium and
fluid retention.
[Table 8-2. Prevalence of Hypertension by Ethnic Group for Adults Ages 20-74 (percent)]
Water and sodium retention
• Acute: Increased fluid volume causes increased cardiac output, which causes increased blood
pressure (BP).
• Chronic: Excess intracellular sodium causes vascular hypertrophy, which increases vascular
resistance and response to vasoconstriction and, in turn, increases BP.
Etiology
Primary (essential) hypertension
• Unknown cause
• Found in 85-95% of all hypertension cases
Secondary hypertension
• Renovascular disease: This condition is suggested by increased blood urea nitrogen (BUN) and
creatinine and by abdominal bruits.
• Primary aldosteronism: This condition is suggested by unprovoked hypokalemia.
• Cushing's syndrome: This condition is suggested by unprovoked hypokalemia and truncal

obesity with purple striae.
• Pheochromocytoma: This condition is suggested by increased urinary catecholamine excretion

(i.e., vanillylmandelic acid and metanephrine) accompanied by headache, palpitations, and
perspiration
• Aortic coarctation: This condition is suggested by delayed or absent femoral pulses and
decreased BP in the lower extremities.
[Table 8-3. Classification and Management of Blood Pressure for Adults]
[Figure 8-1. Sympathetic Nervous System Activation]
• Drug-induced hypertension: The following drugs may induce hypertension:
• Steroids and estrogens (including oral contraceptives)
• Alcohol
• Cocaine
• Cyclosporine and tacrolimus
• Sympathomimetics
• Erythropoietin
• Licorice (in chewing tobacco)
• Monoamine oxidase (MAO) inhibitors
• Tricyclic antidepressants
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
Diagnostic Criteria
Diagnosis and treatment begin with proper BP measurement, assessment, and follow-up planning (
Table 8-4). The patient should avoid ingesting caffeine and smoking for 30 minutes prior to BP
measurement and should be resting for 5 minutes prior to BP measurement. BP is measured as
follows:
• Position arm (brachial artery) at heart level.
• Uncover arm; do not put cuff over clothes.
• Determine proper size cuff.
[Table 8-4. Recommendations for Follow-Up Based on Initial BP Measurements for Adults]
Upper arm circumference Cuff size required

16.0-22.5 cm Pediatric cuff

22.6-30.0 cm Regular adult cuff

30.1-37.5 cm Large adult cuff

37.6-43.7 cm Thigh cuff

• Position cuff 1 inch above antecubital crease.
• Ask patient about previous readings.
• Place stethoscope over brachial artery (medial to the center).
• Inflate cuff rapidly to approximately 30 mm Hg above previous readings.
• Deflate cuff slowly.
• Remember to deflate cuff completely when done.
• Wait 1-2 minutes before repeating.
• Take pressure in both arms.
• If orthostatic hypotension is suspected, take BP while patient is sitting, standing, and supine.
• If two readings are taken at least 2 minutes apart, average the readings.
• If readings differ by > 5 mm Hg, take additional readings.
Treatment Principles and Goals
Figure 8-2 and

Table 8-5 outline some important treatment principles. Goals include the following:
• To reduce end-organ damage
• To minimize or control other risk factors for cardiovascular (CV) disease

• To maintain BP, with minimal side effects, at or below the level appropriate for the patient's risk:
• 140/90 mm Hg with uncomplicated hypertension
• 140/90 mm Hg with target organ damage or CV disease
• <130/80 mm Hg with diabetes and chronic kidney disease
• <125/75 mm Hg with proteinuria > 1 g/24 h
Monitoring and Evaluation
Initial evaluation
The initial evaluation of patients with hypertension has the following goals:
• To identify known causes of high blood pressure (

Table 8-6)
[Figure 8-2. Algorithm for the Treatment of Hypertension]
[Table 8-5. Identifiable Causes, Diagnostic Tests, and Clinical Findings for Secondary
Hypertension]
[Table 8-6. Clinical Trial and Guideline Basis for Compelling Indications for Individual Drug
Classes]
• To assess presence or absence of target organ damage and CV disease, extent of the disease, and
the response to therapies (Box 8-1)
• To identify other CV risk factors or concomitant disorders that may affect prognosis and guide
therapy (Box 8-1)
The patient's history should be looked at in the initial evaluation:
• Duration and levels of elevated blood pressure
• History or symptoms of coronary heart disease (CHD), heart failure, cerebrovascular disease,
pulmonary vascular disease, diabetes mellitus, renal disease, or dyslipidemia
• Family history of hypertension, premature CHD, stroke, diabetes, dyslipidemia, or renal disease
• Symptoms suggesting the cause of hypertension
• Recent weight changes, physical activity levels, or smoking or other tobacco use
• Dietary assessment of intake of sodium, alcohol, saturated fat, and caffeine
• Complete medication history, including prescription, over-the-counter, and herbal or natural

products that may increase BP or decrease effectiveness of antihypertensive agents
• Results and adverse effects of previous antihypertensive therapy
• Psychosocial and environmental factors that may influence hypertension control
An examination should also be done:
• Two or more blood pressure measurements separated by at least 2 minutes
• Measurement of height, weight, and waist circumference
• Funduscopic exam for hypertensive retinopathy
• Exam of neck for carotid bruits, distended veins, or an enlarged thyroid gland
• Exam of heart for abnormalities in rate and rhythm, increased size, precordial heave, clicks,
murmurs, and third and fourth heart sounds
• Exam of lungs for rales and evidence of bronchospasm
• Exam of abdomen for bruits, enlarged kidneys, masses, and abnormal aortic pulsation
• Exam of extremities for decreased or absent peripheral arterial pulsations, bruits, and edema
• Neurologic assessment
Box 8-1. Cardiovascular Risk Factors
Major Risk Factors
• Hypertensiona
• Cigarette smoking
• Obesitya (body mass index e 30 kg/m2)
• Physical inactivity
• Dyslipidemiaa
• Diabetes mellitusa
• Microalbuminuria or estimated GFR < 60 mL/min
• Age (> 55 for men, > 65 for women)
• Family history of premature cardiovascular disease (men under age 55, women under age 45)
Target Organ Damage
Heart
• Left ventricular hypertrophy
• Angina or prior myocardial infarction
• Prior coronary revascularization
• Heart failure
Brain
• Stroke or transient ischemic attack
Kidney
• Chronic kidney disease
• End stage renal disease
Vascular System
• Peripheral arterial disease
Eyes
• Retinopathy
Adapted from JNC-7 Express, National Heart, Lung, and Blood Institute. GFR, glomerular
filtration rate.
a. Components of the metabolic syndrome.
Routine laboratory are necessary:

• Urinalysis
• Complete blood cell count
• Blood chemistries (sodium, potassium, creatinine, BUN, and glucose)
• Fasting lipid profile: total cholesterol, triglycerides, HDL (high-density lipoprotein), and LDL
(low-density lipoprotein)
• Electrocardiogram (ECG)
The following laboratory tests are optional:
• Creatinine clearance
• Microalbuminuria
• 24-hour urinary protein
• Blood calcium
• Uric acid
• Glycosylated hemoglobin
• Thyroid-stimulating hormone
• Limited echocardiography
• Ankle-brachial index
• Plasma renin activity and urinary sodium determination
Follow-up evaluation
Follow-up evaluation includes any of the previous exams completed during the initial evaluation
that are required to monitor both response to and possible adverse effects from prescribed
antihypertensive therapies, in addition to the assessment of any new symptoms of target organ
damage and the assessment of patient adherence to therapy (Box 8-2).
Box 8-2. General Guidelines to Improve Patient Adherence to Antihypertensive Therapy
• Be aware of signs of patient nonadherence to antihypertensive therapy.
• Establish the goal of therapy: to reduce blood pressure to nonhypertensive levels with minimal or
no adverse effects.
• Educate patients about the disease, and involve them and their families in its treatment. Have
them measure blood pressure at home.
• Maintain contact with patients; consider telecommunication.
• Keep care inexpensive and simple.
• Encourage lifestyle modifications.
• Integrate pill taking into routine activities of daily living.
• Prescribe medications according to pharmacologic principles, favoring long-acting formulations.
• Be willing to stop unsuccessful therapy and try a different approach.
• Anticipate adverse effects. Adjust therapy to prevent, minimize, or ameliorate side effects.
• Continue to add effective and tolerated drugs, stepwise, in sufficient doses to achieve the goal of
therapy.
• Encourage a positive attitude about achieving therapeutic goals.
• Consider using nurse case management.
Adapted from JNC-7 Express, National Heart, Lung, and Blood Institute.
8-2. Nondrug Therapy
Lifestyle modifications are recommended to improve both BP and overall cardiovascular health (
Table 8-7).
Research has shown that diets rich in fruits, vegetables, and low-fat dairy foods, and with reduced
saturated and total fats, significantly lower blood pressure (
Tables 8-8 and
8-9).
8-3. Drug Therapy

Introduction
All patient factors (severity of blood pressure elevation, presence of target organ damage, and
presence of CV disease or other risk factors) must be considered when initiating therapy.
Initial Therapy
• For candidates for therapy, see Figure 8-2 and Table 8-5.
• Use of lifestyle modifications (Table 8-7) should continue to be stressed to patients after the
decision to initiate drug therapy has been made to further decrease the risk of complications from
cardiovascular disease.
• Prehypertension represents a new classification in JNC-VII (Table 8-3) and represents a

significant risk for future development of stage 1 hypertension. Lifestyle modifications should be
stressed for this classification, and medication therapy should be used only for patients with
compelling indications.
• JNC-VII recommends the use of thiazide diuretics as initial therapy in most patients alone or in
[Table 8-7. Lifestyle Modifications to Manage Hypertension]
[Table 8-8. Dietary Suggestions for Hypertensive Patients]
[Table 8-9. The DASH Diet Sample Menu Based on 2000 Calories per Day]
combination with other agents (angiotensin-converting enzyme inhibitors, angiotensin II receptor

blockers, -blockers, and calcium channel blockers) unless compelling indications for the use of
other medication classes exist or if the patient has comorbid conditions that would suggest the
use of classes other than thiazide diuretics (Figure 8-2, and Tables 8-5 and
8-10).
• Current data also suggest that angiotensin-converting enzyme inhibitors (ACEIs), calcium channel
blockers (CCBs), and angiotensin II receptor blockers (ARBs) can also be considered as initial
agents for the treatment of hypertension. European hypertension guidelines do not recommend
one particular class of antihypertensive over another for first-line therapy but instead emphasize
the importance of selecting a therapy for each individual on the basis of the comorbidities he or
she may have.
• For patients who are 20/10 mm Hg greater than their goal blood pressure, two-drug combination
therapy (one drug is a diuretic) should be strongly considered.
• If a patient requires a second agent for treatment of hypertension, it is strongly recommended that
it be a diuretic if one is not chosen as the initial agent.
• All causes for inadequate response should be addressed before additional agents are added to a
patient's antihypertensive regimen (Box 8-3).
• Vasodilators, 1-receptor antagonists, ±2-receptor agonists, and postganglionic adrenergic neuron

blockers should be avoided as initial agents for hypertension.
Diuretics
Thiazide and thiazide-like diuretics
See
Table 8-11 for a list of thiazide and thiazide-like diuretics, their usual dose range, and adverse
effects associated with these medications.
Mechanism of action
• Direct arteriole dilation
• Reduction of total fluid volume through the inhibition of sodium reabsorption in the distal tubules,
which causes increased excretion of sodium, water, potassium, and hydrogen
• Increase in the effectiveness of other antihypertensive agents by preventing reexpansion of plasma

volume
• Significant decrease in efficacy in renal failure: serum creatinine > 2 mg/dL or glomerular
filtration rate (GFR) < 30 mL/min
• Diuretics are also available in combination with other drugs (

Table 8-12).
Patient instructions and counseling
• Medication may be taken with food or milk.
• Take early in the day to avoid nocturia.
• Medication may increase sensitivity to sunlight. Consider using sunscreen with SPF (sun
protection factor) > 15.
• Medication may increase blood glucose in diabetics.
• Report problems with muscle cramps, which may indicate decreased potassium level.
Drug-drug and drug-disease interactions

• Steroids cause salt retention and antagonize thiazide action.
• NSAIDs blunt thiazide response.
• Class IA or III antiarrhythmics (that prolong the QT interval) may cause torsades de pointes with
diuretic-induced hypokalemia.
• Probenecid and lithium block thiazide effects by interfering with thiazide excretion into the urine.
• Thiazides decrease lithium renal clearance and increase risk of lithium toxicity.
Parameters to monitor
• Blood pressure
• Weight
• Serum electrolytes and uric acid
• BUN and creatinine
• Cholesterol levels
Loop diuretics
See Table 8-11 for a list of loop diuretics, their usual dose range, and adverse effects associated
with these medications.
Mechanism of action
• Reduction of total fluid volume occurs through the inhibition of sodium and chloride reabsorption
in the ascending loop of Henle, which causes increased excretion of water, sodium, chloride,
magnesium, and calcium.
• Loop diuretics are more effective than thiazides in patients with renal failure: serum creatinine > 2
mg/dL or GFR < 30 mL/min.
• Medication may be taken with food or milk.
• Take early in the day to avoid nocturia.
[Table 8-10. Considerations for Individualizing Antihypertensive Drug Therapy]

• Medication may increase sensitivity to sunlight. Consider using sunscreen with SPF > 15.
• Report problems with muscle cramps, which may indicate decreased potassium level.
• Rise slowly from a lying or sitting position.
Box 8-3. Causes of Inadequate Responsiveness to Therapy
Pseudoresistance
• "White-coat hypertension" or office elevations
• Pseudohypertension in older patients
• Use of regular adult cuff on a very obese arm
Nonadherence to therapy
Volume overload
• Excess salt intake
• Progressive renal damage (nephrosclerosis)
• Fluid retention from reduction of blood pressure
• Inadequate diuretic therapy
Drug-related causes
• Doses too low
• Wrong type of diuretic
• Inappropriate combinations
• Rapid inactivation (e.g., hydralazine)
• Drug actions and interactions
• Nasal decongestants
• Appetite suppressants
• Cocaine and other illicit drugs
• Caffeine
• Oral contraceptives
• Adrenal steroids
• Licorice (as may be found in chewing tobacco)
• Cyclosporine or tacrolimus
• Erythropoietin
• Antidepressants
• Nonsteroidal anti-inflammatory drugs
Associated conditions
• Smoking
• Increasing obesity
• Sleep apnea
• Insulin resistance or hyperinsulinemia
• Ethanol intake of more than 1 oz (30 mL) per day
• Anxiety-induced hyperventilation or panic attacks
• Chronic pain
• Intense vasoconstriction (arteritis)
• Organic brain syndrome (e.g., memory deficit)
Identifiable causes of hypertension
Adapted from JNC-7 Express, National Heart, Lung, and Blood Institute.
• Aminoglycosides can precipitate ototoxicity when combined with loop diuretics.
• NSAIDs blunt diuretic response.
• Class IA or III antiarrhythmics (that prolong the QT interval) may cause torsades de pointes with
diuretic-induced hypokalemia.
• Probenecid blocks loop diuretic effects by interfering with excretion into the urine.
• Weight
• Serum electrolytes
• Uric acid
• Hearing (in high doses)
Potassium-sparing diuretics
See Table 8-11 for a list of potassium-sparing diuretics, their usual dose range, and adverse effects
associated with these medications.
Mechanism of action
• Potassium-sparring diuretics interfere with potassium and sodium exchange in the distal tubule,
decrease calcium excretion, and increase magnesium loss.
• Take early in day to avoid nocturia.
• Take after meals.
• Avoid excessive ingestion of foods high in potassium and use of salt substitutes.
• Report problems with muscle cramps, which may indicate decreased potassium levels.
• Sexual dysfunction is possible.
• ACE inhibitors may increase risk of hyperkalemia.
• Indomethacin can cause decrease in renal function when combined with triamterene.
• Cimetidine increases bioavailability and decreases clearance of triamterene.
• Weight
• Serum electrolytes (especially potassium)
[Table 8-11. Thiazide Diuretics, Thiazide-Like Diuretics, Loop Diuretics, Potassium-Sparing

Agents, and Aldosterone-Receptor Blocker]
Adrenergic Inhibitors
Postganglionic adrenergic neuron blockers
This medication class is best avoided unless necessary to treat refractory hypertension that is
unresponsive to all other agents, because the medications are poorly tolerated. See
Table 8-13 for a list of postganglionic adrenergic neuron blockers, their usual dose range, and
adverse effects associated with these medications.
Mechanism of action
Postganglionic adrenergic neuron blockers cause presynaptic inhibition of the release of the
neurotransmitter from peripheral neurons by agonistic activity on the ±2 receptor and depletion of
the neurotransmitter
[Table 8-12. Combination Drugs for Hypertension]
[Table 8-13. Postganglionic Adrenergic Neuron Blockers]
through competitive uptake into the neurosecretory vesicles.
• Report symptoms of dizziness or hypotension.

• Do not take over-the-counter (OTC) cold products without first asking the doctor or pharmacist.
• Report new fluid retention.
• OTC sympathomimetics may potentiate an acute hypertensive effect.
• Tricyclic antidepressants and chlorpromazine antagonize therapeutic effects of guanethidine.
• Pheochromocytoma is a contraindication to this class of medications.
• This medication class should be avoided in patients with CHF, angina, and cerebrovascular
disease.
• History of depression (reserpine)
• Sleep disturbances, drowsiness, and lethargy (reserpine)
• Symptoms of peptic ulcer (reserpine)
Centrally active ±2-agonists
See
Table 8-14 for a list of centrally active ±2-agonists, their usual dose range, and adverse effects
associated with these medications.
Mechanism of action
These medications cause decreased sympathetic outflow to the cardiovascular system by agonistic
activity on central ±2 receptors.
• Exercise sedation precautions.
• Fever and flu-like symptoms may represent hepatic dysfunction (methyldopa).

• Report new fluid retention.
• Use cautiously with other sedating medications.
• Use cautiously in patients with angina, recent myocardial infarction (MI), cerebrovascular
accident (CVA), and hepatic or renal disease (guanabenz and guanfacine).
[Table 8-14. Centrally Active ± 2-Agonists]
• Complete blood count (CBC)—positive Coombs test in 25% of those tested; less than 1% develop
hemolytic anemia (methyldopa)
• Sleep disturbances, drowsiness, or dry mouth
• Symptoms of depression
• Impotence
• Pulse
• Rebound hypertension
Peripherally acting ±1-adrenergic blockers
See
Table 8-15 for a list of peripherally acting ±1-adrenergic blockers, their usual dose range, and
adverse effects associated with these medications.
Mechanism of action
• Blocks peripheral 1 postsynaptic receptors, which causes vasodilation of both arteries and veins
(indirect vasodilators)
• Causes less reflex tachycardia than do direct vasodilators (hydralazine and minoxidil)
• Take first dose of no more than 1 mg of any agent, and take at bedtime.
• Medication may cause dizziness.
• Priapism is possible.
[Table 8-15. Peripherally Acting ± 1-Adrenergic Blockers]
• NSAIDs decrease antihypertensive effects of 1 blockers.
• Increased antihypertensive effects occur with diuretics and -blockers.
• BP and pulse
• Peripheral edema
-blockers
See
Table 8-16 for a list of -blockers, their usual dose range, and adverse effects associated with these
medications.
Mechanism of action
These medications competitively block response to ²-adrenergic stimulation:
• Block secretion of renin
• Decrease cardiac contractility, thereby decreasing cardiac output
• Decrease central sympathetic output
• Decrease heart rate, thereby decreasing cardiac output
• Exercise sedation precautions (with lipid-soluble compounds).
• Abrupt withdrawal of the drug should be avoided.

• Use with caution in patients with diabetes.
• Use with caution in patients with Raynaud's phenomenon or peripheral vascular disease.
• -blockers may decrease effectiveness of sulfonylureas.
• Nondihydropyridines may increase effect and toxicity of -blockers.
• ECG
• Rebound hypertension
• Cholesterol levels
• Pulse (apical and radial)
• Glucose levels
[Table 8-16. -Blockers and Combination - and -Blockers]
Direct Vasodilators
This medication class is best avoided (second-line agents) unless necessary to treat refractory
hypertension that is unresponsive to all other agents.
These agents should not be used alone secondary to increases in plasma renin activity, cardiac
output, and heart rate and should therefore be used only when ²-blockers and diuretics are part of
the antihypertensive regimen.
See
Table 8-17 for a list of direct vasodilators, their usual dose range, and adverse effects associated
Mechanism of action
These agents cause direct relaxation of peripheral arterial smooth muscle and thereby significantly
decrease peripheral resistance.
[Table 8-17. Direct Vasodilators]
• Hirsutism is possible (minoxidil).
• Report any new symptoms of fatigue, malaise, low-grade fever, and joint aches.
• Report rapid weight gain (> 5 pounds), unusual swelling, and pulse increases of > 20 beats per
minute above normal.
• Use with caution in patients with pulmonary hypertension.
• Use with caution in patients with significant renal failure or CHF.
• Use with caution in patients with coronary artery disease or a recent MI.
• Weight (fluid status)
• BP and pulse
• CBC with antinuclear antibody test (hydralazine)
Calcium Antagonists
Low-renin hypertensive, African American, and elderly patients respond well to this class of
medications. See
Table 8-18 for a list of calcium antagonists, their usual dose range, and adverse effects associated
Mechanism of action
• Inhibits the influx of calcium ions through slow channels in vascular smooth muscle and causes
relaxation of both coronary and peripheral arteries
• Causes sinoatrial (SA) and atrioventricular (AV) nodal depression and a decrease in myocardial
contractility (nondihydropyridines)
• Constipation is possible (verapamil).
• Report any new symptoms of shortness of breath, fatigue, or increased swelling of the extremities.
[Table 8-18. Calcium Antagonists]
• Use with caution in patients on -blockers (nondihydropyridines), which may increase CHF and
bradycardia. This combination can also cause conduction abnormalities to the AV node.
• Use with extreme caution in patients with conduction disturbances in the SA or AV node.
• Grapefruit juice may increase the levels of some dihydropyridines.
• ECG
• Peripheral edema
• BP and pulse
• Bowel habits
• Symptoms of conduction disturbances
Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers
Ethnic differences exist in the response to these classes of medications. These agents are relatively
ineffective as monotherapy in African American patients. However, the addition of diuretic therapy
has been shown to sensitize African American patients to these agents to obtain similar responses as
in non-African American patients.
See
Table 8-19 for a list of ACEIs and ARBs, their usual dose range, and adverse effects associated
Mechanism of action
ACEIs
• Inhibit the conversion of angiotensin I to angiotensin II (a potent vasoconstrictor; see Figure 8-1)
[Table 8-19. Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers]
• Indirectly inhibit fluid volume increases by inhibiting angiotensin II-stimulated release of

aldosterone
ARBs
• Inhibit the binding of angiotensin II to the angiotensin II receptor, thereby inhibiting the
vasoconstrictive properties of angiotensin II as well as its ability to stimulate release of
aldosterone
• Currently considered as alternative therapy in patients not able to tolerate ACEIs because of cough
• Symptoms of swelling of the lips, mouth, or face should be considered an emergency. Report
immediately to a doctor's office or emergency department.
• Report new rashes (especially with captopril).
• Do not use salt substitutes containing potassium, and do not take OTC potassium supplements.
• NSAIDs will decrease the effectiveness of ACEIs and ARBs.
• Potassium-sparing diuretics, potassium supplements, and salt substitutes will increase the risk of
hyperkalemia when used in combination with ACEIs and ARBs.
• ACEIs and ARBs should be avoided in patients with bilateral renal artery stenosis or stenosis in a
single kidney.
• ACEIs and ARBs should be avoided in pregnant patients.
• Serum electrolytes (especially creatinine and potassium)
• Symptoms of angioedema
• BP
• Symptoms of hypotension
• CBC (especially with captopril and enalapril) for neutropenia, which is more common in patients
with preexisting renal impairment
• Cough
• Urinary proteins
Direct Renin Inhibitor
• See
Table 8-20 for a list of direct renin inhibitors, their usual dose range, and adverse effects associated
Mechanism of action
Direct renin inhibitors competitively inhibit human renin, which decreases plasma renin activity and
inhibits the conversion of angiotensinogen to angiotensin I.
• Medicine can be taken with or without food.
• Establish a routine pattern for taking aliskiren with regard to meals. High-fat meals decrease
absorption significantly.
• Store the medicine in a closed container at room temperature, away from heat, moisture, and
direct light.
• Diarrhea is possible.
• Symptoms of swelling of the lips, mouth, or face should be considered an emergency. Report
immediately to a doctor's office or emergency department.

• Concomitant use of aliskiren with cyclosporine is not recommended.
[Table 8-20. Direct Renin Inhibitors]
• Potassium-sparing diuretics, potassium supplements, and salt substitutes will increase risk of
hyperkalemia when used in combination with aliskiren.
• Blood concentrations of furosemide are significantly reduced when given with aliskiren.
• Ketoconazole significantly increases aliskiren plasma levels.
• Aliskiren should be avoided in pregnant patients.
• Symptoms of angioedema
• BP
• Symptoms of hypotension
• Serum electrolytes (especially creatinine and potassium)
8-4. Hypertensive Urgencies and Emergencies
Introduction
The classification of hypertensive urgencies and emergencies is determined by the presence or

absence of acute target-organ damage, not by BP, and determines the appropriate treatment
approach.
The relative rise and rate of increase in BP is more important than the actual BP.
Hypertensive Emergencies
Acute elevations of BP (> 180 mm Hg systolic or > 120 mm Hg diastolic) with the presence of
acute or ongoing target organ damage constitute a hypertensive emergency (Box 8-4). This situation
requires immediate lowering of BP to prevent or minimize target organ damage.
Table 8-21 shows details of parenteral drugs used for treatment of hypertensive emergencies. Such
emergencies should be treated as follows:
• As an initial goal, reduce mean arterial pressure (MAP) by no more than 25% within minutes to
hours. Reach BP of 160/100 mm Hg within 2-6 hours.
• Measure BP every 5-10 minutes until goal MAP is reached and life-threatening target organ
damage resolves.
• Maintain goal BP for 1-2 days, and further reduce BP toward normal over several weeks.
• Excessive falls in BP may precipitate renal, cerebral, or coronary ischemia.
• Intravenous agents are preferred because of the ability to titrate dosages on the basis of BP
response; however, specific agents should be chosen on the basis of patient findings (
Table 8-22).
Box 8-4. Clinical Findings of Target Organ Damage
Target Organ Damage
Hypertensive encephalopathy
Intracranial hemorrhage
Unstable angina
Acute myocardial infarction
Acute left ventricular failure with pulmonary edema
Dissecting aortic aneurysm
Eclampsia
Clinical Findings
Funduscopic: papilledema, hemorrhage, exudates
Neurologic: somnolence, confusion, seizures, coma, visual deficits or blindness
Cardiac: S4 gallop, ischemic changes on ECG, chest x-ray consistent with pulmonary edema,
chest pain
Renal: oliguria, progressive azotemia, hematuria, proteinuria
Other: dyspnea
Reprinted with permission from JNC-VII.

Hypertensive Urgencies
Hypertensive urgencies are accelerated, malignant, or perioperative elevations in blood pressure in

the absence of new or progressive target organ damage; therefore, immediate lowering of BP is not
required.
Table 8-23 shows the agents used to treat hypertensive urgencies. Such situations require the
following considerations:
• There is no agent of choice; medications should be selected on the basis of patient characteristics.
• Oral therapy is preferred.
• Onset of action should be in 15-30 minutes, and peak effects should be seen in 2-3 hours.
• Check BP every 15-30 minutes to ensure response.
• Use of immediate-release nifedipine is inappropriate to lower BP in patients with hypertensive

urgencies.
8-5. Key Points
• Hypertension is defined as a systolic blood pressure exceeding 140 mm Hg, a diastolic blood
pressure exceeding 90 mm Hg, or any condition in a patient that requires antihypertensive
therapy.
[Table 8-21. Parenteral Drugs for Treatment of Hypertensive Emergencies]
• Prehypertension (120-139/80-89 mm Hg) represents a new classification in JNC-VII that

significantly increases the risk of developing stage 1 hypertension. Lifestyle modifications should
be stressed for this classification, and medication therapy should be used only for patients with
compelling indications.
• Secondary causes of hypertension include renovascular disease, primary aldosteronism, Cushing's

syndrome, pheochromocytoma,
[Table 8-22. Selected Agents for Specific Hypertensive Emergencies]
aortic coarctation, and drugs (steroids and estrogens, alcohol, cocaine, cyclosporine and
tacrolimus, sympathomimetics, erythropoietin, licorice, MAO inhibitors, tricyclic
antidepressants, and NSAIDs).
• Recommended lifestyle modifications to improve both BP and overall cardiovascular health

include losing weight; limiting alcohol intake; increasing aerobic physical activity; reducing
sodium intake; maintaining adequate dietary intake of potassium, magnesium, and calcium;
stopping smoking; and reducing dietary cholesterol and saturated fat intake.
• Diuretics are considered by JNC-VII to be the initial agent for treatment of hypertension in most
patients unless compelling indications for the use of other medication classes exist or the patient
has comorbid conditions that would suggest the use of classes other than diuretics.
• JNC-VII considers ACEIs, ARBs, -blockers, and CCBs equivalent choices as initial therapy for
hypertension.
• Vasodilators, 1-receptor antagonists, ±2-receptor agonists, and postganglionic adrenergic neuron

blockers should be avoided as initial agents for hypertension.
• Antihypertensive drug therapy should be individualized. There are classifications of

recommendations from JNC-VII based on the level of evidence, which include compelling
indication
[Table 8-23. Agents Used to Treat Hypertensive Urgencies]
unless contraindicated, possibility of favorable effects on comorbid conditions, and possibility of

unfavorable effects on comorbid conditions.
• The classification and treatment of hypertensive urgencies and emergencies is determined by the
presence or absence of acute target organ damage and not by blood pressure.
• All causes for inadequate response should be addressed before additional agents are added to a
patient's antihypertensive regimen (i.e., pseudoresistance, nonadherence, volume overload, drug-
related causes, associated conditions, and secondary causes of hypertension).
8-6. Questions
According to the Seventh Report of the Joint National Committee on Detection, Evaluation,
and Treatment of High Blood Pressure (JNC-VII), all of the following agents are suitable as
initial therapy for the treatment of uncomplicated hypertension except
1. A. hydrochlorothiazide.
B. chlorthalidone.
C. indapamide.
D. hydralazine.
E. atenolol.

Hyperkalemia is a possible adverse effect of all the following medications except
A. trandolapril.
2. B. Teveten.
C. doxazosin.
D. amiloride.
E. captopril.

A 48-year-old patient presents with a new diagnosis of hypertension. The patient is also noted
to have congestive heart failure with an ejection fraction of 28%. Which agent would be an
appropriate choice as initial therapy in this patient based on JNC-VII?
3. A. Clonidine
B. Guanethidine
C. Diltiazem
D. Perindopril
E. Nisoldipine

A 62-year-old patient with a history of hypertension and gout presents to begin
pharmacotherapy for hypertension. Which agent is the most appropriate choice as initial
therapy based on JNC-VII?
4. A. Chlorothiazide
B. Torsemide
C. Tenormin
D. Chlorthalidone
E. Metolazone

All of the following medications can cause bradycardia except
A. terazosin.
5. B. verapamil.
C. diltiazem.
D. Ziac.
E. clonidine.

A patient requires a cardioselective -blocker in his or her outpatient medication regimen after
recent discharge from the hospital with a new myocardial infarction. You suggest he or she
take
6. A. labetalol.
B. esmolol.
C. propranolol.
D. atenolol.
E. carvedilol.

A patient presents to your ambulatory clinic with a blood pressure of 210/125 mm Hg. Past
medical history is significant for type 2 diabetes, congestive heart failure, and renal
insufficiency. Which of the following would cause the patient to be classified as a hypertensive
emergency?
7.
A. Blood glucose levels > 300 mg/dL, which increase the patient's risk for acute renal failure
B. A serum creatinine of 3 mg/dL
C. Nausea, vomiting, and diarrhea for 3 days
D. S4 gallop and a chest x-ray consistent with pulmonary edema
E. Polyuria combined with polydipsia

What are the treatment goals for the patient with hypertensive emergency described in question
7?
A. Systolic pressure should be reduced to 120 mm Hg within the first hour of treatment to
reduce the risk of further end organ damage.
B. Diastolic pressure should be reduced to 80 mm Hg within the first hour of treatment to
8.
reduce the risk of further end organ damage.
C. Blood pressure should be reduced to 160/100 mm Hg in the first 2-6 hours of therapy.
D. Mean arterial pressure should be reduced by at least 50% within the first minutes to hours of
therapy.
E. Blood pressure should be reduced to no lower than 180/110 mm Hg in the first hour,
because excessive falls in blood pressure may precipitate coronary ischemia.

What would be the recommended treatment for the patient with hypertensive emergency
described in question 7?
A. Clonidine orally, 0.1-0.2 mg; repeat in 1-2 hours as needed (up to 0.6 mg)
9.
B. Labetalol orally, 100-400 mg; repeat in 2-3 hours as needed
C. Nifedipine sublingually, 10 mg; repeat in 0.5-1.0 hours as needed (up to 60 mg)
D. Labetalol intravenously, 20- to 80-mg bolus, followed by 0.5-2.0 mg/min infusion
E. Enalaprilat intravenously 1.25-5.0 mg every 6 hours

Which of the following antihypertensive agents can cause first-dose syncope, palpitations,
peripheral edema, and priapism?
A. Hydralazine
10.
B. Nitroprusside
C. Prazosin
D. Verapamil
E. Moexipril

Which of the following antihypertensive agents is most likely to cause lupus syndrome,
postural hypotension, and peripheral neuropathy?
A. Atenolol
11.
B. Hydralazine
C. Guanfacine
D. Mibefradil
E. Nitroprusside

Which of the following medications is not associated with drug-induced hypertension?
A. Prednisone
12. B. Indomethacin
C. Rosiglitazone
D. Cocaine
E. Cyclosporine

What is the best recommendation for antihypertensive medication in a patient who has atrial
fibrillation, coronary artery disease with angina, and hyperthyroidism?
A. Minoxidil
13.
B. Betaxolol
C. Telmisartan
D. Nicardipine
E. Amiloride

What antihypertensive agent should not be used in a patient with essential hypertension and a
history of depression with suicidal ideation?
A. Captopril
14.
B. Prazosin
C. Metolazone
D. Reserpine
E. Amlodipine

All of the following are secondary causes of hypertension except
A. renovascular disease.
15. B. pheochromocytoma.
C. systemic lupus erythematosus.
D. primary aldosteronism.
E. aortic coarctation.

Answer questions 16-20 on the basis of the patient medication profile provided on the next page.
A. I only is correct.
B. III only is correct.
C. I and II are both correct.
D. II and III are both correct.
E. I, II, and III are correct.
Patient Profile

Date: 4/12/09
Patient name: Buddy Manwich Address: 61 Heavenly Highway
Phone: 555-8181 Date of birth: 4/14/44
Height: 5'11" Weight: 248 lb
Race: African American Allergies: NKDA
Known diseases: DM (15 years), HTN (20 Pharmacist notes and other patient information: +
years), Obstructive Sleep Apnea (5 years), tobacco—1.5 ppd, 4-5 cups of coffee/day, ETOH—2
Osteoarthritis drinks/week
OTC use: Aleve, Actron
Rx
Date No. Medication/Strength Route Quantity Regimen Refills Pharmacist Prescriber
1/15/09 001 Glipizide 5 mg PO 30 1 qd 5 BCE NTE
1/15/09 002 Lisinopril 5 mg PO 30 1 qd 5 BCE NTE
1/15/09 003 Hydrodiuril 12.5 mg PO 30 1 qd 5 BBC NPR
1/20/09 003 Ibuprofen 800 mg PO 90 1 tid 5 REM FTD
001-
2/11/09 Glipizide 5 mg PO 30 1 qd 4 BCE NTE
RF
003-
2/11/09 Hydrodiuril 12.5 mg PO 30 1 qd 4 BBC NPR
RF
004-
2/11/09 Ibuprofen 800 mg PO 90 1 td 4 REM FTD
RF
001-
3/13/09 Glipizide 5 mg PO 30 1 qd 3 BCE NTE
RF
002-
3/13/09 Lisinopril 5 mg PO 30 1 qd 3 BCE NTE
RF
004-
3/13/09 Ibuprofen 800 mg PO 90 1 td 3 REM FTD
RF
Possible complications that the patient is at risk of developing secondary to uncontrolled
hypertension include
16.
I. hyperaldosteronism.
II. myocardial infarction.
III. blindness.

Education regarding lifestyle modification issues in this patient should include
I. Limit smoking to a half pack per day and alcohol intake to no more than 2 drinks per day.
17.
II. Maintain adequate intake of dietary magnesium, calcium, and sodium.
III. Increase aerobic physical activity, lose weight, and limit dietary saturated fat and
cholesterol.

Possible reasons for the patient's blood pressure being uncontrolled include
I. Use of NSAIDs, which cause decreased effectiveness of ACE inhibitor therapy

18.
II. Possible problems with adherence to antihypertensive therapy
III. Lack of blood pressure response to ACE inhibitor therapy, which should not be used in
combination with diuretics in an African American patient

The appropriate initial antihypertensive agent in this patient could be
19. I. benazepril.
II. terazosin.
III. minoxidil.

If the patient is not able to tolerate lisinopril because of adverse effects such as cough, an
appropriate alternative agent would be
20.
I. telmisartan.
II. labetalol.
III. guanabenz.

8-7. Answers
D. Appropriate choices for initial agents in the treatment of uncomplicated hypertension

1. include -blockers and diuretics. Hydralazine is a direct vasodilator, which would never be
considered a first-line agent in the treatment of hypertension.

C. Hyperkalemia is a possible side effect with angiotensin-converting enzyme inhibitors,
2. angiotensin II receptor antagonists, and potassium-sparing diuretics. Doxazosin is a
peripherally acting ±1 blocker, which does not cause hyperkalemia.

D. For patients who have hypertension and congestive heart failure, JNC-VII recommends the
3. use of ACE inhibitors, diuretics, -blockers, and aldosterone antagonists (see Table 8-10). The
only listed ACE inhibitor is perindopril.

C. For patients who have hypertension and gout, JNC-VII recommends not using diuretic
4. therapy, which increases the risk of gouty attacks (see Table 8-10). The only medication listed
that is not a diuretic is atenolol (Tenormin), which is a ²-blocker.

A. Verapamil and diltiazem are nondihydropyridine calcium channel blockers, Ziac (bisoprolol
and hydrochlorothiazide) is a -blocker, and clonidine is a centrally acting 2 agonist. They all
5.
have negative inotropic effects on the myocardium. Terazosin is a peripherally acting ±1
blocker, which does not cause bradycardia.

D. Labetalol, propranolol, and carvedilol are all nonselective ²-blockers. Esmolol is a
cardioselective agent available only in injectable form and, therefore, would not be for
6.
outpatient use. Atenolol is a cardioselective -blocker that is available as an oral tablet and,
therefore, can be used for outpatient dosing.

D. The classification of hypertensive urgencies and emergencies is determined by the presence
or absence of acute target organ damage and not by the actual blood pressure measurement.
7. Presence of an S4 gallop and a chest x-ray consistent with pulmonary edema suggests acute left
ventricular failure with pulmonary edema, which represents defined target organ damage and,
in turn, means the patient should be classified as a hypertensive emergency.

C. According to JNC-VII, the initial goal of blood pressure lowering in patients with
8. hypertensive emergencies is a drop in mean arterial pressure of no more than 25% within
minutes to hours and to 160/100 mm Hg within 2-6 hours.

E. In a patient with CHF and a hypertensive emergency, recommended treatments include
nitroglycerin, nitroprusside, and enalaprilat (Table 8-21). Clonidine and labetalol (PO) are
9. incorrect choices because the patient requires intravenous (IV) therapy. Nifedipine SL is not
indicated for immediate reduction of blood pressure. Labetalol IV is not an appropriate choice
in this patient with CHF because it could decrease cardiac output.

C. Possible side effects of peripherally acting ±1 blockers (prazosin) include first-dose
10.
syncope, palpitations, peripheral edema, and priapism (Table 8-15).

B. Possible side effects of direct vasodilators (hydralazine) include postural hypotension and
11. peripheral neuropathy. However, lupus syndrome is unique to hydralazine and does not occur
with minoxidil (Table 8-17).

C. All agents listed are possible causes of drug-induced hypertension through multiple
12.
mechanisms except rosiglitazone (Box 8-3).

B. The diagnoses of atrial fibrillation, coronary artery disease with angina, and
13. hyperthyroidism are all considered comorbid conditions with hypertension in which the use of
-blockers may have favorable effects.

D. Because of its possible increased risk of depression, reserpine should not be used for
14.
patients for whom the risk for depression or suicide already exists.

C. All listed diseases are possible causes of secondary hypertension through various
15.
mechanisms, except systemic lupus erythematosus.

D. Uncontrolled hypertension causes multiple organ system problems, including cardiovascular
(CHF, MI, and peripheral arterial disease); ophthalmologic (retinopathy and blindness);
16. cerebrovascular (transient ischemic attack and CVA); and renovascular (nephropathy, renal
failure, and dialysis) issues. Therefore, this patient is at risk for MI and blindness, not for
hyperaldosteronism.

B. Lifestyle modification issues to be considered in hypertensive patients include weight loss;
17. limit of alcohol intake; increased aerobic activity; reduced sodium intake; maintenance of
adequate dietary potassium, calcium, and magnesium intake; and smoking cessation.

18. C. Possible causes for inadequate responsiveness to therapy are listed in Box 8-3.

A. In patients with hypertension and comorbid conditions of CHF and diabetes, the initial
19.
agent should be an ACE inhibitor (Table 8-10).

A. In patients who cannot tolerate ACE inhibitor therapy secondary to the adverse effect of
20.
cough, angiotensin II receptor antagonists are considered good alternative agents.

8-8. References
Carter BL, Saseen JL. Hypertension. In: DiPiro JT, Talbert RL, eds. Pharmacotherapy: A
Pathophysiologic Approach. New York: McGraw-Hill; 2002:157-83.
JNC-VII (The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation and Treatment of High Blood Pressure). Hypertension. 2003;42:1206-52.
JNC-7 Express (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure [JNC-7] Express). NIH Pub. No. 03-5233, May 2003. Available at
www.nhlbi.gov/guidelines/hypertension/express.pdf.
9. Heart Failure - Robert B. Parker, PharmD, FCCP
9-1. Overview
Introduction
Heart failure is a clinical syndrome resulting from a variety of cardiac disorders that impair the
ventricle's ability to fill with or eject blood. When the ventricle is impaired as such, the heart is
unable to pump blood at a sufficient rate to meet the metabolic demands of the body, a condition
that is described as heart failure.
• Nearly 6 million people in the United States have heart failure; 670,000 new patients are
diagnosed each year.
• Heart failure is the only major cardiovascular disease that is increasing in prevalence.
• Approximately 300,000 patients die from heart failure each year. At the time of heart failure
diagnosis, the 5-year mortality rate is nearly 50%.
• A large majority of patients are elderly; approximately 10% of individuals over the age of 75 have
heart failure.
• Each year, there are more than 1 million hospital discharges for heart failure, and it is the most
common hospital discharge diagnosis for Medicare patients. More Medicare dollars are spent for
diagnosis and treatment of heart failure than for any other disorder.
• Current estimates indicate that annual expenditures for heart failure exceed $37 million.
Classification
The New York Heart Association Functional Classification for heart failure has been widely used
for many years. The classification scheme primarily reflects the severity of heart failure symptoms
based on a subjective assessment by the provider. A patient's functional class can change frequently
over a short period because of changes in medications, diet, or intercurrent illnesses. The
classification scheme, as follows, does not recognize preventive measures, nor does it recognize the
progressive nature of heart failure:
• Functional class I includes patients with cardiac disease but without limitations of physical
activity. Ordinary physical activity does not cause undue fatigue, dyspnea, or palpitations.
• Functional class II includes patients with cardiac disease that results in slight limitations of
physical activity. Ordinary physical activity results in fatigue, palpitations, dyspnea, or angina.
• Functional class III includes patients with cardiac disease that results in marked limitation of
physical activity. Although patients are comfortable at rest, less than ordinary activity will lead to
symptoms.
• Functional class IV includes patients with cardiac disease that results in an inability to carry on
physical activity without discomfort. Symptoms of heart failure are present even at rest. With any
physical activity, increased discomfort is experienced.
The most recent guidelines for evaluation and management of heart failure from the American
College of Cardiology (ACC) and the American Heart Association (AHA) recommend an
additional classification scheme that emphasizes both the evolution and the progression of the
disease. That additional classification scheme more objectively identifies patients within the course
of the disease and links to treatments that are appropriate for each stage. Patients in stages A and B
do not have heart failure but do have risk factors that predispose them to the development of heart
failure.
• Stage A includes patients at high risk of developing heart failure because of the presence of
conditions that are strongly associated with heart failure. Patients in stage A have no known
cardiac abnormalities and no heart failure signs or symptoms. Examples include patients with
hypertension, coronary artery disease, and diabetes mellitus.
• Stage B includes patients with structural heart disease that is strongly associated with the
development of heart failure but who have never shown signs or symptoms of heart failure.
Examples include patients with previous myocardial infarction, left ventricular hypertrophy, or
impaired left ventricular systolic function.
• Stage C includes patients who have current or prior symptoms of heart failure associated with
underlying structural heart disease. Examples include patients with dyspnea or fatigue
attributable to left ventricular systolic dysfunction, as well as asymptomatic patients who are
undergoing treatment for prior symptoms of heart failure. Most patients with heart failure are in
stage C.
• Stage D includes patients who have advanced structural heart disease, who have marked
symptoms of heart failure at rest despite maximal medical therapy, and who require specialized
interventions. Patients in stage D include those who frequently are hospitalized for heart failure
and cannot be discharged from the hospital safely, those who are in the hospital awaiting heart
transplantation, and those who are supported with a mechanical circulatory assist device.
Acute Decompensated Heart Failure
Both the growing number of patients with heart failure and the progressive nature of the syndrome
have led to substantial increases in hospitalizations for heart failure. Acute decompensated heart
failure (ADHF) is defined as new or worsening signs or symptoms that are usually caused by (1)
volume overload (pulmonary congestion, systemic congestion, or both); (2) hypoperfusion
(hypotension, renal insufficiency, shock syndrome, or some combination); or (3) both volume
overload and hypoperfusion. ADHF frequently requires hospitalization for acute treatment.
Causes of ADHF include medication and dietary noncompliance, atrial fibrillation, myocardial
ischemia, uncorrected high blood pressure, recent addition of negative inotropic drugs, nonsteroidal
anti-inflammatory drugs (NSAIDs), excessive alcohol or illicit drug use, and progression of heart
failure.
To determine the proper approach to therapy, patients are assigned to one of four hemodynamic
profiles:
• Warm and dry: Adequate perfusion (i.e., cardiac output) and no signs or symptoms of volume
overload
• Warm and wet: Adequate perfusion but signs or symptoms of volume overload
• Cold and dry: Inadequate perfusion and no signs or symptoms of volume overload
• Cold and wet: Inadequate perfusion and signs or symptoms of volume overload
Most patients (about 70%) are assigned to the warm and wet classification.
Clinical Presentation
The primary manifestations of heart failure are (1) dyspnea and fatigue that may limit exercise
tolerance and (2) fluid retention that may lead to pulmonary and peripheral edema. Both
abnormalities can limit a patient's functional capacity and quality of life, but they do not necessarily
occur at the same time. Some patients may have marked exercise intolerance but little evidence of
fluid retention, whereas others may have prominent edema with few dyspnea or fatigue symptoms.
Other symptoms may include paroxysmal nocturnal dyspnea, orthopnea, tachypnea, cough, ascites,
and nocturia. Other signs include jugular venous distension, hepatojugular reflux, hepatomegaly,
bibasilar rales, pleural effusion, tachycardia, pallor, and S3 gallop. Patients with ADHF experience
similar symptoms but they may be more severe.
Pathophysiology
Heart failure can result from any disorder (see "Specific Causes of Heart Failure" next) that impairs
the heart's systolic function (i.e., pumping ability) or diastolic function (impaired cardiac
relaxation). Many patients have manifestations of both abnormalities. In either case, the initiating
event in heart failure is a decrease in cardiac output, which results in the activation of a number of
compensatory mechanisms that attempt to maintain an adequate cardiac output.
Recent studies suggest that mutations in certain adrenergic receptors (²1 and ±2c) and -receptor
signaling pathways may play an important role in the development of heart failure and response to
therapy.
The beneficial effects of angiotensin-converting enzyme (ACE) inhibitors, ²-blockers, and
aldosterone antagonists on reducing mortality and slowing heart failure progression have resulted in
the neurohormonal model of heart failure pathophysiology. The decrease in cardiac output leads to
the activation of compensatory systems that release a number of neurohormones, including
angiotensin II, norepinephrine, aldosterone, proinflammatory cytokines, and vasopressin. Those
neurohormones can increase renal sodium and water retention, vasoconstriction, and tachycardia
and can stimulate ventricular hypertrophy and remodeling. Activation of the compensatory systems
results in a systemic disorder that is not confined just to the heart, whose progression is largely
mediated by these neurohormones.
Specific Causes of Heart Failure
Coronary artery disease is the cause of heart failure in about 65% of patients with left ventricular
systolic dysfunction. Other causes include nonischemic cardiomyopathy (e.g., attributable to
hypertension, thyroid disease, or valvular disease). Most of those patients have a reduced left
ventricular ejection fraction (usually less than 40%).
Approximately 20%-50% of patients with heart failure have preserved (normal) left ventricular
systolic function, and their heart failure is secondary to diastolic dysfunction. This type of heart
failure is most often observed in elderly patients.
A number of drugs can precipitate or worsen heart failure:
• Drugs with negative inotropic effects include antiarrhythmics (disopyramide, flecainide,

propafenone, and others); -blockers; calcium channel blockers (verapamil and diltiazem); and
oral antifungals (itraconazole and terbinafine).
• Cardiotoxic drugs include doxorubicin, daunorubicin, cyclophosphamide, ethanol, amphetamines

(cocaine and methamphetamine), trastuzumab, and imatinib.
• Drugs that cause sodium and water retention can precipitate or worsen heart failure and include
NSAIDs (which can also attenuate the efficacy and increase the toxicity of diuretics and ACE
inhibitors), glucocorticoids, rosiglitazone, and pioglitazone.
Diagnostic Criteria
No single diagnostic test for heart failure exists; rather, the diagnosis is a clinical one based on
history, signs and symptoms, and physical examination. A thorough history and physical
examination are important for identifying cardiac and noncardiac disorders or behaviors (e.g., diet,
adherence to medications) that may cause or hasten the progression of heart failure.
A rapid bedside assay for B-type natriuretic peptide (BNP) often is used in acute care settings (e.g.,
emergency departments) as an aid in the diagnosis of suspected heart failure. BNP is synthesized
and released from the ventricles in response to pressure or volume overload. BNP counteracts
increased sympathetic nervous system activity and renin-angiotensin-aldosterone system activity by
increasing diuresis, renal sodium excretion, and vasodilation. The degree of elevation of BNP
correlates with prognosis. The BNP assay is useful for differentiating between heart failure
exacerbations and other causes of dyspnea, such as chronic obstructive pulmonary disease (COPD),
asthma, or infection). Patients with dyspnea secondary to heart failure will have elevated plasma
BNP concentrations.
The echocardiogram is one of the most useful diagnostic tests in patients with heart failure.
Patients with a left ventricular ejection fraction (LVEF) less than 40% generally are considered to
have systolic dysfunction. LVEF can be determined by an echocardiogram, by nuclear imaging
scans, or during a cardiac catheterization. Note that, in general, there is a poor correlation between
LVEF and symptoms.
Treatment Principles and Goals of Therapy
The goals of therapy include improving the patient's quality of life, reducing symptoms, reducing
hospitalizations for heart failure exacerbations, slowing progression of the disease, and improving
survival.
ACC-AHA guidelines for heart failure treatment according to stage are shown in
Figure 9-1. In stages A and B, therapy primarily is targeted toward prevention of heart failure
development; in stages C and D, however, the focus is targeted toward treatment of patients with
symptomatic heart failure.
An algorithm for treatment of patients with ADHF is shown in

Figure 9-2.
9-2. Drug Therapy of Heart Failure
Introduction
The following section on drug therapy focuses on treatment of patients with stage C heart failure
(i.e., patients with left ventricular dysfunction with current or prior symptoms). This drug therapy
commonly is referred to as outpatient treatment. Patients with stage C heart failure should be
routinely managed with a combination of three drugs: a diuretic (if needed to control volume
retention), an ACE inhibitor,
[Figure 9-1. American College of Cardiology-American Heart Association Stages of Heart Failure
and Recommended Therapy by Stage]
[Figure 9-2. Acute Decompensated Heart Failure]
and a -blocker. Drug therapies that can be considered in selected patients include angiotensin II
receptor blockers (ARBs), digoxin, aldosterone antagonists, and hydralazine-isosorbide dinitrate.
Loop Diuretics
Only patients with signs or symptoms of volume overload will need diuretic therapy. Most heart
failure patients require use of the more potent loop diuretics versus thiazide diuretics (
Table 9-1).
Mechanism of action
Loop diuretics reduce the sodium and fluid retention associated with heart failure by inhibiting
reabsorption of sodium and chloride in the loop of Henle.
• Patients allergic to sulfa-containing medications also may be allergic to loop diuretics.
• Patients should take medication once a day in the morning, or, if taking twice daily, take in the
morning and afternoon.
[Table 9-1. Loop Diuretics]
• Loop diuretics can cause frequent urination.
• Patients should weigh themselves daily (preferably in the morning, after urinating). Patients who
gain more than 1 pound per day for several consecutive days or 3-5 pounds in a week should
contact their health care provider.
• Patients should report muscle cramps, dizziness, excessive thirst, weakness, or confusion, as those
may be signs of overdiuresis.
• Patients should avoid sun exposure or use sunscreen when taking loop diuretics.
Adverse drug events
• Electrolyte depletion: hypokalemia and hypomagnesemia
• Hypotension
• Renal insufficiency
• Food decreases the bioavailability of furosemide and bumetanide, which should be taken on an
empty stomach. Food does not affect torsemide absorption.
• The absorption of oral furosemide is slowed significantly in patients with ADHF, resulting in
decreased diuretic response. Therefore, those individuals usually will require the use of
intravenous (IV) furosemide.
• NSAIDs may diminish the medication's diuretic effect.
• Potassium supplementation may not be required in patients also receiving ACE inhibitors, ARBs,
or aldosterone antagonists.
• Serum sodium, potassium, magnesium, creatinine, and blood urea nitrogen (BUN)
• Patient weight (a loss of 0.5-1.0 kg daily is desired until the patient achieves the desired dry
weight)
• Urine output
• Blood pressure
• Jugular venous distension
• Improvement in heart failure symptoms (dyspnea and peripheral edema)
Kinetics
Bioavailability of torsemide is not affected by food and is less variable than that of furosemide.
Angiotensin-Converting Enzyme Inhibitors
Angiotensin-converting enzyme inhibitors (ACEIs) are recommended for all patients with current
or prior symptoms of heart failure and reduced LVEF, unless contraindicated (
Table 9-2). Clinical trials in more than 7,000 patients consistently demonstrate that ACEIs alleviate
symptoms, improve clinical status and quality of life, and improve mortality.
Mechanism of action
• ACEIs interfere with the renin-angiotensin system by inhibiting angiotensin-converting enzyme,

which is responsible for the conversion of angiotensin I to the potent vasoconstrictor angiotensin
II. That inhibition results in a decrease in plasma angiotensin II and aldosterone concentrations,
thus reducing the adverse effects of those neurohormones. Inhibition of angiotensin-converting
enzyme also prevents the breakdown of the endogenous vasodilator bradykinin.
• ACEIs improve heart failure symptoms and reduce hospitalizations for heart failure.
• ACEIs reduce mortality by 20%-30% and slow the progression of heart failure.
• Patients who are pregnant or breast-feeding should not take ACEIs. If patients become pregnant
while taking an ACEI, they should contact their physician immediately.
• Captopril should be taken on an empty stomach, either 1 hour before or 2 hours after meals.
[Table 9-2. Angiotensin-Converting Enzyme Inhibitors]
• Salt substitutes that contain potassium should be used cautiously.
• Patients should call their physician immediately if they experience swelling of the face, eyes, lips,
tongue, arms, or legs or if they have difficulty breathing or swallowing.
• ACEIs may cause cough.
Adverse drug events
• Hypotension
• Dizziness
• Cough
• Angioedema
• Hyperkalemia
• Rash
• Taste disturbances
• NSAIDs can increase the risk of renal insufficiency and attenuate the beneficial effects of ACEIs.
• Potassium supplements or potassium-sparing diuretics should be used with caution.
• Cyclosporine and tacrolimus may increase the risk of nephrotoxicity and hyperkalemia.
• Diuretics increase the risk of hypotension.

• Blood pressure
• Renal function (i.e., serum BUN and creatinine)
• Serum potassium
• Heart failure symptoms
• Dose (initiate therapy at low doses; if lower doses are tolerated well, follow with gradual
increases)
Other
ACEIs are pregnancy category C during the first trimester and pregnancy category D during the
second and third trimesters. ACEIs can cause fetal and neonatal morbidity and death when
administered to pregnant women.
Angiotensin Receptor Blockers
ACEIs remain the drugs of choice for inhibiting the renin-angiotensin-aldosterone system in
patients with chronic heart failure. Recent clinical trials confirm the efficacy and safety of
candesartan and valsartan in the treatment of heart failure. Whether other ARBs are equally
effective in the treatment of heart failure is unknown. Current guidelines recommend candesartan or
valsartan for patients that are intolerant to ACEIs—both of those agents are approved for use in
patients with heart failure. Intolerance to ACEIs is most often due to cough or angioedema,
although caution is advised when using ARBs in patients that have angioedema secondary to an
ACEI. Note that ARBs are just as likely as ACEIs to cause impaired renal function, hyperkalemia,
or hypotension (
Table 9-3).
Mechanism of action
• ARBs interfere with the renin-angiotensin system by blocking the angiotensin-1 receptor, thereby
attenuating the detrimental effects of this hormone.
• Unlike ACEIs, ARBs do not affect the kinin system and thus are not associated with cough.
• ARBs reduce hospitalizations and improve survival.
• Patients who are pregnant or breast-feeding should not take ARBs. If a patient becomes pregnant
while taking an ARB, she should contact her physician immediately.
• Use salt substitutes that contain potassium cautiously.
• Dizziness or light-headedness may occur, especially in patients taking diuretics.
Adverse drug events
• Hypotension
• Dizziness
• Hyperkalemia
• Potassium supplements or potassium-sparing diuretics should be used with caution.
• Diuretics increase the risk of hypotension.
[Table 9-3. Angiotensin Receptor Blockers]
• Blood pressure
• Renal function (i.e., serum BUN and creatinine)
• Serum potassium
• Dose (initiate therapy at low doses; if lower doses are tolerated well, follow with gradual
increases)
Other
• ARBs are pregnancy category C during the first trimester and pregnancy category D during the
second and third trimesters. ARBs can cause fetal and neonatal morbidity and death when
administered to pregnant women.
-Blockers
Because of their negative inotropic effects, -blockers once were considered to be contraindicated
in patients with heart failure. However, by inhibiting the deleterious effects of long-term activation
of the sympathetic nervous system in heart failure, ²-blockers repeatedly have been shown to
provide hemodynamic, symptomatic, and survival benefits. Metoprolol succinate (extended-release
metoprolol), bisoprolol, and carvedilol all have been shown to be effective, and one of those three
agents should be used for the treatment of heart failure (
Table 9-4).
Mechanism of action
• Blockade of -receptors antagonizes the increase in sympathetic nervous system activity that is
one of the important mechanisms responsible for the progression of heart failure. Bisoprolol and
metoprolol succinate are ²1-selective agents, whereas carvedilol blocks ²1-, ²2-, and ±1-receptors.
Whether those differences in pharmacologic actions have any important effects on outcomes for
patients with heart failure remains uncertain.
[Table 9-4. -Blockers]
• Treatment with -blockers reduces symptoms, improves clinical status, and decreases the risk of
death and hospitalization.
• One of the three -blockers that have been shown to reduce mortality (bisoprolol, carvedilol, and
extended-release metoprolol succinate) should be used in all stable patients with current or prior
heart failure symptoms and reduced LVEF, unless contraindicated.
• In general, -blockers should be used in combination with ACEIs and diuretics.
• -blockers may cause fluid retention or worsening of heart failure upon initiation of therapy or
after an increase in dose. Patients should report any cases of body or leg swelling or increased
shortness of breath. Patients should weigh themselves daily; if they gain more than 1 pound per
day for several consecutive days or 3-5 pounds in a week, they should contact their health care
provider.
• Fatigue or weakness may occur in the first few weeks of treatment but usually will resolve
spontaneously.
• Patients should report any cases of dizziness, lightheadedness, or blurred vision, which may be
caused by the patient's blood pressure being too low or from bradycardia or heart block.
• Patients should take carvedilol with food.
• It is important not to miss doses or stop taking these medications abruptly.
• In patients with diabetes, -blockers may cause an increase in blood sugar, possibly masking the
signs of hypoglycemia (except for sweating).
Adverse drug events
A list of adverse events most commonly observed in heart failure patients receiving ²-blockers
follows. For other adverse effects of -blockers, see the chapters on hypertension and ischemic
heart disease.
• Fluid retention and worsening heart failure
• Fatigue
• Bradycardia and heart block
• Hypotension
• Abrupt withdrawal can lead to hypertension, tachycardia, or myocardial ischemia
• Amiodarone and calcium channel blockers (verapamil and diltiazem) can increase the risk of
bradycardia, heart block, and hypotension.
• Quinidine, fluoxetine, paroxetine, and other inhibitors of cytochrome P4502D6 inhibit hepatic
metabolism of metoprolol and carvedilol and may result in increased plasma concentrations and
enhanced effects.
• Concomitant use of ophthalmic -blockers may increase the risk of bradycardia, heart block, and
hypotension.
• -blockers may cause bronchoconstriction in patients with asthma or COPD.
• Do not use -blockers in patients with symptomatic bradycardia or heart block unless a pacemaker
is present.
• -blockers may worsen blood glucose control in diabetics and mask the signs of hypoglycemia.
• Blood pressure and heart rate
• Weight (daily)
Kinetics
• Bisoprolol is eliminated about 50% by the kidneys, so dosage adjustment may be required in
patients with renal insufficiency.
• Both metoprolol and carvedilol are metabolized by the liver.
Other
• Patients must be stable (i.e., minimal evidence of fluid overload or volume retention) before -
blocker treatment is initiated.
• Treatment should be initiated with low doses and titrated slowly upward until the target dose is
reached. Doses usually are increased no more frequently than every 2 weeks, with close
monitoring of symptoms required during the titration period.
• Fluid accumulation during dose titration usually can be managed by adjusting diuretic doses.
• Staggering the schedule of other heart failure medications that lower blood pressure (e.g., ACEIs
and diuretics) may help reduce the risk of hypotension.
• A recent study comparing the effects of carvedilol with immediate-release metoprolol (metoprolol
tartrate) in patients with heart failure found that survival is improved in patients receiving
carvedilol. Whether carvedilol is superior to extended-release metoprolol (metoprolol succinate)
is unknown. However, these results strongly suggest that only ²-blockers proven to improve
survival (carvedilol, metoprolol succinate, and bisoprolol) should be used in patients with heart
failure.
Aldosterone Antagonists
Elevated plasma aldosterone plays an important detrimental role in the pathophysiology and
progression of heart failure. Although short-term treatment with ACEIs or ARBs lowers circulating
aldosterone concentrations, that suppression is not sustained with long-term therapy. In low doses,
the aldosterone antagonists spironolactone and eplerenone reduce the risk of death and
hospitalization in patients with moderate to severe heart failure. Current guidelines recommend the
addition of aldosterone antagonists in patients with moderately severe to severe symptoms of heart
failure and reduced LVEF that can be monitored closely for renal function and serum potassium (
Table 9-5).
Mechanism of action
Antagonism of aldosterone results in reduced renal potassium excretion.

• Potassium-containing salt substitutes should be avoided.
• Patients should call their physician immediately if they experience muscle weakness or cramps;
numbness or tingling in hands, feet, or lips; or slow or irregular heartbeat.
• Spironolactone may cause swollen or painful breasts in men.
Adverse drug events
• Hyperkalemia
• Gynecomastia (only with spironolactone)
• Irregular menses
[Table 9-5. Aldosterone Antagonists]
• ACEIs, ARBs, and NSAIDs increase the risk of hyperkalemia.
• Spironolactone can increase digoxin plasma concentrations.
• Potassium supplements increase the risk of hyperkalemia. Supplements should not be used if
serum potassium exceeds 3.5 mEq/L.
• Elderly patients and patients with diabetes are at an increased risk of hyperkalemia.
• Erythromycin, clarithromycin, verapamil, ketoconazole, fluconazole, itraconazole, and other

inhibitors of cytochrome P450 3A4 inhibit hepatic metabolism of eplerenone and may result in
increased plasma concentrations and enhanced effects.
• Serum creatinine should be less than 2.5 mg/dL in men or less than 2.0 mg/dL in women before
therapy is initiated.
• Serum potassium should be less than 5.0 mEq/L before therapy is initiated. Potassium should be
evaluated three days after therapy is started, again one week after therapy is started, and at least
monthly for the first three months of therapy.
Digoxin
Unlike ACEIs or -blockers, digoxin does not improve mortality but does appear to produce
symptomatic benefits (
Table 9-6).
Mechanism of action
• Digoxin inhibits the Na+-K+-ATPase pump, which results in an increase in intracellular calcium
that, in turn, causes a positive inotropic effect.
• Recent evidence indicates that digoxin reduces sympathetic outflow from the central nervous
system, thus blunting the excessive sympathetic activation that occurs in heart failure. Those
effects occur at low plasma concentrations, where little positive inotropic effect is seen.
[Table 9-6. Digoxin]
Patients should report any of the following to their health care provider:
• Dizziness, lightheadedness, or fatigue
• Changes in vision (blurred or yellow vision)
• Irregular heartbeat
• Loss of appetite
• Nausea, vomiting, or diarrhea
Adverse drug events
Major adverse effects involve three systems:
• Cardiovascular (cardiac arrhythmias, bradycardia, and heart block)
• Gastrointestinal (anorexia, abdominal pain, nausea, and vomiting)
• Neurological (visual disturbances, disorientation, confusion, and fatigue)
Toxicity typically is associated with serum digoxin concentrations >2 ng/mL but may occur at
lower levels in elderly patients and in patients with hypokalemia or hypomagnesemia.
The following drugs increase serum digoxin concentrations:
• Quinidine, verapamil, and amiodarone (the dose of digoxin should be decreased by 50% if these
medications are added)
• Propafenone
• Flecainide
• Macrolide antibiotics (erythromycin and clarithromycin)
• Itraconazole and ketoconazole
• Spironolactone
• Cyclosporine
Drugs that decrease serum digoxin concentrations include:
• Antacids
• Cholestyramine and colestipol
• Kaolin-pectin
• Metoclopramide
Diuretics increase the risk of digoxin toxicity in the presence of hypokalemia or hypomagnesemia.
Digoxin clearance is reduced in patients with renal insufficiency (see section on kinetics).
• Digoxin serum concentration
• There is little relationship between serum digoxin concentration and therapeutic effects in heart
failure.
• Current guidelines suggest a target range of 0.5-1.0 ng/mL.
• Heart rate
• Serum potassium and magnesium
• Renal function (serum BUN and creatinine)

Kinetics
See
Table 9-7 for information about the pharmacokinetics of digoxin. Note the following:
• Approximately 60%-80% of the dose is eliminated unchanged in the kidney; therefore, dosage
adjustment is required in patients with renal insufficiency.
• Lower doses (0.125 mg daily or every other day) should be used in the elderly or in patients with a
low lean body mass.
• No loading dose is needed in the treatment of heart failure.
• Because of the long distribution phase after either oral or intravenous digoxin administration,
blood samples for determination of serum digoxin concentrations should be collected at least 6
and preferably 12 hours or more after the last dose.
[Table 9-7. Digoxin Pharmacokinetics]
Hydralazine-Isosorbide Dinitrate
Hydralazine and isosorbide dinitrate initially were combined because of complementary

hemodynamic actions. An early clinical trial reported reduced mortality with this combination when
compared with placebo. A comparison with an ACEI, however, showed that the ACEI was superior
to hydralazine-isosorbide dinitrate. Adverse effects with the combination are common (primarily
headache, dizziness, and gastrointestinal complaints), and those effects lead many patients to
discontinue therapy. Current guidelines indicate that hydralazine-isosorbide dinitrate can be
considered as a therapeutic option in patients who cannot be given an ACEI or an ARB because of
drug intolerance, hypotension, or renal insufficiency.
A recent clinical trial found that the hydralazine-isosorbide dinitrate combination, when added to
standard background therapy (ACEIs or ARBs, -blockers, diuretics, digoxin), reduced mortality in
African Americans with heart failure by 40% compared with placebo. Whether those benefits are
specific to African Americans is unclear. The current heart failure treatment guidelines indicate that
the addition of hydralazine-isosorbide dinitrate is a reasonable therapy in patients with reduced
LVEF and persistent heart failure symptoms despite therapy with ACEIs and ²-blockers.
A fixed-dose combination product is now available (BiDil).
9-3. Drug Therapy for Acute Decompensated Heart Failure
Introduction
Patients with ADHF usually are admitted to the hospital for aggressive treatment with IV diuretics,
vasodilators (see
Table 9-8), or positive inotropic drugs (see
Table 9-9). When such patients have hypotension in addition to low cardiac output, they are said to
have cardiogenic shock. In those severe cases, therapy may be guided by invasive hemodynamic
monitoring. Treatment goals include reducing volume overload and improving cardiac output. The
approach to treatment is dictated by the patient's hemodynamic profile.
Warm and Dry
• No specific therapy is needed.
Warm and Wet
• The goal is to reduce volume overload and minimize congestive symptoms.
[Table 9-8. Vasodilators]
[Table 9-9. Inotropes]
• IV loop diuretics often are used. For patients who are unresponsive to loop diuretics, the addition
of supplemental thiazide diuretics (e.g., metolazone) may be helpful.
• The addition of IV vasodilators (nitroglycerin, nitroprusside, and nesiritide) also can reduce
symptoms.
• Inotropic therapy usually is not necessary.
Cold and Dry
• Patients may be clinically stable and often do not present with acute symptoms.
• Rule out volume depletion from overdiuresis as the cause of decreased cardiac output.
• Gradual introduction of -blockers may be helpful.
Cold and Wet
• Improve cardiac output first (i.e., before removing excess volume).
• Cardiac output can be increased by IV vasodilators or inotropes, or both.
• The relative roles of vasodilators and inotropes in this patient population are controversial.
Nondrug therapies include the following:

• Ultrafiltration
• Intra-aortic balloon pump
• Left ventricular assist devices
• Biventricular pacing
• Implantable cardioverter-defibrillator
• Cardiac transplantation
9-5. Key Points
• Heart failure is a clinical syndrome caused by the heart's inability to pump sufficient blood to meet
the body's needs.
• Although heart failure has many causes, the most common are coronary artery disease and
hypertension.
• Several compensatory mechanisms are activated to help maintain adequate cardiac output;
activation of those systems is responsible for heart failure symptoms and contributes to disease
progression. Medications that improve patient outcomes antagonize those compensatory
mechanisms.
• Drugs that can precipitate or worsen heart failure should be avoided (e.g., NSAIDs, verapamil,
and diltiazem).
• All patients with stage C (symptomatic) heart failure should be treated with diuretics, ACEIs, and
-blockers.
• The goal of treatment with diuretics is to eliminate signs of fluid retention, thus minimizing
symptoms.
• ACEIs are an integral part of heart failure pharmacotherapy. They improve survival and slow
disease progression. ARBs are the preferred alternative for patients who are intolerant to ACEIs.
• -blockers are recommended for all patients with systolic dysfunction and mild to moderate
symptoms. -blockers improve survival, decrease hospitalizations, and slow disease progression.
Bisoprolol, carvedilol, and extended-release metoprolol succinate are agents with proven
benefits. They should be started at low doses with slow upward titration to the target dose.
• Digoxin does not improve survival in patients with heart failure but does provide symptomatic
benefits. The goal plasma concentration is 0.5-1.0 ng/mL.
• Spironolactone and eplerenone improve survival in patients with moderate to severe heart failure.
• Patients with ADHF often require hospitalization and aggressive therapy with IV diuretics,
vasodilators, and positive inotropic drugs.
9-6. Questions
Which of the following combinations represents optimal pharmacotherapy of chronic heart

failure?
A. Furosemide, clonidine, hydrochlorothiazide, and propranolol

1.
B. Furosemide, lisinopril, and carvedilol
C. Carvedilol, verapamil, amlodipine, and nesiritide
D. Cardizem, hydrochlorothiazide, digoxin, and sotalol
E. Dobutamine, amiodarone, furosemide, and nitroglycerin

Which of the following mechanisms most likely contributes to the benefits of ²-blockers in the
treatment of heart failure?
A. Stimulation of ²2-receptors
2.
B. Increased heart rate and decreased blood pressure
C. Stimulation of ²1-receptors
D. Blockade of increased sympathetic nervous system activity
E. Blockade of angiotensin II receptors

Appropriate monitoring parameters for enalapril therapy in the treatment of heart failure
include
I. serum creatinine.
II. serum potassium.
III. hemoglobin A1c.
3.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Patients taking eplerenone for heart failure should avoid taking
A. NSAIDs.
4. B. ACEIs.
C. -blockers.
D. Demadex.
E. calcium supplements.

All of the following are adverse effects of digoxin except
A. nausea.
5. B. anorexia.
C. confusion.
D. arrhythmias.
E. acute renal failure.

Heart failure may be exacerbated by which of the following medications?
I. Naproxen
II. Glipizide
III. Crestor
6.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Cough is an adverse effect associated with which of the following medications?
A. Ramipril
7. B. Valsartan
C. Carvedilol
D. Torsemide
E. Eplerenone

Which of the following ACEIs has the shortest duration of action?
A. Ramipril
8. B. Captopril
C. Lisinopril
D. Monopril
E. Fosinopril

Which of the following adverse effects of lisinopril can be avoided by switching to
candesartan?
I. Hypotension
II. Renal insufficiency
III. Hyperkalemia
9. IV. Cough
A. I, II, and III

B. I and III only
C. II and III only
D. III only
E. IV only

A significant interaction can occur if digoxin is administered with
A. Biaxin.
10. B. fosinopril.
C. glyburide.
D. Lipitor.
E. warfarin.

All of the following medications can cause bradycardia except
A. carvedilol.
11. B. amiodarone.
C. digoxin.
D. verapamil.
E. dobutamine.

Which of the following is contraindicated in patients with a history of lisinopril-induced
angioedema?
A. Captopril
12.
B. Torsemide
C. Spironolactone
D. Milrinone
E. Carvedilol

Nesiritide would be indicated in
A. patients with asymptomatic left ventricular dysfunction.

13. B. patients with acute decompensated heart failure not responsive to IV diuretics.
C. patients with stage B heart failure.
D. patients with type 2 diabetes.
E. patients intolerant to digoxin.

All of the following are true about the use of furosemide in heart failure except
A. the drug reduces mortality and slows heart failure progression.

14. B. hypokalemia is a common adverse effect.
C. response can be evaluated by monitoring patient weight.
D. oral absorption is slowed in patients with acute decompensated heart failure.
E. furosemide's bioavailability is reduced by food.

Which of the following is an important consideration when using ²-blockers for treating heart
failure?
A. They are effective only in post-myocardial infarction patients.

15.
B. All -blockers are equally effective for the treatment of heart failure.
C. Therapy should be initiated at the target dose.
D. Patients with fluid overload are the optimal candidates for initiating therapy.
E. Therapy should be initiated at low doses and titrated upward slowly.

The dose of which of the following medications should be reduced in patients with renal
insufficiency?
A. Metoprolol
16.
B. Carvedilol
C. Digoxin
D. Nitroglycerin
E. Dobutamine

Which of the following is true regarding digoxin therapy in patients with chronic heart failure?
A. Digoxin reduces mortality.

17. B. Concomitant amiodarone therapy decreases digoxin plasma concentrations.
C. Digoxin is contraindicated in patients with heart failure and atrial fibrillation.
D. The target digoxin plasma concentration is 0.5-1.0 ng/mL.
E. Concomitant glyburide therapy increases digoxin plasma concentrations.

Which of the following ²-blockers also blocks ±1-receptors and is effective for treating heart
failure?
A. Metoprolol
18.
B. Carvedilol
C. Bisoprolol
D. Propranolol
E. Atenolol

Patients with heart failure who experience fluid retention after ²-blocker initiation should have
A. the -blocker dose increased.

19. B. the digoxin dose increased.
C. the -blocker discontinued.
D. the ACEI discontinued.
E. their diuretic dose adjusted.

Which of the following is correct regarding the treatment of ADHF?
A. Nesiritide is the agent of choice in patients with ADHF and hypotension.

20. B. Milrinone is preferred over dobutamine in patients receiving concomitant ²-blocker therapy.
C. Absorption of oral loop diuretics is increased.
D. Dobutamine and milrinone improve survival.
E. Verapamil reduces volume overload and improves cardiac output.

Use Patient Profile 1 to answer questions 21 and 22.
Patient Profile 1

Patient Name William Johnson
Age 64
Sex Male
Allergies NKA
Height 5'11"
Weight 185 lbs
DIAGNOSIS Myocardial infarction 2008
Hypertension
Heart failure
Hyperlipidemia
LABORATORY AND DIAGNOSTIC TESTS
Echocardiogram in 12/08 showed LVEF 30%
Blood pressure on 4/1/09: 145/90 mm Hg
Heart rate on 4/1/09: 88 bpm
Lipid profile on 4/1/09:
Total cholesterol, 160 mg/dL

LDL cholesterol, 95 mg/dL

HDL cholesterol, 50 mg/dL
Triglycerides, 100 mg/dL
Serum potassium, 2.0 mEq/L

MEDICATION RECORD
Date Rx # Physician Drug/Strength Quantity Sig Refills
4/1 1000 Smith Lanoxin 0.125 mg 90 1 tab qd 2
4/1 1001 Smith Lasix 40 mg 60 1 tab q am 3
4/1 1002 Smith KCl 20 mEq 90 1 tab q am 1
4/1 1003 Smith Zocor 40 mg 90 1 tab qhs 3
4/1 1004 Smith EC aspirin 325 mg 90 1 tab q am 2
4/1 1005 Smith Plavix 75 mg 90 1 tab q am 3
Which of the following medications should be added to Mr. Johnson's regimen?
A. Lisinopril and carvedilol

21. B. Valsartan and prazosin
C. Torsemide and amlodipine
D. Verapamil and amiodarone
E. Clonidine and hydrochlorothiazide

Mr. Johnson's serum potassium level of 2.0 mEq/L (normal 4.0-5.0 mEq/L) could
A. increase the risk of Lanoxin toxicity.

22. B. be treated by increasing the dose of Lasix.
C. be considered a side effect of therapy with EC aspirin.
D. be caused by an interaction between Zocor and Lanoxin.
E. increase the risk of bleeding from Plavix.

Hospital Inpatient Profile 2

Patient Name Ellen Smith
Age 71
Sex Female
Allergies NKA
Height 5'4"
Weight 150 lbs
DIAGNOSIS Heart failure exacerbation with 20-lb weight gain over last 3-4 weeks
Hypertension
Osteoarthritis
LABORATORY AND DIAGNOSTIC TESTS
Echocardiogram in 2/09 showed LVEF 25%
Blood pressure on 4/1/09: 130/85 mm Hg
Heart rate on 4/1/09: 80 bpm
Serum digoxin concentration on 4/1/09: 0.8 ng/mL
MEDICATION RECORD
Date Rx # Physician Drug/Strength Quantity Sig Refills
2/1 100 Jones Lanoxin 0.125 mg 90 1 tab qd 2
3/1 101 Jones Furosemide 80 mg 60 1 tab q am 3
1/4 102 Jones Zestril 20 mg 90 1 tab q am 1
1/4 103 Jones Toprol-XL 50 mg 90 1 tab qd 3
3/1 104 Nelson Naproxen 500 mg 90 1 tab bid 3
with food
Use Hospital Inpatient Profile 2 to answer questions 23 and 24.

According to her profile, the recent worsening of Mrs. Smith's heart failure most likely is
related to
A. Zestril.
23.
B. naproxen.
C. subtherapeutic serum digoxin concentration.
D. furosemide.
E. drug interaction between Zestril and furosemide.

Toprol-XL is an agent that
A. is contraindicated in heart failure.

24. B. blocks ²1-, ²2-, and ±1-receptors.
C. blocks only ²1-receptors.
D. should not be used in combination with Zestril.
E. increases the serum digoxin concentration.

9-7. Answers
B. Furosemide, lisinopril (an ACEI), and carvedilol (a ²-blocker) in combination should be

1.
used routinely in patients with heart failure.

D. Activation of the sympathetic nervous system plays an important role in the initiation and
2. progression of heart failure. The benefits of -blockers are thought to be due to the blockade of
the sympathetic nervous system's increased activity.

C. Enalapril, as well as other ACEIs, can cause renal insufficiency and an increase in serum
3.
potassium. Thus, serum creatinine and potassium should be monitored.

A. Use of eplerenone is associated with renal potassium retention. Concomitant use of NSAIDs
4.
significantly increases the risk of hyperkalemia.

E. Nausea, anorexia, confusion, and arrhythmias all are common signs and symptoms of
5.
digoxin toxicity. Digoxin does not affect renal function.

A. Naproxen, an NSAID, can worsen heart failure (1) by increasing renal sodium and water
6. retention and (2) by attenuating the efficacy and enhancing the toxicity of ACEIs and diuretics.
Neither glipizide nor Crestor affects heart failure.

7. A. Cough is frequently encountered as an adverse effect of ACEIs.

B. Captopril must be given three times daily in patients with heart failure. The other agents can
8.
be given once daily.

E. The angiotensin receptor blocker candesartan is just as likely to cause hypotension,
9. hyperkalemia, and renal insufficiency as is lisinopril (or any other ACEI). Candesartan is an
alternative agent for patients intolerant to ACEIs because of cough.

A. The macrolide antibiotic Biaxin (clarithromycin) is associated with a 50%-100% increase in
10.
serum digoxin concentrations.

E. Dobutamine is a -receptor agonist and is associated with an increase in heart rate. The
11.
other choices listed as possible answers all slow heart rate through various mechanisms.

A. Lisinopril is an ACEI, and angioedema is a known adverse effect of all agents in that class.
12.
Thus, captopril, which also is an ACEI, should not be used in this situation.

B. Nesiritide is indicated for use only in patients with severe or decompensated heart failure. It
13.
must be given intravenously.

A. Although furosemide plays an important role in patients with heart failure by interfering
14. with sodium and water retention, it provides only symptomatic benefits. Furosemide and other
diuretics do not improve survival or affect heart failure progression.

E. When used to treat heart failure, -blocker therapy should be started at low doses and
gradually titrated upward to the target dose that was shown in clinical trials to improve
15. survival. Starting at the target dose or initiating treatment in patients with fluid overload
increases the risk of worsening heart failure. Only carvedilol, bisoprolol, and metoprolol
succinate extended-release are proven to be effective in heart failure.

16. C. Only digoxin is eliminated by the kidneys.

D. Current guidelines suggest a target digoxin plasma concentration of 0.5-1.0 ng/mL. Digoxin
does not improve survival in patients with heart failure—it only improves symptoms.
17. Amiodarone increases digoxin plasma concentrations; glyburide does not affect digoxin
concentrations. Digoxin is useful in the management of patients with heart failure who also
have atrial fibrillation.

B. Only carvedilol blocks ±1-receptors and has been shown to be effective in patients with
18.
heart failure.

E. Some patients with heart failure may experience increases in fluid retention after initiation
19. of -blocker therapy. Fluid retention typically is managed best by adjusting the diuretic dose
and closely monitoring the patient's weight.

B. The positive inotropic effects of milrinone are not mediated through the ²-receptor;
therefore, its effects are not diminished by concomitant ²-blocker therapy. Nesiritide is
20. associated with an increased risk of hypotension. No inotropic agents are shown to improve
survival. Absorption of oral loop diuretics is decreased in ADHF. Verapamil has negative
inotropic effects and would worsen volume overload.

A. An ACEI and -blocker are indicated in this patient with heart failure to improve survival
21.
and slow disease progression.

22. A. Hypokalemia increases the risk of digoxin toxicity.

B. The addition of the NSAID naproxen approximately 3-4 weeks before admission likely is
23. the cause of this episode of ADHF. NSAIDs can increase sodium and water retention and
negate the effects of diuretics and ACEIs.

C. Toprol-XL (metoprolol succinate) is a cardioselective ²-blocker. It blocks only the ²1-
24.
receptor at usual therapeutic doses.

9-8. References
Adams KF, Lindenfeld J, Arnold JMO, et al. Evaluation and management of patients with acute
decompensated heart failure. J Card Fail. 2006; 12:e86-103.
Brater DC. Pharmacology of diuretics. Am J Med Sci. 2000;319:38-50.
Cohn JN, Tognoni G, for the Valsartan Heart Failure Trial Investigators. A randomized trial of the
angiotensin receptor blocker valsartan in chronic heart failure. N Engl J Med. 2001;345:1667-75.
Digitalis Investigation Group. The effect of digoxin on mortality and morbidity in patients with
heart failure. N Engl J Med. 1997;336:525-33.
Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL randomised intervention
trial in congestive heart failure (MERIT-HF). Lancet. 1999;353:2001-7.
Gislason GH, Rasmussen JN, Abildstrom SZ, et al. Increased mortality and cardiovascular
morbidity associated with use of nonsteroidal anti-inflammatory drugs in chronic heart failure.
Arch Int Med. 2009;169:141-9.
Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 guideline update for the diagnosis and
management of chronic heart failure in the adult: A report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee
to update the 2001 guidelines for the evaluation and management of heart failure). Circulation.
2005;112:e154-235.
Jessup M, Abraham WT, Casey DE, et al., writing on behalf of the 2005 Guideline Update for the
Diagnosis and Management of Chronic Heart Failure in the Adult Writing Committee. 2009
focused update: ACC/AHA guidelines for the diagnosis and management of heart failure in
adults—A report of the American College of Cardiology/American Heart Association Task Force
on Practice Guidelines. J Am Coll Cardiol. 2009;53:1-40.
Packer M, Bristow MR, Cohn JN, et al. The effect of carvedilol on morbidity and mortality in
patients with chronic heart failure. N Engl J Med. 1996; 334:1349-55.
Parker RB, Rodgers JE, Cavallari LH. Heart failure. In: DiPiro JT, Talbert RL, Yee GC, et al., eds.
Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-Hill; 2008:173-
216.
Petersen JW, Felker GM. Inotropes in the management of acute heart failure. Crit Care Med. 2008;
36:S106-11.
Pfeffer MA, Swedberg K, Granger CB, et al. Effects of candesartan on mortality and morbidity in
patients with chronic heart failure: The CHARM-Overall programme. Lancet. 2003;362:759-66.
Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left
ventricular dysfunction after myocardial infarction. N Engl J Med. 2003;348:1309-21.
Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in
patients with severe heart failure. N Engl J Med. 1999;341:709-17.
Poole-Wilson PA, Swedberg K, Cleland JGF, et al. Comparison of carvedilol and metoprolol on
clinical outcomes in patients with chronic heart failure in the Carvedilol or Metoprolol European
Trial (COMET): Randomised controlled trial. Lancet. 2003;362:7-13.
Schentag J, Bang A, Kozinski-Tober J. Digoxin. In: Burton M, Shaw L, Schentag J, Evans W, eds.
Applied Pharmacokinetics and Pharmacodynamics. 4th ed. Baltimore: Lippincott Williams and
Wilkins; 2006:411-39.
Taylor AL, Ziesche S, Yancy C, et al. Combination of isosorbide dinitrate and hydralazine in blacks
with heart failure. N Engl J Med. 2004;351:2049-57.
Wong J, Patel RA, Kowey PR. The clinical use of angiotensin-converting enzyme inhibitors. Prog
Cardiovasc Dis. 2004;47:116-30.
10. Cardiac Arrhythmias - Robert B. Parker, PharmD, FCCP
Introduction
Cardiac arrhythmias are abnormal heart rhythms resulting from alterations in impulse formation or
conduction.
10-1. Electrophysiology
Impulse Generation (Automaticity) and Conduction
• Initiation and propagation of the electrical impulse in cardiac cells is dependent on regulation of
the action potential.
• Conduction velocity is determined by regulation of action potential, specifically the slope of phase
0 depolarization (
Figure 10-1 and
Table 10-1).
• The absolute refractory period is the time during which cardiac cells cannot conduct or propagate
an action potential (Figure 10-1 and Table 10-1).
• The relative refractory period is the time during which cardiac cells may conduct and propagate
action potentials secondary to strong electrical stimuli.
Normal Conduction System
The sinoatrial (SA) node, located in the right atrium, initiates an impulse that
• Stimulates the left atrium and atrioventricular (AV) node, which
• Stimulates the left and right bundle branches via the bundle of His, which then
• Stimulates Purkinje fibers and causes ventricular contraction
10-2. Mechanisms of Arrhythmia
Cardiac arrhythmias arise secondary to the following disorders:
• Automaticity (impulse generation)
• Latent pacemaker (non-SA node pacemaker)
• Triggered automaticity (early or late after-depolarizations)

• Reentry
• Impulse conduction
• Automaticity and impulse conduction
10-3. Clinical Manifestations
Symptoms
Symptoms associated with ventricular arrhythmias range from asymptomatic to loss of

consciousness and death. Patients with ventricular tachycardia (VT) may be asymptomatic, but VT
can result in hypotension, syncope, or death. Ventricular fibrillation (VF) produces no cardiac
output and causes most cases of sudden cardiac death.
Symptoms generally related to poor cardiac output include dizziness, syncope, chest pain, fatigue,
confusion, and exacerbation of heart failure. Patients with tachyarrhythmias may report palpitations.
With atrial fibrillation or flutter, patients may also experience dizziness, palpitations, light-
headedness, and dyspnea
[Figure 10-1. Action Potential for Atrial and Ventricular Tissue]
as well as symptoms of transient ischemic attack (TIA) or stroke.
Signs
• Electrocardiogram (ECG) abnormalities may present.
• Ventricular rate can be assessed by documenting the heart rate from the radial artery or by carotid
palpation.
10-4. Diagnostic Criteria and Therapy According to Arrhythmia Classification
Introduction
Arrhythmias are defined by
• Anatomic location
• Supraventricular arrhythmias arise from abnormalities in the SA node, the atrial tissue, the AV
node, or the bundle of His.
[Table 10-1. Phases of Atrial and Ventricular Tissue Action Potential]

• Ventricular arrhythmias originate from below the bundle of His.
• Ventricular rate
• Bradyarrhythmias: Heart rate < 60 beats per minute (bpm).
• Tachyarrhythmias: Heart rate > 100 bpm.
Bradyarrhythmias
Sinus bradycardia
Diagnostic criteria and characteristics

Heart rate is less than 60 bpm; otherwise, the ECG is normal.
Mechanism of arrhythmia
The mechanism of arrhythmia is decreased SA node automaticity.
Clinical etiology
Causes include acute myocardial infarction; hypothyroidism; drug-induced causes (²-blockers
including ophthalmic agents, digoxin, calcium channel blockers [diltiazem, verapamil], clonidine,
amiodarone, and cholinergic agents); and hyperkalemia
Treatment goals
Restore normal sinus rhythm if the patient is clinically symptomatic.
Drug and nondrug therapy

For intermittent symptomatic episodes: give atropine 0.5-1.0 mg intravenously repeated up to
maximum dose of 3.0 mg.
For persistent episodes or if there is no response to atropine: place transvenous or transcutaneous

pacemaker.
Atrioventricular block

Criteria are as follows:
• First-degree: Prolonged PR interval > 0.20 seconds, 1:1 atrioventricular conduction
• Second-degree Mobitz type I: Gradual prolongation of PR interval followed by P wave without

ventricular conduction
• Second-degree Mobitz type II: Constant PR interval with intermittent P wave without
ventricular conduction; may have widened QRS complex
• Third-degree: Heart rate 30-60 bpm; no temporal relation between atrial and ventricular
contraction; ventricular contraction initiated by AV junction or ventricular tissue
The mechanism of arrhythmia is prolonged conduction.
Clinical etiology
Causes include AV nodal disease; acute myocardial infarction; myocarditis; increased vagal tone;
drug-induced causes ( -blockers, digoxin, calcium channel blockers [diltiazem and verapamil];
clonidine, amiodarone, cholinergic agents); and hyperkalemia.
Treatment goals
Restore sinus rhythm if the patient is symptomatic
Drug and nondrug therapy

If the cause is reversible, treat with a temporary pacemaker or intermittent atropine.
If the condition is chronic, implant a permanent pacemaker.
Supraventricular Arrhythmias
Atrial fibrillation and atrial flutter

Criteria are as follows:
• Atrial Fibrillation: No P waves; irregularly irregular QRS pattern
• Atrial Flutter: Sawtooth P wave pattern; regular QRS pattern
• Ventricular response: Usually fast but can also be slow or normal
The mechanism of arrhythmia is enhanced automaticity and reentrant circuits.
Clinical etiology
Causes include rheumatic heart disease, heart failure, hypertension, ischemic heart disease,
pericarditis, cardiomyopathy, mitral valve prolapse, cardiac surgery, infection, alcohol abuse,
hyperthyroidism, chronic obstructive pulmonary disease, pulmonary embolism, and idiopathic
causes (lone atrial fibrillation).
Atrial fibrillation and flutter are the most commonly occurring arrhythmia, and risk increases with
age.
Complications include stroke, heart failure exacerbation.
Specific treatment goals for atrial fibrillation

Figure 10-2 illustrates the treatment algorithm for atrial fibrillation.
Control the ventricular rate

Digoxin is the drug of first choice in patients with left ventricular systolic dysfunction (e.g., left
ventricular ejection fraction < 40%); it slows the ventricular rate but has poor control in
hyperadrenergic-induced atrial fibrillation.
The most effective agents are -blockers (esmolol, metoprolol, propranolol, others).
Calcium channel blockers (diltiazem, verapamil) may be used but should be avoided in patients
with left ventricular systolic dysfunction.
For rapid control of ventricular rate, the intravenous (IV) route of administration should be used.
Digoxin, calcium channel blockers, and ²-blockers do not restore sinus rhythm.
Restore and maintain sinus rhythm

Acute conversion to sinus rhythm may be required in patients with atrial fibrillation who are
hemodynamically unstable (e.g., hypotensive).
Restoration of sinus rhythm is usually accomplished by electrical cardioversion or administration of

antiarrhythmic drugs (AADs).
An important area of controversy centers on whether chronic AAD therapy should be administered
to maintain sinus rhythm after cardioversion (rhythm control approach) or whether patients should
simply be treated with agents to control ventricular response and anticoagulants to prevent
thromboembolic stroke (rate control approach).
Historically, AADs were frequently used to restore and maintain sinus rhythm in patients with atrial
fibrillation (rhythm control approach). With chronic therapy, AADs approximately double the
chances of a patient remaining in sinus rhythm. However, this approach exposes patients to the
large number of adverse effects associated with AADs. The rationale for this approach includes the
possibility of fewer symptoms, lower risk of stroke, improved quality of life, and reduced mortality.
However, these benefits had never been proven in large clinical trials.
The alternative approach, so called rate control, involves using drugs to control the ventricular
response and chronic anticoagulation, usually with warfarin, for stroke prevention.
The rate control and rhythm control approaches have recently been compared in a number of large
clinical trials, and the studies demonstrate no advantage for rhythm control over the rate control
approach. Regardless of the approach, adequate anticoagulation is needed to prevent stroke.
Even when chronic antiarrhythmic therapy is used to maintain sinus rhythm, it is not 100%
effective. Therefore, this approach is usually reserved for patients with recurrent, symptomatic
episodes.
Prevent thromboembolism
Prior to use of pharmacologic or direct-current cardioversion: If atrial fibrillation is present for e 48
hours or of unknown duration, anticoagulate with warfarin (INR [international normalized ratio] 2-
3) for 3 weeks prior to elective cardioversion, and continue for at least 4 weeks after sinus rhythm
has been restored.
If atrial fibrillation is present for 48 hours or of unknown duration, transesophageal

echocardiography (TEE) is often used to determine the presence of atrial thrombus. If no thrombus
is seen, cardioversion can be attempted after initiation of IV unfractionated heparin (aPTT
[activated partial thromboplastin time] 50-70 seconds) or low molecular weight heparin (full deep
vein thrombosis treatment doses). If cardioversion is successful and sinus rhythm is maintained,
patients should receive warfarin (INR 2-3) for at least 4 weeks. If atrial thrombus is seen on TEE,
anticoagulation should be initiated and repeat TEE performed before attempting later cardioversion.
Risk factors for nonvalvular atrial fibrillation thromboembolism are as follows:
• Previous ischemic stroke, systemic embolism, or TIA
• History of hypertension
• Moderately or severely impaired left ventricular systolic function, heart failure, or both
• Diabetes mellitus
• Age over 75 years
Recommended antithrombotic therapy

The following treatments are recommended:
• Patients with a prior ischemic stroke, systemic embolism, or TIA should receive warfarin INR 2-3.
• Patients with two or more of the following risk factors should receive warfarin (INR 2-3): (1) age
exceeding 75 years; (2) history of hypertension; (3) diabetes; and (4) moderately or severely
impaired left ventricular systolic function, heart failure, or both. This treatment corresponds to
individuals with a CHADS2 (cardiac failure, hypertension, age, diabetes, stroke [doubled]) score
2.
[Figure 10-2. Treatment Algorithm for Atrial Fibrillation]
• Patients with only one of the following risk factors should receive warfarin (INR 2-3) or aspirin
75-325 mg daily: (1) age exceeding 75 years; (2) history of hypertension; (3) diabetes; (4)
moderately or severely impaired left ventricular systolic function, heart failure, or both.
• Patients with none of the following risk factors should receive aspirin 75-325 mg daily: (1) age >
75 years; (2) history of hypertension; (3) diabetes; (4) moderately or severely impaired left
ventricular systolic function, heart failure, or both.
Dosage forms for warfarin (Coumadin) are as follows:
• Tablets: 1 mg (pink), 2 mg (lavender), 2.5 mg (green), 3 mg (tan), 4 mg (blue), 5 mg (peach), 6

mg (teal), 7.5 mg (yellow), 10 mg (white)
• Injections (IV): 5 mg powder for reconstitution (2 mg/mL)
Mechanism of action
Warfarin inhibits vitamin K epoxide-reductase and vitamin K reductase, preventing the conversion
of vitamin K epoxide to vitamin K. It ultimately inhibits formation of vitamin K-dependent
coagulation factors II, VII, IX, and X, as well as proteins C and S
Absorption
Bioavailability of warfarin is 80% to 100% following oral administration. It is absorbed in the
upper gastrointestinal tract. Food or enteral feedings may decrease rate and extent of absorption.
Distribution
Warfarin is 99.0% to 99.5% protein bound, primarily to albumin.
Metabolism and elimination

Warfarin is administered as a racemic mixture of S- and R-warfarin; the S-isomer is five times
more potent than the R-isomer. The S-isomer is primarily metabolized in the liver via cytochrome
P450 2C9 (CYP2C9). The R-isomer is metabolized by several other enzymes of the cytochrome
P450 system.
Warfarin has low-extraction pharmacokinetic characteristics.
Clearance decreases with increasing age.
The half-life of the R-isomer is 45 hours; for the S-isomer, it is 33 hours.
Pharmacogenomics
Recent studies show that genetic polymorphisms can markedly influence the metabolism and
response to warfarin. Mutations in two genes—CYP2C9, which codes for the hepatic enzyme that
metabolizes S-warfarin, and VKORC1, which regulates the vitamin K epoxide-reductase enzyme
(VKORC1)—can account for up to 50% of the variability in the dose of warfarin. The current
package insert contains information regarding altered responses caused by polymorphisms in the
CYP2C9 and VKORC1 genes. However, the use of genetic testing to prospectively determine the
dose of warfarin remains controversial.
Pharmacodynamics
The S-isomer is approximately five times more potent than the R-isomer in inhibiting vitamin K
reductase. Its pharmacodynamic effect (change in INR) is an indirect effect of the decreased
formation of the vitamin K-dependent coagulation factors II, VII, IX, and X. The long half-lives of
these factors result in delayed onset of action and delayed response to dosage changes.
Adverse effects
Several adverse effects are possible:
• Bleeding can occur, roughly proportional to the degree of anticoagulation.
• Skin necrosis, related to depletion of or deficiency of protein C, is possible. This effect usually
occurs within 10 days of warfarin initiation. Incidence is low.
• Purple-toe syndrome may occur. This syndrome usually occurs 3-8 weeks after warfarin initiation.
Incidence is low.
• Birth defects and fetal hemorrhage are possible. Therefore, warfarin is pregnancy category X.
Some common drug interactions

Medications decreasing warfarin anticoagulant response are as follows:
• Barbiturates
• Carbamazepine
• Cholestyramine
• Griseofulvin
• Nafcillin
• Phenytoin (chronic therapy)
• Rifampin
Medications increasing warfarin anticoagulant response are as follows:
• Acetaminophen
• Allopurinol
• Amiodarone
• Azole antifungal agents
• Cimetidine
• Ciprofloxacin, levofloxacin
• Diltiazem
• Erythromycin, clarithromycin
• Fenofibrate
• Fish oil
• Metronidazole
• Omeprazole (R-enantiomer)
• Phenytoin (acute therapy)
• Propafenone
• Simvastatin, fluvastatin
• Sulfinpyrazone
• Trimethoprim-sulfamethoxazole
Dosing management
Patients should take a once-daily dose of 1-10 mg orally. Patient response is highly variable.
Management of elevated INR is described in
Table 10-2.
Monitoring
The standard for assessing the degree of anticoagulation is the INR = (observed prothrombin
ratio)ISI, where ISI is the International Standardized Index, which corrects for variability in
thromboplastin sensitivity.
Initially, the INR is monitored every 1-2 days until the desired INR is achieved and has stabilized at
a given dose. Periodic INR monitoring (i.e., monthly) is recommended thereafter unless dosage
changes are made.
Paroxysmal supraventricular tachycardia

Criteria for paroxysmal supraventricular tachycardia (PSVT) are as follows:
• Heart rate of 160-240 bpm that is abrupt in onset and termination with a normal QRS interval
• 1:1 AV conduction
The mechanism of arrhythmia is reentry.
Clinical etiology
Causes include idiopathic causes, fever, and drug-induced causes (sympathomimetics,
anticholinergics, ²-agonists).
Treatment goals
See
Figure 10-3 for the treatment algorithm for PSVT. Treatment goals are as follows:
• Acute: Terminate reentry circuit by prolonging refractoriness and slowing conduction.
• Chronic: Prevent or minimize the number and severity of episodes. Antiarrhythmic drugs are no
longer the treatment of choice to prevent recurrences. Most patients undergo radiofrequency
catheter ablation of the reentrant substrate, which is curative and is associated with a low
complication rate.
Acute nonpharmacologic therapy

Vagal maneuvers may terminate PSVT: carotid massage and Valsalva maneuver (most common),
squatting, deep breathing, coughing, inducing eyeball pressure, and diving reflex (less common).
Ventricular Arrhythmias
Major classifications and diagnostic criteria
• Premature ventricular contractions
• Premature ventricular contractions (PVCs) are extra abnormal heartbeats that originate in the
[Table 10-2. Management of Elevated International Normalized Ratio]
[Figure 10-3. Treatment Algorithm for Paroxysmal Supraventricular Tachycardia]
ventricles. They are termed premature because they occur before the normal heartbeat.
• PVCs often are asymptomatic or cause only mild palpitations.
• Ventricular tachycardia
• Ventricular tachycardia (VT) is defined as three or more consecutive PVCs at a rate exceeding
100 bpm and a wide QRS interval (> 0.12 seconds), usually with a regular pattern.
• Nonsustained VT (NSVT) is defined as an episode that lasts less than 30 seconds.
• Sustained VT is defined as an episode lasts more than 30 seconds.
• Ventricular fibrillation
• Ventricular fibrillation is defined as an absence of organized cardiac electrical or mechanical

activity and no recognizable P waves, QRS complexes, or T waves on the ECG.
• Ventricular fibrillation rapidly results in no effective cardiac output, blood pressure, or pulse.
Clinical etiology
Causes include acute myocardial infarction, electrolyte disturbances, catecholamines, and drug-
induced causes.
Treatment goals
• Treat acute symptoms precipitating causes
• Restore sinus rhythm
• Prevent/minimize recurrences
10-5. Drug and Nondrug Therapy
Premature Ventricular Contractions
Apparently healthy patients without underlying structural heart disease are not at increased risk for
VT or sudden cardiac death; therefore, no drug therapy is necessary.
Patients with PVCs and underlying heart disease (e.g., previous myocardial infarction) are at
increased risk for more serious arrhythmias. However, AADs do not reduce this risk, and in fact,
their use is associated with increased risk of lethal arrhythmias. All such patients should receive
medications proven to improve survival, including ²-blockers, antiplatelet agents, statins, ACE
inhibitors, and aldosterone antagonists if appropriate. An implantable cardioverter defibrillator
(ICD) is indicated in such patients with a left ventricular ejection fraction (LVEF) d 30-40% to
reduce mortality.
Nonsustained Ventricular Tachycardia

For patients with heart disease and LVEF > 40%, Maximize other cardiovascular medications with
proven effects on survival (see previous paragraph).
For patients with heart disease and LVEF 30% to 40%, recent studies indicate that they are at
increased risk for sudden cardiac death (usually from ventricular fibrillation). Use of an ICD
improves survival in this group, whereas amiodarone does not affect survival. Even in the absence
of PVCs or NSVT in this patient group, these patients are at increased risk for sudden cardiac death,
and an ICD is indicated to improve survival.
Unless contraindicated, these patients should also receive standard background therapy, which
includes aspirin, ACE inhibitors, -blockers, statins, and aldosterone antagonists.
Sustained Ventricular Tachycardia or Ventricular Fibrillation (Postresuscitation)
If the event occurs within 24-48 hours of myocardial infarction or because of other reversible
causes, no antiarrhythmic drug therapy is needed except ²-blockers.
If the event is not secondary to myocardial infarction or another reversible cause, ICD placement is
recommended.
Antiarrhythmic drugs (i.e., amiodarone) may still be required to decrease the number of defibrillator
discharges, increase patient comfort, and prolong battery life.
Amiodarone can be considered if the patient refuses ICD placement.
Torsades de Pointes
This is a specific variety of ventricular tachycardia with QRS complexes that appear to twist around
the ECG baseline. It is associated with a prolonged QT interval.
Clinical etiology
Causes are as follows:
• Genetic abnormalities in cardiac potassium channels
• Acquired
• Hypokalemia, hypomagnesemia
• Myocardial ischemia or infarction
• Subarachnoid hemorrhage
• Hypothyroidism
• Myocarditis or cardiomyopathy
• Arsenic poisoning
• Drug-induced causes (known association with torsades de pointes)
• Antiarrhythmics: Quinidine, procainamide, disopyramide, sotalol, ibutilide, dofetilide,

amiodarone
• Antipsychotics: Chlorpromazine, haloperidol, mesoridazine, thioridazine, pimozide, atypical

antipsychotics (e.g., quetiapine, ziprasidone)
• Antidepressants: amitriptyline, desipramine, doxepin, imipramine, nortriptyline
• Antibiotics: erythromycin, clarithromycin, gatifloxacin, moxifloxacin, sparfloxacin,

pentamidine, trimethoprim-sulfamethoxazole
• Others: methadone, droperidol
Treatment
• Stop the offending drug if possible.
• Administer direct-current cardioversion for hemodynamically unstable patients.
• Administer magnesium sulfate 2 g over 1 minute IV.
• Use a pacemaker or isoproterenol infusion to increase heart rate.
• Correct hypokalemia or hypomagnesemia.
Drug therapy
See
Tables 10-3,
10-4, and
10-5 for information about antiarrhythmic drugs. Antiarrhythmic drugs terminate or minimize
arrhythmias by
[Table 10-3. Effects of Antiarrhythmic Drugs on Cardiac Electrophysiology]
• Decreasing automaticity of abnormal pacemaker tissues
• Altering conduction characteristics of reentry

• Increasing refractory period
• Eliminating premature impulses that trigger reentry
Patient counseling
Patients should be counseled to take medication as prescribed. If a dose is missed, have the patient
take the dose as soon as it is remembered, unless close to the next scheduled dose. In this case, the
patient should skip the missed dose and continue the regular regimen; doses should not be doubled.
Many drug interactions are possible. Patients should inform health care providers of medications
prescribed prior to starting new medications, including over-the-counter medications (
Table 10-6).
Periodic ECG and laboratory assessments may be required to minimize or prevent adverse effects.
Patients should be educated that complete remission of their arrhythmia is unlikely. However,
symptomatic arrhythmias that have increased in frequency or severity should be reported to the
physician immediately.
Patients with atrial fibrillation or flutter should be educated about the importance of antithrombotic
therapy as well as the signs and symptoms of stroke. Patients with symptoms including sudden
onset of slurred speech, facial drooping, or muscle weakness should seek emergent care.
Antiarrhythmic drugs that are administered as extended-release formulations should not be crushed,
opened, or chewed. Advise patients to swallow the dose whole.
Drug-specific information
Amiodarone
The U.S. Food and Drug Administration now requires that a medication guide be distributed
directly to each patient to whom amiodarone is dispensed.
Visual disturbances are rare but should be reported immediately to the physician.
Difficulty breathing, shortness of breath, wheezing, or persistent cough should be reported

immediately to the physician.
If the patient experiences nausea or vomiting, passes brown or dark-colored urine, feels more tired
than usual, or experiences stomach pain, or if the patient's skin or whites of the eyes turn yellow, the
symptoms should be reported immediately to the physician.
Cardiac symptoms such as pounding heart, skipping a beat, or very rapid or slow heartbeats, as well
as lightheadedness or feeling faint, should be reported immediately to the physician.
Periodic laboratory tests to evaluate thyroid function, liver function, and pulmonary function, as
well as diagnostic tests such as chest x-ray, ECG, and eye exams may be necessary to assess and
prevent adverse events (
Table 10-7).
Amiodarone may cause skin photosensitivity. Patients should be advised to wear protective clothing
and sunscreen when exposed to sunlight or ultraviolet light.
Prolonged use may cause blue-gray skin discoloration.
Patients should tell their doctor and pharmacist about all other medicines they take, including
prescription and nonprescription medicine, vitamins, and herbal supplements.
Frequent administration with grapefruit juice may increase oral absorption. Encourage patients to
drink water with amiodarone or separate grapefruit juice consumption by at least 2 hours.
-blockers (including sotalol)

Patients with asthma and chronic obstructive pulmonary disease should be advised that ²-blockers
may worsen their symptoms of airway disease. Advise patients to notify physician immediately if
this occurs.
Patients with diabetes should be advised that ²-blockers may mask symptoms of hypoglycemia.
Patients should avoid abrupt withdrawal of -blocker therapy. If withdrawal of -blocker therapy is
desired, the patient should contact the physician for the dosage-tapering regimen, if necessary.
Digoxin
Refer to chapter 9.
[Table 10-4. Antiarrhythmic Drug Availability and Standard Dosing Regimens]
[Table 10-5. Pharmacokinetics of Antiarrhythmic Drugs]
[Table 10-6. Antiarrhythmic Drug Interactions and Significant Adverse Effects]
[Table 10-7. Suggested Monitoring Guidelines for Amiodarone]
Warfarin
Warfarin should be avoided at any time during pregnancy.
To determine the correct dosage, the physician may need to check the patient's INR regularly.
Encourage patients to maintain consistency in their diet. Abrupt changes, particularly in the intake
of green leafy vegetables, may alter the effectiveness of warfarin.
Minor cuts may take longer to stop bleeding. If a cut or injury fails to stop bleeding, patients should
be advised to contact their health care provider.
Excessive alcohol intake may alter the effectiveness of this medication.
Patients should tell their doctor and pharmacist about all other medicines they take, including
prescription and nonprescription medicine, vitamins, and herbal supplements.
10-6. Key Points
• All antiarrhythmic drugs are proarrhythmic.
• Cardiac arrhythmias range from benign to lethal.
• Antiarrhythmic drug therapy should be individualized to patient response while minimizing

adverse effects.
• Most antiarrhythmic drugs are hepatically eliminated and are associated with significant drug
interactions.
• Nonpharmacologic therapy is an important treatment modality, particularly for life-threatening

ventricular tachycardia and ventricular fibrillation.
• Treatment of atrial fibrillation should always include an assessment of antithrombotic therapy.
• Direct-current cardioversion is typically the treatment of choice for severely symptomatic

arrhythmias.
• Anticoagulant response to warfarin therapy is influenced by numerous factors, including diet, drug
interactions, genetics, and concomitant diseases.
• The treatment of excessive anticoagulation secondary to warfarin should be based on the INR, the
presence of active bleeding, and the risk of recurrent thromboembolism.
• Patient education and appropriate monitoring are important aspects of successful therapy that can
minimize adverse effects.
10-7. Questions
Which of the following is (are) adverse effect(s) of orally administered amiodarone?
I. Photosensitivity
II. Pulmonary fibrosis
III. Phlebitis
1.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Which of the following antiarrhythmic agents' mechanism of action is primarily the result of
sodium ion transport blockade?
A. Propafenone
2.
B. Ibutilide
C. Sotalol
D. Verapamil
E. Diltiazem

First-degree atrioventricular heart block can be categorized as a disorder of
I. automaticity.
II. reentry.
III. conduction.
3.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Each of the following can be symptoms of atrial fibrillation except
A. dizziness.
4. B. palpitations.
C. angina.
D. hypertension.
E. sudden-onset slurred speech.

Each of the following is recommended for monitoring patients requiring chronic amiodarone
therapy except
A. electrocardiogram.
5.
B. coagulation tests.
C. thyroid function tests.
D. liver function tests.
E. chest x-ray.

For the treatment of chronic atrial fibrillation, each of the following patients should receive
long-term warfarin therapy with a target INR 2.0-3.0 except for
A. patients with heart failure and diabetes.

6.
B. patients over 75 years old with hypertension.
C. a 50-year-old male with no risk factors for thromboembolism.
D. a 77-year-old female with diabetes and hypertension.
E. a 63-year-old male who has had a previous stroke.

Patients with which type of arrhythmia should be educated on performing vagal maneuvers to
restore sinus rhythm?
A. Paroxysmal supraventricular tachycardia

7.
B. Torsades de pointes
C. Atrial flutter
D. Sinus bradycardia
E. Ventricular fibrillation

Which of the following medications would be preferred for control of ventricular response in
patients with atrial fibrillation and heart failure?
A. Digoxin
8.
B. Verapamil
C. Diltiazem
D. Amlodipine
E. Dofetilide

Which of the following medications is (are) associated with torsades de pointes?
I. Dofetilide
II. Droperidol
III. Erythromycin
9.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Which of the following are important determinants of the pharmacokinetics and response to
warfarin?
I. CYP2C9 genotype
II. CYP2D6 genotype
III. VKORC1 genotype
10.
A. I only
B. II only
C. I and II only
D. I, II, and III
E. I and III only

What is the recommended dosage regimen for dofetilide in a patient with a calculated
creatinine clearance of 30 mL per minute?
A. Dofetilide therapy not recommended.

11.
B. 125 mcg PO bid
C. 125 mg PO bid
D. 500 mcg PO bid
E. 500 mg PO bid

Sotalol is metabolized by and inhibits the metabolism of which cytochrome P450 enzymes,
respectively?
A. CYP3A4 and CYP2D6

12.
B. CYP2D6 and CYP3A4
C. P-gp and CYP2D6
D. P-gp and CYP3A4

Which of the following antiarrhythmic agents does not increase digoxin concentrations when
used concomitantly?
A. Quinidine
13.
B. Dofetilide
C. Amiodarone
D. Diltiazem
E. Verapamil

A 66-year-old male with a past medical history of congestive heart failure and hypertension is
receiving lisinopril 10 mg PO qd, digoxin 0.25 mg PO qd, carvedilol 25 mg bid, and
spironolactone 25 mg PO qd at home. He now presents to the emergency room with a 1-week
history of intermittent palpitations and dizziness. The ECG reveals atrial fibrillation with a
ventricular rate of 130 bpm. The decision is made to attempt to restore normal sinus rhythm.
Which of the following represents the best therapeutic approach to cardioverting the patient?
A. Perform transesophageal echocardiography; if no thrombus is present, cardiovert; no need

14.
for anticoagulation.
B. Perform transesophageal echocardiography; if no thrombus is present, cardiovert;
anticoagulate for at least 4 weeks postcardioversion.
C. Anticoagulate for 4 weeks prior to cardioversion; discontinue anticoagulation
postcardioversion.
D. Anticoagulate for 2 weeks prior to cardioversion; continue anticoagulation for at least 4
weeks postcardioversion.
E. Direct-current cardiovert immediately.

After the initial successful cardioversion, the patient in the previous question continues to have
recurrent symptomatic atrial fibrillation episodes. Chronic therapy to maintain sinus rhythm is
to be initiated. Which of the following antiarrhythmic drugs would be the best choice to
maintain sinus rhythm?
15.
A. Flecainide
B. Amiodarone
C. Sotalol
D. Ibutilide
E. Digoxin

In a patient with mildly symptomatic paroxysmal supraventricular tachycardia, verapamil
should be used for which rhythm(s)?
I. Narrow QRS complex, regular interval

II. Wide QRS complex, regular interval
III. Wide QRS complex, irregular interval
16.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

A 53-year-old male has a past medical history of myocardial infarction and hypertension. He
presents to his doctor complaining of short (about 10 seconds in duration), intermittent
palpitations during the past 2 days. Tests rule out an acute myocardial infarction, and an
echocardiogram shows a left ventricular ejection fraction of 25%. The patient is sent home
with a Holter monitor to identify any arrhythmias. The Holter monitor reveals episodes of
PVCs and nonsustained ventricular tachycardia. What is the most appropriate intervention for
17. this patient?
A. No therapy is indicated.
B. Place an implantable cardioverter defibrillator (ICD).
C. Start propafenone.
D. Start verapamil.
E. Use direct-current cardioversion.

Treatment of torsades de pointes may include all of the following except
A. discontinuing any drugs associated with prolonged QT interval.

18. B. isoproterenol infusion.
C. adenosine.
D. magnesium sulfate.
E. atrial-ventricular pacing.

Which of the following antiarrhythmic agents requires dosage adjustment in patients with
impaired renal function?
A. Digoxin
19.
B. Amiodarone
C. Lidocaine
D. Verapamil
E. Propafenone

Which of the following is not a characteristic of atrial fibrillation?
A. No discernable P waves
20. B. Ventricular rate of 100-130 bpm
C. Regular QRS pattern
D. Narrow QRS complex
E. Chaotic atrial contractions

Which of the following would be the best choice for ventricular rate control in atrial fibrillation
secondary to hyperthyroidism?
A. Adenosine
21.
B. Digoxin
C. Verapamil
D. Propranolol
E. Atropine

A dose-limiting adverse effect of sotalol is
A. bradycardia.
22. B. polyneuropathy.
C. metallic taste.
D. agranulocytosis.
E. lupus-like syndrome.

Which of the following is not available in both intravenous and oral dosage forms?
A. Metoprolol
23. B. Amiodarone
C. Verapamil
D. Digoxin
E. Ibutilide

Dosage adjustment should be considered when warfarin is administered with the following
drugs, except for
A. amiodarone.
24.
B. sotalol.
C. quinidine.
D. propafenone.
E. diltiazem.

10-8. Answers
C. Photosensitivity is a common adverse effect of oral amiodarone. Patients should be

counseled to limit sun exposure and use sunscreen. Pulmonary fibrosis occurs during
1. prolonged therapy. Phlebitis would be expected to occur only during intravenous amiodarone
infusion, particularly through a peripheral intravenous line. A central line is preferred to
decrease risk of phlebitis.

A. Propafenone blocks sodium entry into the cardiac cell, slowing depolarization. Ibutilide and
2. sotalol act primarily by blocking potassium transport, whereas verapamil and diltiazem inhibit
the calcium channel.

B. Atrioventricular heart block is caused by slowed conduction through the atrioventricular
3.
node.

D. Because of loss of functional atrial contraction and rapid ventricular rate (producing
palpitations), cardiac output may decrease, resulting in decreased perfusion of major organs,
particularly the brain (dizziness, confusion, etc.) and heart (angina and heart failure
4. exacerbation). Depending on the vascular tone, blood pressure may remain stable or fall as a
direct result of decreased cardiac output; however, hypertension would not be expected.
Patients with atrial fibrillation are at increased risk of thrombosis, particularly stroke,
secondary to pooling of blood in the left atrium and subsequent thrombus formation.

B. See Table 10-7 for recommended monitoring parameters and schedule. Coagulation tests
are not routinely recommended for patients receiving amiodarone therapy. Coagulation tests
5.
may be required if a patient develops severe hepatotoxicity secondary to amiodarone or simply
requires concomitant warfarin therapy for atrial fibrillation.

C. Patients under age 75 with no thromboembolic risk factors are at low risk of stroke and
6.
should be treated with aspirin 75-325 mg daily rather than warfarin.

A. Vagal maneuvers are effective nonpharmacologic therapy for PSVT because the reentry
impulse circuit exists in the atrioventricular node. Although vagal maneuvers will slow the rate
7. in atrial fibrillation or flutter, they will not terminate the arrhythmia because the reentry circuit
is in the atrial tissue. Vagal maneuvers will have no effect on ventricular arrhythmia because
the impulse arises from below the AV node.

A. Digoxin would be the drug of first choice because it will help slow the ventricular rate and
it does not have negative inotropic effects. Both verapamil and diltiazem are negative inotropes
8. and should not be used in patients with heart failure and low LVEF. Although it is a calcium
channel blocker, amlodipine does not affect AV nodal conduction. Dofetilide is used for
conversion to and maintenance of sinus rhythm, not rate control.

9. E. All three medications are associated with torsades de pointes.

E. S-warfarin is primarily metabolized by CYP2C9. The VKORC1 gene determines the
activity of the vitamin K epoxide-reductase enzyme, which is the target for warfarin. Together,
10.
the CYP2C9 and VKORC1 genotypes account for nearly 50% of the variability in warfarin
dose. Warfarin is not affected by mutations in the CYP2D6 gene.

B. Dofetilide is renally eliminated and therefore must be adjusted according to creatinine
11.
clearance to decrease the significant risk of torsades de pointes. See Table 10-4.

12. E. Sotalol is eliminated almost entirely by the kidneys and is not affected by CYP450 enzymes.

13. B. Dofetilide does not increase digoxin concentrations when used concomitantly.

B. Since the patient appears to have been in atrial fibrillation for 1 week by history, there is a
significant risk of thromboembolism during conversion to sinus rhythm. Proper treatment
would require at least 3-4 weeks of anticoagulation (warfarin INR 2-3) prior to cardioversion,
14. followed by at least 4 weeks of anticoagulation postcardioversion. Alternatively, a
transesophageal echocardiogram can be used to rule out an atrial thrombus, allowing
immediate cardioversion. Because the atria will require time to recover normal contractile
activity, anticoagulation will be required for at least 4 weeks postconversion.

B. Because the patient has heart failure, the results of the Cardiac Arrhythmia Suppression
Trial (CAST) indicate that class Ic agents should be avoided because of increased risk of death.
15. Sotalol may worsen heart failure. Ibutilide is indicated for conversion only, not for
maintenance of sinus rhythm. Digoxin will control only the ventricular rate; it will have no
effect on maintaining sinus rhythm.

A. A wide QRS complex signifies conduction via an accessory pathway other than the AV
node. Because calcium channel blockers prolong conduction in the AV node and not in the
16. accessory pathways, administration of these agents will block the AV node and force impulses
to be conducted via the accessory pathways, which have shorter refractory periods.
Consequently, the ventricular response will significantly increase.

B. Patients with LVEF 30-40% and previous myocardial infarction are at increased risk of
sudden cardiac death, usually from ventricular fibrillation. Implantation of an ICD in these
patients reduces the risk of mortality. Propafenone has negative inotropic effects and may
17. worsen heart failure. The risk of ventricular proarrhythmia is significantly increased if
propafenone is used in this patient. Verapamil also would worsen heart failure and not reduce
the risk of mortality. Direct-current cardioversion is not indicated because the patient is stable.
All standard heart failure medications should be optimized.

C. Adenosine is typically used only to terminate paroxysmal supraventricular tachycardia.
Discontinuation of drugs that prolong the QT interval is essential to terminate torsades de
18.
pointes and prevent recurrences. Treatment should consist of intravenous magnesium sulfate
and electrical pacing. An isoproterenol infusion can be used while waiting for electrical pacing.

19. A. Digoxin requires dosage adjustment in patients with impaired renal function.

C. Atrial fibrillation represents chaotic atrial activity resulting in no identifiable P wave.
20. Because atrial fibrillation originates above the AV node, the QRS complex is narrow and the
ventricular rate is typically greater than 100 bpm.

D. -blockers are the preferred rate-controlling agent for hyperthyroidism because they inhibit
the adrenergic response and decrease thyroid hormone conversion (especially propranolol).
21.
Digoxin is not as effective in controlling the ventricular rate related to a hyperadrenergic state
(hyperthyroidism).

A. Sotalol possesses significant -blocking activity, and therefore the patient may experience
22.
adverse effects similar to traditional ²-blockers.

E. All of these medications except ibutilide are available in both intravenous and oral dosage
23.
forms.

B. Warfarin is metabolized by multiple cytochrome P450 isoenzymes, including CYP2C9,
CYP1A2, and CYP3A4. Amiodarone inhibits by CYP2C9, CYP1A2, and CYP3A4, quinidine
24. by unknown mechanisms, propafenone by CYP1A2 and CYP3A4, and diltiazem by CYP3A4.
Sotalol is primarily renally eliminated and does not result in cytochrome P450-mediated drug
interactions.

10-9. References
Ansell J, Hirsh J, Hylek E, et al. Pharmacology and management of the vitamin K antagonists.
Chest. 2008;133:160S-98S.
Antiarrhythmics Versus Implantable Defibrillators (AVID) Investigators. A comparison of

antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from near
fatal ventricular arrhythmias. N Engl J Med. 1997;337:1576-83.
Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A

comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med.
2002; 347:1825-33.
Bardy GH, Lee KL, Mark, DB, et al. Amiodarone or an implantable cardioverter-defibrillator for
congestive heart failure. N Engl J Med 2005;352:225-37.
Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, et al. ACC/AHA/ESC guidelines for the
management of patients with supraventricular arrhythmias: Executive summary. J Am Coll
Cardiol. 2003; 42:1493-531.
Cheng JWM, Frank L, Garrett SD, et al. Key articles and guidelines in pharmacotherapeutic
management of arrhythmias. Pharmacotherapy. 2004;24: 248-79.
Echt DS, Liebson PR, Mitchell LB, et al. Mortality and morbidity in patients receiving encainide,
flecainide, or placebo. N Engl J Med. 1991; 324:781-88.
Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC guidelines for the management of patients
with atrial fibrillation: A report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines and the European Society of Cardiology
Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the
Management of Patients with Atrial Fibrillation). J Am Coll Cardiol. 2006;48: e149-246.
Josephson M, Wellens HJ. Implantable defibrillators and sudden cardiac death. Circulation. 2004;
2685-91.
Klein AL, Grimm RA, Murray RD, et al. Use of transesophageal echocardiography to guide
cardioversion in patients with atrial fibrillation. N Engl J Med. 2001;344:1411-20.
Limdi NA, Veenstra DL. Warfarin pharmacogenetics. Pharmacotherapy. 2008;28:1084-97.
Ommen SR, Odell JA, Stanton MS. Atrial arrhythmias after cardiothoracic surgery. N Engl J Med.
1997;336:1429-34.
Sanoski CA, Schoen MD, Bauman JL. The Arrhythmias. In: Dipiro JT, Talbert RL, Yee GC, et al,
eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-Hill;
2008:279-314.
Singer DE, Albers GW, Dalen JE, et al. Antithrombotic therapy in atrial fibrillation. Chest.
2008;133:546S-92S.
Trujillo TC, Nolan PE. Antiarrhythmic agents: Drug interactions of clinical significance. Drug
Safety. 2000;23:509-12.
Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 guidelines for management of
patients with ventricular arrhythmias and the prevention of sudden cardiac death: A report of the
American College of Cardiology/American Heart Association Task Force and the European
Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop
Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of
Sudden Cardiac Death). Circulation. 2006;114:e385-484.
11. Ischemic Heart Disease - Kelly C. Rogers, PharmD Carrie S. Oliphant, PharmD, BCPS
Shannon Finks, PharmD, BCPS (AQ Cardiology)
11-1. Introduction
Definitions
• Ischemia: Lack of oxygen from inadequate perfusion caused by an imbalance between oxygen
supply and demand.
• Ischemic heart disease (IHD): Disease caused most frequently by atherosclerosis. IHD may
present as silent ischemia, chest pain (at rest or on exertion), or myocardial infarction (MI).
• Angina: Syndrome classically described as discomfort or pain in the chest, arm, shoulder, back,
or jaw. Angina is frequently worsened by physical exertion or emotional stress and usually
relieved by sublingual (SL) nitroglycerin (NTG). Patients with angina usually have coronary
artery disease (CAD) in at least one large epicardial artery.
• Atypical angina: Transient pain or discomfort lacking one or more of the criteria of classic
angina. Atypical angina is more common in women, elderly patients, and diabetics.
• Acute coronary syndrome (ACS): Syndrome encompassing the following:
• Unstable angina (UA)
• Non-ST-segment myocardial infarction (NSTEMI)
• ST-segment myocardial infarction (STEMI)
• Coronary artery disease: Chronic disorder that typically cycles in and out of the clinically
defined phases of ACS and asymptomatic, stable, or progressive angina.
• Percutaneous coronary intervention (PCI): Procedure to reopen a partially or completely

occluded coronary vessel to restore blood flow.
• Coronary artery bypass graft (CABG): Surgical procedure in which a vein is harvested from
the leg and attached to the heart as a new coronary vessel in order to bypass a diseased vessel.
Epidemiology of IHD
IHD is the leading cause of death in the United States for both men and women. It causes as many
deaths as cancer, chronic lower respiratory diseases, accidents, and diabetes combined.
Approximately 80 million adult Americans have some type of cardiovascular disease, which
includes high blood pressure, coronary heart disease (CHD), heart failure, stroke, and congenital
defects. In 2006, 829,072 Americans died of cardiovascular disease—nearly 2,400 per day, which
averages to one death every 37 seconds. Approximately every 25 seconds an American will suffer a
coronary event, and every minute someone will die from one. In 2006, there were 4,378,000 visits
to emergency departments and 72,151,000 physician office visits with a primary diagnosis of
cardiovascular disease.
In 2009, the estimated direct and indirect cost of cardiovascular disease is $475.3 billion. CHD,
which includes acute MI, angina, atherosclerotic cardiovascular disease, and all forms of chronic
IHD, is the single largest killer of American men and women. CHD caused one of every five deaths
in the United States in 2005.
In 2009, an estimated 785,000 people will have a new coronary attack. About 470,000 will have a
recurrent attack, and approximately 195,000 silent attacks occur per year.
For adults under 40 years of age, the lifetime risk for developing CHD is 49% for men and 32% for
women.
11-2. Normal Physiology versus Pathophysiology
Normal Physiology
The arterioles change their resistance and dilate as needed to enable the heart to receive a fixed
amount of O2. In response to physical exertion, an increase in blood pressure (BP), or an increase in
myocardial oxygen demand (MVO2), the arterioles dilate to maintain O2 supply to the heart.
Note: In atherosclerosis, plaque narrows the conductance vessel, causing the arterioles to dilate
under normal or resting conditions to prevent ischemia. With stress or exercise, the vasodilator
response is minimal, which causes ischemia and angina.
Pathophysiology Determinants of MVO2
• Heart rate (HR): Tachycardia will increase MVO2.
• Contractility: Increases in contractility will increase MVO2.
• Myocardial wall tension: It depends on ventricular volume and pressure. Increased pressure or
enlargement of the ventricle will increase systolic wall force and increase MVO2.
Determinants of Myocardial Oxygen Supply and Flow
Myocardial O2 supply is determined by
• Arterial O2 saturation and myocardial O2 extraction, which are relatively fixed under normal
circumstances
• Coronary flow, which is dependent on the luminal cross-sectional area of the coronary artery and
coronary arteriolar tone
Limits of flow are as follows: thrombi, spasm, congenital abnormalities, severe anemia, and severe
ventricular hypertrophy attributable to hypertension or aortic stenosis (abnormally high oxygen
demands).
Autoregulation of coronary blood flow occurs as follows:
• Adenosine, a potent vasodilator, is released from myocardial cells in response to decreased O2

supply (e.g., occlusion); increased sympathetic activity (exercise, mental stress, exposure to
cold); increased BP; and increased HR, which leads to increased MVO2.
• Normal arteries respond to the increased demand with increased blood flow and some vasodilation
of the large epicardial vessels.
• Atherosclerotic vessels lose this vasodilator response and develop constriction.
Vascular endothelium and control of arteriolar tone
The endothelium is the protective surface of the artery wall that separates the blood from the
vascular smooth muscle of the artery wall and promotes smooth muscle relaxation and inhibits
thrombogenesis. It secretes substances such as nitric oxide (NO), which produces vasodilation
similar to the therapeutic effects of NTG. Additionally, these substances are antithrombotic and
anti-inflammatory and can be thought of as defense mechanisms against noxious stimuli.
It also secretes substances that cause vasoconstriction. Normally, there is a beneficial balance
between vasodilation and vasoconstriction.
Things that can damage the endothelium (cigarettes, oxidized low-density lipoprotein, hypertension,
and PCI) lead to decreased NO production and loss of the endothelium's protective effects, which
leads to an imbalance promoting vasoconstriction as the predominant response to stress.
Diastole
Normally, the distribution of blood flow between the epicardial and endocardial layers is equal
during the period when coronary artery filling occurs.
In atherosclerosis, subendocardial blood flow is reduced.
Coronary vasospasm
A coronary vasospasm reduces blood flow, thereby causing ischemia, usually in areas of
atherosclerotic plaques.
Atherosclerosis
Atherosclerosis is the most common cause of myocardial ischemia. A decrease in the lumen of
coronary arteries attributable to stenosis leads to reduced myocardial perfusion and subsequent
ischemia.
Segmental atherosclerotic narrowing is most commonly caused by a plaque, which can fissure,
hemorrhage, and cause thrombosis, which then worsens the obstruction, reduces blood flow further,
and leads to ACS.
11-3. Diagnostic Procedures
Introduction
Diagnostic procedures include the following:
• History and physical examination
• Laboratory workup:
• Complete blood count (CBC) with platelet count
• Serial creatine kinase-myocardial bound and troponin levels (enzyme markers specific for
myocardial necrosis)
• Activated partial thromboplastin time (aPTT)
• Prothrombin time (PT) and international normalized ratio (INR)
• Fasting lipid panel within 24 hours of admission
• Resting electrocardiogram (ECG)
Exercise Tolerance Test
The following drugs can interfere with the exercise tolerance test (ETT, or treadmill test):
• Digoxin causes abnormal exercise-induced ST depression in about 30% of healthy patients.
• -blockers and vasodilators alter hemodynamic response to BP:
• Hold four or five half-lives before ETT.
• Withdraw -blockers gradually to avoid precipitating an attack.

• In some situations, patient may continue anti-ischemic therapy.
• Nitrates can attenuate angina.
• Flecainide may cause exercise-induced ventricular tachycardia.
Stress Imaging
Thallium Stress Test
The thallium stress test is a type of nuclear scanning test.
Pharmacologic stress imaging
In pharmacologic stress imaging, drugs "do the exercise" by increasing MVO2.
Dobutamine
• High doses up to 40 mcg/kg per minute cause positive inotropic and chronotropic effects that
increase cardiac demand that lead to ischemia.
• This drug is commonly used with an echocardiogram. Side effects include nausea, anxiety, tremor,
arrhythmias, angina, and headache.
Dipyridamole, adenosine, and regadenoson
• These drugs induce coronary vasodilation; they are used in conjunction with myocardial perfusion
scintigraphy.
• Dipyridamole side effects occur in up to 50% of patients and include angina, headache, nausea,
dizziness, flushing, and severe bronchospasm in patients with chronic obstructive pulmonary
disease (COPD) or asthma.
• Adenosine side effects occur in up to 80% of patients and include chest pain, headache, flushing,
shortness of breath, first-degree atrioventricular (AV) block, and severe bronchospasm in patients
with COPD or asthma.
• Regadenoson, a newer agent, has fewer side effects than adenosine. The most common are
shortness of breath and headache.
Drug interactions
• Xanthines (theophylline, caffeine) are adenosine receptor antagonists that attenuate the effects of
adenosine and dipyridamole.
• -blockers interact with dobutamine, but the interaction can be overcome by increasing the dose of
dobutamine.
Cardiac Catheterization
Cardiac catheterization (also called cath or angiography) involves the following procedure:
• A catheter is inserted into the femoral artery and guided to the heart.
• Radiocontrast dye is injected directly into the coronary arteries.
• The dye shows which arteries are involved and the extent of occlusion.
Complications may arise as follows:
• The patient can have an allergic reaction to iodine in the dye.
• The dye can be nephrotoxic.
• Arterial bleeding from access site, stroke, MI, or in rare cases death may occur.
11-4. Chronic Stable Angina, Prinzmetal's or Variant Angina, and Silent Ischemia
Chronic stable angina
Symptoms are caused by decreased O2 supply secondary to reduced flow.
Angina is considered stable if symptoms have been occurring for several weeks without worsening.
Characteristics of stable angina are as follows:
• Pain located over sternum that may radiate to left shoulder or arm, jaw, back, right arm, or neck
• Pressure or heavy weight on chest, burning, tightness, deep, squeezing, aching, viselike,
suffocating, crushing
• Duration of 0.5-30.0 minutes
• Symptoms may be precipitated by exercise, cold weather, postprandial, emotional stress, sexual
activity
• Pain relieved by SL NTG or rest

Prinzmetal's or variant angina
• This uncommon form of angina is usually caused by spasm without increased MVO2.
• Most patients have severe atherosclerosis.
• Recurrent, prolonged attacks of severe ischemia are characteristic.
• Patients are often between 30 and 40 years old.
• Pain usually occurs at rest or awakens the patient from sleep.
• ECG shows ST-segment elevation, which returns to baseline when the patient is given NTG.
Silent ischemia
• Ischemia in the absence of symptoms is "silent."
• About 75% of ischemic episodes in patients with stable angina are undetected.
• ECG shows ST-segment changes with elevation or depression during activity, but patient
experiences no symptoms.
• Silent ischemia occurs in about 20-30% of post-MI patients.
• Of patients with stable angina, 50% have silent ischemia; it is common in diabetics.
Pharmacologic Management
Chronic stable angina
Goals of therapy are as follows:
• To prevent MI and death
• To reduce symptoms of angina and occurrence of ischemia to improve quality of life
Antiplatelets
• Aspirin decreases the incidence of MI, adverse cardiovascular events, and sudden death.
• Clopidogrel (Plavix) has a greater antithrombotic effect than ticlopidine (Ticlid) and has fewer
side effects. Note: Ticlopidine has not been shown to reduce cardiovascular events in stable
angina.
• Indications for therapy are as follows:
• Aspirin (75-162 mg daily) is recommended in all patients with chronic IHD (with or without
symptoms) in the absence of contraindications.
• Clopidogrel (75 mg daily) is chosen when aspirin is absolutely contraindicated.
• Ticlopidine is not recommended because of its poor side effect profile.
• The combination of clopidogrel plus aspirin is not indicated in patients with stable disease not
undergoing PCI.
Anti-ischemic therapy
-blockers
• Effects on MVO2 are as follows:
• Inhibit catecholamine effects, thereby decreasing MVO2
• Decrease HR (negative chronotrope effects cause a decrease in conduction through the AV

node)
• Decrease contractility (negative inotrope effects cause a decrease in force of contraction)
• Reduce BP
• Effects on oxygen supply are as follows:
• -blockers cause no direct improvement of oxygen supply.
• They increase diastolic perfusion time (coronary arteries fill during diastole) secondary to
decreased HR, which may enhance left ventricle (LV) perfusion.
• Ventricular relaxation causes increased subendocardial blood flow.
• Unopposed alpha stimulation may lead to coronary vasoconstriction.
• Dosing is as follows:
• Start low, go slow.
• Titrate to resting HR of 55-60 bpm, maximal exercise HR 100.
• Avoid abrupt withdrawal, which can precipitate more severe ischemic episodes and MI; taper
over 2 days.
• Selection of -blockers is based on the following factors:
• -blockers with cardioselectivity have fewer adverse effects; they lose cardioselectivity at
higher doses.
• The intrinsic sympathomimetic activity (ISA) with acebutolol, carteolol, penbutolol, and
pindolol may not be as effective because the reduction in HR would be minimal; therefore,
there is a small reduction in MVO2. -blockers with ISA are generally reserved for patients
with low resting HR who experience angina with exercise.
• Lipophilicity is associated with more central nervous system (CNS) side effects.
• -blockers should be avoided in patients with primary vasospastic angina.
• -blockers are preferred in patients with a history of MI, chronic heart failure, high resting HR,
and fixed angina threshold.
• -blockers are used as first-line therapy if not contraindicated in patients with prior MI, ACS, or
history of heart failure.
• They are often used as initial therapy if not contraindicated in patients without prior MI.
• They are more effective than nitrates and calcium channel blockers (CCBs) in silent ischemia.
• They are effective as monotherapy or with nitrates, CCBs, ranolazine, or a combination thereof.
• They should be avoided in Prinzmetal's angina.
• They improve symptoms 80% of the time.
• All -blockers are effective, but not all are FDA indicated.
Nitrates (endothelium-independent vasodilators)
• Peripheral vasodilation leads to decreased blood return to the heart (preload), which leads to
decreased LV volume, decreased wall stress, and decreased O2 demand.
• Arterial vasodilation leads to decreased peripheral resistance (afterload), decreased systolic BP,
and decreased O2 demand.
• Nitrates can cause a reflex increase in sympathetic activity, which may increase HR or
contractility and lead to an increase in O2 demand in some patients. This problem can be
overcome with the use of a ²-blocker.
• Effects on O2 supply: Dilation of large epicardial coronary arteries and collateral vessels in areas
with or without stenosis leads to increased O2 supply.
• SL nitroglycerin or NTG spray can be used for the immediate relief of angina.
• Long-acting nitrates should be used as initial therapy to reduce symptoms only if -blockers or
CCBs are contraindicated.
• Long-acting nitrates in combination with -blockers can be used when initial treatment with -
blockers is ineffective.
• Long-acting nitrates can be used as a substitute for -blockers if -blockers cause unacceptable
side effects.
• Nitrates are used in patients with CAD or other vascular disease.
• Nitrates are preferred agents in the treatment of Prinzmetal's or vasospastic angina.
• Nitrates improve exercise tolerance.
• They produce greater effects in combination with -blockers or CCBs.
Calcium channel blockers
• CCBs act primarily by decreasing systemic vascular resistance and arterial BP by vasodilation
of systemic arteries.
• They cause decreased contractility and O2 requirement (all CCBs exert varying degrees of
negative inotropic effects): verapamil > diltiazem > nifedipine.
• Verapamil and diltiazem promote additional decreases in MVO2 by decreasing conduction

through the AV node, thereby decreasing HR.
• Effects on O2 supply are as follows:
• Increased diastolic perfusion time secondary to decreased HR, which may enhance LV
perfusion
• Decreased coronary vascular resistance and increased coronary blood flow by vasodilation of
coronary arteries
• Coronary vasodilation at sites of stenosis
• Prevention or relief of vasospastic angina by dilation of the epicardial coronary arteries
• CCBs can be used as initial therapy for reduction of symptoms. They are usually second line when
-blockers are contraindicated.
• They are used in combination with -blockers when initial treatment with -blockers is not
successful.
• They are used as a substitute for -blockers if initial treatment with -blockers causes
unacceptable side effects.
• Slow-release, long-acting dihydropyridines and nondihydropyridines are effective in stable angina.
• Avoid using short-acting dihydropyridines.
• Newer-generation dihydropyridines, such as amlodipine or felodipine, can be used safely in

patients with depressed LV systolic function and can be used in combination with ²-blockers.
Combination therapy: -blockers and nitrates
• -blockers can potentially increase LV volume and LV end-diastolic pressure. Nitrates attenuate
this effect.
• Nitrates increase sympathetic tone and may cause a reflex tachycardia. -blockers attenuate this
response.
Combination therapy: ²-blockers and CCBs
• -blockers and long-acting dihydropyridine CCBs are usually efficacious and well tolerated.
• CCBs, especially the dihydropyridines, increase sympathetic tone and may cause reflex
tachycardia. -blockers attenuate this effect.
• -blockers and nondihydropyridine CCBs should be used together cautiously because the
combination can lead to excessive bradycardia or AV block. The combination can also
precipitate symptoms of heart failure in susceptible patients.
Ranolazine
• Unlike -blockers and CCBs, ranolazine's antianginal and anti-ischemic effects occur without
causing any hemodynamic changes in BP or HR.
• The mechanism of action is not clearly understood, but it appears to inhibit the late Na current
(INa), preventing Ca overload and ultimately blunting the effects of ischemia by improving
myocardial function and perfusion.
• Ranolazine is indicated as first-line or add-on therapy in combination with -blockers, CCBs, or

nitrates for management of chronic stable angina.
Angiotensin-converting enzyme inhibitors
• Angiotensin-converting enzyme inhibitors (ACEIs) reduce the incidence of MI, cardiovascular

death, and stroke in patients at high risk for vascular disease (data from the Heart Outcomes
Prevention Evaluation [HOPE] trial).
• Controversy exists whether all ACEIs are equally effective or whether "tissue ACEIs" provide
better protection.
• Low-risk patients with stable CAD and normal or slightly reduced LV function may not benefit
from ACEI therapy as greatly as high-risk patients.
• ACEIs are used in all patients with left ventricular ejection fraction (LVEF) 40% and in those
with hypertension, diabetes, or chronic kidney disease unless contraindicated.
• They are used in all patients with CAD (by angiography or previous MI) or other vascular
disease.
• It is reasonable to consider angiotensin receptor blockers (ARBs) for patients who have
hypertension and other indications but who are intolerant of ACEIs, have heart failure, or have
had a MI with LVEF d 40%.
Lipid-lowering therapy
• Clinical trials have proved that lipid-lowering therapy should be recommended in patients with
established CAD, including chronic stable angina, even if only mild or moderate elevations of
LDL (low-density lipoprotein) cholesterol are present.
• Omega-3 fatty acids can be encouraged in either dietary consumption or capsule form (1 g daily)
for risk reduction; higher doses are recommended for treatment of elevated triglycerides.
• Therapeutic options to treat triglycerides or non-HDL cholesterol include niacin and fibrates (after
LDL-lowering therapy).
• Lipid-lowering therapy is used in patients with documented or suspected CAD or CHD risk
equivalents and LDL 100 mg/dL: target LDL < 100 mg/dL.
• It is used in high-risk patients: target LDL < 70 mg/dL may be appropriate.
• A combination of statins with other lipid-lowering therapy requires careful monitoring for
prevention of myopathy, rhabdomyolysis, and elevation of liver enzymes.
Prinzmetal's or variant angina
• -blockers have no role in management and may increase painful episodes.
• -blockers may induce coronary vasoconstriction and prolong ischemia.
• Nitrates are often used for acute attacks.
• CCBs may be more effective, may be dosed less frequently, and have fewer side effects than
nitrates.
• Nifedipine, diltiazem, or verapamil are all equally effective as single agents.
• Nitrates can be added if there is no response to CCBs.
• Combination therapy with nifedipine + diltiazem or nifedipine + verapamil has been reported to
be useful.
• Dose titration is recommended to obtain efficacy without unacceptable side effects.
• Treat acute attacks and provide prophylactic treatment for 6-12 months.
Silent ischemia
• The goal is to decrease the number of episodes, both symptomatic and asymptomatic.
• The initial step is to modify risk factors for IHD (smoking, hypercholesterolemia, hypertension).
• -blockers have shown improvement in patients with ischemic episodes and are preferred in
patients post-MI.
• CCBs are somewhat less effective than -blockers.

11-5. Unstable Angina or Non-ST-Segment Elevation Myocardial Infarction Pathophysiology
Introduction
The process of ischemic syndromes involves two essential events:
• Disruption of an atherosclerotic plaque
• Formation of a platelet-rich thrombus
The clinical manifestation depends on the extent and duration of the thrombotic occlusion. In UA or
NSTEMI, the thrombus does not completely occlude the vessel.
Pathogenesis and clinical presentations of UA and NSTEMI are similar but differ in severity. Many
structural and functional differences in disease pathophysiology exist between men and women.
Women present more commonly than men with NSTEMI and are found to have less obstructive
coronary disease than men.
Presentation
• Central or substernal or crushing chest pain can radiate to the neck, jaws, back, shoulders, and
arms.
• Patients may present with diaphoresis, nausea, vomiting, arm tingling, weakness, shortness of
breath, or syncope.
• Pain may be similar to typical angina except that the occurrences are more severe, may occur at
rest, and may be caused by less exertion than typical angina.
• UA and NSTEMI may be incorrectly interpreted as dyspepsia or indigestion.
• Pain is not relieved by SL NTG or rest.
• UA and NSTEMI may evolve into STEMI without treatment.
Diagnosis
• Chest pain persisting longer than 5 minutes that is unrelieved by SL NTG or rest
• Cardiac enzymes and ECG changes (

Table 11-1)
[Table 11-1. Cardiac Enzymes and ECG Changes: UA versus NSTEMI/STEMI]

Goals of Therapy
• Completely restore blood flow to the myocardium
• Prevent MI, arrhythmias, and ischemia
Pharmacologic Management of UA and NSTEMI
Morphine, oxygen, nitrates, and aspirin
Indications for therapy are shown in

Table 11-2.
Anti-ischemic therapy
-adrenergic blockade
• Preference is for an agent without ISA.
• Agents with 1 selectivity are preferred in patients with bronchoconstrictive disease.
• There is no evidence that one agent is superior to another.
• Initial choices include metoprolol, atenolol, and propranolol.
• -blockers can be used in all patients without contraindications.
• The first dose should be given orally within the first 24 hours unless contraindications exist,
including signs of heart failure, symptoms of low output state, increased risk of cardiogenic
shock, or other relative contraindications (e.g., bradycardia, hypotension, heart block, reactive
airway disease).
Nitrates
Nitrates are discussed in Table 11-2.
• There is no mortality benefit from the use of CCBs; therefore, they are not recommended as first-
line therapy.
• In patients with contraindications to -blockers, a nondihydropyridine CCB

[Table 11-2. Morphine, Oxygen, Nitrates, and Aspirin Therapy]
(verapamil, diltiazem) should be used in the absence of significant LV dysfunction or other

contraindications.
• Oral long-acting dihydropyridine CCBs provide additional control of anginal symptoms in

patients who are already receiving ²-blockers and nitrates.
• Avoid short-acting dihydropyridines.
Inhibition of the renin-angiotensin-aldosterone system
• ACEIs, ARBs, and aldosterone inhibitors are used for inhibition of the renin-angiotensin-
aldosterone (RAA) system.
• ACEIs should be started orally within the first 24 hours in all patients with UA, NSTEMI, or
STEMI with pulmonary congestion or LVEF d 40% unless contraindicated.
• It is reasonable to use ACEIs orally within the first 24 hours of STEMI in patients without
pulmonary congestion or LVEF d 40% unless contraindicated.
• ACEIs are recommended for life in those patients post UA or post NSTEMI with heart failure,
hypertension, or diabetes unless contraindicated.
• On the basis of the results from the HOPE trial, ACEIs may be considered in all patients post
UA or NSTEMI who do not have contraindications.
• ACEIs are recommended indefinitely in all patients post STEMI with LVEF 40% and for
those with hypertension, diabetes, or chronic kidney disease, unless contraindicated.
• ARBs should be given to those patients who are intolerant of an ACEI and who have heart
failure, LVEF 40%, or hypertension. Valsartan and candesartan are the only ARBs that have
established efficacy for this indication.
• Unless contraindicated, long-term aldosterone blockade should be prescribed for post-UA,

NSTEMI, or STEMI patients already receiving therapeutic doses of ACEIs and BBs who have
an LVEF 40% and either symptomatic heart failure or diabetes.
Antiplatelet therapy
Aspirin
Aspirin is discussed in Table 11-2.
Thienopyridines
• Thienopyridines include clopidogrel (Plavix) and ticlopidine (Ticlid).
• Inhibition of platelet aggregation is irreversible and takes 2-5 days to achieve full effect. Often
clopidogrel or ticlopidine is given in a loading dose for a more rapid effect (within 2 hours).
• Clopidogrel is the preferred agent in this class. Ticlopidine is rarely used because of severe
toxicities.
• The mechanism of platelet aggregation for clopidogrel and aspirin (ASA) differs; therefore, their
effects are additive.
• Clopidogrel is an alternative for patients who are allergic to ASA or who have a gastrointestinal
intolerance to ASA.
• Clopidogrel should be combined with ASA in patients undergoing stent implantation for a
minimum of 1-12 months, depending on the type of stent used and bleeding risk.
• In patients who do not undergo a PCI procedure, clopidogrel 75 mg daily should be combined
with ASA for at least 1 month and ideally up to 12 months.
Glycoprotein IIb/IIIa receptor inhibitors (GPIs)

Agents
• Abciximab (ReoPro)
• Eptifibatide (Integrilin)
• Tirofiban (Aggrastat)
Uses
• All of the agents can be used as adjunctive therapy in patients undergoing PCI.
• In combination with heparin and ASA, eptifibatide and abciximab have been shown to reduce the
incidence of combined death, MI, and recurrent ischemia in patients with UA or NSTEMI who
undergo PCI.
• GPIs are alternatives to clopidogrel when the appropriate loading dose was not given prior to PCI.
• Abciximab is used only when PCI will likely be done shortly after starting infusion.
• Eptifibatide and tirofiban are the preferred agents if PCI will be delayed.
• Special attention should be focused on proper dosage adjustments of renally cleared agents,
especially in elderly patients, women, and those with renal insufficiency.
• GPIs can be considered as an adjunct to ASA, clopidogrel, and anticoagulation during PCI.
• GPIs can be given during the intervention procedure just before stent deployment or
angioplasty.
• GPIs can be given upstream (prior to PCI) with aspirin +/- clopidogrel, depending on risk
factors.
• Upstream eptifibatide and tirofiban are preferred over abciximab.
• These agents are appropriate to use in patients who are not given a clopidogrel loading dose
upstream or in cases where the loading dose was not given more than 2-6 hours prior to PCI.
Anticoagulant therapy
Unfractionated heparin
• Heparin or enoxaparin should be given to all patients in combination with ASA and clopidogrel.
• Heparin is continued for a total of 24-48 hours or until a PCI procedure is completed.
• In patients with a planned CABG within 24 hours, heparin use is preferred to low molecular
weight heparin (LMWH).
Low molecular weight heparin and anti-Xa inhibitors
• Enoxaparin (Lovenox) is an LMWH.
• LMWH differs from unfractionated heparin (UFH) in size and affinity for thrombin.
• Advantages of LMWH over UFH include better bioavailability, a more predictable response, ease
of administration, fewer side effects, and no recommended routine monitoring.
• Trials comparing UFH to LMWH for the treatment of UA and NSTEMI have shown superiority
of enoxaparin over UFH, whereas trials with dalteparin showed equivalence to UFH.
• Fondaparinux (Arixtra) is an anti-Xa inhibitor.

• Fondaparinux has been found to be noninferior to enoxaparin in reducing the risk of ischemic
events.
• Fondaparinux significantly lowers major bleeding events compared with enoxaparin.
• Fondaparinux currently does not have FDA approval for this indication.
• Enoxaparin or UFH in combination with aspirin and clopidogrel should be given to all patients
unless contraindicated.
• Enoxaparin or fondaparinux is continued for the duration of hospitalization, up to 8 days, or

until a PCI procedure is completed.
• Enoxaparin may be superior to heparin in patients with UA or NSTEMI.
• For patients with increased risk of bleeding and not undergoing angiography, fondaparinux is
preferred.
• Fondaparinux is not recommended if a patient is going to undergo PCI.
Lipid-lowering therapy
• Lipid-lowering therapy is used in patients with documented or suspected CAD or CHD risk
equivalents and LDL 100 mg/dL: target LDL < 100 mg/dL.
• In high-risk patients, target LDL < 70 mg/dL may be appropriate.
• Lipid-lowering medications should be initiated prior to discharge.
11-6. Acute Myocardial Infarction: STEMI
Pathophysiology
More than 85% of all MIs occur by thrombus formation precipitated by atherosclerotic plaque
rupture. Aggregated platelets after plaque rupture can serve as a substrate for thrombus propagation,
leading to formation of an occlusive thrombus. This complete occlusion results in abrupt and
persistent ischemia that clinically manifests as STEMI. Left untreated, occlusion of the coronary
arteries can lead to sudden cardiac death. See
Table 11-3 for a comparison of STEMI and NSTEMI.
Location
Patients with right ventricular (RV) wall infarction should be managed similarly to LV infarction
except that NTG, diuretics, and other preload reducing agents should be avoided in RV wall MIs
because these patients are dependent on preload.
RV MI may require volume loading with IV fluids to maintain preload and cardiac output.
Symptoms differ from an LV wall MI in that an RV wall MI can cause hypotension, elevated
jugular venous pressure, and cardiogenic shock because of inadequate filling of the LV.
[Table 11-3. STEMI versus UA or NSTEMI]
Ventricular remodeling
Ventricular remodeling can occur as a result of myocardial necrosis and may continue for months
following MI. It leads to activation of the neurohormonal and renin-angiotensin systems that will
ultimately affect ventricular shape, size, and function. It precipitates chronic changes in ventricular
volume, ventricular dilation, hypertrophy, and eventually heart failure. ACEIs, ARBs, and ²-
blockers and the combination of hydralazine plus nitrates reduce the progression of ventricular
remodeling. A combination of ACEI plus ARB has been noted to cause more frequent side effects,
such as renal dysfunction and hyperkalemia. Aldosterone blockade has been proven beneficial in
the post-MI setting with LV dysfunction with eplerenone.
Prognosis
Mortality factors
• The highest risk of death from MI is generally within the first 48 hours.
• Anterior MIs usually involve a larger area of the myocardium than do inferior MIs, and thereby
have a higher mortality.
• An important prognostic factor following MI is LV function because heart failure is one of the
most serious complications of MI.
• Large anterior wall MIs, LV dysfunction, and complex ventricular ectopy carry the highest
mortality rate post-MI.
• Early identification and risk stratification can reduce mortality following MI.
Predictors of death
• High troponin concentration correlates with higher death rates in STEMI and NSTEMI.
• Predictors of death within 30 days post-MI include age greater than 70 years, hypertension, atrial
fibrillation, tachycardia, large infarct size, previous MI, and female.
• Lower-risk patients include those younger than 71 years of age with an LVEF 40%.
• Patients who continue to have frequent ventricular arrhythmias following MI are at high risk of
sudden cardiac death.
Presentation
Symptoms are similar to UA/NSTEMI. Atypical presentation is common in women, elderly

patients, and those with diabetes.
Diagnosis
Two of the following three criteria must be met:
• Chest pain generally lasting for more than 30 minutes
• ECG changes such that there is ST-segment elevation of 0.1 mV in two contiguous limb leads or
0.1-0.2 mV elevation in at least two contiguous precordial leads
• With respect to cardiac isoenzymes, troponin T or I elevation
Goals of Therapy in Acute MI
• Limit infarct size.
• Reverse myocardial ischemia and thereby salvage myocardium.
• Minimize complications.
• Reduce mortality.
Pharmacologic Management of STEMI
Morphine, oxygen, nitrates, and aspirin
Refer to see Table 11-2 for information about morphine, oxygen, nitrates, and aspirin therapy.
The following points apply to nitrate use in STEMI:
• If chest pain is not relieved by sublingual nitroglycerin, intravenous nitrates may be used for the
first 24-48 hours in all patients with acute MI who do not have hypotension, bradycardia,
tachycardia, or suspected RV infarctions. Nitrates salvage ischemic myocardium by relaxation of
vascular smooth muscles in veins, arteries, and arterioles.
• Nitrates demonstrate insignificant reductions in mortality beyond 48 hours. Use is reserved for
those patients with large acute MIs, persistent chest discomfort, heart failure, hypertension, or
persistent pulmonary congestion.
• Cautions and contraindications: Carefully titrate in patients with inferior wall MI because of its
frequent association with RV infarction. Such patients are especially dependent on adequate RV
preload to maintain cardiac output and can experience profound hypotension during nitrate
administration.
• Do not administer nitrates to patients who have received a phosphodiesterase inhibitor for erectile
dysfunction within the last 24 hours (48 hours for tadalafil).
Reperfusion therapy
Primary PCI
(See Section 11-7 for more information.)
• PCI is an intervention designed to reopen a partially or completely occluded coronary artery to

reestablish blood flow.
• The goal is door-to-balloon time of < 90 minutes.
• Mechanical reperfusion (percutaneous transluminal coronary angioplasty, or PTCA, with coronary

stenting) has been shown to be more successful than fibrinolysis.
• In patients who receive a stent, dual antiplatelet therapy with aspirin and clopidogrel therapy
should be added to the regimen, as in UA and NSTEMI, and continued for at least 12 months.
Fibrinolytic therapy
• Fibrinolytic therapy is also known as thrombolytic therapy.
• Fibrinolytic therapy improves myocardial O2 supply, limits infarct size, and decreases mortality.
• Controversy exists about one lytic agent's superiority over another.
• A door-to-needle time of < 30 minutes is an important goal.
• Signs of successful reperfusion include relief of chest pain, resolution of ST-segment changes, and
reperfusion arrhythmias, usually ventricular in nature.
• Fibrinolytic therapy is unsuccessful in approximately 22-30% of patients.

• ST-segment elevation is > 1 mm in two or more contiguous leads or left bundle branch block is
present (obscuring ST observational changes).
• Presentation is within 12 hours of symptom onset.
• The patient has no contraindications to fibrinolytic therapy and indications for therapy.
• In patients age > 75 years, fibrinolytic therapy may be useful and appropriate.
• Fibrinolytic therapy can be used in STEMI when time to therapy is 12-24 hours if chest pain is
ongoing.
• It should not be used if the time to therapy is > 24 hours and the ischemic pain is resolved.
• It should not be used for ST depression.
• Long-term therapy (e.g., 1 year) with clopidogrel plus aspirin is reasonable in patients who receive
fibrinolytic therapy.
Antithrombotic and anticoagulant therapy
• Indications for UFH, enoxaparin, and fondaparinux therapy are as follows:
• IV UFH is administered with selective fibrinolytics (e.g., alteplase, reteplase, and tenecteplase)
for the prevention of recurrent coronary thrombosis for a minimum of 48 hours.
• IV UFH can be administered with nonselective fibrinolytic agents (e.g., streptokinase) in

patients at high risk for systemic emboli (large or anterior MI, atrial fibrillation, previous
emboli, or known LV thrombus).
• Enoxaparin can be used as an alternative to UFH in patients receiving fibrinolytic therapy, with
different dosing strategies dependent on age and renal function.
• Patients not treated with a thrombolytic and without contraindications can be treated with IV
UFH or LMWH (enoxaparin 1 mg/kg subcutaneous bid or fondaparinux 2.5 mg IV followed
by 2.5 mg subcutaneous daily) for at least 48 hours for UFH and for up to 8-9 days for the
latter agents.
• Two studies support the benefits of clopidogrel 75 mg daily in addition to aspirin in STEMI
patients regardless of whether they receive fibrinolytic therapy or no reperfusion therapy. In
patients < 75, it is reasonable to administer a 300 mg loading dose of clopidogrel.
-adrenergic blockade
• Early -blocker use post-MI reduces infarct size, cardiovascular mortality, reinfarction rate, and
nonfatal cardiac arrests and increases probability of long-term survival.
• Oral -blocker therapy should be administered within the first 24 hours to patients who do not
have contraindications.
• It is reasonable to administer early IV -blocker therapy to STEMI patients who are hypertensive
and without any contraindications (e.g., heart failure, low output state, risk for cardiogenic shock,
bradycardia, blocks, hypotension).
• Late administration of a -blocker (at least 24 hours after MI) improves LV diastolic filling and
reduces risk of recurrent MI and death.
• Early therapy: -blockers should be given to all patients with acute MI who can be treated
within 12 hours of STEMI, regardless of administration of concomitant thrombolytic therapy.
IV or oral treatment should be started as soon as possible in all patients within 12-24 hours
after onset of symptoms if no contraindications exist.
• Late therapy: -blockers should be given to all patients without a clear contraindication to -
blocker therapy. Treatment should begin within a few days of the event (if not initiated earlier)
and should be continued indefinitely.
Glycoprotein IIb/IIIa Inhibitors (GPIs)
• Trials evaluating the role of platelet GPI in STEMI in combination with full- and half-dose
fibrinolytic agents have shown a more complete reperfusion at the price of higher bleeding rates,
especially in elderly patients.
• Abciximab administered early before primary PCI reduces the incidence of combined death, MI,
and recurrent ischemia in patients with STEMI.
Inhibition of the RAA system: ACEIs, ARBs, and aldosterone inhibitors
• The primary goal is to limit postinfarction LV dilatation and hypertrophy so that pump function is
preserved or improved. ACEIs attenuate the remodeling process and thereby slow the progression
to heart failure post-MI.
• Benefits of ACEIs are clearly most pronounced in patients with evidence of ventricular
dysfunction (either objective evidence such as LVEF d 40% or subjective evidence such as heart
failure symptoms).
• Other high-risk patients (previous MI, heart failure, and anterior MI without thrombolytic therapy)
have shown marked benefit from ACEIs.
• Recent studies of ACEI therapy suggest acute treatment should be given to patients considered at
higher risk because of a history of hypertension, diabetes, or previous MI and should be
continued indefinitely.
• An ARB can be used for those patients who are intolerant of an ACEI and have either clinical or
radiological signs of heart failure or an LVEF of d 40%.
• Aldosterone blockade (eplerenone, spironolactone) should be prescribed post-STEMI in those

patients already on an ACEI with an LVEF 40% and with either symptomatic heart failure or
diabetes.
• Aldosterone blockers should be avoided in patients with renal dysfunction (serum creatinine 2.5
mg/dL in men or 2.0 in women) or hyperkalemia (potassium > 5 mEq/L).
• Indications for therapy are discussed in Section 11-5.
Lipid lowering
Indications for therapy are discussed in Section 11-5.
• Verapamil or diltiazem should be used only with continuing ischemia when -blockers are either
contraindicated or used at maximum dose with nitrates.
• Verapamil or diltiazem should not be used in patients with left ventricular systolic dysfunction,
AV block, hypotension, or bradycardia.
Warfarin
• Warfarin is recommended in patients with indications for anticoagulation (e.g., LV thrombus,

atrial fibrillation, extensive wall motion abnormalities).
• In patients requiring triple therapy with aspirin, clopidogrel, and warfarin, an INR range of 2.0-2.5
is recommended with low-dose aspirin (75-81 mg daily).
• Use of warfarin in combination with aspirin, clopidogrel, or both is associated with an increased
risk of bleeding and should be carefully monitored.
Treatment of ventricular fibrillation post-MI
• The risk of ventricular fibrillation (VF) is at highest during the first 4 hours post-MI and then
declines sharply.
• Prophylactic antiarrhythmic use has been shown to increase all-cause mortality when used to
prevent VF; it is not recommended.
• Amiodarone may be used if patients experience VF or hemodynamically compromising

ventricular tachycardia following MI.
11-7. Revascularization
Percutaneous Coronary Intervention Procedures
Procedure types include balloon angioplasty (PTCA), coronary stenting, and ablative technologies
(laser, atherectomy).
Primary PCI is a very effective method for reestablishing coronary perfusion and is suitable for at
least 90% of patients. Primary PCI should be performed as quickly as possible with the goal of a
medical contact-to-balloon or door-to-balloon time of 90 minutes or less. Primary PCI is favored
over fibrinolytic therapy because PCI-treated patients experience lower short-term mortality rates
and fewer nonfatal reinfarctions and hemorrhagic strokes than those treated with fibrinolytic
therapy.
Facilitated PCI refers to a strategy of planned immediate PCI after an initial pharmacologic
regimen, such as full-dose fibrinolytics, GPIs, or another pharmacologic regimen. Rescue PCI refers
to the use of PCI when fibrinolytic therapy has failed.
Revascularization is not preferred in women with low-risk features.
Potential complications of invasive PCI include problems with arterial access site, technical
complications, acute vessel closure, restenosis, and acute renal failure secondary to nephrotoxic
dye.
Bare Metal Stents and Drug-Eluting Stents
Restenosis is the loss of 50% or more of the diameter of the in-stent lumen at the site of an initially
successful intervention; it usually occurs within the first 3-6 months.
Drug-eluting stents (DES) were introduced in 2003 and have the principal advantage of reducing
restenosis over angioplasty alone and bare metal stents (BMS).
Pharmacologic agents, such as sirolimus, paclitaxel, zotarolimus, and everolimus, are embedded in
the steel stent and released over time.
DES have reduced the rate of restenosis to less than 5%.
Anticoagulation during PCI
Anticoagulation is mandatory because the vessel manipulation during PCI is inherently

thrombogenic.
Possible agents include the following:
• UFH has traditionally been the mainstay of therapy.
• Studies have shown that the direct thrombin inhibitor bivalirudin may be as effective as heparin
but with less bleeding. The use of bivalirudin seems to eliminate the need for GPIs when an
appropriate clopidogrel loading dose is given.
• Enoxaparin use during PCI can be challenging. Dosing is determined based on the last
administered dose of enoxaparin. If the last subcutaneous dose was administered within 8 hours,
no additional enoxaparin needed; if the last dose was administered after 8-12 hours, 0.3 mg/kg IV
should be given.
• Fondaparinux is not recommended during PCI secondary to catheter thromboses. If PCI is

planned, an alternative anticoagulant should be used.
Antiplatelet therapy during PCI
Aspirin and clopidogrel

Clopidogrel in combination with aspirin is used to reduce in-stent thrombosis and is used for at
least 1 month with BMS, ideally up to 12 months, and a minimum of 12 months with DES for
patients not at high risk for bleeding.
The dose of aspirin is 162-325 mg daily for at least 1 month after BMS, 3 months after sirolimus-
eluting stents, and 6 months after paclitaxel-eluting stents. With the newer DES, everolimus, and
zotarolimus, a minimum of 75 mg of aspirin daily is acceptable after PCI. After the initial poststent
period is complete, the dose of aspirin can be reduced to 75-162 mg daily.
Glycoprotein IIb/IIIa inhibitors

Although similar effects have been noted with each of the GPIs, the timing of PCI should be
determined before an agent is selected.
GPIs are administered before or during PCI for patients who are troponin-positive or have other
high-risk features.
Use abciximab or eptifibatide if PCI is anticipated soon after presentation (< 4 hours).
GPIs can be omitted if bivalirudin is used in place of UFH and at least 300 mg clopidogrel was
administered at least 6 hours prior.
Coronary Artery Bypass Graft Surgery
CABG is indicated in patients with multivessel disease with LV dysfunction or significant disease
of a major coronary vessel that is not amenable to PCI.
Clopidogrel should not be used for a minimum of 5 days prior to CABG to reduce the risk of
bleeding.
11-8. Primary Prevention: Risk Factor Modification
Introduction
The majority of the causes of cardiovascular disease are known and modifiable. Therefore, risk
factor screening should begin at age 20 with the hope that all adults know the levels and
significance of risk factors as routinely assessed by their primary care provider.
Nonmodifiable Risk Factors
Age
• Men > 45
• Women > 55 (or those who had an early hysterectomy regardless of age)
Race
Higher risk in African American males and females than in Caucasian males and females
Family history
• Father or brother with a coronary event before age 55
• Mother or sister with a coronary event before age 65
Modifiable Risk Factors
• Smoking
• Hypertension
• Hyperlipidemia
• Diabetes
• Metabolic syndrome
• Obesity
• Physical inactivity
• Alcohol consumption
Pharmacologic Therapy
Aspirin
The Eighth American College of Clinical Pharmacy Evidence-Based Clinical Practice Guidelines
on Antithrombotic and Thrombolytic Therapy (Chest Guidelines) recommends that ASA (75-325
mg/day) be considered for individuals who have at least moderate risk (based on age and cardiac
risk factor profile with a > 10% risk of cardiac event over 10 years) for CAD and who are without
contraindications.
The American College of Cardiology and American Heart Association (AHA) recommend doses of
75-162 mg/day in persons at higher risk of cardiovascular disease (especially those with a 10-year
risk of CHD > 10%).
The American Diabetes Association recommends ASA therapy to prevent cardiovascular events in
most patients with diabetes who are > 40 years of age and have no contraindications to ASA.
The recommendation for aspirin use for primary prevention is stronger in men than in women, and
aspirin can be prescribed based on risk profile (stroke versus MI) and age:
• For women < 65 years of age who are at risk for ischemic stroke and low bleeding risk, 75-100
mg/day can be preventive.
• For women > 65 years of age who are at risk for ischemic stroke or MI and low bleeding risk, 75-
100 mg/day can be preventive.
ACEIs and ARBs
In the HOPE trial, ramipril demonstrated effectiveness in reducing the risk of MI, stroke, and death
from cardiovascular causes in patents at high risk of a major cardiovascular event. ACEIs may be
used as protective agents.
The European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery
Disease (EUROPA) similarly showed perindopril to be beneficial in patients with evidence of
coronary heart disease but without heart failure and has led to the increased use of ACEIs in
patients with vascular disease but without heart failure or LV dysfunction.
Results from the Prevention of Events with Angiotensin Converting Enzyme (PEACE) inhibition
trial suggest that low-risk patients with CAD who are receiving maximal therapy with ²-blockers,
aspirin, and lipid-lowering therapies do not gain clinically significant benefit from the addition of
trandolapril 4 mg daily.
Chronic ACEI therapy may be most beneficial in high-risk patients (uncontrolled hyperlipidemia,
hypertension, smoking, proteinuria, vascular disease).
Lipid lowering
Consider lipid lowering in all patients at risk for a coronary event.
Antioxidants
There is no consistent evidence with vitamin E or other antioxidant therapy to recommend its use
for primary prevention of heart disease.
Nonpharmacologic Therapy for IHD
Smoking cessation
Smoking cessation is one of the most important risk-modifying behaviors. Evidence suggests that
the best adherence to a cessation program combines pharmacotherapy with behavioral modification.
A wide range of smoking cessation aids (prescription and nonprescription) products is available.
Nicotine replacement alone is not an effective management strategy for smoking cessation. Nicotine
combined with bupropion has been the most successful.
Diet
Diets low in saturated fat and high in fruits, vegetables, whole grains, and fiber are associated with
a reduced risk of cardiovascular disease. With respect to omega-3 fatty acids: the AHA Dietary
Guidelines recommends inclusion of at least two servings of fish per week (particularly fatty fish).
Food sources high in alpha-linolenic acid (e.g., soy bean, canola, walnut, and flaxseed oil and
walnuts and flaxseeds) are also recommended.
Exercise
Regular aerobic physical activity increases a person's capacity for exercise. Exercise plays a role in
both primary and secondary prevention of cardiovascular disease.
Current guidelines from the U.S. Centers for Disease Control and Prevention and National Institutes
of Health recommend that Americans should accumulate at least 30 minutes of moderate-intensity
physical activity on most, preferably all, days of the week to prevent risk of chronic disease in the
future. The Institute of Medicine recommends 60 minutes of physical activity per day.
Weight loss
Weight loss can reduce blood pressure, lower blood glucose levels, and improve blood lipid
abnormalities. A goal of 5% to 10% of body weight loss is associated with decreased morbidity and
mortality.
Pharmacotherapy used for weight loss should be reserved for (a) those with a body mass index
exceeding 30 and (b) those with a body mass index exceeding 25 plus other risk factors for
comorbid diseases.
Alcohol consumption
Lowest cardiovascular mortality occurs in those who consume one or two drinks per day. People
with no alcohol consumption have higher total mortality than those drinking one or two drinks per
day.
In the absence of alcohol-related illnesses, one or two drinks per day in males and one alcoholic
drink per day in females may be considered for high-risk patients. A drink equivalent amounts to a
12-ounce bottle of beer, a 4-ounce glass of wine, or a 1.5-ounce shot of 80 proof spirits.
A general increase in alcohol consumption at the population level is not recommended.
11-9. Pharmacology
Anti-ischemic Drug Therapy
-blockers
The use of -blockers in anti-ischemic drug therapy is discussed in Chapter 8.
Nitrates
Mechanism of action
• Organic nitrates are prodrugs that must be transformed to exert pharmacological effect.
• NTG leads to denitration of the nitrate, liberation of NO, guanylyl cyclase stimulation, the
conversion of guanosine triphosphate to cGMP, and vasodilation.
• NO also reduces platelet adhesion and aggregation and affects endothelial function and vascular
growth.
Properties
• Oral: Isosorbide dinitrate and NTG undergo extensive first-pass metabolism when given orally.
Mononitrate does not; it is completely bioavailable.
• IV: IV use achieves the highest concentrations. Usually, IVs are used for only 24 hours to avoid
developing tolerance.
• SL tablet or spray for immediate-release: Unlike tablets, spray does not degrade when exposed
to air. The half-life is 1-5 minutes regardless of route.
Doses
See
Table 11-4 for information about doses.
Monitoring parameters
Blood pressure and heart rate should be monitored.
Adverse drug reactions

Adverse drug reactions to nitrate are described in
Table 11-5.
Drug-drug interactions
Nitrate drug-drug interactions are described in
Table 11-6.
Drug-disease interactions
• Glaucoma
• Intraocular pressure may increase.
• Use with caution in patients with glaucoma.
• Hypertrophic obstructive cardiomyopathy
• Severe aortic stenosis: Can cause hypotension and syncope
Contraindications
• If sildenafil and vardenafil are used within 24 hours.
• If tadalafil is used within 48 hours.
• Hypersensitivity to nitrates can occur.
• General instructions:
• Avoid alcohol consumption.
• May cause dizziness; use caution when driving or engaging in hazardous activities until drug
effect is known.
• When standing from a sitting position, rise slowly to avoid an abrupt drop in blood pressure.
• Notify physician of acute headache, dizziness, or blurred vision.
• Instructions for sublingual tablets:
• Keep tablets in their original container.
• Dissolve tablet under the tongue. Lack of tingling does not indicate a lack of potency.
[Table 11-4. Pharmacologic Properties and Doses of Nitrates]
[Table 11-5. Nitrate Adverse Reactions]
[Table 11-6. Nitrate Drug-Drug Interactions]
• Take one tablet at the first sign of chest pain. If chest pain is unrelieved, seek emergency
medical attention.
• Instructions for translingual spray:
• Spray under tongue or onto tongue.
• Hold spray nozzle as close to the mouth as possible and spray medicine onto or under the
tongue.
• Do not inhale the spray, use near heat or open flame, or use while smoking.
• Close mouth immediately after spraying.
• Avoid eating, drinking, or smoking for 5-10 minutes.
• If the pain does not go away after one spray, seek emergency medical attention.
• Instructions for transmucosal tablets:
• Place tablet between cheek and gum. Do not chew tablet; allow it to dissolve over a 3- to 5-hour
period.
• Touching the tablet with the tongue or hot liquids may increase release of the medication.
• Instructions for ointment:
• Measure the correct amount using the papers provided with the product.
• Use papers for the application, not fingers.
• Apply to the chest or back.
• Instructions for transdermal patches:
• Tear the wrapper open carefully. Never cut the wrapper or patch with scissors. Do not use any
patch that has been cut by accident.
• Apply to a hairless area and rotate sites to avoid irritation. Be sure to remove the old patch
before applying a new one.
• Do not put the patch over burns, cuts, or irritated skin.
• Remove the patch approximately 12-14 hours after placing it on every day. This prevents
tolerance to the beneficial effects of NTG.
• Used patches may still contain residual medication; use caution when disposing around children
and pets.
• Store the patches at room temperature in a closed container, away from heat, moisture, and
direct light. Do not refrigerate.
• Instructions for sustained-release tablets:
• Take at the same time each day as directed.
• Do not chew or crush tablets or capsules.
The use of calcium channel blockers in anti-ischemic drug therapy is discussed in Chapter 8.
Ranolazine (Ranexa)
Mechanism of action
The mechanism of action of ranolazine not clearly understood, but appears to inhibit the late Na
current (INa), preventing Ca overload and ultimately blunting the effects of ischemia by improving
myocardial function and perfusion.
Dose
• Initiate at 500 mg po bid and titrate to a maximum dose of 1 g po bid as tolerated.
• Take without regard to meals. Do not crush, break, or chew tablet.
• Monitor anginal symptoms.
• Perform baseline and follow-up ECGs to evaluate QT interval.
• Monitor BP regularly in patients with severe renal insufficiency.

Adverse reactions to ranolazine are described in
Table 11-7.
Drug-drug interactions are described in
Table 11-8.
Contraindications
• Use with strong CYP3A inhibitors.
• Use with CYP3A inducers.
• Use in patients with clinically significant hepatic impairment.
• Ranolazine is not for acute anginal symptoms.
• Notify physician if you take any other medications, including over-the-counter medications.
[Table 11-7. Ranolazine Adverse Drug Reactions]
[Table 11-8. Ranolazine Drug-Drug Interactions]
• Notify physician if you have any history or family history of QTc prolongation or congenital long-
QT syndrome or if you are receiving drugs that prolong the QTc interval, such as antiarrhythmic
agents, erythromycin, and certain antipsychotics (thioridazine, ziprasidone).
• Do not take drugs that are strong CYP3A inhibitors (e.g., ketoconazole, clarithromycin,
nefazodone, ritonavir) or strong inducers of CYP3A (e.g., rifampin, carbamazepine, phenytoin).
• Notify physician if you take drugs that are moderate CYP3A inhibitors (e.g., diltiazem, verapamil,
erythromycin) or P-glycoprotein inhibitors (e.g., cyclosporine).
• Ranolazine can be taken with or without meals.
• Ranolazine should be swallowed whole; do not crush, break, or chew tablets.
• Ranolazine may cause dizziness or lightheadedness; therefore, notify physician if you experience
fainting spells, and know how you react to this drug before operating heavy machinery.
Inhibition of the RAA system
See Chapter 9 for information about angiotensin-converting enzyme inhibitors, angiotensin receptor
blockers, and aldosterone blockers.
Antiplatelet Drug Therapy
Aspirin
Mechanism of action
Aspirin blocks prostaglandin synthesis, which prevents the formation of thromboxane A2.
Dose
• At the onset of chest pain: 160-325 mg chewed and swallowed
• Maintenance dose: 75-162 mg for life, except immediately post PCI, when a maintenance dose
of 75-325 mg daily is appropriate depending on the type of stent received
• Monitoring parameters: signs of bleeding, renal function, tinnitus

Adverse reactions to aspirin are described in
Table 11-9.
Antiplatelet agents, anticoagulants, nonsteroidal anti-inflammatory drugs (NSAIDs), and celecoxib
may all increase the risk of bleeding if used in combination with ASA.
• Peptic ulcer disease (PUD).

• Other active bleeding.
• Aspirin may cause gastric ulceration.
• An enteric-coated tablet is recommended.
• Avoid additional over-the-counter products containing ASA, NSAIDs, or salicylate ingredients

without the direction of a physician.
[Table 11-9. Aspirin Adverse Reactions]
• Patients who received a stent or were treated medically after an acute coronary event will need the
combination of clopidogrel and aspirin.
• Notify physician of dark, tarry stools, persistent stomach pain, difficulty breathing, unusual
bruising or bleeding, or skin rash.
• Do not crush an enteric-coated product.
Thienopyridines
Mechanism of action
Thienopyridines block adenosine diphosphate (ADP)-mediated activation of platelets by selectively
and irreversibly blocking ADP activation of the glycoprotein IIb/IIIa complex.
Dose
Clopidogrel
• Loading dose: 300-600 mg orally
• Maintenance dose:
• 75 mg daily combined with aspirin for at least 1 month and ideally up to 12 months in patients
who were treated medically and did not undergo cardiac cath
• 75 mg daily combined with aspirin for at least 1 month with BMS, ideally up to 12 months, and
a minimum of 12 months with DES for patients not at high risk for bleeding
• 75 mg daily for life in patients who cannot tolerate aspirin
Ticlopidine
• Loading dose: 500 mg orally

• Maintenance dose: 250 mg bid
Clopidogrel
Monitor for signs of bleeding.
Ticlopidine
Monitor CBC with differential every 2 weeks for the first 3 months of therapy, liver function tests
periodically, and for signs of bleeding.
Discontinue ticlopidine if the absolute neutrophil count drops to < 1,200 or platelet count drops to <
80,000.

Adverse reactions to thienopyridine are described in
Table 11-10.
Drug-drug interactions are described in
Table 11-11.
PUD or other active bleeding
[Table 11-10. Thienopyridine Adverse Reactions]
Contraindications
• Hypersensitivity to an individual product
• Active bleeding (e.g., gastrointestinal or intracranial hemorrhage)
• Severe liver disease
• Neutropenia, thrombocytopenia
• All patients who received a stent or were treated medically after an acute coronary event will need
the combination of clopidogrel and aspirin.
• Avoid additional ASA, salicylates, and NSAID products unless under the direction of a physician.
• Notify physician for unusual bleeding or bruising; blood in the urine, stool, or emesis; skin rash;
or yellowing of the skin or eyes.
• Do not stop taking without discussing with physician.
• Discontinue clopidogrel at least 5 days prior to CABG.
Glycoprotein IIb/IIIa receptor inhibitors
Mechanism of action
• Blockade of the glycoprotein IIb/IIIa receptor prevents fibrinogen binding, thus inhibiting platelet
aggregation, the final common pathway for platelet aggregation.
Properties of individual agents

See
Table 11-12 for properties of GPIs.
[Table 11-11. Thienopyridine Drug-Drug Interactions]
[Table 11-12. Pharmacologic Properties of Glycoprotein IIb/IIIa Receptor Inhibitors]
Indications and doses

Table 11-13 provides information about indications and doses.
Hematocrit and hemoglobin, platelet count, PT and aPTT, and activated clotting time (with PCI)
should be monitored.

Adverse drug reactions include bleeding, thrombocytopenia, and allergic reaction from repeated
exposure (abciximab).
Antiplatelet agents, anticoagulants, NSAIDs, and celecoxib may all increase the risk of bleeding if
used in combination with GPIs.
Contraindications
• Active bleeding
• Platelet count < 100,000

• History of intracranial hemorrhage, neoplasms, AV malformations, or aneurysm
• History of stroke within the past 30 days or any history of hemorrhage stroke
• Severe hypertension (BP > 180/110 mm Hg)
• Major surgery within past 6 weeks
• Dialysis dependent (eptifibatide only)
Anticoagulants
Heparin
Mechanism of action
Heparin enhances the action of antithrombin III, thereby inactivating thrombin and preventing the
conversion of fibrinogen to fibrin.
Dose
• UA and NSTEMI: 60-70 units/kg (maximum 5,000 units) IV bolus, 12-15 units/kg/h (maximum
1,000 units/h) infusion titrated to an aPTT range of 50-70 seconds
• STEMI (in combination with tPA, rPA, or tenecteplase): 60 units/kg (maximum 4,000 units)
IV bolus, 12 units/kg/h (maximum 1,000 units/h)
[Table 11-13. Indications and Doses of the Glycoprotein IIb/IIIa Receptor Inhibitors]
infusion titrated to an aPTT range of 50-70 seconds for 48 hours
Monitor aPTT, PT, platelet count, hemoglobin and hematocrit, signs of bleeding, and activated
clotting time (with PCI).

Bleeding, thrombocytopenia, hemorrhage, epistaxis, allergic reactions, and osteoporosis may occur.
Protamine can be used to reverse the effects of heparin; 1 mg of protamine neutralizes 100 units of
heparin.
used in combination with UFH. Switching from heparin to LMWH may increase the risk of
bleeding and has been reported to cause death.
Drug-disease interaction
Contraindications
• History of heparin-induced thrombocytopenia
• Severe thrombocytopenia
• Active bleeding
• Suspected intracranial hemorrhage
LMWH (enoxaparin) and factor Xa inhibitors (fondaparinux)
Mechanism of action
The mechanism of action is similar to that of heparin; however, these drugs are stronger inhibitors
of thrombin formation through inhibition of factor Xa.
Properties
Properties are described in
Table 11-14.
Dose
• Enoxaparin (Lovenox):
• UA and NSTEMI: 1 mg/kg SC q12h (creatinine clearance < 30 mL/min: 1 mg/kg SC q24h)
• STEMI with fibrinolytic therapy: 30 mg IV then, 1 mg/kg SC q12h (creatinine clearance <
30 mL/min: 1 mg/kg SC q24h); for patients > 75 years of age, eliminate the IV bolus and give
0.75 mg/kg SQ q12h
• Fondaparinux (Arixtra), as an alternative to UFH:
• UA and NSTEMI: For patients in whom a conservative strategy is selected over an invasive
strategy, 2.5mg SC daily up to 9 days
• STEMI (with or without fibrinolytics): 2.5 mg IV, then SC daily up to 9 days; not
recommended if patient undergoing primary PCI
[Table 11-14. Properties of Low Molecular Weight Heparin versus Unfractionated Heparin]
Serum creatinine, platelet count, hemoglobin and hematocrit, anti-Xa levels (optional), and signs of
bleeding should be monitored. It is not necessary to monitor aPTT or PT with LMWH or direct Xa
inhibitors.

Adverse reactions include bleeding, thrombocytopenia, hemorrhage, and epistaxis.
used in combination with LMWH.
Switching from LMWH to UFH may increase the risk of bleeding and has been reported to cause
death.
PUD or any active bleeding
Warnings
Patients with recent or anticipated epidural or spinal anesthesia are at risk of hematoma and
subsequent paralysis.
Contraindications
• Severe thrombocytopenia
• Active bleeding
• Suspected intracranial hemorrhage
Thrombolytic Therapy
Mechanism of action
Thrombolytic therapy acts either directly or indirectly to activate or convert plasminogen to plasmin
to lyse a formed clot. The conversion of plasminogen to plasmin activates the body's natural
thrombolytic-fibrinolytic system, which lyses the clot and releases fibrin degradation products.
Dose
Thrombolytic doses are given in

Table 11-15.
CBC, ECG, aPTT, signs of bleeding, and signs of reperfusion should be monitored.
Adverse reactions include bleeding, intracranial hemorrhage (< 1%), stroke (< 2%), and epistaxis.
used in combination with thrombolytics.
Contraindications
Contraindications
• Any prior intracranial hemorrhage
• Known structural cerebrovascular lesion
• Ischemic stroke within 3 months, except acute ischemic stroke within 3 hours
• Known intracranial neoplasm (primary or metastatic)
• Active internal bleeding or bleeding diathesis (does not include menses)
• Suspected aortic dissection
• Significant closed head or facial trauma within 3 months
[Table 11-15. Thrombolytic Doses]
Relative contraindications
• Severe uncontrolled hypertension (BP > 180/110 mm Hg)
• History of prior ischemic stroke greater than 3 months, dementia, or known intracerebral
pathology not covered in contraindications
• Current use of anticoagulants in therapeutic doses (INR > 2-3)
• Traumatic or prolonged (> 10 min) cardiopulmonary resuscitation or major surgery (< 3 weeks)
• Noncompressible vascular punctures
• Recent (within 2-4 weeks) internal bleeding
• For streptokinase, prior exposure (especially within 5 days to 2 years) or prior allergic reaction
• Pregnancy
• Active peptic ulcer
• History of chronic severe hypertension
11-10. Key Points
• Angina is a syndrome described as discomfort or pain in the chest, arm, shoulder, back, or jaw.
Angina is frequently worsened by physical exertion or emotional stress and is usually relieved by
sublingual NTG. Patients with angina usually have CAD.
• Anginal symptoms are caused by a decrease in O2 supply because of reduced blood flow.
• The goals for treating stable angina are to prevent death, reduce symptoms, and improve quality of
life.
• Aspirin has been shown to decrease the incidence of MI, adverse cardiovascular events, and
sudden death in patients with CAD.
• -blockers are first-line therapy for treatment of angina in patients with or without a history of MI
if there are no contraindications.
• Patients prescribed nitrates for treatment of angina need to be counseled on their appropriate use.
• Ranolazine is a novel antianginal medication that does not affect BP or HR. It can be used as
initial therapy or in combination with other antianginal medications.
• Upon hospital presentation with UA, NSTEMI, or STEMI, initial therapy for all patients is
morphine, oxygen, nitroglycerin, and aspirin. If there are no contraindications, all patients should
be given aspirin therapy for life.
• The first-line anti-ischemic therapy for the treatment of UA and NSTEMI is a -blocker. If chest
pain continues or a -blocker is contraindicated, a calcium channel blocker or long-acting nitrate
should be considered, in that order.
• In addition to aspirin therapy for life, clopidogrel should be administered to all patients who
undergo stent replacement for at least 1 month after BMS but ideally up to 12 months and for at
least 12 months after DES stents. Long-term treatment with clopidogrel may be beneficial in
patients with established vascular disease. Clopidogrel should be withheld for 5-7 days prior to
surgery to reduce the risk of major bleeding.
• Any of the available glycoprotein IIb/IIIa agents should be considered in patients undergoing a
PCI procedure. In patients without a planned PCI, eptifibatide or tirofiban can be used for
medical treatment.
• All patients presenting with UA or NSTEMI should receive anticoagulation with UFH or LMWH.
• STEMI differs from UA and NSTEMI in that a totally occlusive clot causes damage across the
entire thickness of the myocardial wall. The damage to the heart is more extensive with STEMI
and ECG changes differ.
• Primary reperfusion (either PCI or fibrinolytic therapy) is the main treatment strategy for STEMI,
with primary PCI being preferred.
• Ventricular remodeling (post-MI) resulting after myocardial damage can be slowed and possibly
reversed by using long-term ACE inhibition and ²-blockade (use ARBs as alternative to ACEIs
and hydralazine + nitrates in combination with ACEIs in African American patients with LV
dysfunction).
• Secondary prevention of MI should include aspirin, -blockers, ACEIs, and statin therapy (to
achieve an LDL goal of < 100 mg/dL; < 70 mg/dL in high-risk patients) in all patients who have
no contraindications.
• Aldosterone blockade should be considered post-STEMI in patients with an LVEF 40% and
either symptomatic heart failure or diabetes.
11-11. Questions
Questions 1-3 refer to this case:
Mr. Smith is a 66-year-old white male who presented to his local physician with complaints of
chest pain. He described the pain as sharp, aching, and non-radiating. The pain, which he has had
for the past few weeks, has occurred mainly during his daily walk and is usually relieved when he
stops to rest.
Past medical history: hypertension, PUD, asthma, CAD
Family history: Father died of a stroke at 86; mother died at age 82 with diabetes mellitus and heart
failure; sister died of MI at 52
Social history: Smokes 1 pack per day × 40 years; drinks alcohol socially 1-2 times a week
Medications:
• Proventil MDI 2 puffs prn
• Flovent 44 mcg 2 puffs bid

• Prilosec 20 mg daily
• Aspirin 75 mg daily
• HCTZ 25 mg daily
Vital signs: BP 148/92; HR 82; RR 18; height 72 ; weight 200 lbs
Labs: (fasting) total cholesterol 226 mg/dL; TG 110 mg/dL; HDL 38 mg/dL; LDL 166 mg/dL;
Chem 12-within normal limits
ECG: Normal (patient currently pain free)
Cath 6 years ago: Minimal two-vessel disease
How would you classify Mr. Smith's chest pain?
A. Unstable angina
1. B. Stable angina
C. Variant angina
D. Silent ischemia
E. NSTEMI

Considering Mr. Smith's situation, which of the following would be the most appropriate
therapeutic intervention?
A. SL NTG prn
2.
B. Propranolol
C. Tirofiban
D. Verapamil and SL NTG prn
E. Atenolol, amlodipine, and SL NTG

What additional medication should be considered for Mr. Smith?
A. Ticlopidine
3. B. Atorvastatin
C. Clopidogrel
D. Eptifibatide
E. Reteplase

Which of the following effects on myocardial oxygen demand do ²-blockers not cause?
A. Decreased HR
4. B. Decreased BP
C. Decreased contractility
D. Peripheral vasodilation
E. Decreased conduction through the AV node

Which of the following statements is true regarding the use of calcium channel blockers in
IHD?
A. Amlodipine and felodipine reduce MVO2 by decreasing conduction through the AV node.
B. Calcium channel blockers should be used as first-line therapy in patients with stable angina.
5. C. Newer-generation dihydropyridines like nifedipine immediate-release are safe in the
treatment of IHD.
D. Calcium channel blockers can be used in combination with ²-blockers to attenuate the effect
of increased sympathetic tone that some dihydropyridines may cause.
E. The combination of verapamil and metoprolol in a patient with reduced LV systolic function
is safe and well tolerated by most patients.

Which of the following counseling points should be made to a patient being prescribed SL
NTG?
I. Take at the same time each day as directed.

II. Keep tablets in their original container.
III. Take at the first sign of chest pain; if chest pain is unrelieved, seek emergency medical
6. attention.
A. III only
B. I, II, and III
C. I and III only
D. I and II only
E. II and III only

Which of the following is not considered a potential cardiovascular benefit of ACEIs in IHD?
A. They reduce the incidence of MI.

B. They reduce the incidence of cardiovascular death and stroke in patients at high risk for
vascular disease.
7.
C. Agents with high tissue ACE inhibition have been proven to be superior and provide better
protection.
D. ACE inhibitors should be used in all stable angina patients with known CAD who also have
diabetes.
E. ACE inhibitors have shown greater benefit post-MI in higher-risk patients.

Which of the following drugs do not appear to interact with an exercise tolerance test (ETT)?
A. Nitrates
8. B. Digoxin
C. Atenolol
D. Flecainide
E. Clopidogrel

Ideal properties for a -blocker in the treatment of UA or NSTEMI include which of the
following?
A. Available as an IV product, cardioselectivity

9.
B. Low lipophilicity, has intrinsic sympathomimetic activity (ISA)
C. Has ISA, cardioselectivity
D. Cardioselectivity, low lipophilicity, does not have ISA
E. Noncardioselective, high lipophilicity

Nitrates decrease oxygen demand through the following mechanism(s):
I. Peripheral vasodilation
II. Arterial vasodilation
III. Decreasing contractility
10.
A. I only
B. II only
C. I and II only
D. II and III only
E. I, II, and III

The possible benefits of LMWH over UFH include all of the following except
A. predictable response.
11. B. ease of administration.
C. no recommended routine monitoring.
D. stronger affinity for thrombin.
E. no renal adjustment necessary.

Which of the following -blockers has ISA activity?
A. Tenormin
12. B. Sectral
C. Inderal
D. Lopressor
E. Coreg

Which of the following medications is contraindicated within 24 hours of a nitrate?
A. Metoprolol
13. B. Quinapril
C. Verapamil
D. Sildenafil
E. Felodipine

Which of the following is the preferred narcotic to relieve chest pain after the use of SL NTG?
A. Meperidine
14. B. Oxycodone
C. Morphine
D. Hydromorphone
E. Fentanyl

Questions 15 and 16 refer to this case:
J. O. is a 54-year-old male who presents to the hospital with crushing substernal chest pain and
radiation to his left arm. Past medical history is significant for hypertension, COPD, and gout. J. O.
has a history of smoking × 30 years and occasionally consumes alcohol. Vital signs on admission
include BP 170/85; pulse 72; RR 18; temp 97. Before admission, the patient was taking enteric-
coated aspirin 81 mg daily; Combivent inhaler 2 puffs qid; Tiazac 240 mg daily; allopurinol 300 mg
daily.
Allergies: sulfa
Lab/diagnostic tests:
• ECG: ST-segment depression, T-wave changes
• Troponin: T-positive × 3
• Ejection fraction: < 35%
• LDL: 135 mg/dL
Diagnosis:
• NSTEMI
• Heart failure
What is the preferred -blocker for this patient?
A. Propranolol
15. B. Carvedilol
C. Labetalol
D. Metoprolol
E. Nadolol

All of the following therapies should be considered in this patient except
A. reteplase.
16. B. clopidogrel.
C. enalapril.
D. simvastatin.
E. unfractionated heparin.

Questions 17 and 18 refer to this case:
S. D. is a 56-year-old female who presents to the local emergency room complaining of crushing,
substernal chest pain × 3 hours, which has been unrelieved by SL NTG. PMH is pertinent for
hypertension, T2DM, hypercholesterolemia, and metabolic syndrome. Heart rate and rhythm are
regular, and no S3 or S4 sounds are present. Vital signs include BP 184/119, HR 100, and RR
32/min. S. D.'s ECG shows ST-segment elevation > 1 mm in leads II, III, and aVF. She is
immediately admitted to the chest pain center and started on oxygen.
Which of the following criteria for the diagnosis of MI are present in S. D.?
A. Chest pain symptoms are relieved by SL NTG.

B. ST-segment elevation is greater than 1 mm in two or more noncontiguous leads.
17.
C. Chest pain symptoms with ECG changes are consistent with MI or necrosis.
D. S. D. does not meet the criteria for MI based on the above presentation because myocardial
enzymes have not been evaluated.
E. Negative enzymes rule out MI.

Which of the following agents should be administered to S. D.?
A. tPA 100 mg IV over 90 minutes

18. B. IV magnesium
C. Prophylactic lidocaine
D. Metoprolol 5 mg IV
E. Diltiazem 240 mg po

What medications should a patient who is post-MI with preserved LVEF receive as discharge
therapy?
A. Aspirin, clopidogrel, diltiazem, and simvastatin

19.
B. Aspirin, metoprolol, enalapril, atorvastatin, and SL NTG
C. Clopidogrel, metoprolol, enalapril, and simvastatin
D. Morphine, aspirin, SL NTG, and clopidogrel
E. Morphine, SL NTG, aspirin, and oxygen

The anticoagulant effect of unfractionated heparin requires the binding to which plasma
cofactor?
A. Thrombospondin
20.
B. Antithrombin III
C. Plasminogen
D. Factor XIIa
E. Factors II, VII, IX, and X

Question 21 refers to this case:
S. P. is a 45-year-old marathon runner. He presents to the emergency department with complaints of

chest pain during his morning run. His father died of a myocardial infarction at age 48. His past
medical history is positive for angina, hyperlipidemia, and hypertension. His current medications
include aspirin, pravastatin, nifedipine, and clonidine. His electrocardiogram is consistent with
acute ischemia. His HR is 52 and BP is 170/100. CBC and Chem-7 are within normal limits.
All of the following interventions are appropriate for S. P. except
A. enoxaparin 1 mg/kg SC bid.

21. B. IV metoprolol followed by po metoprolol.
C. nitroglycerin SL prn and IV drip titrated to pain and blood pressure.
D. continue aspirin.
E. morphine if NTG does not control the pain.

Which one of the following agents is not indicated in the setting of STEMI when
pharmacologic reperfusion is the planned strategy?
A. Eptifibatide
22.
B. LMWH
C. Aspirin
D. tPA
E. Metoprolol

Which of the following agents would not be administered at the same time as heparin?
A. tPA
23. B. Reteplase
C. Eptifibatide
D. TNKase
E. Streptokinase

Which of the following statements about the GPIs is not true?
A. Abciximab, eptifibatide, and tirofiban are all administered as a bolus followed by a

continuous infusion.
24. B. It is possible to experience an allergic reaction after repeated exposure to abciximab.
C. Eptifibatide, tirofiban, and abciximab can all be reversed by a platelet infusion.
D. Tirofiban and eptifibatide are renally eliminated; therefore, dosage adjustment is required
for patients with renal dysfunction.
E. Abciximab, eptifibatide, and tirofiban are all indicated as adjuncts to PCI.

11-12. Answers
B. Angina is considered stable if symptoms have been occurring for several weeks without
1.
worsening, it lasts < 30 minutes, and it is relieved by rest or SL NTG.

D. This regimen will help control his angina without ²2-blocking effects in this asthmatic
patient, as well as lower his BP. SL NTG will be useful for acute attacks. A is not the best
answer because this patient also needs a medication to lower his BP. B is incorrect because
2. propranolol is not ²1-selective and could worsen his asthma. C is incorrect because GPIs are
not indicated in stable angina. E is incorrect; combination therapy is not recommended as first-
line therapy and should be considered only when initial treatment with a ²-blocker is not
successful.

B. Mr. Smith has an elevated LDL with known heart disease, and he needs to be treated to a
goal LDL of < 100 mg/dL (consider LDL < 70 mg/dL). A and C are incorrect; these antiplatelet
3.
agents are not indicated for treating stable angina unless a patient cannot tolerate aspirin. D and
E are incorrect because GPIs and thrombolytics are not indicated in stable angina.

D. Unlike nitrates or calcium channel blockers, ²-blockers do not cause peripheral
4.
vasodilation.

D. The increased sympathetic tone caused by some dihydropyridines can lead to a reflex
tachycardia, which would be detrimental in an IHD patient. Therefore, using a ²-blocker to
block this effect would be desirable. A is incorrect; unlike verapamil or diltiazem, the
dihydropyridines do not decrease conduction through the AV node. B is incorrect; CCBs are
5.
not indicated as first-line therapy unless a patient has a contraindication to a ²-blocker. C is
incorrect because immediate release nifedipine can lead to increased side effects if not
combined with a -blocker. E is incorrect because both verapamil and metoprolol can lead to
worsening systolic function, and used in combination, they would be unsafe.

E. SL NTG should be kept in the original amber bottle, because exposure to light or extreme
temperatures will cause it to lose potency. III is correct, and patients should be counseled to
6.
take one tablet and seek medical attention if chest pain is not relieved. I is incorrect; SL NTG is
used on a prn basis and should not be taken at the same time each day.

7. C. It has not been proven that so-called tissue ACEIs are better than other ACE inhibitors.

E. Clopidogrel, or Plavix, does not have any pharmacologic interaction with an ETT. Digoxin
can cause an abnormal exercise-induced ST depression in approximately 30% of healthy
8. patients. -blockers and vasodilators can alter hemodynamic response to BP and should be
withdrawn gradually 4-5 half-lives before ETT. Nitrates can attenuate angina and flecainide
may cause exercise-induced ventricular tachycardia.

D. Ideally, a -blocker used for the treatment of UA or NSTEMI would have 1-receptor
selectivity, no ISA, and low lipophilicity. Being available as an intravenous agent is not an
advantage because -blockers should be initiated orally to avoid adverse effects. 1-receptor
9.
selectivity would reduce the chance for bronchospasm, and low lipophilicity would reduce the
neurological side effects. -blockers with ISA reduce heart rate to a lesser degree than non-ISA
-blockers, thus producing a smaller decrease in oxygen demand.

C. Nitrates are vasodilators acting on both arteries and in the periphery, thereby decreasing
10. preload and afterload. Regarding anti-ischemic therapy, only ²-blockers and
nondihydropyridine calcium channel blockers reduce contractility.

E. Renal adjustment is necessary with LMWH. UFH does not require dosage adjustment in
renal patients and is preferred to LMWH in patients with a creatinine clearance < 30 mL/min.
11. LMWH does appear to have advantages over UFH in ease of administration, its affinity to
thrombin (stronger than UFH), its more predictable response, and the fact that it does not
require monitoring.

B. -blockers with ISA activity include Sectral (acebutolol), Cartrol (carteolol), Levatol
12. (penbutolol), and Visken (pindolol). Tenormin (atenolol), Inderal (propranolol), Lopressor
(metoprolol), and Coreg (carvedilol) do not have ISA activity.

D. Sildenafil use is contraindicated within 24 hours of a nitrate. ²-blockers (metoprolol),
13. ACEIs (quinapril), and calcium channel blockers (verapamil and felodipine) can be safely
combined with nitrates.

C. Morphine has vasodilator properties, thereby decreasing both preload and afterload, which
decreases oxygen demand. In addition, morphine lowers heart rate by relieving pain and
14. anxiety. If a true morphine allergy exists, meperidine may be used as an alternate agent.
Oxycodone, hydromorphone, and fentanyl are not recommended for the treatment of anginal
pain.

D. With the patient's history of COPD, a ²-blocker with ²1-receptor selectivity is preferred.
The only agent with ²1-selectivity in this list is metoprolol. All of the remaining agents are
15.
nonselective. In addition, metoprolol would be an appropriate ²-blocker to use in this patient
with heart failure.

A. Reteplase is a thrombolytic agent, which does not have a role in the treatment of NSTEMI.
Thrombolytic therapy is indicated for the treatment of STEMI. Clopidogrel and GPI
(eptifibatide) should be considered in all patients with NSTEMI with or without PCI.
Eptifibatide and tirofiban can be used in patients who are medically managed; abciximab is
16. reserved for patients with a scheduled PCI procedure. Lipid-lowering therapy with an HMG-
CoA reductase inhibitor (e.g., simvastatin) should be initiated in this patient because his LDL
is > 130 mg/dL. This patient has a clear indication for an ACEI (enalapril) because of his
ejection fraction of < 40%. An anticoagulant should be started on presentation; options include
UFH or LMWH.

C. A is incorrect. Although chest pain unrelieved by NTG is a diagnostic criterion for MI, two
criteria must be present before the diagnosis can be made. B is incorrect because ST-segment
elevation > 1 mm must be found in two or more contiguous leads. S. D. has both chest pain
symptoms and ECG changes that are consistent with myocardial infarction. C is correct
17.
because she meets two of the three criteria for diagnosing MI. S. D. does not have positive
enzymes, which would meet the third diagnostic criteria. D is incorrect because positive
enzymes do not have to be present for the diagnosis of MI to be made (as is the case with S.
D.).

D. One of the relative contraindications to fibrinolytic therapy is severe uncontrolled
hypertension (BP > 180/110 mm Hg). A is not appropriate in this patient with BP of 184/119
mm Hg. Routine use of magnesium post-MI is not recommended and should be reserved for
patients with hypomagnesemia. No labs were given for S. D., so answer B is not appropriate at
this time. Prophylactic lidocaine has been shown to increase all-cause mortality and is not
18.
recommended in the early management of STEMI for prevention of VF. Therefore, C is
incorrect. -blockers reduce the incidence of ventricular arrhythmias, recurrent ischemia,
reinfarction, infarct size, and mortality in patients with STEMI. Because S. D. does not have
any contraindications to -blockade, D is the correct choice. E, calcium channel blockers, do
not have a role in STEMI when a ²-blocker can be given.

B. ACEIs, -blockers, aspirin, statin therapy, and SL NTG should be given to all patients
without contraindications post-MI. Clopidogrel can be combined with aspirin and can be
continued for at least 12 months regardless of whether the patient underwent PCI. Answers A
and C, which include clopidogrel, are incorrect, however, because A omits ²-blockade, and C
19.
omits aspirin therapy. Calcium channel blockers can be given if a patient has contraindications
to -blockade, but it is not recommended as first-line treatment. Answers D and E are incorrect
because ACE inhibition and -blockade are omitted. Answer E would be a correct choice for
the immediate treatment of someone who presents with STEMI, but not as discharge therapy.

B. Heparin's anticoagulant effect requires binding to antithrombin (previously antithrombin
20. III), and that binding converts antithrombin from a slow, progressive thrombin inhibitor to a
very rapid inhibitor of thrombin and factor Xa.

B. One of the contraindications to -blockade is a HR < 55 bpm. Because S. P. has an HR of
21. 52 bpm, the only inappropriate therapy of the choices given would be B. Enoxaparin, NTG,
morphine, and aspirin are all therapies that should be continued.

A. Glycoprotein IIb/IIIa inhibition is still controversial in the setting of STEMI, especially
when a fibrinolytic agent is administered. The role of GPIs in STEMI is rapidly evolving, and
22. trials to date in combination with full- and half-dose fibrinolytic agents have shown a more
complete reperfusion at the price of higher bleeding rates. At this point, there is no formal
recommendation on using eptifibatide or another GPI in STEMI.

E. A GPI should be administered with heparin, and therefore C is not the correct answer.
Combination of UFH with streptokinase is less desirable because it is a nonspecific
23. fibrinolytic, and UFH may increase the risk of bleeding because of streptokinase's long half-
life. Therefore, answer E is the correct choice. Heparin should be administered for at least 48
hours with the other lytic choices to reduce risk of reocclusion.

C. The only GPI that is reversed by a platelet infusion is abciximab. All of the remaining
selections are true statements. All of the available GPI agents are administered as a bolus and
24. infusion. Abciximab is a monoclonal antibody; therefore, it is possible to develop an allergic
reaction upon rechallenge. Only two GPIs are renally eliminated: eptifibatide and tirofiban. All
of the agents are indicated as adjunct to PCI, so E is true.

11-13. References
American Diabetes Association. Aspirin therapy in diabetes. Diabetes Care. 2004;27(suppl 1): S72-
73.
Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines update for the
management of patients with unstable angina/non-ST-segment elevation myocardial infarction: A
report of the American College of Cardiology/American Heart Association Task Force on
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Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction). J Am Coll Cardiol.
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Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA Guidelines for the Management of
Patients with ST-Elevation Myocardial Infarction: A Report of the American College of
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Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction).
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Antman EM, Hand M, Armstrong PW, et al. 2007 Focused update of the ACC/AHA 2004
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the American College of Cardiology/American Heart Association Task Force on Practice
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http://content.onlinejacc.org/cgi/reprint/51/2/210.pdf.
Becker RC, Meade TW, Berger PB, et al. The primary and secondary prevention of coronary artery
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Dagenais GR, Yusuf S, Bourassa MG, et al. Effects of ramipril on coronary events in high-risk
persons: Results from the Heart Outcomes Prevention Evaluation Study. Circulation.
2001;104:522-26.
Deepak LB, Fox KA, Hacke W, et al. Clopidogrel and aspirin versus aspirin alone for the
prevention of atherothrombotic events. N Engl J Med. 2006;354: 1706-17.
Dobesh PP, Trujillo TC. Ranolazine: A new option in the management of chronic stable angina.
Pharmacotherapy. 2007;27:1659-76.
Fox KM, European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary
Artery Disease Investigators. Efficacy of perindopril in reduction of cardiovascular events among
patients with stable coronary artery disease: Randomised, double-blind, placebo-controlled,
multicentre trial (the EUROPA study). Lancet. 2003;362:782-8.
Fraker TD Jr, Fihn SD, writing on behalf of the 2002 Chronic Stable Angina Writing Committee.
2007 chronic angina focused update of the ACC/AHA 2002 guidelines for the management of
patients with chronic stable angina: A report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines Writing Group to develop the focused
update of the 2002 guidelines for the management of patients with chronic stable angina. J Am
Coll Cardiol. 2007;50: 2264-74. Available at:
http://content.onlinejacc.org/cgi/reprint/50/23/2264.pdf.
Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 Guideline Update for the Management
of Patients with Chronic Stable Angina: A Report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to
Update the 1999 Guidelines for the Management of Patients with Chronic Stable Angina). 2002.
Available at: www.acc.org/qualityandscience/clinical/guidelines/stable/stable_clean.pdf.
Grundy SM, Cleeman JI, Berz NB, et al. Implications of recent clinical trials for the national
cholesterol education program adult treatment panel III guidelines. Circulation. 2004;110:227-39.
King SB III, Smith SC Jr., Hirshfeld JW Jr, et al. 2007 focused update of the ACC/AHA/SCAI
2005 guideline update for percutaneous coronary intervention: A report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines: (2007 Writing
Group to Review New Evidence and Update the 2005 ACC/AHA/SCAI Guideline Update for
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http://content.onlinejacc.org/cgi/content/full/51/2/172.
Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics—2009 update: A
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long-term therapy in patients undergoing percutaneous coronary intervention: The PCI-CURE
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Meister FL, Stringer KA, Spinler SA, et al. Thrombolytic therapy for acute myocardial infarction.
Pharmacotherapy. 1998;18:686-98.
Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease
prevention in women: 2007 update. Circulation. 2007; 115:1481-501.
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Evidence-Based Clinical Practice Guidelines (8th edition). Chest. 2008;133:199S-233S.
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prevention of cardiovascular disease in women. N Engl J Med. 2005;352:1293-304.
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with coronary and other atherosclerotic vascular disease: 2006 update. Circulation
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12. Hyperlipidemia - Lawrence M. Brown, PharmD, PhD
12-1. Introduction
Introduction
• Hyperlipidemia is an elevation in the blood concentration of a lipid such as cholesterol or

triglyceride (in the form of lipoprotein).
• Dyslipidemia refers to any lipid disorder.
• Lipids include cholesterol, triglycerides (TGs), and phospholipids.
• Lipoproteins are apolipoproteins + cholesterol + TGs + phospholipids.
• Major lipoproteins are chylomicrons, very-low-density lipoproteins (VLDLs), intermediate-

density lipoproteins (IDLs), low-density lipoproteins (LDLs), high-density lipoproteins (HDLs),
and lipoprotein (a).
• Apolipoproteins are structural components of lipoproteins.
• The Friederwald equation is a formula used to calculate LDL:
LDL = total cholesterol - (HDL + TG/5).
Classification of Lipids
Total cholesterol, LDL, HDL, and TG are measured in mg/dL. Adult Treatment Panel III (ATP III)
recommendations from the National Cholesterol Education Program (NCEP) are shown in
Table 12-1.
Hyperlipidemia can cause atherosclerosis, atheroma formation, atherothrombosis, and the

subsequent consequences of the following disease processes:
• Coronary artery disease (angina and myocardial infarction)
• Cerebrovascular disease (transient ischemic attack, stroke, or both)
• Peripheral arterial disease (intermittent claudication)
A state of elevated lipids alone generally promotes no symptoms, except in some familial lipid
disorders, in which there may be cutaneous manifestations of lipid deposition (e.g., tendon
xanthomas, planar xanthomas, xanthelasmas, and eye manifestations [corneal arcus]).
Pathophysiology of Atherosclerosis
A progressive, systemic disease starting early in life, atherosclerosis has the following
pathophysiology:
• Atheroma lesions, called fatty streaks, develop in the arterial vascular walls as a result of the
accumulation of cholesterol within vessel walls.
• Atheroma lesions may lead to occlusion by thrombus or embolus formation.
• LDL cholesterol accumulates below the intimal surface of the artery. The general guideline is the
higher the cholesterol elevation in the blood, the more LDL migration into the artery.
• Endothelial dysfunction occurs, which increases LDL cholesterol's permeability.
• LDL becomes oxidized and recruits monocytes.
• Monocytes are transformed into macrophages and ingest the oxidized LDL.
• This process results in lipid-filled cells called foam cells.
• Foam cells are the initial lesion of atherosclerosis. Growth factors are produced by macrophages.
• Other processes are also occurring (e.g., additional endothelial cell injury and inflammatory
[Table 12-1. Classification of Lipids]
responses that can further accelerate the development of plaque).
• Elevated cholesterol and hyperlipidemia enhance this process.
• Plaque may continue to develop, may become stable, or may rupture.
• Plaque rupture exposes atherogenic materials in the lesion to blood.
• Platelets are activated, and a clot may form.
• Partial occlusion or obstruction can result in angina; complete occlusion results in myocardial
infarction (MI).
• Other vascular beds promote similar outcomes.
Diagnostic Criteria
Lipid disorders (dyslipidemias) are classified as familial or secondary.
Familial disorders
• Familial disorders usually are caused by a defect in lipid metabolism.
• They are categorized into the hypercholesterolemias and the combined hyperlipidemias.
• Assessment of fasting lipid panels provides diagnostic information and classification of lipid
disorders.
• For familial hypercholesterolemia, LDL = 250-450 mg/dL.
• Familial defective apolipoprotein B-100 may be present.
• Polygenic hypercholesterolemia is the most common form (LDL = 160-250 mg/dL).
• Combined hyperlipidemias are as follows:
• Familial combined hyperlipidemia (LDL = 160-250 mg/dL and TG = 200-800 mg/dL)
• Familial hyperapobetalipoproteinemia
• Hypoalphalipoproteinemia
• Dysbetalipoproteinemia
• Elevated lipoprotein (a)
• Familial disorders are characterized by variations in the amounts of HDL, IDL, LDL, and VLDL.
Secondary disorders
The most common secondary causes of lipid disorders are as follows:
• Hypothyroidism
• Renal failure
• Obstructive liver disease
• Drugs such as -blockers, thiazide diuretics, oral contraceptives, oral estrogens,

glucocorticosteroids, and cyclosporine
Risk factors are used to assess the potential for an individual to develop coronary heart disease
(CHD) or another equivalent atherosclerotic process over the next 10 years. The Framingham
Global Risk Score is calculated to provide this information. The major nonlipid risk factors for
CHD are counted and used to assess the 10-year risk of developing CHD.
Major nonlipid risk factors for CHD are as follows:
• Hypertension (patient with blood pressure 140/90 mm Hg or patient on antihypertensive

medication)
• Low HDL cholesterol (< 40 mg/dL)
• Family history of premature CHD (CHD in a male first-degree relative age < 55 years and CHD in
a female first-degree relative age < 65 years)
• Age (men 45 years; women 55 years)
HDL 60 mg/dL counts as a negative risk factor and acts to remove one of the other risk factors
from the total count.
Treatment Principles
Treatment and target lipid goals are based on the estimation of risk for CHD using the Framingham
Global Risk Score.
If a patient has a form of clinical CHD, such as angina, MI, stroke, or transient ischemic attack, he
or she is considered to be at high risk for another ischemic event within the next 10 years.
Those at highest risk require the most aggressive therapy (i.e., drug therapy and achievement of the
lowest possible LDL level). The major nonlipid risk factors noted previously are used in the risk
analysis for those individuals who do not have CHD or a CHD risk equivalent.
Table 12-2 identifies risk categories, lipid goals, and risk of event.
Treatment consists of lifestyle changes (i.e., therapeutic lifestyle changes), which are discussed in
the nonpharmacologic and pharmacotherapy sections of this chapter.
The algorithm for drug therapy in primary prevention (< 20% risk) is as follows:
• Initiate LDL-lowering drug therapy (statins, niacin, and resin) for 6 weeks.
• If the LDL goal is not met, intensify LDL-lowering therapy (higher dose or combination therapy)
for 6 weeks.
• If LDL goal is still not achieved, intensify drug therapy or refer to a lipid specialist for 4-6 months.
• Monitor response and adherence.
Drug therapy in secondary prevention (> 20% risk) requires the most aggressive treatment. A large
LDL reduction requires a statin and possibly a statin in combination with another agent. Follow the
same algorithm as outlined in the primary prevention (< 20% risk) algorithm just listed.
Monitoring (Clinical Evaluation) of Adults
For screening, the NCEP's ATP III recommends that, starting at age 20, adults receive a fasting lipid
profile (FLP). If the FLP is normal, screening is repeated in 5 years.
[Table 12-2. Risk Categories, Lipid Goals, and Risk of Event]
Monitoring and Treatment of Children and Adolescents
The American Academy of Pediatrics has historically recommended cholesterol screening of

children with a family history of high cholesterol or heart disease. However, the academy now
recommends screening of children age 2 to 10 if family history is unknown or if the child has other
risk factors for heart disease such as obesity, hypertension, or diabetes. Screenings that result in
normal range results should be repeated in 3 to 5 years.
Children age 8 and older (previously age 10 and older) with LDL levels > 190 mg/dL should be
considered for medication therapy (> 160 mg/dL for children with family history of heart disease or
more than two other risk factors and > 130 mg/dL for children with diabetes). First line medication
options include bile acid sequestrants, cholesterol absorption inhibitors, and statins (statins
previously not recommended as first-line medication option). Niacin products are not recommended
for use, and fibrates should be used with caution and under the supervision of a pediatric lipid
specialist.
Children age 2 and older who are overweight or obese and who have a high TG level or low HDL
level should receive a recommendation of weight management and increased physical activity as the
primary treatment.
Monitoring Tool
The main monitoring tool is a fasting lipid panel. The baseline FLP is done before drug or dietary
interventions.
After therapeutic lifestyle changes or drug therapy is started, the patient should be monitored every
6 weeks for 12 weeks initially, again in 4-6 months, and then periodically thereafter (usually
annually). Results of the FLP will show the effects of lifestyle and drug therapy interventions and
help direct changes in therapy.
12-2. Drug Therapy
Introduction
See
Tables 12-3,
12-4, and
12-5 for details on dosing, efficacy, and drug combinations.
[Table 12-3. Drug Products and Dosage]
Statins
• Conduct baseline liver function tests (LFTs) and creatine kinase (CK) before therapy is initiated.
LFTs should be repeated again in 4-6 weeks, at 3 months, and then periodically (usually
annually).
• CK needs to be monitored only if the patient has suspected muscle damage.
• Assess effectiveness at 6 weeks.
Resins
• Determine baseline FLP to screen for hypertriglyceridemia:
• If TG > 200 mg/dL, use resins with caution.
• If TG > 400 mg/dL, resins are contraindicated.
[Table 12-4. Efficacy of Drugs Used to Treat Hyperlipidemia]
Nicotinic Acid
• Determine baseline fasting glucose, conduct LFTs, and determine serum uric acid levels before
initiating therapy.
• Repeat these tests 4-6 weeks after each dose level is reached.
• Sustained-release niacin requires monthly LFT readings while dosage is titrated; subsequent LFT
readings should occur every 12 weeks for the first year and then periodically.
• Diabetics require routine fasting glucose tests.
• Monitor serum uric acid after the highest dose level is achieved in patients with a history of
hyperuricemia or gout.
[Table 12-5. Pharmacotherapeutic Options for Treatment of Hyperlipidemia]
Fibric Acids
• Determine baseline FLP (total cholesterol, HDL, LDL, and TG) before therapy and again at 3 and
6 months.
• Monitor changes in TG at 3 months, and assess effectiveness.
Cholesterol Inhibitors
• Determine baseline FLP.
Omega-3 Fatty Acids
• Determine very high baseline TG of 500 mg/dL.
• Can be used in combination with diet therapy or with diet and statin therapy.
• Assess effectiveness at 2 months. Discontinue use if decrease in TG level is adequate.
• Periodic monitoring of alanine aminotransferase levels is recommended.
• Periodic monitoring is recommended for increase in LDL cholesterol levels.
Mechanisms of Action
HMG-CoA reductase inhibitors (statins)
These agents competitively inhibit HMG-CoA (3-hydroxy-3-methyl-glutaryl-coenzyme A)

reductase, which is the enzyme responsible for conversion of HMG-CoA to mevalonate.
Mevalonate is an early precursor to and a rate-limiting step in cholesterol synthesis. This reduction
in liver cholesterol synthesis results in upregulation of liver LDL receptors and increased clearance
of LDL and VLDL particles in the blood. These actions induce a decrease in total cholesterol and
LDL cholesterol, promote a slight increase in HDL cholesterol, and effect a modest decrease in TG.
Bile acid sequestrants (resins)
Nonabsorbable anion exchange resins exchange chloride ions for bile acids and other anions in the
intestine. This action inhibits enterohepatic recycling, which results in bile excretion and a decrease
in the cholesterol pool in the liver. LDL receptors are upregulated, increased LDL is cleared, and
LDL is lowered.
Niacin
Niacin reduces LDL cholesterol and TG and increases HDL. It may decrease VLDL synthesis,
thereby leading to decreased LDL cholesterol and TG. It may inhibit metabolism of apolipoprotein
A-I, which increases HDL cholesterol.
Fibric acids (fibrates)
Fibrates reduce TG by reduction of apolipoproteins B, C-III, and E. They increase HDL by

increasing apolipoproteins A-I and A-II.
Cholesterol inhibitors (ezetimibe)
Cholesterol inhibitors selectively inhibit intestinal absorption of dietary and biliary cholesterol at
the brush border of the small intestine, which results in a decrease in the absorption of cholesterol
and a decrease in cholesterol in the blood.
Omega-3 fatty acids
The mechanism of action for omega-3 fatty acids is not completely understood. Possible
mechanisms of action include the following:
• Inhibition of acyl CoA: 1,2-diacylglycerol acyltransferase
• Increased mitochondrial and peroxisomal -oxidation in the liver
• Decreased lipogenesis in the liver
• Increased lipoprotein lipase activity
Patient Instructions and Counseling
Statins
Statins are usually administered in the evening because most hepatic cholesterol production occurs
during the night. Lovastatin conventional tablets should be given with the evening meal because
absorption is better with food; however, the extended-release lovastatin products should be taken at
bedtime. The lovastatin plus Niaspan combination product should be taken at bedtime with a low-
fat snack.
Non-extended release statins can be dosed once daily. Other regular dosage forms should be divided
as the doses are raised above 40 mg/day.
Atorvastatin may be given any time of the day because of its longer half-life.
Rosuvastatin dosage adjustment is required in patients with severe renal impairment. Plasma
concentrations of rosuvastatin increased to a clinically significant extent (about threefold) in
patients with severe renal impairment (creatinine clearance < 30 mL/min/1.73m2) compared with
healthy subjects (creatinine clearance > 80 mL/min/1.73m2). Dosage adjustment is also required in
patients with liver disease.
Monitor LFTs and muscle toxicity as described earlier.
Cholestyramine and colestipol should be started with one dose daily with the largest meal. They
may be increased (after the patient adjusts to the resin) to two doses daily with the largest meals or
divided between breakfast and dinner.
Titrate doses slowly to avoid gastrointestinal side effects.
Powdered doses can be mixed with food, such as soup, oatmeal, nonfat yogurt, applesauce, and so
forth. The mixture can also be chilled overnight to improve palatability. Do not mix with
carbonated beverages, because they promote increased air swallowing. Counsel the patient that
drinking through a straw may also help.
Patients who suffer constipation with the resins may mix them with psyllium; however, this mixture
should be ingested immediately after mixing to prevent a gel from forming.
Counsel the patient to rinse the glass and drink remains to ensure ingestion of all resin.
Colesevelam is a tablet formulation, which may be easier for some patients to self-administer.
However, the tablets are large, and some patients may not be able to swallow them.
Monitor for adherence and gastrointestinal side effects for all resins.
Nicotinic acid (niacin)
Immediate-release niacin should be started at a low dose and slowly titrated upward:
• Start with 100 mg tid and adjust upward the second week to 200 mg tid; the next week, increase to
350 mg tid; and the following week, raise to 500 mg tid. When 1,500 mg/day is reached and
maintained for 4 weeks, assess effectiveness before increasing the dose.
• If further titration is needed, go to 750 mg tid and assess effectiveness after 4 weeks before
increasing titration. Maximum dose is 1,000 mg tid.
• Aspirin 325 mg or ibuprofen 200 mg must be given 30 minutes before the morning dose to
minimize flushing and itching.
• Caution patients to avoid hot beverages and hot showers so as not to exacerbate the flushing
effect.
Extended-release formulation should be taken at bedtime (500 mg) and titrated weekly to a
maximum dose of 1,500 mg/day. Aspirin should be taken 30 minutes before the dose.
Sustained-release formulations are started at 250 mg bid and increased at weekly intervals to a
maximum dose of 2,000 mg/day. Aspirin should be given 30 minutes before the dose.
Monitor for adherence and side effects. The titration schedule for some patients may have to be
gradual because of flushing and itching.
Gemfibrozil should be taken twice daily 30 minutes before meals.
Tricor can be taken with or without food once daily.
Reduce the dose in patients with renal insufficiency, and monitor for muscle toxicity, especially
when used in combination with statins and niacin.
Cholesterol inhibitors
Cholesterol inhibitors are dosed once daily without regard to food. They can be taken
simultaneously in combination with statins.
Omega-3 fatty acids
The daily dose (4 g) can be taken in single or divided dose (2 g bid). These agents should be taken
with meal(s).
Use of omega-3 fatty acids does not reduce the importance of patient adhering to a diet.
Omega-3 fatty acids are not for use in patients with a history of allergy or sensitivity to fish.
Assess effectiveness at 2 months. Discontinue use if the decrease in TG level is adequate.

Adverse Drug Events
• Myopathy owing to muscle damage may occur.
• Myalgia from muscle soreness or tenderness may occur.
• Myositis occurs in 0.2% of patients:
myalgia + creatine kinase
(3 - 10 times upper limit of normal)
• Rhabdomyolysis occurs rarely, but can cause acute renal failure. Stop the drug immediately.
severe myositis + creatine kinase
10 × upper limit of normal,
serum creatinine and urine myoglobin
• Elevated liver enzymes occur in 0.1-2.3% of patients. Obtain baseline LFTs, and repeat at 4-6
weeks, again at 6 months, and yearly thereafter.
• Flu-like symptoms and headache may occur.
• Patients may have mild gastrointestinal (GI) complaints.
• Contraindication is absolute in active or chronic liver disease.
• Contraindication is relative in combination with certain drugs (see discussion of drug

interactions).
• GI distress may occur.
• Patients may experience palatability problems with the resin slurry.
• Constipation may occur that increases with the dose and in the elderly.
• Decreased absorption of other drugs may occur. Dose other drugs 1 hour before or 4 hours after
ingestion of resin.
• Contraindication is absolute in dysbetalipoproteinemia (highly elevated VLDL) and TG > 400
mg/dL.
• Contraindication is relative when TG > 200 mg/dL.
• Flushing is common. Pretreat with aspirin (325 mg) 30 minutes before the first niacin dose of the
day.
• Hyperglycemia is a risk. Use with caution in diabetics.
• Hyperuricemia (or gout) may occur:
• Upper GI distress
• Hepatotoxicity
• Absolute contraindication in chronic liver disease and severe gout
• Relative contraindication in diabetes, hyperuricemia, or severe gout
• Dyspepsia may occur.
• Gallstones may occur.
• Myopathy increases when combined with statins.
• Contraindication is absolute in severe renal or severe hepatic disease.
• Elevated liver enzymes (same as placebo) may occur.
• GI distress (less than with resins) may occur.
• Contraindication is absolute in moderate to severe hepatic disease.
Omega-3 fatty acids
• Burping
• Indigestion
• Taste sense alteration
• Backache
Drug-Drug and Drug-Disease Interactions
CYP450 (cytochrome P450) mixed-function oxidase enzymes metabolize statins, and drugs that
inhibit this process can cause increases in statin concentrations, thus predisposing patients to
myopathy and liver toxicity.
Common CYP450 3A4 inhibitors include amiodarone, clarithromycin, cyclosporine, danazol,

delavirdine, diltiazem, erythromycin, fluoxetine, fluvoxamine, grapefruit juice, indinavir,
itraconazole, ketoconazole, miconazole, nefazodone, nelfinavir, nicardipine, nifedipine, pimozide,
propoxyphene, quinidine, ritonavir, saquinavir, sildenafil, tacrolimus, tamoxifen, testosterone,
troleandomycin, verapamil, and zafirlukast.
Pravastatin is not metabolized by the CYP450 system; therefore, these drug-drug interactions are
avoided.
Contraindication is absolute in active or chronic liver disease.
Avoid concomitant use with all other drugs, especially digoxin, levothyroxine, tetracycline,
warfarin, fat-soluble vitamins, and minerals.
Always separate other drugs by 1 hour before use and 4 hours after use.
Colesevelam does not appear to have these drug and nutrient interactions.
Contraindication is absolute in dysbetalipoproteinemia.
Use caution in combination with resins. Combination therapy with statins and gemfibrozil may
cause an increased risk of myopathy.
Contraindication is absolute in chronic liver disease and severe gout.
These agents are highly protein bound, and they are metabolized by the CYP450 3A4 enzyme
system.
The effect of warfarin may be increased.
Cyclosporine may increase gemfibrozil concentrations.
Fenofibrate may have less interaction potential with warfarin and cyclosporine.
Bile acid sequestrants (resins) decrease fibrate absorption.
Combinations with statins and niacin may increase the risk of myopathy.
Contraindication is absolute in severe renal disease and severe liver disease.
Cyclosporine may increase ezetimibe concentrations.
Combination with a resin may decrease absorption. Combination with a fibric acid may predispose
to gallbladder disease.
Contraindication is absolute in moderate to severe hepatic disease.
Omega-3 fatty acids
Possible prolonged bleeding time may occur when used with anticoagulants.
Landmark Clinical Trials with Statins
Primary prevention trials
West of Scotland Study

This trial with pravastatin showed decreased coronary morbidity and mortality in
hypercholesterolemic men with no clinical evidence of CHD.
Air Force-Texas Coronary Atherosclerosis Prevention Study

This trial with lovastatin showed reduced incidence of first acute major coronary events in patients
who did not have CHD but did have normal to mildly elevated total cholesterol and LDL with low
HDL.
Secondary prevention trials
Scandinavian Simvastatin Survival Study

This trial with simvastatin showed decreased cardiac morbidity and mortality in patients with CHD
and elevated cholesterol.
Cholesterol and Current Events Study
This trial with pravastatin showed reduced incidence of MI, death from CHD, stroke, and need for
revascularization procedures in patients with recent MI and normal cholesterol levels.
Long-Term Intervention with Pravastatin in Ischemic Disease Study

This trial with pravastatin showed reduced mortality and incidence of MI and stroke in patients with
CHD and a broad range of cholesterol.
Heart Protection Study

This trial with simvastatin is the largest single cholesterol trial (as of 2002) in patients at high risk
of CHD (prior MI, diabetes, or hypertension) and LDL > 135 mg/dL. Antioxidants studied included
vitamins E and C and beta-carotene. Simvastatin therapy showed a reduced incidence of CHD
regardless of age (also elderly) or preexisting condition. There was no threshold for LDL at 100
mg/dL (i.e., benefits extended below this level). In addition, there was no cardiovascular protective
effect from vitamins E and C and beta-carotene.
Introduction
Nonpharmacologic therapy focuses on therapeutic lifestyle changes (TLCs), which incorporate

dietary changes, physical activity, and weight reduction. "Heart healthy" nutrition is the foundation
for any therapeutic interventions.
General TLC Recommendations
• Decrease the amount of high-fat foods consumed (especially foods high in saturated fat).
• Decrease intake of high-cholesterol foods.
• Replace saturated fats with monounsaturated fats and fish oils.
• Use foods high in complex carbohydrates (fiber, starch, fruits, and vegetables).
• Strive for and maintain an acceptable weight.
• Patients should be instructed on how to read a nutrition label.
• Recommended nutrient makeup of the TLC diet is shown in

Table 12-6.
Algorithm for TLCs
Begin lifestyle therapies and continue for 6 weeks. Evaluate LDL response, and if the LDL goal is
not achieved, intensify LDL-lowering therapy (diet + weight management + physical activity) for 6
more weeks. Evaluate LDL response, and if LDL goal is still not achieved, consider adding drug
therapy (if not already added). Monitor adherence to TLC every 4-6 months thereafter.
Other Nonpharmacologic Therapies
• Soluble fiber and plant sterols and stanols can help lower LDL.
• Viscous or soluble fiber such as psyllium or pectin in the amount of 5-10 g/d or other sources of
fiber such as vegetables, fruits, and whole grains can reduce LDL by up to 8%.
• The active ingredient in fish oils is omega-3 fatty acid. Fish oils can reduce TGs as much as 30-
60%. Fish oils can be added when niacin or fibrates do not control TGs.
• Recent clinical trials have shown that antioxidants; vitamins A, C, and E; and beta-carotene are
not protective for cardiovascular disease.
• Light to moderate alcohol use (one drink per day for women, two drinks per day for men) has been
associated with reductions in CHD rates. The benefit may be due to a rise in HDL. Use of alcohol
should not be encouraged as a means of
[Table 12-6. Nutrient Makeup of the TLC Diet]
lowering cholesterol. Excessive alcohol use can cause elevations of TGs.
• Alternative therapies such as herbal therapies have not been systematically studied in
hyperlipidemia and should not be recommended for treatment of hyperlipidemia or other lipid
disorders.
12-4. Key Points
• Hyperlipidemia is the elevation of the blood concentration of a lipid such as cholesterol or

triglyceride (in the form of lipoprotein).
• There are four major classifications of lipids: total cholesterol, low-density lipoproteins, high-
density lipoproteins, and triglycerides.
• The process of atherosclerosis begins with atheroma lesions in the arterial vascular walls resulting
from the accumulation of cholesterol within vessel walls.
• Polygenic hypercholesterolemia (LDL = 160-250 mg/dL) is the most common form of familial
dyslipidemia.
• Major nonlipid risk factors for coronary heart disease are cigarette smoking, hypertension, family
history of premature CHD, and age (men e 45 years, women e 55 years).
• People with a history of CHD, such as angina, MI, stroke, or transient ischemic attack, are
considered at highest risk of having another ischemic event in the next 10 years and require the
most aggressive therapy and the lowest target LDL goal (< 100 mg/dL).
• Monitoring for drug therapy of hyperlipidemia includes laboratory monitoring for adverse effects
(e.g., liver function tests, uric acid, and creatine kinase) and fasting lipid profiles for
effectiveness.
• The mechanism of action of statin agents to treat hyperlipidemia is to competitively inhibit HMG-
CoA reductase, which is the enzyme responsible for conversion of HMG-CoA into
mevalonate—an early precursor to and a rate-limiting step in cholesterol synthesis.
• The statins are usually administered in the evening (except for atorvastatin, which has a longer
half-life than the other agents in this class) because most hepatic cholesterol production occurs
during the night.
• Lovaza is a prescription formulation of omega-3 fatty acid, and its use should be discontinued if
an adequate reduction in TGs is not achieved after 2 months of use.
• The only class of agents to control hyperlipidemia that is not contraindicated in patients with
active or chronic liver disease is the bile acid sequestrant (resin) type.
• Pravastatin is not metabolized by the CYP450 enzyme system and, thus, avoids most of the drug
interactions with the other statin agents.
• Cholesterol screenings are now recommended for children age 2-10 years if they have a family
history of high cholesterol or heart disease, if the family history is unknown, or if the child has
other risk factors for heart disease such as obesity, hypertension, or diabetes.
• Advicor should not be substituted for equivalent doses of immediate-release (crystalline) niacin.
For patients switching from immediate-release niacin to extended-release niacin, therapy with the
latter should be initiated with low doses (i.e., 500 mg once daily at bedtime), and the dose should
then be titrated to the desired therapeutic response.
• The bile acid sequestrants (resins) may decrease the absorption of digoxin, levothyroxine,
tetracycline, warfarin, fat-soluble vitamins, and minerals.
• The new formulation of Tricor can be taken with or without food once daily.
• Therapeutic lifestyle changes that incorporate dietary changes, increased physical activity, and
weight reduction are the first recommended therapy for hyperlipidemia for 6-12 weeks prior to
addition of drug therapy.
12-5. Questions
Use the following case study to answer Questions 1-5.
J. B. is a 50-year-old man who comes to your pharmacy for cholesterol and medication monitoring.
His medical history is notable for stage 1 hypertension, recent-onset type 2 diabetes, and
hypercholesterolemia. Family history is noncontributory. Social history indicates he neither smokes
nor uses alcohol. He has no known allergies. His medication history reveals that he occasionally
takes acetaminophen for headaches and no other over-the-counter medications or herbal products.
Current medications include hydrochlorothiazide 25 mg/d (for 4 years) and a new prescription today
for atorvastatin 10 mg/d. Your physical assessment reveals the following: BP 144/90 mm Hg; pulse,
70 and regular; weight, 185 pounds; height, 5´9 . An FLP today reveals the following: total
cholesterol = 250 mg/dL, HDL = 40 mg/dL, and triglycerides = 145 mg/dL.
What is J. B.'s LDL cholesterol?
A. 130 mg/dL
1. B. 153 mg/dL
C. 162 mg/dL
D. 178 mg/dL
E. 181 mg/dL

What is J. B.'s LDL goal?
A. < 100 mg/dL

2. B. 130-160 mg/dL
C. 160-189 mg/dL
D. < 200 mg/dL
E. > 40 mg/dL

J. B. is started on TLC and atorvastatin because of his high LDL. When should you assess the
effectiveness of therapy?
A. 12 weeks
3.
B. 6 months
C. 3 weeks
D. 6 weeks
E. Annually

J. B. is most likely to have which of the following?
A. Familial hypercholesterolemia
4. B. Polygenic hypercholesterolemia
C. Familial combined hyperlipidemia
D. Elevated triglycerides
E. Isolated low HDL

J. B. returns for reassessment at the appropriate time. His FLP shows that his LDL is now 115
mg/dL. What is your recommendation?
A. Stop the statin because the patient has achieved optimal LDL.
5.
B. Increase statin dose.
C. Intensify TLC.
D. Add gemfibrozil.
E. Add cholestyramine.

The National Cholesterol Education Program Expert Panel identifies which of the following as
a positive risk factor for coronary heart disease?
A. Hypertension
6.
B. Low HDL (< 40 mg/dL)
C. Family history of premature CHD
D. Current cigarette smoking
E. All of the above

Which of the following is not a secondary cause of hyperlipidemia?
A. High LDL
7. B. Hypothyroidism
C. Diabetes
D. Renal disease
E. -blockers

Cholesterol biosynthesis can be decreased by which of the following?
A. Statins
8. B. Oat bran
C. Bile acid sequestrants (resins)
D. Ezetimibe
E. Aspirin

Choose the medication with the greatest effect on raising HDL.
A. Lovastatin
9. B. Pravastatin
C. Gemfibrozil
D. Niaspan
E. Colesevelam

Choose the drug class with the most potent lowering effect on LDL.
A. Nicotinic acid
10. B. Fibric acids
C. Omega-3 fatty acids
D. Cholesterol inhibitors
E. HMG-CoA reductase inhibitors

The initial lesion in the development of atherosclerosis is
A. development of foam cells.

11. B. increase in HDL reverse transport.
C. rupture of a vulnerable plaque.
D. clot formation in the artery lumen.
E. development of a thin cap over the lipid pool.

Choose the correct statement.
A. Diabetes is an absolute contraindication to the use of nicotinic acid.

12. B. Aspirin is dosed three times per day to prevent flushing from niacin.
C. Gemfibrozil may reduce triglycerides by as much as 50%.
D. Colesevelam has similar patient tolerability problems as does cholestyramine.
E. Ezetimibe frequently causes muscle toxicity.

Hyperlipidemia refers to
A. elevation of apolipoproteins.
13. B. hypercholesterolemia.
C. high levels of white blood cells.
D. increased ingestion of protein.
E. endothelial dysfunction.

Which of the following indicates an optimal LDL?
A. > 190 mg/dL

14. B. < 40 mg/dL
C. > 60 mg/dL
D. < 100 mg/dL
E. < 150 mg/dL

Polygenic hypercholesterolemia is characterized by which of the following?
A. LDL = 150-450 mg/dL

15. B. LDL = 160-250 mg/dL
C. TG > 400 mg/dL
D. HDL = 50 mg/dL
E. LDL = 160-250 mg/dL + TG > 400 mg/dL

Identify a baseline laboratory test required before statin treatment.
A. White blood cell count

16. B. Complete blood cell count
C. Liver function test
D. Serum creatinine
E. Creatinine clearance

The major troublesome side effect in nicotinic acid therapy is
A. diarrhea.
17. B. vomiting.
C. hair growth.
D. flushing.
E. dizziness.

Which of the following medications has this warning: "For patients switching from immediate-
release niacin, therapy with this drug should be initiated with a low dose and then titrated to the
desired therapeutic response"?
18. A. Pravigard
B. Vytorin
C. Advicor
D. Atorvastatin
E. Ezetimibe

Identify the drug interaction that involves the CYP450 system.
A. Ezetimibe + niacin
19. B. Colestipol + simvastatin
C. Gemfibrozil + cholestyramine
D. Fenofibrate + ezetimibe
E. Lovastatin + itraconazole

A TLC diet could include
A. antioxidant therapy such as vitamin E.
20. B. < 7% of total calories from saturated fat.
C. 150-250 g/d of fiber.
D. 2-4 drinks of alcohol per day.
E. assessment of the effectiveness of TLC at 12-week intervals.

12-6. Answers
E. Use the Friederwald equation to calculate LDL:
1. LDL = total cholesterol - (HDL + TG/5)
LDL = 250 - (40 + 145/5) = 181

A. J. B. has type 2 diabetes, which is a risk equivalent for coronary heart disease. Therefore, he
2. is at highest risk for an event in the future, and his LDL goal should be optimal or < 100
mg/dL.

3. D. Both TLC and drug therapy measures should be assessed at 6-week intervals.

B. J. B.'s LDL is 181 mg/dL, which falls into the range for polygenic hypercholesterolemia
4.
(160-250 mg/dL), and he does not have elevated TGs or low HDL.

C. Because J. B.'s LDL is still slightly above optimal, intensify TLC. That is, continue to
decrease saturated fat in the diet and to intensify weight reduction and physical activity. If the
5.
LDL is still above 100 mg/dL at the next assessment in 6 weeks, options would be to increase
the statin dose (double it) or add another agent such as niacin or ezetimibe.

E. All of the answers are positive risk factors for CHD as defined by the NCEP's Adult
6. Treatment Panel III. The remaining positive risk factors are gender and age (i.e., males 45 years
and over and females 55 years and over).

A. Causes of hyperlipidemia must be ruled out. The common secondary causes are renal
7. failure; hypothyroidism; obstructive liver disease; diabetes; and drugs such as ²-blockers,
thiazide diuretics, oral contraceptives, oral estrogens, glucocorticoids, and cyclosporine.

A. Statins competitively inhibit HMG-CoA reductase, which is the enzyme responsible for
8.
converting HMG-CoA to mevalonate. Inhibition of mevalonate reduces cholesterol synthesis.

D. Nicotinic acid (Niaspan) has the most efficacy in raising HDL compared with other
9.
therapies. HDL may be raised 15-35%.

E. Statins (HMG-CoA reductase inhibitors) have the most efficacy in lowering LDL. LDL may
10.
be lowered 18-55%.

A. Foam cells represent the initial lesion of atherosclerosis and develop as a result of the
11.
ingestion of oxidized LDL by macrophages in the subintimal space of the artery.

C. Diabetes is a relative contraindication to the use of nicotinic acid. Aspirin is dosed once
daily, before the first nicotinic acid dose of the day. Gemfibrozil can reduce TGs 20-50%.
12.
Colesevelam is a tablet and avoids most of the palatability problems of other resins. Ezetimibe
does not cause muscle toxicity.

B. Hyperlipidemia is defined as an elevation of a lipid in the blood. The lipid can be
13.
cholesterol or triglyceride in the form of a lipoprotein.

D. Level < 100 = optimal; 100-129 = near optimal or above optimal; 130-159 = borderline
14.
high; 160-189 = high; and e 190 = very high.

B. Polygenic hypercholesterolemia is the most common cause of mild to moderately elevated
15.
LDL (LDL = 160-250 mg/dL).

16. C. Baseline tests before statin use include liver function tests and creatine kinase.

D. The most common side effect is flushing, which may occur in many patients. To decrease
17. flushing intensity, a patient should take aspirin 325 mg 30 minutes prior to the first dose of
nicotinic acid. Itching may also occur with flushing.

C. Advicor (Niaspan + lovastatin) contains Niaspan, which is not dose equivalent to
18. immediate-release niacin or modified-release (sustained-release or time-release) niacin
preparations.

E. Lovastatin is metabolized by CYP450 3A4 enzymes, and itraconazole will inhibit this
19. enzyme system. Inhibition causes lovastatin blood and tissue concentrations to rise, thus
predisposing the patient to muscle or liver toxicity.

B. A TLC diet includes < 7% saturated fat, 20-30 g/d fiber, avoidance of alcohol, and
20.
assessment at 6 weeks. Vitamin E is not recommended for cardiovascular risk reduction.

12-7. References
Beaird SL. HMG-CoA reductase inhibitors: Assessing differences in drug interactions and safety
profiles. J Am Pharm Assoc. 2000;40:6337-44.
Daniels SR, Greer FR, Committee on Nutrition. Lipid screening and cardiovascular health in
childhood. Pediatrics. 2008;122:198-208.
Downs JR, Clearfield M, Weis S, et al. Primary prevention of acute coronary events with lovastatin
in men and women with average cholesterol levels: Results of AFCAPS/TexCAPS. JAMA.
1998;279: 1615-22.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.
Executive summary of the Third Report of the National Cholesterol Education Program (NCEP)
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults
(Adult Treatment Panel III). JAMA. 2001;285:2486-97.
Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol
lowering with simvastatin in 20,536 high-risk individuals: A randomised placebo-controlled trial.
Lancet. 2002;360:7-22.
Knopp RH. Drug treatment of lipid disorders. N Engl J Med. 1999;341:498-511.
Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. Prevention of
cardiovascular events and death with pravastatin in patients with coronary heart disease and a
broad range of initial cholesterol levels. N Engl J Med. 1998;339:1349-57.
McKenney JM, Hawkins DW, eds. Handbook on the Management of Lipid Disorders. Springfield,
N.J.: Scientific Therapeutics Information/National Pharmacy Cardiovascular Council; 2001.
Pasternak RC, Smith SC Jr, Bairey-Merz CN, et al. ACC/AHA/NHLBI clinical advisory on the use
and safety of statins. J Am Coll Cardiol. 2002;40: 568-73.
Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4,444
patients with coronary heart disease: The Scandinavian Simvastatin Survival Study (4S). Lancet.
1994;344:1383-89.
Sudhop T, Lutjohann D, Kodal A, et al. Inhibition of intestinal cholesterol absorption by ezetimibe

in humans. Circulation. 2002;106:1943-48.
Talbert RL. Hyperlipidemia. In: DiPiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A
Pathophysiologic Approach. 5th ed. New York: McGraw-Hill; 2002:395-418.
West of Scotland Coronary Prevention Study Group. Influence of pravastatin and plasma levels on
clinical events in the West of Scotland Coronary Prevention Study (WOSCOPS). Circulation.
1998; 97:1440-45.
Wolf MI, Vartnian SF, Ross JL, et al. Safety and effectiveness of Niaspan when added sequentially
to a statin for treatment of dyslipidemia. Am J Cardiol. 2001;87:476-79.
13. Diabetes Mellitus - Joni Foard, PharmD, CDE, L. Brian Cross, PharmD, CDE
13-1. Overview
Introduction
Diabetes mellitus (DM) is a group of chronic metabolic diseases caused by defects in insulin
secretion, action, or both that result in hyperglycemia; abnormal metabolism of carbohydrates, fats,
and proteins; and long-term macrovascular and microvascular complications.
DM affects 23.6 million people or approximately 8% of the population: 17.9 million diagnosed and
5.7 million undiagnosed.
It is the seventh-leading cause of death. Risk of death is two times that of people without diabetes
of similar age.
Classification
Type 1 diabetes
Type 1 diabetes was previously called insulin-dependent diabetes mellitus or juvenile-onset

diabetes. It requires exogenous insulin for survival. It comprises 5-10% of all diagnosed cases.
Type 2 diabetes
Type 2 diabetes was previously called noninsulin-dependent diabetes mellitus or adult-onset

diabetes. It comprises 90-95% of all diagnosed cases.
Gestational diabetes mellitus
Gestational diabetes mellitus (GDM) involves glucose intolerance with onset of pregnancy or first
recognition during pregnancy (second and third trimesters). Approximately 7% of pregnancies
develop GDM: > 200,000 annually. Women with GDM have 40-60% chance of later developing
type 2 diabetes; 5-10% of those are diagnosed in the postpartum period. The primary fetal
complication of concern is macrosomia.
Other types: Secondary DM
Secondary DM is attributable to genetic defects of ²-cell function (e.g., maturity-onset diabetes of

youth), surgery, drugs, malnutrition, infections, and other illnesses. It comprises 1-5% of all
diagnosed cases.
Prediabetes
In prediabetes, plasma glucose levels are higher than normal but lower than those diagnostic for
diabetes. Prediabetes was formerly characterized as impaired fasting glucose (IFG) and impaired
glucose tolerance (IGT). It is a risk factor for future diabetes and cardiovascular disease.
Classic signs and symptoms include polydipsia, polyuria, and polyphagia. Other common findings
include fatigue, blurred vision, and frequent infections.
Type 1 diabetes
Signs include rapid onset and unexplained weight loss. Patients are potentially ketonuric or
experience ketoacidosis. They may experience a "honeymoon" period, a phase of erratic insulin
secretion lasting months to a year during destruction of ²-cells.
Type 2 diabetes
Onset is progressive. Patients may be asymptomatic or experience mild classic signs and symptoms;
80% are obese or have history of obesity. Patients may present with microvascular and
macrovascular chronic complications
Type 1 diabetes
• -cell destruction leads to absolute insulin deficiency.
• Subgroups are as follows:
• Immune mediated, in which a strong human leukocyte antigen association indicates genetic
predisposition. This subgroup is related to environmental factors; a stimulus (e.g., virus)
triggers the immunologic process.
• Idiopathic, in which there is no evidence of autoimmunity or other known etiology.
• Patients are prone to ketoacidosis.
• Peak onset occurs at the time of puberty but may occur at any age.
Type 2 diabetes
• Insulin resistance and progressive -cell dysfunction are characteristic.
• Development of type 2 DM often involves a strong genetic predisposition.

• It is also associated with environmental factors such as excessive calorie intake, decreased
activity, weight gain, and obesity.
• Insulin resistance may be present years before the onset of diabetes.
• Initially normal glucose levels are maintained by increased insulin secretion by -cells.
• Increasing insulin resistance or a failure of -cells to maintain insulin secretion leads to glucose
intolerance and development of diabetes.
• Insulin resistance is influenced by age, ethnicity, physical activity, medications, and weight.
• Type 2 DM is usually diagnosed in adulthood but can occur at any age.
• The incidence of type 2 diabetes is higher among certain ethnic populations (

Figure 13-1).
Diagnostic Criteria
Box 13-1 shows the criteria for the diagnosis of DM.
[Figure 13-1. Estimated Age-Adjusted Total Prevalence of Diabetes in People 20 Years or Older,
by Race and Ethnicity: United States, 2005]
Box 13-1. Criteria for the Diagnosis of Diabetes Mellitus

Symptoms of diabetes and a casual plasma glucose e 200 mg/dL (11.1 mmol/L). Casual is defined
as any time of day without regard to time since last meal. The classic symptoms of diabetes
include polyuria, polydipsia, and unexplained weight loss.
OR
FPG 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours.
OR
Two-hour plasma glucose 200 mg/dL (11.1 mmol/L) during an OGTT. The test should be
performed as described by the World Health Organization, using a glucose load containing the
equivalent of 75 g anhydrous glucose dissolved in water.
Source: Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the
Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care
1997;20:1183-97. Reprinted with permission from the American Diabetes Association.
Note: In the absence of unequivocal hyperglycemia, criteria should be confirmed by repeat testing
on a different day.
Type 1 and type 2 DM

Diagnosis can be made on the basis of a fasting plasma glucose (FPG) test, a random plasma
glucose test, or an oral glucose tolerance test (OGTT). Diagnosis must be confirmed on a
subsequent day using any of the three methods.
The FPG test is the test of choice because of simplicity, lower cost, and reproducibility.
Abnormal results not meeting criteria outlined in Box 13-1 are classified as prediabetes:
• IFG = FPG 100 mg/dL to 125 mg/dL
• IGT = 2-hour OGTT plasma glucose 140 mg/dL to 199 mg/dL
Serum C peptide level is diagnostic for functioning of ²-cells and may be used for classification.
Gestational diabetes mellitus
OGTT is preferred screening test in pregnancy. For average-risk patients, test at 24-28 weeks of
gestation. For high-risk patients (marked obesity, personal history of GDM, glycosuria, diagnosis of
polycystic ovarian syndrome, or strong family history of DM), perform a risk assessment at the first
prenatal visit and test as soon as possible; if initial screenings are negative, retest between 24 and 28
weeks of gestation.
In average- or high-risk patients use one of two approaches:
• One-step approach: diagnostic 100 g OGTT
• Two-step approach: 1-hour 50 mg glucose challenge test followed by diagnostic 100 g glucose
OGTT if 1-hour level e 140 mg/dL
Diagnosis of GDM with a 100 g glucose load is positive if at least two glucose values meet or
exceed the following levels:
• Fasting: 95 mg/dL
• 1 hour: 180 mg/dL
• 2 hours: 155 mg/dL
• 3 hours: 140 mg/dL
If on the subsequent day FPG 126 mg/dL or casual plasma glucose 200 mg/dL, a glucose
challenge is not needed. Reevaluation and reclassification should be conducted 6-12 weeks
postpartum.
• To achieve and maintain glycemic control (

Table 13-1)
• To attain recommended blood pressure and lipid goals (Table 13-1)
• To modify lifestyle to promote general health and achieve weight management goals
• To prevent or slow progression of chronic complications
• To prevent or resolve acute complications
• To achieve an acceptable quality of life and satisfaction with care
Prevention of complications
The following activities can prevent complications from arising:
• Smoking cessation
• Aspirin or antiplatelet therapy
• Use as secondary prevention with a history of cardiovascular disease.
• Use as primary prevention if patient is > 40 years of age or has additional risk factors (family
history of cardiovascular disease, hypertension, smoking, dyslipidemia, or albuminuria).
• Prescribe aspirin 75-162 mg/d.
• Immunization
• Annual influenza vaccine if patient is 6 months of age or older and no contraindications
• At least one lifetime pneumococcal vaccine for adults with no contraindications
[Table 13-1. Summary of Recommendations for Adults with Diabetes]
• One-time pneumococcal revaccination if patient is > 64 years of age, previously immunized at

< 65 years of age, and vaccine administered > 5 years ago
• Foot care: self-inspection daily, visual inspection at each office visit, and an annual
comprehensive exam
• Skin care: self-inspection and care daily

• Dental care: annual examination
• Eye care: annual dilated eye examination
Complications of diabetes
Chronic complications
• Coronary atherosclerosis: Death rate is two to four times higher in adults with DM than in
adults without diabetes.
• Cerebrovascular atherosclerosis: Risk of stroke is two to four times higher among people with
diabetes.
• Peripheral vascular disease: Pain is due to intermittent claudication; insufficient circulation

impairs healing and increases risk of gangrene and amputation.
Microvascular disease
• Retinopathy
• It is the leading cause of new cases of blindness in adults 20-74 years of age.
• Retinopathy may develop without symptoms; annual dilated eye examination is recommended
for detection.
• Treatment includes glycemic and blood pressure control and laser photocoagulation.
• Nephropathy
• It occurs in 20-40% of diabetics and is the leading cause of end-stage renal disease.
• Random spot collection of the albumin-to-creatinine ratio should be performed yearly; a value
of > 30 mg/g is considered abnormal.
• Serum creatinine should be measured at least annually for the estimation of glomerular filtration
rate (GFR).
• Treatment includes glycemic and blood pressure control; angiotensin-converting enzyme (ACE)
inhibitors or angiotensin II receptor blockers should be used except during pregnancy.
• Polyneuropathy
• Sensorimotor nervous system dysfunction occurs.

• Pain and diminished sensation occur, with potential for poor detection of trauma, which
increases risk for ulcers and infection.
• Autonomic neuropathy
• Gastrointestinal (GI) effects include gastroparesis, constipation, and diarrhea.
• Genitourinary effects include neurogenic bladder and sexual dysfunction in men.
• Cardiovascular effects include orthostatic hypotension and resting tachycardia.
• Diabetic foot problems
• DM accounts for > 60% of nontraumatic amputations in the United States.
• Prevention, early detection with regular foot exams, and prompt treatment of lesions are
essential to avoid complications.
Acute complications
• Hypoglycemia
• Hypoglycemia is defined as plasma glucose < 70 mg/dL.
• Glucose (15-20 g) is the preferred treatment, but other forms of carbohydrates that contain
glucose can be used.
• Treatment effects should be seen in 15 minutes.
• Symptoms can range from mild (tremor, palpitations, sweating) to severe (unresponsiveness,
unconsciousness, or convulsions).
• Severe hypoglycemia may require assistance from another individual for treatment with
glucagon or IV glucose.
• Diabetic ketoacidosis (DKA)
• DKA is a medical emergency in type 1 diabetes because of absolute or relative insulin

deficiency.
• Omission of insulin, major stress, infection, or trauma may precipitate DKA.
• DKA is characterized by glucose > 250 mg/dL, elevated ketones, arterial pH < 7.2, plasma
bicarbonate < 15 mEq/L.
• Ketone bodies are formed in excess because of fatty acid metabolism in the liver, leading to
ketonuria and ketonemia and ultimately diabetic ketoacidosis.
• Kussmaul respirations (deep and rapid) are characteristic in an attempt to compensate for
metabolic acidosis.
• DKA requires prompt intervention with insulin, fluids, and electrolytes to prevent coma and
death.
• Hyperosmolar hyperglycemic state
• It is also known as hyperglycemic hyperosmolar nonketotic coma.
• It is a complication of type 2 diabetes.
• The state is characterized by elevated plasma glucose (typically > 500 mg/dL), dehydration, and
hyperosmolality in the absence of significant ketoacidosis.
• It may be triggered by infection or other stressors such as stroke or myocardial infarction.
• Treatment includes fluid and electrolyte replacement as well as insulin.
13-2. Drug Therapy
Oral Medications for DM Treatment
Secretagogues
Mechanism of action
The primary mechanism of secretagogues is to cause a reduction in blood glucose by stimulating
the release of insulin from the pancreas. This mechanism may in turn cause a decrease in hepatic
gluconeogenesis and a slight decrease in insulin resistance at the muscle level. Effectiveness
depends on pancreatic ²-cell function.
Clinical and counseling considerations
• Medication should be taken before meals: sulfonylureas, qd bid; meglitinides, before each meal.
• Medication causes a 1-2 kg weight gain.
• A positive risk of hypoglycemia exists, which is greater with sulfonylureas than with meglitinides.
• Secretagogues are typically not indicated during pregnancy, when breast-feeding, or in children.
• A fast-acting oral carbohydrate should be carried for emergency use.
A1c reduction
• 1-2% (sulfonylureas)
• 0.5-2% (meglitinides)
Cost
• Medications are generically available.
• For meglitinides, the monthly cost is about $75-200.
Cautions and contraindications
• Use with caution in elderly patients; do not use chlorpropamide.
• Use with caution in cases of renal and hepatic insufficiency; glipizide and glimepiride safer.
• Avoid in patients with significant alcohol use.
• Drug interactions (worse with first-generation sulfonylureas) may cause increased risk of
hypoglycemia: anticoagulants, fluconazole, salicylates, gemfibrozil, sulfonamides, tricyclic
antidepressants, digoxin.
• Use is contraindicated in patients with DKA, severe infection, surgery, or trauma.
• Patients should wear medical identification.
• Store drug in a cool, dry place (not the bathroom or kitchen).
• Syndrome of inappropriate antidiuretic hormone secretion, disulfiram-like reaction with alcohol

(ETOH), and sun-sensitivity reactions are more common in first-generation sulfonylureas than in
second-generation sulfonylureas.
Dosing
See
Table 13-2 for information about dosing.
Biguanides
Mechanism of action
The primary mechanism is seen through decreased hepatic gluconeogenesis as well as improved
glucose
[Table 13-2. Sulfonylureas]
utilization and uptake in peripheral tissues and decreased intestinal absorption of glucose.
Clinical considerations
• Biguanides are considered the first choice when beginning drug treatment in newly diagnosed DM
patients unless contraindicated.
• They pose minimal risk of hypoglycemia unless combined with secretagogues or insulin.
• They may decrease weight up to 5 kg.
• They decrease triglycerides, decrease LDL, and increase HDL.
• GI symptoms (nausea, vomiting, bloating, flatulence, anorexia, and diarrhea) are the most
common adverse effects.
• Take doses with or after meals to reduce GI symptoms.
• GI symptoms are transient and improve in most patients over time.
• Titrate the dose up slowly to minimize GI symptoms: 500 mg qd with the largest meal × 1
week; then increase to 500 mg bid with the two largest meals × 1 week; then increase to 1 g
(two 500 mg tablets) with largest meal and 500 mg with the second-largest meal × 1 week;
then increase to 1 g bid with the two largest meals of the day.
• Biguanides interfere with vitamin B12 absorption.
• They may require as much as 8 weeks of therapy before effectiveness can be assessed.
• Biguanides are generally not indicated during pregnancy or breast-feeding.
• They are indicated for the treatment of type 2 DM in children 10 years and older.
• They may decrease the progression to diabetes from IGT and IFG (prediabetes).
• They have positive cardiovascular benefits when used in obese patients with DM.
A1c reduction
A reduction of 1-2% is expected.
Cost
Biguanides are generically available.
Most cautions and contraindications are related to the ability of biguanides to increase the risk of
lactic acidosis with metformin (less than one case per 100,000 treated patients).
Contraindications
• Renal insufficiency (serum creatinine, or SCr 1.4 females; SCr 1.5 males) is a
contraindication; recent studies have suggested that metformin is safe unless the estimated GFR
falls to < 30ml/min.
• Hepatic dysfunction is a contraindication.
• Excessive alcohol use (binge or chronic use of more than two drinks per day or at one sitting) is a
contraindication.
• Medication may be contraindicated in congestive heart failure (New York Heart Association
classifications III and IV).
Cautions
• Medication should be held back in situations of increased risk for lactic acidosis, including acute
myocardial infarction, congestive heart failure exacerbation, severe respiratory disease, shock,
and septicemia.
• Medication should be held back 48 hours after iodinated contrast media and major surgeries.
Dosing
See
Thiazolidinediones (glitazones/TZDs)
Mechanism of action
Thiazolidinediones (also called glitazones or TZDs) are agonists of the PPAR³ (peroxisome
proliferators-activated receptor- ) receptor, which, when stimulated, improves peripheral muscle
and adipose tissue insulin sensitivity as well as suppresses hepatic glucose output.
• Minimal risk of hypoglycemia exists unless combined with secretagogues or insulin.
• TZDs may cause a 5 kg weight gain—more if combined with secretagogues or insulin.
• They decrease triglycerides (pioglitazone > rosiglitazone), increase high-density lipoprotein

(HDL) (pioglitazone = rosiglitazone), and increase low-density lipoprotein (LDL)
(rosiglitazone)/LDL (pioglitazone).
• They are dosed qd, though rosiglitazone may be slightly more effective when dosed bid.
• As much as 16 weeks of therapy may be required before assessing effectiveness.
• Generally, they are not indicated during breast-feeding or pregnancy.
• They may decrease the progression to diabetes from IGT and IFG.
• Edema may best be treated by aldosterone antagonists.
• They are not indicated by the U.S. Food and Drug Administration for treatment of type 2 DM in
children, though they have been used.
• They may be helpful in nonalcoholic fatty liver disease.
• Recent meta-analyses suggest a 30-40% relative increase in risk for myocardial infarction with
rosiglitazone, though not with pioglitazone.
[Table 13-3. Biguanides]
A1c reduction
A reduction of 1-2% is expected.
Cost
The monthly cost of the medication is approximately $120-200.
• Edema—with oral therapies (approximately 5%), with insulin (approximately 15%)—may occur
in patients with no history of heart problems. (The condition may be dose related.)
Recommendation: Discontinue therapy if the problem is significant, decrease the dose if the
problem is minor, and consider further cardiac workup.
• Recently, a black box warning was added for congestive heart failure (pioglitazone and
rosiglitazone).
• Hepatotoxicity incidence is approximately 0.2% of alanine aminotransferase (ALT) > three times
upper limit of normal (ULN) for both agents. Recommendation: Liver function tests (LFTs)
every other month for first 12 months and periodically thereafter. If ALT > 2.5 ULN, do not start;
if ALT = 1.0-2.5 ULN, monitor closely; if ALT 3× ULN, discontinue medication.
• Medication may cause resumption of ovulation in anovulatory women.

• Medication decreases oral contraceptive effectiveness.
Dosing
See
Alpha-glucosidase inhibitors
Mechanism of action
Alpha-glucosidase inhibitors delay the digestion of carbohydrates into simple sugars and their
subsequent absorption in the small intestine.
• Minimal risk of hypoglycemia exists unless the drug is combined with secretagogues or insulin.
• Alpha-glucosidase inhibitors have minimal effect on weight but can cause possible decrease in
weight secondary to side effects.
• Main target of therapy should be postprandial hyperglycemia.
• GI symptoms (flatulence, GI upset, abdominal pain, diarrhea, bloating) are the most common side
effects. These side effects tend to dissipate over time with continued treatment. Dosing must be
individualized and slowly titrated up as tolerated: 25 mg qd × 1 week; then 25 mg bid × 1 week;
then 25 mg tid × 1 week; then continued increased dose as tolerated up to 50 mg tid.
• Patient should be counseled to increase complex carbohydrate intake and decrease intake of
simple sugars.
• Treatment of hypoglycemia:
• Patient should use milk (lactose) or fruit juice (fructose), not sucrose.
• Any carbohydrate can be used if > 2-3 hours since last dose of alpha-glucosidase inhibitor
agent.
• Alpha-glucosidase inhibitors are generally not indicated during pregnancy, while breast-feeding,
or in children.
• Alpha-glucosidase inhibitors decrease the bioavailability of digoxin, propranolol, and ranitidine.
A1c reduction
A reduction of 0.5-1.0% is expected.
Cost
The monthly cost of the medication is approximately $75-100.
• Avoid use in patients with GI disorders such as ulcerative colitis, Crohn's disease, possible bowel
obstruction, and short bowel syndrome.
[Table 13-4. Thiazoladinediones]
[
Table 13-5. Alpha-Glucosidase Inhibitors]
• Avoid use in patients with SCr > 2 mg/dL (acarbose) or creatinine clearance (CrCl) of
25mL/min (both agents).
• Increased LFTs may be needed (acarbose) depending on the dose (> 300 mg/day) and weight of
patient. Avoid use in patients with cirrhosis.
Dosing
See Table 13-5 for information about dosing.
Dipeptidyl peptidase—4 inhibitors
Mechanism of action
Dipeptidyl peptidase—4 (DPP-4) inhibitors inhibit the degradation of endogenous glucagon-like
peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), which in turn causes
(1) increased insulin production in a glucose-dependent fashion, (2) decreased production of
glucagon, and (3) improved ²-cell functioning.
• Minimal risk of hypoglycemia exists unless drug is combined with secretagogues or insulin.
• These drugs have minimal or no effect on weight.
• They can be used either as monotherapy or in combination with metformin or thiazolidinediones

and possibly with insulin.
• This is the only drug class affecting the GLP-1 system dosed orally.
• Generally, DPP-4 inhibitors are very well tolerated. The most common side effects include
nasopharyngitis and upper respiratory tract infections.
• Secondary to newness of the drug, no significant long-term outcome data are yet available.
A1c reduction
Cost
The monthly cost is about $150.
• The dose should be adjusted for renal insufficiency.
• The drug may cause adverse immunologic reactions through T-cell inhibition.
• The drug should not be used in patients with DKA or type 1 DM.
Dosing
See
Combination oral agents for DM
Figure 13-2 shows the combination oral agents for DM. See individual agents for details.
Injectable Medications for DM Treatment
Insulin products
Mechanism of action
At low levels, insulin causes suppression of endogenous hepatic glucose production. At higher
[Table 13-6. Dipeptidyl Peptidase-4 Inhibitors]
[Figure 13-2. Combination Oral Agents]
levels, insulin promotes glucose uptake by muscle tissue.
• Insulin carries a positive risk of hypoglycemia.
• It causes an increase in weight.
• Insulin should be considered as initial agent if glucose is > 250 mg/dL or A1c is > 10%.
• There is no dosage limit.

• Dosing is often started with a basal insulin (0.1-0.2 units/kg/d) and added to an existing oral
regimen of two or more agents.
• Insulin regimen should be individualized to the patient accounting for
• Glucose readings
• Patient preferences
• Patient schedule
• Patient education and intelligence level
• Level of intensity needed
• Cost to patient
• Consider patient for prandial insulin coverage when
• Patient with fasting blood glucose target (< 100), but A1c 7%
• A1c 7% with evidence of frequent 2-hour postprandial glucose values > 160 mg/dL
• Nighttime or daytime hypoglycemia with skipped or delayed meals
A1c reduction
A reduction of 2.5% is expected.
Cost
Monthly cost varies, depending on the insulin product prescribed and the device used (i.e., pen
versus vial or syringe).
• Dose cautiously in patients with renal and hepatic insufficiency.
• Dose cautiously in elderly patients.
• Do not mix the following insulins with any others: Lantus, Levemir, Lente, and Ultralente.
• Counsel patients on signs and symptoms of hypoglycemia and how to appropriately treat.
• Most insulin products are stable at room temperature for 30 days, other than premixed insulin
products (14 days) and Levemir (45 days).
Dosing
Table 13-7 provides sample titration schedules for basal and prandial insulin. See
Table 13-8 for further dosing information.
Incretin mimetics
Mechanism of action
Incretin mimetics are receptor agonists of endogenous GLP-1 that cause (1) increased insulin
production in a glucose-dependent fashion, (2) decreased production of glucagon, (3) slowing of
gastric emptying, (4) increased satiety and weight loss, and (5) improved ²-cell functioning.
• Minimal risk of hypoglycemia exists unless the drug is combined with secretagogues (consider
initial reduction in secretagogue). There is a minor increase in hypoglycemia risk if the drug is
combined with TZDs.
• Moderate weight loss of about 10 pounds is seen after sustained use.
• A dose-limiting side effect is nausea. Approximately 50% of patients report some degree of
nausea, but stop the drug secondary to the problem. This problem seems to lessen with time.
• Patients should decrease meal size and carbohydrate content of meals prior to use of exenatide to
lessen problem of nausea.
• Dose should be given 10-15 minutes prior to the two largest meals of the day, which should be
spaced at least 6 hours apart.
• Drugs can be stored at room temperature for 30 days after first dose is given.
• Drugs can be combined with sulfonylurea, metformin, sulfonylurea + metformin, TZDs, or

metformin + TZD. Currently, they are not indicated in combination with insulin.
• Begin with 5 mcg injected bid for 1 month; then increase to 10 mcg bid as tolerated secondary to
GI toxicity.
• Drugs are supplied as a pen device that contains 60 doses (1-month supply).
• They are most effective in lowering postprandial glucose elevations.
• Recent reports suggest a possible risk for pancreatitis associated with use of GLP agonists;
however, whether the relationship is causal or coincidental is not yet clear.
A1c reduction
Cost
The monthly cost is approximately $150-200.
[Table 13-7. Sample Titration Schedules for Basal and Prandial Insulin]
[Table 13-8. Insulin Products]
• Medication should not be given to patients with GFR d 30 mL/min.
• It should not be given to patients with severe gastrointestinal disease, including gastroparesis.
• It should not be used in patients with DKA or type 1 DM.
Dosing
Table 13-9 provides further dosing information.
Amylin mimetics
Mechanism of action
The medication is an analog of endogenous amylin that when dosed at therapeutic levels causes (1)
decreased production of glucagon, (2) slowing of
[Table 13-9. Incretin Mimetics]
gastric emptying, and (3) increased satiety and weight loss.
• Drug can be used in combination with insulin therapy in both type 1 and type 2 DM patients who
have failed to achieve desired glucose control.
• Because of significant risk of severe hypoglycemia, prandial insulin dose should be decreased by
50% when starting pramlintide.
• A dose-limiting side effect is nausea, which seems to lessen over time.
• For type 2 DM, start with 60 mcg (10 units) before meals; increase to 120 mcg before meals when
no significant nausea has occurred for 3-7 days.
• For type 1 DM, start with 15 mcg (2.5 units) before meals; increase to 30 to 60 mcg before meals
when no significant nausea has occurred for 3-7 days.
• Opened vials may be stored at room temperature for 28 days.
A1c reduction
Cost
The cost per month is about $100-300.

The medication should not be used in patients with
• Severe gastrointestinal disease, including gastroparesis
• Poor adherence with current insulin regimen or self-monitoring of blood glucose
• Recurrent severe hypoglycemia requiring assistance in the past 6 months
• A1c 9%
• Hypoglycemia unawareness
Dosing
Table 13-10 provides further dosing information.
Introduction
Weight loss is recommended for all diabetics who are overweight or obese. Modest weight loss
(5%) has been shown to decrease insulin resistance in type 2 diabetes.
Lifestyle changes through diet and exercise should be emphasized. Patient education is an essential
component of successful diabetes management.
Medical Nutrition Therapy
Medical nutrition therapy (MNT) should be individualized to achieve treatment goals with
consideration of usual dietary habits, metabolic profile, and lifestyle.
Carbohydrate (CHO) should be monitored by exchanges, carbohydrate counting, or experience-

based estimation. CHO should be 45-60% of total daily caloric intake. If intensive insulin therapy is
used with a premeal bolus dose of insulin, insulin should be adjusted to cover the daily CHO intake.
With basal insulin therapy (when the premeal bolus is not used) or oral antidiabetic medications,
the CHO intake must be adjusted so that it is consistent with the effects of therapy.
Protein should be 15-20% of total daily caloric intake. Protein intake should be modified if renal
function is reduced. Saturated fat should be < 7% of total daily calories. Cholesterol should be <
200 mg/d.
Fiber intake should be encouraged, but there is no reason to recommend a greater amount than that
recommended for persons without DM (14 g fiber/1,000 kcal).
Daily alcohol intake should be limited (adult females: one drink or fewer; adult males: two drinks
or fewer).
Physical Activity and Exercise
Regular exercise improves blood glucose control, reduces cardiovascular risk factors, and
contributes to
[Table 13-10. Amylin Mimetics]
weight loss. An exercise regimen should be individualized. The patient's preexercise program
history and a detailed medical examination are essential.
For most patients, a program of 150 min/week of moderate-intensity aerobic exercise is

recommended. The program should be adjusted in the presence of macro- and microvascular
complications that may be worsened:
• Retinopathy: Vigorous exercise may be contraindicated because of the risk of triggering vitreous
hemorrhage or retinal detachment.
• Peripheral neuropathy: Non-weight-bearing activities may be best because decreased pain

sensation in the extremities increases the risk of skin breakdown and infection.
• Autonomic neuropathy: Patients should undergo cardiac investigation before increasing physical
activity, which may lead to decreased cardiac responsiveness to exercise, postural hypotension,
and so forth.
Blood glucose monitoring may be necessary before and after exercise. Fast-acting oral
carbohydrates should be available during and after exercise.
Diabetes Self-Management Education
Diabetes self-management education (DSME) provides a means for persons with DM to become
empowered and assist with self-care. Education content includes the disease process; acute and
long-term complications; drug and nondrug treatments; monitoring; preventive measures; decision-
making skills; specific self-care measures relative to foot, skin, dental, and eye care; goal setting;
and psychosocial adjustment.
DSME should be offered in a variety of settings, typically by a multidisciplinary team.
13-4. Key Points
• DM is a group of chronic metabolic diseases exhibiting hyperglycemia resulting from defects in

insulin secretion, action, or both.
• Type 1 diabetes results from immune-mediated -cell destruction, which leads to absolute insulin
deficiency.
• Type 2 diabetes is characterized by relative insulin deficiency, insulin resistance, or both.
• See
Table 13-11 for a comparison of type 1 and type 2 diabetes.
[Table 13-11. Comparison of Type 1 and Type 2 Diabetes Mellitus]
• The principal treatment goals include maintaining blood glucose levels in the normal or near-
normal range and preventing acute and chronic complications.
• Goals of diabetes therapy include achieving and maintaining glycemic control and reaching
recommended blood pressure and lipid goals.
• Outcomes of uncontrolled blood glucose include cardiovascular, kidney, eye, and nerve disease.
• Pharmacotherapy treatment of DM should be individualized to each patient considering such

factors as glucose control goals; length of time with DM; concomitant diseases; psychosocial
issues, including available support for the patient, patient motivation, medication and DM supply
costs, and the level of risk for complications secondary to DM control.
• Multiple studies have shown improved glycemic control delays the onset of, slows the progression
of, and lowers the risk of long-term microvascular complications.
• Combination therapy of two or more po therapies, po therapies plus insulin, or po products plus
GLP-1 analogs will be required in most patients to maintain continued DM control.
• Metformin
• Is considered first-line therapy in newly diagnosed type 2 DM
• Is contraindicated in renal dysfunction patients
• Has low or minimal risk of hypoglycemia with monotherapy

• Has GI side effects (flatulence, GI upset, abdominal pain, diarrhea, bloating), which are dose-
limiting problems
• Causes no weight gain
• May decrease the progression to DM in high-risk patients
• Secretagogues
• Are helpful in combination with other po agents and injectable products
• Increase risk of hypoglycemia (sulfonylureas > meglitinides)
• Increase weight (sulfonylureas > meglitinides)
• Have high rate of failure over time
• Must be used with caution in renally impaired and elderly patients
• Thiazolidinediones
• Help improve peripheral insulin resistance
• Increase weight and edema
• Have low or minimal risk of hypoglycemia with monotherapy
• Are contraindicated in patients with congestive heart failure
• Have delayed time to see full effects on DM control
• May decrease the progression to DM in high-risk patients
• Alpha-glucosidase inhibitors
• Block absorption of carbohydrates in the small intestine
• Have low or minimal risk of hypoglycemia with monotherapy
• Have GI side effects (flatulence, GI upset, abdominal pain, diarrhea, bloating), which are dose-
limiting problems
• Are more effective for postprandial hyperglycemia
• Have minimal effect on weight

• GLP-1 and amylin-based medications
• Include Byetta (GLP-1 analog)
• Increase insulin production in a glucose-dependent fashion
• Decrease production of glucagon
• Improve -cell functioning
• Slow gastric emptying
• Increase satiety and possible weight loss
• Have a dose-limiting side effect of nausea
• Are injectable products
• Are for use in type 2 DM
• Are high cost
• DPP-IV inhibitor (Januvia)
• Increases insulin production in a glucose-dependent fashion
• Decreases production of glucagon
• Improves -cell functioning
• Has no effect on weight
• Is well tolerated with few side effects
• Is for use in type 2 DM
• Is high cost
• Amylin mimetic (Symlin)
• Decreases production of glucagons
• Slows gastric emptying

• Increases satiety and possible weight loss
• Has significant risk of hypoglycemia in combination with insulin in type 1 DM
• Has the dose-limiting side effect of nausea
• Is for use in type 1 and 2 DM
• Is high cost
• Insulin
• Is essential for type 1 DM
• Is often used in type 2 DM in combination with other therapies
• Should be considered initial agent if glucose is > 250 mg/dL or A1c > 10%
• Is often started as basal therapy (0.1-0.2 units/kg/d) added to an existing po regimen
• Should be individualized to the patient's goals and motivation: intensive insulin therapy (> 3
doses/d or use of continuous subcutaneous insulin infusion) is replacing conventional insulin
therapy (split-mix dosing: two-thirds of total daily dose)
• Varies principally by source; appearance; time-activity profiles (onset, peak, and duration);
dosing; and route of administration
• May have these adverse events: hypoglycemia, weight gain, and lipodystrophies
• Has the same mechanism of action for all types
• Patient education is essential for the management of DM because it provides a means for persons
with this chronic disease to become empowered, cope effectively, and engage in appropriate self-
care.
• Recommended lifestyle modifications include weight management, increased physical activity,

and smoking cessation.
13-5. Questions
Use Patient Profile 1 to answer Questions 1-5.
Patient Profile 1—Institution or Nursing Home Care

Patient Barbara

Name: Evens
413 Summit
Address:
Street
Age: 68
Height: 5' 5"
Weight: 190 lb
Sex: Female
African
Race:
American
Penicillin,
Allergies:
sulfa drugs
Diagnosis:
Primary 1) Type 2 DM
1)
Secondary
Hypertension
2) Asthma
Lab/Diagnostic Tests:
Date Test
1) 2/1 LFTs
2) 2/1 Serum K
3) 5/1 LFTs
4) 5/1 Serum K
5) 6/1 A1c
Serum
6) 6/1
creatinine
7) 6/1 BUN
8) 6/1 Serum K
Additional Orders:
1. Referral to dietitian for weight reduction diet

2. Low impact exercise 30 mins 3 days per week
Dietary Considerations:
1. Dietary changes per dietitian consult

2. Enteral and parenteral
Pharmacist Notes and Other Patient Information:
Date Comment
Advise patient to continue SMBG and to report any hypoglycemic
episodes. Instructed patient to treat hypoglycemia with glucose or
1) 2/1 lactose products. Instructed patient to take acarbose with first bite of
meal. Foot exam negative. Patient reports having 1-2 drinks of bourbon
per day.
2) Informed patient to report any changes in BG.
Medication Orders:
Date RX No Physician Drug & strength Qty Sig Refills

2/1 834924 Jones Propranolol 20 mg 30 1 PO bid 3
1-2 inhalations q4-
2/1 834925 Jones Albuterol inhaler 1 3
6h
2/1 834926 Jones Acarbose 25 mg 90 1 tab PO w/meals 2
5/1 834927 Jones Acarbose 50 mg 90 1 tab PO w/meals 2
6/1 834928 Jones Prednisone 10 mg 30 1 tab PO daily 0
6/1 834929 Jones Propranolol 20 mg 30 1 tab PO bid 3
1-2 inhalations q4-
6/1 834930 Jones Albuterol inhaler 1 3
6h
6/1 834931 Jones ASA 81 mg 30 1 tab PO daily 3
Chlorpropamide would be problematic in this case for which of the following reasons?
I. Alcohol intake
II. Sulfa allergy
III. Asthma
IV. Hypertension
1. V. Drug-drug interaction
A. I only
B. III only
C. I and II only
D. II, III, and IV
E. I, II, and V

Because of a renal protection mechanism, the drug class of choice for Ms. Even's hypertension
is a(n)
A. -blocker.
2.
B. loop diuretic.
C. thiazide diuretic.
D. -adrenergic blocker.
E. angiotensin-converting enzyme inhibitor.

One of the most common adverse drug events caused by Ms. Even's oral antidiabetic agent is
A. flatulence.
3. B. hypoglycemia.
C. renal failure.
D. hyperglycemia.
E. weight gain.

Which of the following medications on the medication list in this case can mask the symptoms
of hypoglycemia?
A. Propranolol
4.
B. Albuterol
C. Acarbose
D. Prednisone
E. Aspirin

What change in the following laboratory tests might be observed with the addition of prednisone
to Ms. Even's drug regimen?
A. Increase in LFTs
5.
B. Decrease in BUN
C. Decrease in serum creatinine
D. Increase in serum creatinine
E. Increase in blood glucose

Use Patient Profile 2 to answer questions 6-10.
Patient Profile 2—Community

Patient
Tom Right
Name:
20 Blue Ridge
Address:
Drive
Age: 48
Height: 5' 6"
Weight: 135 lb
Sex: Male
Race: Caucasian
Allergies: NKDA
Diagnosis:
1) Type 2 DM
Primary
2) Epilepsy
1) Hypertension
Secondary 2) Fungal
infection under
toenails
Pharmacist Notes and Other Patient Information:
Date Comment
Patient should be monitored closely for hypoglycemia. Teach
1) 4/8 patient signs and symptoms of hypoglycemia and treatment
measures.
Medication Orders:
Date RX No Physician Drug & strength Qty Sig Refills

Tolazamide 250
1/6 765321 Smith 90 1 tab PO daily 0
mg
4/8 765323 Smith Glimepiride 2 mg 90 1 tab PO daily 0
8/6 765324 Smith Lisinopril 5 mg 90 1 tab PO daily 0
Phenytoin
8/6 765325 Thomas 60 300 mg PO daily 0
extended
8/6 765366 Smith Itraconazole 14 50 mg PO daily 0
5 units SC
8/6 765367 Smith Regular insulin Trial 0
before meals
What is the principal drug-related problem in this patient's medication record?
A. Insulin therapy not indicated for persons with type 2 DM

B. Therapeutic duplication of sulfonylurea therapy
6. C. Potential decrease of BG because of drug-drug interaction between phenytoin and
tolazamide
D. Potential increase of BG because of drug-drug interaction between glimepiride and
itraconazole
E. Use of an ACE inhibitor for hypertension in type 2 DM

All of the following monitoring parameters are necessary for Mr. Right except
A. periodic glycosylated hemoglobin A1c.

7. B. SMBG levels.
C. phenytoin levels.
D. blood pressure readings.
E. quarterly serum C-peptide level.

Which of the following is an inappropriate treatment for a mild hypoglycemic episode?
A. 1/2 cup of diet soda

8. B. 6-7 hard candies containing sugar
C. 3 glucose tablets
D. 1/2 cup of regular soda
E. 5 small sugar cubes

Persons on insulin therapy should be advised to rotate their injection sites for which of the
following reasons?
A. It reduces the risk of infection.

9.
B. It reduces the risk of lipoatrophy.
C. It reduces the risk of lipohypertrophy.
D. It reduces the risk of generalized myalgia.
E. This advice is outdated because of the use of human insulin.

Which of the following is the most appropriate treatment for a severe hypoglycemic episode?
A. 1/2 cup of diet soda
10. B. 3 hard candies containing sugar
C. 1 glucose tablet
D. Glucagon injection
E. 2-3 small sugar cubes

Commercially available insulin (as of May 2005) may be administered by which of the
following routes?
I. Intravenously
II. Subcutaneously
III. Via inhalation
IV. Transdermally
11.
V. Sublingually
A. I only
B. II only
C. I and II only
D. II, III, and IV
E. I, II, and V

Insulin therapy is indicated in all of the following except
A. newly diagnosed type 1 DM.

12. B. gestational diabetes mellitus not controlled by diet.
C. hyperglycemic hyperosmolar nonketotic syndrome (HHNS).
D. newly diagnosed type 2 DM.
E. diabetic ketoacidosis (DKA).

Insulin dosing is adjusted on the basis of the following parameters:
I. Liver function test results

II. Dietary intake
III. Physical activity and exercise
IV. Blood glucose levels
13. V. Ophthalmic examinations
A. I only
B. II only
C. I and II only
D. II, III, and IV
E. I, II, and V

Which of the following oral antidiabetic agents is a micronized formulation?
A. Micronase
14. B. Glynase
C. Glucotrol XL
D. Amaryl
E. Orinase

Insulin that has been stored in a refrigerator should be allowed to reach room temperature prior
to administration to
A. allow for proper mixing.

15.
B. minimize painful injections.
C. prevent frosting or clumping.
D. delay systemic absorption.
E. prevent change in clarity.

When mixing rapid- or short-acting insulin with intermediate- or long-acting insulin, which of
the following insulins should be drawn up first?
A. Regular
16.
B. NPH
C. Lente
D. Ultralente
E. Glargine

Uniform dispersion of insulin suspensions can be obtained by
A. vigorously shaking the vial.

17. B. rolling the vial gently between the hands.
C. warming the vial in a microwave.
D. packing the vial in dry ice.
E. keeping the vial at room temperature (68-75°F).

Of the following types of insulin, which can be administered intravenously?
A. Glargine
18. B. Lente
C. Regular
D. Ultralente
E. NPH

Diabetes mellitus is the leading cause of which of the following complications?
A. Pancreatitis
19. B. Fatty liver
C. Blindness
D. Stroke
E. Deafness

Which of the following is an indication that a patient is developing a long-term complication
from diabetes mellitus?
A. Tachycardia
20.
B. Glucosuria
C. Leukocytosis
D. Proteinuria
E. Tinnitus

Which sulfonylurea has been associated with the greatest incidence of prolonged hypoglycemia
in the elderly?
A. Tolazamide
21.
B. Tolbutamide
C. Chlorpropamide
D. Glimepiride
E. Glipizide

Which of the following drugs taken with alcohol is most likely to cause a disulfiram-like
reaction?
A. Chlorpropamide
22.
B. Acarbose
C. NPH insulin
D. Glucagon
E. Pioglitazone

Metformin should be withheld for 48 hours prior to any procedure requiring the use of
parenteral iodinated contrast medium because of the potential for this adverse drug event:
A. Optic neuritis
23.
B. Metabolic alkalosis
C. Lactic acidosis
D. Purple-toe syndrome
E. Tinnitus

The use of insulin in a woman with GDM helps reduce the incidence of which complication in
the fetus?
A. Macrosomia
24.
B. Cystic fibrosis
C. Deafness
D. "Soft bones"
E. Eczema

Metformin would not be an option for a patient with which of the following diagnoses?
A. Iron deficiency anemia

25. B. Impaired renal function
C. Hypertension
D. Type 2 DM
E. Frequent hypoglycemic episodes

Nocturnal hypoglycemia resulting in rebound hyperglycemia in type 1 DM is termed
A. honeymoon period.
26. B. Somogyi effect.
C. dawn phenomenon.
D. hyperglycemic phase.
E. insulin resistance syndrome.

Which of the following is a potentially fatal adverse drug event of Glucophage?
A. Weight gain
27. B. Frequent urination
C. Diarrhea
D. Lactic acidosis
E. Angioedema

All of the following are true of acarbose therapy except
A. it is contraindicated in inflammatory bowel disease.

B. it should be taken with the first bite of each meal.
28.
C. it does not cause hypoglycemia or weight gain.
D. hypoglycemia attributable to combination therapy should be treated with sucrose.
E. LFTs are given every 3 months during the first year and periodically thereafter (if the dose is
> 50 mg tid).

Prandin is a nonsulfonylurea secretagogue. Adverse drug events include all of the following
except
A. upper respiratory infection.

29.
B. arthropathy.
C. hypoglycemia.
D. back pain.
E. hyperglycemia.

Patient counseling relative to meglitinides should include the following points:
I. It must be taken 30 minutes before main meals.

II. If a meal is omitted, do not take.
III. It enhances preprandial glucose utilization.
IV. Hyperglycemia is a potential adverse drug event.
30. V. Disulfiram-like reaction is possible when ingested with ETOH.
A. I only
B. III only
C. I and II only
D. II, III, and IV
E. I, II, and V

Which one of the following antidiabetic agents does not require liver function tests for
monitoring?
A. Glargine
31.
B. Miglitol
C. Rosiglitazone
D. Acarbose
E. Metformin

Adverse drug events reported for pioglitazone (Actos), a thiazolidinedione, include all of the
following except
A. exacerbation of congestive heart failure.

32.
B. resumption of ovulation.
C. edema.
D. upper respiratory infection.
E. megaloblastic anemia.

All of the following drugs have a direct glucogenic effect except
A. thiazide diuretics.
33. B. corticosteroids.
C. nicotinic acid.
D. sympathomimetics.
E. acetohexamide.

Which of the following is the mechanism of action for the sulfonylureas?
A. They stimulate pancreatic ²-cells to secrete insulin.

B. They delay carbohydrate metabolism and absorption (owing to inhibition of intestinal and
pancreatic enzymes).
34.
C. They increase hepatic insulin sensitivity and decrease hepatic glucose production.
D. They increase skeletal muscle and adipose tissue insulin sensitivity and decrease hepatic
glucose production.
E. They decrease blood glucose and assist with blood glucose control by increasing glucose
uptake and use by peripheral tissues.

All of the following are signs or symptoms of hypoglycemia except
A. tachycardia.
35. B. diaphoresis.
C. shakiness.
D. polyuria.
E. pallor.

Pramlintide (Symlin)
A. is a basal insulin.
36. B. is an insulin analog.
C. is an oral insulin.
D. is an inhaled insulin.
E. is an injectable synthetic version of the human hormone amylin.

13-6. Answers
E. Chlorpropamide is contraindicated in persons with a sulfa allergy. Alcohol (ETOH)

ingestion with chlorpropamide could lead to a disulfiram-like reaction. Also, acute ingestion of
1. ETOH (especially in the fasting state) includes the risk of severe hypoglycemia.
Chlorpropamide and prednisone may produce a drug-drug interaction resulting in
hyperglycemia. Items III and IV are nonproblematic in this case in relation to chlorpropamide.

E. Angiotensin-converting enzyme inhibitors exhibit a renal protective mechanism in people
2.
with DM. None of the remaining drugs exhibits such an effect.

A. The most common adverse drug events for acarbose are flatulence, abdominal pain, and
3. diarrhea. These adverse effects may be decreased by titrating the dose gradually and taking the
drug with the first bite of each meal. There may also be an increase in LFTs.

A. Propranolol (a nonselective -blocker) can mask the symptoms of hypoglycemia (i.e.,
4. tachycardia [palpitations], pallor, shakiness [tremor], paresthesia, hunger, diaphoresis
[sweating], dizziness, and blurred vision). None of the remaining drugs listed has this effect.

E. The increase in LFTs may be due to acarbose, and the increase in serum creatinine may
represent the development or progression of nephropathy, a long-term complication of DM.
5. The decrease in the serum creatinine and BUN (blood urea nitrogen) are incorrect answers.
Prednisone, a corticosteroid, has a dose-dependent, direct glucogenic and glycosuric effect, and
therefore an increase in blood glucose (BG) might be observed.

B. Although tolazamide and glimepiride are first- and second-generation sulfonylureas,
duplication of drug class is inappropriate. These agents are both intermediate acting and
therefore might potentiate the adverse drug event of hypoglycemia. Insulin may be indicated in
a person with type 2 DM as the disease progresses. The potential drug-drug interaction
6.
between phenytoin and tolazamide could result in an increased BG (blood glucose) level, and
the potential drug-drug interaction between glimepiride and itraconazole could result in a
decreased BG level. An ACE inhibitor for hypertension in type 2 DM is appropriate because
this drug is renal protective.

E. The A1c and self-monitoring of blood glucose (SMBG) tests are essential for monitoring the
success of glucose control therapy. The SMBG gives an immediate determination of BG level,
and the A1c gives an average reading over the previous 2-3 months (or 120 days, the lifespan of
7. a red blood cell). Phenytoin levels are necessary for monitoring therapeutically appropriate
levels, and blood pressure readings are necessary for monitoring the success of
antihypertensive therapy. A serum C-peptide might be diagnostic for the determination of
functioning -cells; however, if performed, it is done very infrequently to reduce cost.

A. One-half cup of diet soda would be inappropriate because a mild hypoglycemic episode
8. requires a fast-acting oral carbohydrate for resolution and diet soda has none. The other options
would all be appropriate for resolution of the event.

C. Lipohypertrophy (a bulging of the injection site) is due to nonrotation of injection sites. The
risk of infection may be reduced by using aseptic injecting technique. Lipoatrophy (a pitting of
9.
the injection site) may be due to an antigenic response to insulin. The advice regarding rotation
of injection site is not outdated.

D. Glucagon, a pancreatic hormone that is given parenterally, is the most appropriate treatment
for a severe hypoglycemic episode (life threatening), because the patient may be unconscious
10. and not able to take a fast-acting carbohydrate by mouth. The other items represent
inappropriate treatment for mild to moderate hypoglycemia (the amounts of items B, C, and E
are inadequate, and the soda in item A should be regular soda).

C. Pharmaceutical research has developed inhaled insulin products that are still being tested.
At present, the commercially available insulins may be administered only intravenously or
11.
subcutaneously. A previously available inhaled insulin product, Exubra, was voluntarily
withdrawn from the market by the manufacturer.

D. Newly diagnosed type 2 DM should first have a trial with MNT and exercise, and if this
nondrug therapy fails, oral antidiabetic monotherapy should be added. Combination oral
12. therapy would be indicated next with failure of monotherapy. Then, following the failure of
oral therapy, insulin monotherapy or insulin therapy in combination with oral agents is
indicated. Insulin is indicated in all the other situations.

D. Dietary intake, physical activity and exercise, and blood glucose levels are the parameters
used in adjusting insulin dosing (e.g., if the parameters of dietary intake and blood glucose
13. levels are decreased and if physical activity and exercise are increased, the insulin dosing
would require reduction to avoid hypoglycemia). Monitoring of these parameters is critical to
adjusting the insulin regimen. Items I and V are incorrect.

B. Glynase is a micronized formulation of glyburide that is significantly absorbed (e.g., a 3 mg
tablet provides blood levels similar to a 5 mg conventional tablet). Micronase is a trade name
14. for nonmicronized glyburide. Glucotrol XL is the name of an extended formulation of
glipizide. Orinase is the trade name for tolbutamide (the only first-generation sulfonylurea
listed here), and Amaryl is the trade name for glimepiride.

B. Refrigerated insulin is allowed to reach room temperature prior to administration to
minimize painful injections. Proper mixing, prevention of frosting or clumping, or
15.
maintenance of clarity have nothing to do with reaching room temperature. Systemic
absorption would actually be enhanced by increasing to room temperature, not delayed.

A. Regular or clear insulin is always drawn up first to ensure that all persons mixing insulins
will use the same procedure and that no intermediate- or long-acting insulin will be placed in
16. the regular insulin vial, potentially causing contamination and dose variance. Glargine is also a
clear insulin; however, it is never to be mixed with other insulins because of the low pH (4.0)
of its diluents.

B. Uniform dispersion of insulin suspensions can be obtained by gently rolling the vial
17. between the hands. Insulin is a fragile molecule, and all the other means listed could cause
molecular degradation.

C. Of these insulins, regular is the only one that can be administered intravenously. Although
18. glargine is clear like regular insulin, its pH is 4.0, and it should never be given intravenously.
The remaining insulins are suspensions and also should never be given intravenously.

C. DM is the leading cause of new cases of blindness among adults 20-74 years of age in the
19. United States. There is also an increased incidence of stroke with DM, but DM is not the
leading cause of this problem. The other items are incorrect.

D. Proteinuria is an indication that a patient is developing the long-term complication of
20. nephropathy. Items A, B, and C could be related to acute complications such as DKA
(glucosuria and leukocytosis) and hypoglycemia (tachycardia). Item E is incorrect.

C. Chlorpropamide has a t1/2 of 35 hours and a duration of action of 60 hours; therefore, it has
21. been associated with prolonged hypoglycemia in the elderly (perhaps because of their declining
renal function). The other sulfonylureas have reported less hypoglycemia.

A. Chlorpropamide has had the greatest reporting of this drug interaction relative to the first-
22. generation sulfonylureas. The remaining drugs listed have not had reports of this adverse drug
event.

C. Lactic acidosis can result if metformin (Glucophage) is given in this situation, and it can be
23. potentially fatal. Renal function must be evaluated following such a procedure, and it must be
normal before metformin may be resumed. The other items are incorrect.

A. Macrosomia (abnormally large fetal body size) is one of the fetal complications of concern
24. in GDM. The primary benefit of insulin therapy is reduction in the incidence of macrosomia.
The other items are incorrect.

B. Contraindications for metformin are renal dysfunction for those predisposed to lactic
acidosis. Metformin does not cause hypoglycemia, and it is indicated in type 2 DM.
25.
Hypertension and iron deficiency anemia are incorrect answers. Metformin may cause
megaloblastic anemia.

B. The Somogyi effect is rebound hyperglycemia or early morning hyperglycemia secondary to
nocturnal hypoglycemia. The person with type 1 DM may experience a honeymoon period—a
phase of erratic insulin secretion during destruction of ²-cells by islet cell antibodies. This
26.
short-lived remission lasts months to a year. The dawn phenomenon is fasting hyperglycemia
(prebreak-fast) caused by decreased plasma insulin during the night or the anti-insulin effect of
nocturnal growth hormone. Items D and E are incorrect.

D. Lactic acidosis is a potentially fatal adverse drug event of Glucophage (metformin). It does
not cause weight gain. Modest weight loss is possible, and no hypoglycemia is reported when
27.
metformin is used as monotherapy. Diarrhea is an adverse drug event, but with gradual dose
titration and administration with food, it decreases over time. Items B and E are incorrect.

D. Oral glucose instead of carbohydrate sources with sucrose (cane sugar) or fructose is used
28.
because absorption of these is inhibited. The remaining items are true of acarbose therapy.

E. Prandin may cause hypoglycemia like the sulfonylureas. Hyperglycemia is not one of the
29.
adverse drug events reported. Prandin may cause all the other adverse drug events.

C. Meglitinides should be taken 30 minutes before main meals, and if a meal is omitted, the
30. drug should not be taken. It enhances postprandial glucose utilization; hypoglycemia, not
hyperglycemia, may occur; and disulfiram-like reactions are not reported.

A. The -glucosidase inhibitors (e.g., acarbose), biguanides (e.g., metformin), and
31. thiazolidinediones (e.g., rosiglitazone) all require LFTs for monitoring. Glargine, a long-acting
insulin, does not require LFTs for monitoring; rather it requires blood glucose monitoring.

E. Megaloblastic anemia is a reported adverse drug effect for metformin, but not for Actos. All
the other items listed are reported adverse drug effects. Since troglitazone (Rezulin), a
32. thiazolidinedione, was withdrawn from the market in 2000 because of severe liver toxicity, this
adverse drug effect could potentially occur with Actos; therefore, LFTs should be performed
periodically.

E. Acetohexamide has a hypoglycemic effect. All the other drugs listed have a direct
33.
glucogenic effect.

A. The sulfonylureas stimulate pancreatic -cells to secrete insulin. Item B is the mechanism of
action for -glucosidase inhibitors, item C is the mechanism of action for the biguanide
34.
metformin, item D is the mechanism of action for the glitizones, and item E is the mechanism
of action for insulin.

D. Polyuria (excessive urination) is one of the classic signs and symptoms of DM. All of the
35. other answers listed are some of the signs and symptoms of hypoglycemia, which can be life
threatening.

E. Pramlintide (Symlin) was approved in March 2005 as the first new type 1 diabetes treatment
36.
in more than 80 years. It is an injectable synthetic version of the human hormone amylin.

13-7. References
American Diabetes Association. Standards of medical care in diabetes—2009. Diabetes Care. 2009:
32(suppl 1):S13-61.
Bode BW, ed. Medical Management of Type 1 Diabetes. Alexandria, Va. American Diabetes
Association; 2008.
Burant CF, ed. Medical Management of Type 2 Diabetes. Alexandria, Va. American Diabetes
Association; 2008.
Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert
Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care.
1997;20:1183-97.
Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Follow-up report on
the diagnosis of diabetes mellitus. Diabetes Care. 2003;26:3160-67.
Funnell MM, Brown TL, Childs BP, et al. National Standards for Diabetes Self-Management
Education. Diabetes Care. 2007;30:1630-7.
Diabetes Control and Complications Trial Research Group. The effect of intensive treatment on the
development and the progress of long-term complications in insulin-dependent diabetes mellitus.
N Engl J Med. 1993;329:977-86. Available at:
http://content.nejm.org/cgi/content/full/329/14/977.
Setter SM, White JR Jr, Campbell RK. Diabetes. In: Helms RA, Quan DJ, Herfindal ET, Gourley
DR, eds. Textbook of Therapeutics. 8th ed. Philadelphia: Lippincott Williams & Wilkins;
2006:1042-105.
Stoneking K, Farr G. Early use of insulin in type 2 diabetes. Drug Topics October 2, 2002.
Available at: http://drugtopics.modernmedicine.com/drugtopics/Diabetes/CE--Early-use-of-
insulin-in-Type-2-diabetes-mellit/ArticleStandard/Article/detail/117448.
Triplett CL, Reasner CA, Isley WL. Diabetes mellitus. In: Dipiro JT, Talbert RL, Yee GC, et al.,
2008:1205-41.
UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with
metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet.
1998;352:854-65.
UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with

sulphonylureas or insulin compared with conventional treatment and risks of complications in
patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837-53.
University Group Diabetes Program. A study of the effects of hypoglycemic agents on vascular
complications in patients with adult onset diabetes. Diabetes. 1970;19(suppl 2):1-26.
White JR, Campbell RK. Drug/drug and drug/disease interactions and diabetes. Diabetes Educator.
1995;21:283-9.
14. Thyroid, Adrenal, and Miscellaneous Endocrine Drugs - Jeremy Thomas, PharmD, CDE
14-1. Thyroid
Hypothyroidism
Disease overview
Definition and epidemiology
• Hypothyroidism is a syndrome resulting from deficient thyroid hormone production that results in
a slowing down of all bodily functions.
• Retardation of growth occurs in infants and children.
• Its prevalence is greater in women and increases with age; it affects 1.5% to 2.0% of women and
0.2% of men.
Types
• Most cases are caused by thyroid gland failure (primary hypothyroidism).
• Hashimoto's disease (chronic lymphocytic thyroiditis) is the cause of 90% of primary

hypothyroidism.
• Pituitary failure causes secondary hypothyroidism.
• Hypothalamic failure causes tertiary hypothyroidism.
• Iatrogenic hypothyroidism follows exposure to radiation with radioiodine or external radiation.
• Other causes may include thyroidectomy, iodine deficiency, enzymatic defects, iodine, lithium,
and interferon-alfa.
Clinical presentation
• Symptoms include cold intolerance, fatigue, somnolence, constipation, menorrhagia, myalgia, and
hoarseness.
• Signs include thyroid gland enlargement or atrophy, bradycardia, edema, dry skin, and weight
gain.
• Myxedema coma is an end stage of hypothyroidism characterized by weakness, confusion,

hypothermia, hypoventilation, hypoglycemia, hyponatremia, coma, and shock.
Pathophysiology
• Thyroxine (T4) is the major hormone secreted by the thyroid; T4 is converted to the more potent
triiodothyronine (T3) in tissues.
• Thyroxine secretion is stimulated by thyroid-stimulating hormone (TSH).
• TSH secretion is inhibited by T4, forming a negative feedback loop.
• Hashimoto's disease is an autoimmune-mediated disease resulting from cell- and antibody-

mediated thyroid injury.
• Antimicrosomal antibodies are directed against thyroidal antigens.
Diagnosis
• Plasma TSH assay is the initial test of choice if hypothyroidism is suspected clinically.
• TSH levels are elevated in primary hypothyroidism.
• Low plasma-free T4 (or T4 index) confirms the diagnosis of hypothyroidism.
Treatment principles
• Synthetic thyroxine (levothyroxine) is the drug of choice for hypothyroidism because it is

chemically stable, inexpensive, and free of antigenicity and because it has uniform potency.
• The typical dose is 100-125 mcg po once daily; the dose is reduced to 50 mcg in the elderly and to
25 mcg in patients with coronary artery disease to decrease the risk of precipitating angina.
• The goal of therapy is to maintain plasma TSH in the normal range.
• Dose changes are made at 6- to 8-week intervals until the TSH is normal.
• Overtreatment is detected by subnormal TSH and is associated with osteoporosis and atrial
fibrillation.
• Failure to respond to appropriate doses is most often due to poor compliance.
• Do not use thyroid hormones to facilitate weight loss in euthyroid patients.
• Thyroid hormones have a narrow therapeutic index; careful monitoring of clinical condition and
thyroid function is required.
Drug therapy for hypothyroidism
Thyroid preparations for the treatment of hypothyroidism are described in

Table 14-1.
Mechanism of action
Thyroid hormones enhance oxygen consumption by most tissues and increase basal metabolic rate
and metabolism of carbohydrates, lipids, and proteins.
Patient counseling
• Take once daily, 30 minutes before breakfast, because food may decrease absorption.
• Replacement therapy is usually for life; do not discontinue without advice of the prescriber.
• Notify the prescriber if you experience rapid or irregular heartbeat, chest pain, shortness of breath,
nervousness, irritability, tremors, heat intolerance, or weight loss.
• Do not take antacids, calcium, or iron supplements within 4 hours of levothyroxine.
Adverse effects
• Cardiovascular: Tachycardia, arrhythmia, angina, myocardial infarction
• Central nervous system (CNS): Tremor, headache, nervousness, insomnia, irritability,

hyperactivity
• Gastrointestinal (GI): Diarrhea, vomiting, cramps
• Miscellaneous: Weight loss, fatigue, menstrual irregularities, excessive sweating, heat

intolerance, fever, muscle weakness, hair loss, decreased bone mineral density, hypersensitivity
Drug interactions
• Amiodarone may cause hypothyroidism or hyperthyroidism.
• Antacids decrease absorption of levothyroxine. Separate administration by at least 4 hours.
• Antidiabetic agents may be less effective with levothyroxine. An increase in the insulin or oral
hypoglycemic dose may be needed.
• Bile acid sequestrants reduce absorption of levothyroxine. Separate administration by at least 4

hours.
• Enzyme-inducing antiepileptic agents increase hepatic degradation of levothyroxine. The

thyroxine dosage may need to be increased.
• Estrogens may decrease response to levothyroxine. The levothyroxine dosage may need to be
increased.
• Lithium commonly causes hypothyroidism.
• Levothyroxine may enhance warfarin's effect. The warfarin dosage may need to be decreased.
• Levothyroxine supplementation may reduce digoxin levels.
• Sucralfate may decrease levothyroxine absorption. Separate administration by at least 4 hours.
[Table 14-1. Thyroid Preparations for the Treatment of Hypothyroidism]
• Soybean formula decreases levothyroxine absorption.
• Sympathomimetic drugs may potentiate the effects of levothyroxine.
• Levothyroxine may enhance theophylline clearance.
• Plasma TSH should be done every 6-8 weeks until normalization.
• Signs and symptoms of hypothyroidism should improve within a few weeks.
• Once the optimum replacement dose is attained, a physical examination should be made and TSH
level should be monitored every 6-12 months.
• Patients at risk for coronary artery disease should be monitored for angina.
Pharmacokinetics
• The U.S. Food and Drug Administration states that all levothyroxine products should be
considered therapeutically inequivalent unless equivalence (AB rating) has been established and
noted in the "Orange Book."
• Levoxyl, Levothroid, Synthroid, Unithroid, and some generics are bioequivalent.
• Because of the narrow therapeutic index of levothyroxine, many experts recommend rechecking
TSH concentrations 6-8 weeks after any change in formulation, even when bioequivalent.
• Oral absorption is improved by fasting but decreased by dietary fiber, drugs, and foods.
• A half-life of 7 days allows once-daily dosing.
• Average bioavailability of levothyroxine products ranges from 40% to 80%. When a switch is
made from oral to intravenous levothyroxine, the dosage should be reduced by 25% to 50%.
Other
• Use of natural thyroid hormones such as desiccated thyroid USP is discouraged because their
potency and stability are less predictable than synthetic levothyroxine.
• Synthetic T3 (liothyronine) has a shorter half-life than levothyroxine, has a higher incidence of
cardiac side effects, and is more difficult to monitor.
Hyperthyroidism
Disease overview
• Hyperthyroidism (thyrotoxicosis) is the clinical syndrome that results when tissues are exposed to
high levels of thyroid hormone.
• Thyrotoxicosis is more common in women than men, occurring in 3 per 1,000 women.
Types
• Graves' disease is the most common cause of hyperthyroidism.
• Toxic multinodular goiter (MNG), toxic adenoma, and exogenous thyroid hormone ingestion may
also cause hyperthyroidism.
• Thyroid storm is a life-threatening, sudden exacerbation of all the symptoms of thyrotoxicosis,

characterized by fever, tachycardia, delirium, and coma.
• Hyperthyroidism may be caused by drugs such as amiodarone and iodine.
• Symptoms include heat intolerance, weight loss, weakness, palpitations, and anxiety.
• Signs include tremor, tachycardia, weakness and eyelid lag, and warm, moist skin.
• Other manifestations include atrial fibrillation and congestive heart failure.
Pathophysiology
• Graves' disease is an autoimmune disease in which thyroid-stimulating antibodies are produced.
These antibodies mimic the action of TSH on thyroid tissue.
• Toxic adenomas and MNGs are masses of thyroid tissue that secrete thyroid hormones
independent of pituitary control.
Diagnosis
Elevated T4 or T3 in the presence of a decreased TSH confirms the diagnosis of hyperthyroidism.
• There are three primary methods for controlling hyperthyroidism: surgery, radioactive iodine
(RAI), and antithyroid (thioamide) drugs.
• The goal is to minimize symptoms and eliminate excess thyroid hormone.
• RAI is often considered the treatment of choice in Graves' disease, toxic adenomas, and MNGs.
• Propylthiouracil is preferred in pregnancy; RAI is contraindicated.
• Thioamide drugs (propylthiouracil and methimazole) have no permanent effect on thyroid

function.
• Adjunctive treatments for hyperthyroidism include -adrenergic receptor blockers or calcium

channel blockers to control tachycardia associated with hyperthyroidism.
Drug therapy of hyperthyroidism
Antithyroid medications are summarized in

Table 14-2.
Thioamides
Mechanism of action
• Propylthiouracil and methimazole inhibit the synthesis of thyroid hormones by preventing the
incorporation of iodine into iodotyrosines and by inhibiting the coupling of monoiodotyrosine
and diiodotyrosine to form T4 and T3.
• Propylthiouracil inhibits the peripheral conversion of T4 to T3.
Patient counseling
• This medication prevents excessive thyroid hormone production.

• It must be taken regularly to be effective.
• Do not discontinue use without first consulting your physician.
• Notify your physician if fever, sore throat, unusual bleeding, rash, abdominal pain, or yellowing of
the skin occurs.
Adverse effects
• CNS: Fever, headache, paresthesias
• General: Rash, arthralgia, urticaria
• GI: Jaundice, hepatitis
• Hematologic: Agranulocytosis, leukopenia, bleeding
Drug interactions
Potentiation of warfarin's effect may occur.
• Monitor for improvement in signs and symptoms of hyperthyroidism.
• Perform thyroid function tests; watch for signs and symptoms of agranulocytosis (fever, malaise,
sore throat).
Pharmacokinetics
Propylthiouracil has a short half-life, requiring more frequent dosing than methimazole.
Iodides
Mechanism of action
• Medication blocks hormone release and inhibits thyroid hormone synthesis.
• Medication may be used when rapid reduction in thyroid hormone secretion is desired, such as in
thyroid storm, or to decrease glandular vascularity prior to thyroidectomy.
Patient instructions
• Dilute with water or fruit juice to improve taste.
• Notify physician if fever, skin rash, metallic taste, swelling of the throat, or burning of the mouth
occurs.
Adverse effects
Adverse effects include rash, swelling of salivary glands, metallic taste, burning of the mouth, GI
distress, hypersensitivity, and goiter.
Drug interactions
Lithium potentiates antithyroid effect of iodides.
Monitor for improvement in signs and symptoms of hyperthyroidism and for adverse effects.
14-2. Adrenals
Cushing's Syndrome
Disease overview
• Cushing's syndrome results from chronic glucocorticoid excess.
[Table 14-2. Antithyroid Medications]
• The incidence rate is 2-4 persons per million population cases each year.
Types
• Cushing's syndrome is usually iatrogenic, caused by therapy with glucocorticoid drugs.
• Endogenous Cushing's syndrome is usually caused by overproduction of adrenocorticotropic

hormone (ACTH) by pituitary gland adenomas (Cushing's disease).
Patients may present with obesity involving the face, neck, trunk, and abdomen; hypertension;
hirsutism; acne; amenorrhea; depression; thin skin; easy bruising; diabetes; and osteopenia.
Pathophysiology
The hypothalamus produces corticotropin-releasing hormone, which stimulates the anterior
pituitary gland to release ACTH. Circulating ACTH stimulates the adrenal cortex to produce
cortisol.
Diagnosis
• Diagnosis is usually based on signs and symptoms of hypercortisolism.
• Dexamethasone suppression test or 24-hour urine cortisol measurement may be used.

• If the syndrome is iatrogenic, minimization of corticosteroid exposure is essential.
• Pharmacotherapy of Cushing's syndrome is aimed at reducing cortisol production or activity with

drugs, radiation, or surgery.
Drug therapy of Cushing's syndrome
Drugs for Cushing's syndrome are described in

Table 14-3.
Mechanism of action
• Drugs used to treat Cushing's disease suppress synthesis of cortisol.
• Ketoconazole inhibits cytochrome P-450 (CYP450)-dependent enzymes and cortisol synthesis.
• Aminoglutethimide inhibits conversion of cholesterol to pregnenolone.
• Mitotane is a cytotoxic drug that suppresses ACTH secretion and reduces synthesis of cortisol.
• Metyrapone decreases cortisol synthesis by inhibition of 11-hydroxylase activity.
Patient counseling
Ketoconazole should be taken with food. Separate from antacids by at least 2 hours. Notify the
physician if abdominal pain, yellow skin, or pale stool occurs.
Adverse effects
• Ketoconazole causes nausea, vomiting, headache, impotence, and hepatotoxicity.
• Aminoglutethimide causes drowsiness, rash, weakness, hypotension, nausea, loss of appetite,

hypothyroidism, and blood dyscrasias.
• Metyrapone causes nausea, vomiting, dizziness, and sedation.
• Mitotane may cause nausea, vomiting, diarrhea, and tiredness.
Drug interactions
• Ketoconazole is a CYP450 3A4 enzyme inhibitor and may increase serum concentrations of
cyclosporine, warfarin, cisapride, and triazolam. Drugs that lower gastric acidity will decrease
ketoconazole absorption. Rifampin decreases ketoconazole levels.
• Aminoglutethimide may induce metabolism of warfarin.
Cortisol monitoring is required with mitotane.
Adrenal Insufficiency
Disease overview
• Primary adrenocortical deficiency (Addison's disease) is caused by autoimmune-mediated
[Table 14-3. Drugs for Cushing's Syndrome]
destruction of the adrenal cortex and results in glucocorticoid and mineralocorticoid deficiency.
• Addison's disease occurs in 5-6 persons per million population per year.
Types
• Primary adrenal insufficiency (Addison's disease) involves autoimmune destruction of the adrenal
cortex.
• Secondary insufficiency occurs after cessation of chronic exogenous corticosteroid use.
• Acute adrenal insufficiency, or Addisonian crisis, is an endocrine emergency precipitated by

severe stress.
• Glucocorticoid deficiency (weight loss, malaise, abdominal pain, and depression)
• Mineralocorticoid deficiency (dehydration, hypotension, hyperkalemia, and salt craving)
Pathophysiology
• Cortisol is synthesized in the adrenal cortex when cholesterol is converted to pregnenolone by

ACTH.
• The adrenal cortex secretes aldosterone, cortisol, and androgenic hormones.
• Mineralocorticoids (e.g., aldosterone) enhance reabsorption of sodium and water from the distal
tubule of the kidney and increase urinary potassium excretion.
• Glucocorticoids affect glucose, carbohydrate, and fat metabolism; produce anti-inflammatory and
immunosuppressive effects; and affect other physiologic processes.
• Chronic administration of corticosteroids produces inhibition of pituitary ACTH secretion and

reduced cortisol production (hypothalamic-pituitary-adrenocortical [HPA] axis suppression).
• Abrupt cessation of steroids may precipitate adrenal insufficiency.
Diagnosis
A cosyntropin (ACTH) stimulation test may be used to assess hypocortisolism.
• Addison's disease requires lifelong glucocorticoid and mineralocorticoid replacement.
• Hydrocortisone 100 mg intravenous (IV) q8h is the drug of choice for acute adrenal crisis.
• "Stress doses" of corticosteroids are given for minor illness, injury, or surgery. If stress is severe,
hydrocortisone 100 mg IV q8h is used.
• Gradual tapering of corticosteroids reduces the risk of adrenal insufficiency in patients with HPA
axis suppression.
• Nonadrenal uses for corticosteroids are numerous, including allergic reactions; inflammatory
conditions; hematologic disorders; rheumatic disorders; neurologic diseases; cancer;
immunosuppression; pulmonary, renal, skin and thyroid diseases; and hypercalcemia.
• Fludrocortisone has minimal anti-inflammatory activity and is used only when mineralocorticoid
activity is needed, such as when increased blood pressure is desired.
Drug therapy of adrenal insufficiency
Information about corticosteroids is provided in

Table 14-4.
Mechanism of action
• Glucocorticoids increase blood glucose by stimulating gluconeogenesis and glycogenolysis; fat

deposition is increased.
• Catabolic effects occur in lymphoid, connective tissue, bone, muscle, fat, and skin.
• Inhibition of inflammation and immunosuppression, vasoconstriction, reduction in prostaglandin

and leukotriene synthesis, decreased neutrophils at sites of inflammation, and inhibition of
macrophage function result.
Patient counseling
• These drugs may cause stomach upset, so take them with food.
• It is preferable to take the dose before 9:00 am.
• Wear or carry identification if on chronic steroid therapy.
• Therapy may mask signs of infection.
• Drugs may increase insulin or oral hypoglycemic requirements if patient is diabetic.
• Notify the physician if weight gain, muscle weakness, sore throat, or infection occurs.
• Report tiredness, stomach pain, weakness, and high or low blood sugar to the physician.
• Do not discontinue abruptly if taking long term.
Adverse effects
• Cardiac: Hypertension, sodium and fluid retention, atherosclerosis
• CNS: Insomnia, anxiety, depression, psychosis
• Metabolic: Obesity, hyperglycemia, hypokalemia, amenorrhea, impotence
• Ophthalmic: Cataracts, glaucoma
[Table 14-4. Corticosteroids and Dose Equivalents]
• Immune: Infections, impaired wound healing, leukocytosis
• Musculoskeletal: Myopathy, osteoporosis
Drug interactions
• Rifampin and other enzyme-inducing drugs increase metabolism of corticosteroids and decrease
their effectiveness.
• Concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids increases

risk of peptic ulcer disease.
• Corticosteroids may impair immunologic response to vaccines.

• Estrogens may increase corticosteroid clearance.
• Ketoconazole, macrolides, and other CYP450 3A4 enzyme-inhibiting drugs may decrease
clearance of corticosteroids.
• Corticosteroids increase insulin and oral hypoglycemic drug requirements.
Patients should be monitored for weight gain, edema, increased blood pressure, electrolytes, blood
glucose, and infection.
Pharmacokinetics
Many dosage forms, doses, and schedules are used, including tablets, topicals, enemas, oral liquids,
injections, and depot injection forms for intra-articular or intramuscular use.
14-3. Miscellaneous Endocrine Drugs
ACTH and Cosyntropin
Table 14-5 provides information about ACTH and cosyntropin.
[Table 14-5. ACTH and Cosyntropin]
Therapeutic uses
ACTH and cosyntropin are used for diagnosis of adrenal insufficiency. Occasionally, ACTH is used
as an alternative to corticosteroids.
Mechanism of action
• ACTH stimulates the adrenal cortex to secrete adrenal hormones.
• If ACTH fails to elicit an appropriate cortisol response, adrenal insufficiency is present.
• Cosyntropin is a synthetic peptide that is similar to human ACTH, but less allergenic.
Patient counseling and adverse effects
Patients should receive the same counseling as for corticosteroids. Adverse effects are the same.
Drug interactions
Enzyme-inducing drugs will decrease effects.

Monitoring parameters are the same as for corticosteroids.
Vasopressin and Desmopressin
Table 14-6 describes the dosages for vasopressin and desmopressin.
Therapeutic uses
• Vasopressin: Diabetes insipidus, variceal hemorrhage, shock, ventricular fibrillation
• Desmopressin: Nocturnal enuresis, diabetes insipidus, hemophilia A, von Willebrand's disease
Mechanism of action
• Vasopressin is also known as antidiuretic hormone (ADH); it increases water resorption.
• Vasopressin causes vasoconstriction in portal and splanchnic vessels (GI tract).
• Desmopressin is a synthetic derivative of vasopressin with ADH activity and only minimal
vasoconstrictive properties; it increases clotting factor VIII levels.
Patient counseling
For intranasal desmopressin, the patient should be instructed on proper intranasal use. The
following instructions should also be given:
• Discard the bottle after 25 or 50 doses.
• Do not transfer the solution to another bottle.
• The drug may cause nasal irritation.
• Notify the physician if bleeding is not controlled or if headache, shortness of breath, or severe
abdominal cramps occur.
Adverse effects
• Vasopressin: Angina, myocardial infarction, vasoconstriction, hyponatremia, gangrene,

abdominal cramps, tissue necrosis if extravasation occurs, hypersensitivity
• Desmopressin: Abdominal pain, headache, flushing, nausea, nasal irritation, vulvar pain,
nosebleed, rhinitis, hypersensitivity
Drug interactions
• Drugs may enhance effects of other pressors.
• Carbamazepine and chlorpropamide potentiate the effect of desmopressin on ADH.
[Table 14-6. Vasopressin and Desmopressin]
• With diabetes insipidus, monitor urine volume and plasma osmolality.
• With von Willebrand's disease, monitor factor VIII levels and bleeding time.
• When intravenous vasopressin is used, monitor blood pressure and pulses.
Androgens and Anabolic Steroids
Table 14-7 provides information about androgens and anabolic steroids.
Therapeutic uses
• Androgens and anabolic steroids are used to treat hypogonadism, delayed puberty, metastatic
breast cancer, anemia, AIDS wasting in HIV-infected men, corticosteroid-induced hypogonadism
and osteoporosis, and moderate to severe vasomotor symptoms associated with menopause
(when combined with estrogen).
• They are schedule C-III controlled substances because they are intentionally misused for
performance-enhancing effects and enhanced muscular development and endurance.
Mechanism of action
• Androgens promote growth and development of male sex organs and maintenance of secondary
sex characteristics.
• Androgens also cause retention of nitrogen, sodium, potassium, and phosphorus; increase protein
anabolism; and decrease protein catabolism.
• Androgens are responsible for the growth spurt of adolescence and termination of linear growth by
fusion of epiphyseal growth centers.
• Exogenous androgens stimulate production of red blood cells and suppress endogenous
testosterone release through feedback inhibition of luteinizing hormone and suppress
spermatogenesis through feedback inhibition of follicle-stimulating hormone.
Patient counseling
• Medication may cause stomach upset.
• Notify a physician if swelling of the ankles or persistent erections occur.
[Table 14-7. Androgens and Anabolic Steroids]
• This product is a controlled substance; do not misuse or abuse it.
• For females, notify physician if deepening of the voice, increased facial hair, or menstrual
irregularities occur.
• Patients receiving transdermal testosterone should be provided with the manufacturer's patient
instructions and carefully counseled on use and disposal of the system.
Adverse effects
• General: Jaundice, hepatitis, edema, high abuse potential in an effort to enhance athletic
performance, hypercholesterolemia and atherosclerosis, increased aggression and libido
• Women: Hirsutism, voice deepening, acne, decreased menses, clitoral enlargement
• Men: Acne, sleep apnea, gynecomastia, azoospermia, prostate enlargement, decreased testicular
size
14-4. Key Points
• Levothyroxine is the drug of choice for hypothyroidism.
• Lower doses of levothyroxine are used in elderly and cardiac patients.
• Overtreatment with thyroid hormones causes osteoporosis and atrial fibrillation.
• Antacids, bile acid sequestrants, sucralfate, calcium, and iron supplements decrease absorption of
levothyroxine and must be separated by at least 4 hours.
• Propylthiouracil and methimazole are thioamide derivatives used to treat hyperthyroidism.
• Thioamides may cause life-threatening agranulocytosis or hepatitis, so patients must report to their
physician if they experience fever, sore throat, abdominal pain, or jaundice.
• Drugs used to treat Cushing's disease inhibit synthesis of cortisol.
• Corticosteroid should be used at the lowest dose for the shortest time to reduce the risk of HPA
axis suppression and adrenal insufficiency.
• Patients with adrenal insufficiency must receive supplemental corticosteroids in times of

physiologic stress.
• Vasopressin and desmopressin are antidiuretic hormones.
• Androgens and anabolic steroids are abused by athletes seeking to enhance performance.
14-5. Questions
Patient Profile 1—Corn State Community Pharmacy

Patient name: Jasmine Ricardo Address: 189 Jonesborough Road
Age: 78 Height: 48 inches
Sex: Female Weight: 103 lbs
Race: Hispanic Allergies: Cats
Diagnosis: Pharmacist notes
1.
Primary Date Comment
Hypercholesterolemia
Patient reminded to continue taking aspirin 325
2. Anemia 2/23
mg for CAD
Patient to take OTC ferrous sulfate 325 mg
daily for 3 months for anemia.
3. Coronary artery
2/23
disease
Advised patient to begin docusate 100 mg qd if
constipation occurs.
Secondary 1. Hypertension
Medication orders:
Drug and
Date Rx no. Physician strength Quantity Sig Refills
Synthroid
3/21 89995 Stubie 30 1 po qd 0
0.025 mg
2/23 88768 Hooper Zocor 40 mg 30 1 po qhs 5
1 packet bid, mix with
2/23 88769 Hooper Questran 4 g 60 5
juice
Tenormin 50
2/23 88770 Hooper 30 1 po qd 5
mg
Enalapril 5
2/23 88771 Hooper 60 1 po bid 5
mg
The Synthroid prescription dispensed to Mrs. Ricardo on 3/21 requires advising her to
A. take 4 hours before or 4 hours after Questran.

1. B. take with food.
C. watch for signs of infection.
D. take as needed to keep her desired level of energy.
E. discontinue if she experiences nausea.

Which of the following of Mrs. Ricardo's conditions could the Synthroid exacerbate?
A. Hypercholesterolemia
2. B. Anemia
C. Coronary artery disease
D. Hypertension
E. Constipation

Excessive doses of levothyroxine may cause
A. weight gain.
3. B. osteoporosis.
C. cold intolerance.
D. bradycardia.
E. sedation.

Which of the following drugs may produce hypothyroidism?
I. Amitriptyline
II. Lithium
III. Amiodarone
4.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

All of the following may decrease the effect of thyroid hormone supplementation except
A. antacids.
5. B. bile acid sequestrants.
C. estrogens.
D. sucralfate.
E. theophylline.

A patient who is suffering from heat intolerance, weight loss, tachycardia, tremor, and anxiety
may be treated with
A. acetaminophen.
6.
B. mitotane.
C. cyproheptadine.
D. propylthiouracil.
E. diazepam.

A patient with atrial fibrillation may require a decreased warfarin dosage when which of the
following drugs is initiated?
A. Liothyronine
7.
B. Rifampin
C. Methimazole
D. Phenytoin
E. Diphenhydramine

Which of the following drugs is used to treat Cushing's disease?
I. Ketoconazole
II. Aminoglutethimide
III. Mitotane
8.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Which of the following drugs works by decreasing cortisol synthesis?
A. Cortrosyn
9. B. ACTH
C. Oxandrolone
D. Prednisone
E. Metyrapone

Decreased ketoconazole absorption may occur if it is administered concomitantly with which
of the following?
A. Antacids
10.
B. Food
C. Warfarin
D. Cyclosporine
E. CYP450 3A4 inhibitors

Close monitoring of adrenal hormone secretion may be required when administering which of
the following?
A. Methyltestosterone
11.
B. Mitotane
C. Desmopressin
D. Iodides
E. Propylthiouracil

Which of the following is used to treat adrenal crisis?
A. Cosyntropin
12. B. Aminoglutethimide
C. Fluoxymesterone
D. Vasopressin
E. Hydrocortisone

Which of the following is not an effect of glucocorticoids?
A. Immunosuppression
13. B. Decreased prostaglandin synthesis
C. Inhibition of glycogenolysis
D. Decreased neutrophils at sites of infection
E. Inhibition of macrophages

Patient Profile 2—Big Sky Hospital

Patient name: Stuart Big Date of admission: 4/21 at 15:26
Address: 440 Mountain Lane
Age: 28 Height: 5´83
Sex: Male Weight: 178 lbs
Race: White Allergies: Aspirin
Diagnosis:
Admit diagnosis 1. Anaphylactic reaction to aspirin
Secondary 1. Type 2 diabetes mellitus
2. Hypertension
Laboratory:
Date Time Lab Result (Normal range)

4/21 15:29 Glucose 144 (60-110 mg/dL)
4/21 19:20 Glucose 181 (60-110 mg/dL)
4/22 06:00 Glucose 240 (60-110 mg/dL)
4/22 12:21 Glucose 289 (60-110 mg/dL)
4/22 19:15 Glucose 352 (60-110 mg/dL)
4/23 06:20 Glucose 391 (60-110 mg/dL)
4/23 12:32 Glucose 443 (60-110 mg/dL)
Active medication orders:
Date Time Name and strength Route Frequency or schedule

4/21 15:30 Solu-Medrol 125 mg IV q6h
4/21 15:30 Dextrose 5%/NaCl 0.9% IV 200 mL/h
4/21 15:30 Diphenhydramine 50 mg IV q6h
4/21 17:03 Glipizide 5 mg po bid
4/21 17:03 Glucophage 850 mg po bid
4/21 17:03 Captopril 50 mg po tid
Discontinued medication orders:
Date Time Name and strength Route Frequency or schedule

4/21 15:30 Epinephrine 0.1 mg Subcutaneous Stat
4/21 15:30 Diphenhydramine 50 mg IV Stat
Dietary:
Date
4/21 1,800 kcal American Diabetes Association diet
Which of the following is least likely to contribute to the increased blood glucose seen in this
patient?
A. Dextrose 5%/NaCl 0.9% solution

14.
B. Captopril
C. Epinephrine
D. Methylprednisolone
E. Anaphylaxis

Mr. Big is discharged on a new prescription for Deltasone 40 mg qd for 7 days. He should be
instructed to
A. check feet closely for wounds.

15.
B. take ibuprofen for musculoskeletal pain.
C. take on an empty stomach.
D. take at bedtime.
E. wear identification for steroid therapy.

Chronic administration of glucocorticoids predisposes patients to which of the following?
A. Arthritis
16. B. Obesity
C. Alzheimer's disease
D. Osteoporosis
E. Hepatitis

A patient is taking prednisone 40 mg daily for 6 months. On abrupt cessation, which of the
following may occur?
A. Myopathy
17.
B. Diabetes
C. Infection
D. Adrenal crisis
E. Psychosis

An increased risk of peptic ulcer disease occurs when NSAIDs are combined with which of the
following?
A. Ranitidine
18.
B. Ferrous sulfate
C. Dexamethasone
D. Carbamazepine
E. Acetaminophen

Which of the following drugs may be used to diagnose adrenal insufficiency?
A. Desmopressin
19. B. Clemastine
C. Captopril
D. Cosyntropin
E. Aminoglutethimide

Decreased urine production is an effect of
A. carmustine.
20. B. propylthiouracil.
C. ACTH.
D. desmopressin.
E. SSKI.

Which of the following hormones is secreted by the pituitary gland?
A. Adrenocorticotropic hormone
21. B. Testosterone
C. Cortisol
D. Thyroxine
E. Corticotropin-releasing hormone

Chronic administration of Winstrol may produce all of the following complications except
A. prostate enlargement.
22. B. increased testicular size.
C. gynecomastia in men.
D. accelerated atherosclerosis.
E. decreased menses in women.

Androderm is administered
A. once daily.
23. B. three times per week.
C. once weekly.
D. every 2 weeks.
E. monthly.

Which of the following is not an acceptable indication for testosterone?
A. Anemia
24. B. Hypogonadism
C. Delayed puberty
D. Body building
E. Metastatic breast cancer

14-6. Answers
A. Bile acid sequestrants reduce levothyroxine absorption and must be separated from
1. levothyroxine administration by at least 4 hours. Levothyroxine should be administered before
a meal on an empty stomach to maximize absorption.

C. Thyroid hormones enhance oxygen consumption and increase the oxygen demand. Mrs.
Ricardo has a past medical history of coronary artery disease (CAD) and is elderly. Thyroid
2.
supplementation would actually lower her cholesterol in the long run but may precipitate
angina acutely.

B. Levothyroxine decreases bone mineral density and when given in supratherapeutic doses
3. may cause osteoporosis. For this reason, the lowest possible replacement dose should be
administered.

D. Lithium and amiodarone have both been associated with hypothyroidism. Amiodarone
4.
contains iodine and may cause hypo- or hyperthyroidism.

E. Numerous drugs are known to decrease thyroid hormone absorption, including antacids that
contain divalent and trivalent cations, calcium salts, magnesium, sucralfate, and bile-acid
5.
sequestrants. Estrogens and enzyme-inducing drugs may decrease circulating thyroid hormone
levels and necessitate a dose increase of thyroxine.

D. Heat intolerance, weight loss, tachycardia, tremor, and anxiety are cardinal features of
6.
hyperthyroidism. Propylthiouracil is effective at reducing the excessive thyroxine level.

A. Liothyronine (Cytomel) is T3, a potent thyroid hormone. In states of hypothyroidism,
7. metabolism is decreased. However, if thyroid hormone is supplemented, blood clotting factors
will be metabolized more quickly, leading to decreased warfarin requirements.

E. Ketoconazole, aminoglutethimide, and mitotane are all used to treat Cushing's disease.
8. Ketoconazole is most commonly known as an antifungal agent, but it inhibits cortisol synthesis
at high doses (800-1,200 mg daily).

E. Metyrapone (Metopirone) inhibits 11 hydroxylase activity and thus decreases cortisol
9.
synthesis.

A. Ketoconazole requires the presence of stomach acid to be absorbed. Any drug that decreases
10. gastric acidity will decrease the extent of ketoconazole absorption. Food increases
ketoconazole absorption because food stimulates release of gastric acid.

B. Mitotane is cytotoxic to adrenal cells and thus reduces cortisol synthesis and release. ACTH
11. increases cortisol release. Close monitoring of cortisol levels is important when this drug is
used.

E. Hydrocortisone is the drug of choice for adrenal crisis because it possesses both
mineralocorticoid and glucocorticoid properties. Although cosyntropin increases cortisol
12.
release, patients with adrenal crisis may not have enough adrenal reserve to meet their
increased demand.

C. Glucocorticoids have potent effects on glucose and carbohydrate metabolism. They promote
13.
glycogen breakdown, rather than inhibit it.

B. Captopril increases insulin sensitivity and would not be expected to contribute to increased
blood glucose. This patient's blood glucose began rising shortly after admission. His IV fluids
contain glucose; epinephrine increases blood glucose by increasing glycogen breakdown,
14.
methylprednisolone (Solu-Medrol) promotes glycogenolysis, and anaphylaxis would be
expected to increase stress response, thereby leading to increased epinephrine release and
increased blood glucose.

A. The patient has a history of diabetes and will be given prednisone (Deltasone), which would
be expected to increase blood glucose. When diabetes is poorly controlled, infections are more
15. likely to occur. For this reason, he should monitor more closely for wounds that may become
infected. He will not be taking prednisone long enough to develop adrenal insufficiency, so
there is no need for him to wear identification for steroid therapy.

D. Glucocorticoids have catabolic effects on a number of tissues, including muscle, fat, skin,
16.
and bone. Chronic administration leads to osteopenia and osteoporosis.

D. Chronic administration of glucocorticoids such as prednisone will lead to feedback
inhibition of pituitary ACTH release and atrophy of the adrenal cortex. When prednisone is
17.
abruptly stopped, the adrenals will not be able to meet the body's demand for cortisol during
severe stress, and adrenal crisis may occur.

C. Corticosteroids such as dexamethasone (Decadron) are known to increase the risk of peptic
18.
ulcers when used in combination with NSAIDs.

D. Cosyntropin (Cortrosyn) is a synthetic analogue of ACTH that is used to diagnose adrenal
insufficiency. It works by stimulating the adrenal cortex to secrete cortisol. If cosyntropin
19.
administration does not result in an appropriate increase in cortisol release, adrenal
insufficiency is present.

D. Desmopressin (DDAVP) is a synthetic analogue of vasopressin, or antidiuretic hormone.
20.
Thus, it decreases urine production by increasing water resorption.

A. Adrenocorticotropic hormone, or ACTH, is released by the pituitary and acts on the adrenal
21. glands to increase cortisol release. Corticotropin-releasing hormone is released by the
hypothalamus and acts on the pituitary to stimulate ACTH release.

B. Stanozolol (Winstrol) is an androgen that would be expected to promote growth and
22. development of male sex organs. However, chronic administration leads to feedback inhibition
of testosterone secretion, which leads to testicular atrophy.

A. Testosterone transdermal systems (Androderm, Testoderm) are applied once daily for 24
23. hours. Longer-acting androgens are available, such as nandrolone decanoate (Deca-Durabolin),
for once-weekly administration.

D. Anabolic steroids may be abused by those who are seeking enhanced muscular development
24. and endurance, such as athletes. For this reason, all of these agents are subject to the
Controlled Substances Act.

14-7. References
Baskin HJ, Cobin RH, Duick DS. American Association of Clinical Endocrinologists Medical
Guidelines for Clinical Practice for the evaluation and treatment of hyperthyroidism and
hypothyroidism (AACE Thyroid Task Force). Endocr Pract. 2002; 8:457-69.
Chrousos GP. Adrenocorticosteroids and adrenocortical antagonists. In: Katzung BG, ed. Basic and
Clinical Pharmacology. 11th ed. New York: McGraw-Hill; 2009.
Chrousos GP. The gonadal hormones and inhibitors. In: Katzung BG, ed. Basic and Clinical
Pharmacology. 11th ed. New York: McGraw-Hill; 2009.
Dayan CM, Daniels GH. Chronic autoimmune thyroiditis. N Engl J Med. 1996;335:99-106.
Dong BJ. Thyroid disorders. In: Herfindal ET, Gourley DR, eds. Textbook of Therapeutics: Drug
and Disease Management. Philadelphia: Lippincott Williams & Wilkins; 2006.
Dong BJ, Greenspan FG. Thyroid and antithyroid drugs. In: Katzung BG, ed. Basic and Clinical
Dong, BJ, Hauck WW, Gambertoglio JG, et al. Bioequivalence of generic and brand name
levothyroxine products in the treatment of hypothyroidism. JAMA. 1997;277:1205-13.
Hoffmeister AM, Tietze KJ. Adrenocortical dysfunction and clinical use of steroids. In: Herfindal
ET, Gourley DR, eds. Textbook of Therapeutics: Drug and Disease Management. Philadelphia:
Lippincott Williams & Wilkins; 2006.
Master SB. Hypothalamic and pituitary hormones. In: Katzung BG, ed. Basic and Clinical
McEvoy GK, ed. AHFS Drug Information 2009. Bethesda, Md.: American Society of Health-
System Pharmacists; 2009.
U.S. Food and Drug Administration. Orange book: Approved drug products with therapeutic
equivalence evaluations. Accessed at: http://www.accessdata.fda.gov/scripts/cder/ob/default.cfm.
15. Women's Health - Andrea S. Franks, PharmD, BCPS
15-1. Postmenopausal Hormone Replacement Therapy
Introduction
Menopause is the permanent cessation of menses resulting from diminishing ovarian follicular
function. It is defined as 12 consecutive months of amenorrhea. Median age of onset in the United
States is 51 years of age (range 40-55). Physiologic changes and symptoms of menopause may
present up to 8 years prior to cessation of menses.
Perimenopause, also called the menopausal transition, is the time before menopause and the first
year following menopause. Ovarian function and production of estrogen decline during this time,
and menstrual cycles may be irregular.
• Cessation of menses for at least 12 consecutive months
• Symptoms of perimenopause related to declining estrogen:
• Anovulation
• Dysfunctional uterine bleeding
• Extended menstrual cycle intervals
• Oligomenorrhea
• Symptoms of menopause directly related to lack of estrogen:
• Vaginal dryness and vulvar or vaginal atrophy
• Vasomotor symptoms (night sweats, hot flashes)
• Symptoms associated with menopause, but without a proven link to estrogen deficiency:
• Arthralgia
• Depression
• Insomnia
• Migraines
• Mood swings
• Myalgia
• Urinary frequency
• Cognitive changes (memory, concentration)
Pathophysiology
• Loss of ovarian follicular activity results in endocrine, biologic, and clinical changes.
• Ovarian production of estradiol and progesterone diminishes.
• Follicle-stimulating hormone and luteinizing hormone concentrations increase.
• Primary estrogen available is now estrone (which is converted peripherally from androstenedione
and is less potent), not estradiol.
• Women with an intact uterus must be treated with estrogen plus progestin to reduce the risk of
endometrial hyperplasia and endometrial cancer.
• Women who have had a hysterectomy are treated with unopposed estrogen.
• Hormone replacement therapy (HRT) should be initiated on an individual basis with careful
consideration of the risks and benefits.
• Contraindications to estrogen replacement therapy (ERT) are
• Abnormal, undiagnosed genital bleeding
• Known, suspected, or history of breast cancer
• History of deep-vein thrombosis or pulmonary embolism
• Estrogen-dependent neoplasia
• Pregnancy
• Stroke or myocardial infarction in the past year
• Liver dysfunction or disease

Drug Therapy
Table 15-1 provides an overview of selected HRT products.
Estrogen and progestin
Mechanism of action
ERT is used alone (if no uterus) or in combination with progestin to replace diminished levels of
endogenous hormones.
Combined estrogen-progestin therapy (EPT) includes progestin to prevent endometrial hyperplasia

and cancer.
• Side effects of estrogen may be diminished by starting with a low dose and may be alleviated by
changing products. Most side effects improve with time.
• Side effects of progestin may be alleviated or diminished by changing products or changing from a
continuous to a cyclic regimen.
• Patients should be instructed to immediately report any unusual vaginal bleeding.
• Patients should be instructed to contact their physician promptly if any of the following events
occur:
• Abdominal tenderness, pain, or swelling
• Coughing up of blood
• Disturbances of vision or speech
• Dizziness or fainting
• Lumps in the breast
• Numbness or weakness in an arm or leg
• Severe vomiting or headache
• Sharp chest pain or shortness of breath
• Sharp pain in the calves

Adverse drug events
Increased risks for venous thromboembolism, stroke, coronary heart disease, and breast cancer were
identified in the Women's Health Initiative (WHI) trial with postmenopausal women receiving
estrogen and estrogen plus progestin products. The beneficial effects included reductions in
fractures and colorectal cancer. Both ERT and EPT should be used at the lowest doses and for the
shortest possible time period for women who are experiencing moderate to severe vasomotor
symptoms or vulvovaginal atrophy. Consider topical estrogen.
The following adverse effects are most common with estrogen:
• Breast tenderness
• Heavy or irregular bleeding
• Headache
• Nausea
The following adverse effects are most common with progestin:
• Depression
• Headache
• Irritability

Estrogen may exacerbate illness in the following disease states:
• Depression
• Hypertriglyceridemia (avoid by using transdermal product)
• Thyroid disorder (patients may require an increased dose of thyroid supplement)
• Impaired hepatic function (poor metabolism of estrogens)
• Cardiovascular disorders (coronary heart disease and venous thromboembolism risk may be
increased with estrogens)
• Cholelithiasis
• Gastroesophageal reflux disease
Interaction may result in decreased pharmacologic effect of estrogens:

• Cytochrome P450 (CYP450) 3A4 inducers:
• Barbiturates
• Carbamazepine
• Rifampin
• St. John's wort
• Phenytoin
Interaction may result in increased pharmacologic effect of estrogens:
• CYP450 3A4 inhibitors:
• Azole antifungales
• Macrolide antibiotics
• Ritonavir
Laboratory monitoring is not recommended. Patients should be monitored for symptom
improvement, adverse effects, and appropriate health maintenance (e.g., through annual
mammograms).
[Table 15-1. Selected Hormone Replacement Therapy Products]
Androgens (testosterone)
Mechanism of action
Androgens are the precursor hormones to estrogen production by the ovaries and peripheral sites.
Ovarian testosterone production declines with menopause.
Androgens act at androgen receptor sites or exhibit action following conversion to estrogen.
Androgen replacement improves deficiency-related symptoms (i.e., decreased sexual desire,
decreased energy, diminished well-being).
• Testosterone therapy should be administered only to postmenopausal women who are receiving
concurrent estrogen therapy.
• The following are relative contraindications to testosterone therapy:
• Androgenic alopecia
• Hirsutism
• Moderate to severe acne
Adverse drug events
• Fluid retention
• Decreased high-density lipoprotein and triglycerides
• Hepatic dysfunction
• Hepatocellular carcinoma (prolonged use of high doses)
Laboratory monitoring is not recommended.
Nondrug Therapy
Phytoestrogens
• Phytoestrogens are plant compounds (isoflavones, lignans, coumestans).
• Food sources of phytoestrogens include soy (milk, edamame, tofu); flaxseed; and alfalfa sprouts.
• Some studies have shown improvement in vaginal symptoms.
• Phytoestrogens may decrease loss of bone mineral density.
• No evidence supports improvement in other symptoms of menopause (i.e., hot flashes, depression,
anxiety, headache, myalgia).
• Phytoestrogens may have beneficial effects on lipids, weight, blood pressure.
15-2. Contraception
Introduction
Contraception is the prevention of pregnancy by one of two methods:
• Preventing implantation of the fertilized ovum in the endometrium

• Inhibiting contact of sperm with mature ovum
Prescription Contraceptive Options
Oral contraceptives
• Estrogen plus progestin (combined oral contraceptive)
• Progestin only (minipill)
• Appropriate for use in breast-feeding women
• Less efficacious than combined oral contraceptives
• Free of cardiovascular risks associated with estrogen-containing products
• Long-term injectable or implanted products: progestin only
• Estrogens and progestins used in prescription contraceptives (

Table 15-2):
• Estrogens:
• Ethinyl estradiol
• Mestranol
• Progestins:
• Desogestrel
• Norgestrel; levonorgestrel
• Ethynodiol diacetate
• Norethindrone, norethindrone acetate, norethynodrel
• Drospirenone: progestin with progestogenic, anti-androgenic, and antimineralocorticoid activity
Drug Therapy
Mechanism of action
Estrogens prevent development of a dominant follicle by suppression of follicle-stimulating

hormone. They do not block ovulation.
Progestin blocks ovulation. It contributes to the production of thick and impermeable cervical
mucus. It also contributes to involution and atrophy of the endometrium.
• Efficacy is high but depends on appropriate use and adherence.
• Oral contraceptives do not prevent the transmission of sexually transmitted diseases.
• Patients should be educated on warning signs of important complications:
• Severe abdominal pain
• Severe chest pain, shortness of breath, coughing up of blood
[Table 15-2. Prescription Contraceptive Products]
• Severe headache
• Eye problems (i.e., blurred vision, flashing lights, or blindness)
• Severe leg pain in the calf or thigh
• Patients should be advised to expect changes in characteristics of the menstrual cycle.
• Use of a backup contraceptive method is advised if more than one dose is missed per cycle.
Adverse drug events
The World Health Organization (WHO) suggests refraining from prescribing combined oral
contraceptives to women with the following diagnoses:
• Breast cancer
• Deep-vein thrombosis or pulmonary embolism
• Cerebrovascular disease or coronary artery disease
• Diabetes with nephropathy, neuropathy, retinopathy, or other vascular disease
• Migraine headaches
• Uncontrolled hypertension ( 160/90 mm Hg)

• Breast-feeding women (< 6 weeks postpartum)
• Liver disease
• Pregnancy
• Surgery with prolonged immobilization or any surgery on the legs
• Age > 35 years and currently smoking ( 15 cigarettes a day)
• Hypercoagulable states (e.g., factor V Leiden, protein C or S deficiency)
For these medical conditions, use of progestin-only oral contraceptives, depot medroxyprogesterone
acetate, or an intrauterine device may be an appropriate contraceptive choice.
The most common adverse drug events are
• Nausea and vomiting (usually resolves within 3 months)
• Breakthrough bleeding, spotting, amenorrhea, and altered menstrual flow
• Melasma
• Headache or migraine
• Weight change or edema
Serious but less common effects are venous thrombosis, pulmonary embolism, myocardial
infarction, coronary thrombosis, arterial thromboembolism, and cerebral thrombosis.
Potential hormonal effects are associated with an imbalance in estrogen and progestin (
Table 15-3).
Interaction with the following drugs may result in decreased pharmacologic effect of oral
contraceptives:
[Table 15-3. Potential Hormonal Effects Associated with an Imbalance in Estrogen or Progestin]
• Ampicillin, griseofulvin, sulfonamides, tetracycline
• Anticonvulsants (barbiturates, carbamazepine, felbamate, phenytoin, topiramate)

• Some antiretroviral medications (e.g., nevirapine, lopinavir + ritonavir)
• Rifampin
Interaction with these drugs may result in increased plasma levels of oral contraceptives:
• Atorvastatin
• Vitamin C
• CYP450 3A4 inhibitors
Interaction with the following drugs may result in decreased pharmacologic effect of the interacting
drug:
• Anticoagulants (estrogens have a procoagulant effect)
• Some benzodiazepines (e.g., lorazepam, oxazepam, temazepam)
• Methyldopa
• Phenytoin
Interaction with the following may result in increased pharmacologic effect of interacting drug:
• Benzodiazepine tranquilizers (other than the benzodiazepines previously listed)
• -blockers
• Theophylline
Patients must monitor themselves for warning signs of serious complications previously listed.
Laboratory monitoring is not recommended with use of oral contraceptives.
Nondrug Therapy
Nondrug therapy includes use of the following:
• Condoms
• Diaphragms
• Intrauterine devices
• Spermicides
15-3. Osteoporosis
Introduction
Osteoporosis is characterized by low bone mineral density and deterioration of bone tissue,
increasing fragility of bone, and subsequent risk of fracture.
Types of Osteoporosis
• Primary
• Type I: Postmenopausal (most common and the focus of this chapter)
• Type II: Age related
• Secondary
• Drug induced
• Medical conditions
Diagnostic Criteria
Dual-energy x-ray absorptiometry (DEXA) scans are used to diagnosis osteoporosis. T scores are
used to guide diagnosis and decision to treat osteoporosis. The WHO classification of bone mass is
based on T scores:
• Osteopenia: T score -1.0 to -2.5 standard deviations below the young adult mean
• Osteoporosis: T score below -2.5 standard deviations below the young adult mean
Risk factors for osteoporosis are as follows:
• Advanced age
• Amenorrhea
• Current low bone mass

• Late menarche or early menopause
• Ethnicity (Caucasian or Asian)
• Excessive alcohol use
• Family history of osteoporosis or history of fracture in a primary relative
• Female
• History of fracture over the age of 50
• Inactive lifestyle
• Long-term use of corticosteroids or anticonvulsants
• Low lifetime calcium intake
• Low testosterone levels in men (hypogonadism)
• Thin or small frame
• Vitamin D deficiency
Medical conditions associated with increased risk of osteoporosis are as follows:
• Acquired immune deficiency syndrome (AIDS)
• Cushing's disease
• Eating disorders
• Hyperthyroidism
• Hyperparathyroidism
• Inflammatory bowel disease
• Insulin-dependent diabetes mellitus
• Lymphoma and leukemia
• Malabsorption syndromes
• Rheumatoid arthritis
• Chronic kidney disease
• Chronic obstructive pulmonary disease
The following drugs are associated with an increased risk of osteoporosis:
• Anticonvulsants (phenobarbital, phenytoin)
• Cytotoxic drugs
• Glucocorticoids
• Immunosuppressants
• Lithium
• Long-term heparin use
• Depot medroxyprogesterone
• Supraphysiologic thyroxine doses
• Tamoxifen (premenopausal)
• Aromatase inhibitors
The American Association of Clinical Endocrinologists and the National Osteoporosis Foundation
recommend that all women 65 years of age and older be screened for osteoporosis. In addition,
postmenopausal women less than 65 years of age with a family history of osteoporosis or clinical
risk factors and women with a fracture history unrelated to trauma should be screened.
• Shortened stature
• Vertebra, hip, or forearm fracture
• Kyphosis
• Lordosis
• Bone pain (especially back pain, which could indicate vertebral compression fracture)
Pathophysiology
There are two types of bone: trabecular (i.e., vertebrae, wrist and ankle, and ends of long bones,
which are the most susceptible to fracture) and cortical. Osteoblasts (formation) and osteoclasts
(destruction) create a constant state of bone remodeling.
Bone formation exceeds destruction during childhood. Peak bone mass is reached around age 25-
35; then bone density begins to decline:
• A 3% to 4% decline per decade in men
• A 8% to 12% decline per decade in women 10 years after menopause
Following menopause (postmenopausal osteoporosis), estrogen production declines and osteoclastic

activity increases.
Adequate calcium and vitamin D intake through diet or supplementation is recommended for
everyone (calcium 1,000-1,500 mg daily plus 400-1,000 IU [international units] vitamin D daily) (
Table 15-4).
Lifestyle modifications are recommended, including weight-bearing exercise, smoking cessation,

limited alcohol intake, dietary calcium, and vitamin D.
Prescription drug therapy should be initiated on an individual basis, considering risk factors, bone
mineral density, fracture history, and concomitant diseases and medications.
Initiation of Treatment
The National Osteoporosis Foundation recommends initiation of therapy in the following situations:
• History of vertebral or hip fracture
• T score below -2.5 (osteoporosis)
• T score -1 to -2.5 (osteopenia) with
• Secondary causes (steroids, immobility)
• History of other fractures
• 10-year probability of hip fracture 3% or 10-year probability of any major fracture 20%
based on the U.S.-adapted WHO algorithm (Fracture Risk Assessment Tool, or FRAX)
[Table 15-4. Select Calcium Supplement Products]
Drug Therapy
Calcium and vitamin D
Mechanism of action
Calcium is necessary to improve bone mass. It is absorbed through the gastrointestinal (GI) tract,
stored in the bone, and made available when calcium levels become low.
Vitamin D facilitates absorption and regulation of calcium levels.
• Approximately 500 mg of calcium can be absorbed from the GI tract at a time; separate doses
appropriately to achieve a dose of 1,000-1,500 mg per day.
• Calcium carbonate contains the highest level of elemental calcium; take with food to facilitate
absorption.
• Calcium citrate products may be administered without regard to meals.
Adverse drug events

The most common adverse drug events are as follows:
• GI upset (nausea, vomiting, cramping, flatulence, especially with carbonate)
• Headache
• Hypophosphatemia and hypercalcemia
• Nephrolithiasis

Concomitant administration may decrease the bioavailability of fluoroquinolones, tetracyclines, and
levothyroxine.
Bisphosphonates
Table 15-5 provides summary information about bisphosphonates.
Mechanism of action
Bisphosphonates bind to bone (hydroxyapatite) and incorporate into bone to increase and stabilize
bone mass. They inhibit osteoclasts and have a very long half-life in the bone.
[Table 15-5. Antiresorptive Agents]
• Bisphosphonates must be taken with a full glass of water (8 oz) 30-60 minutes prior to the first
meal of the day and 30-60 minutes before any other medications.
• Remain in an upright position for at least 30 minutes following ingestion.
• Take medication on a regularly scheduled basis.
• Compliance may be increased by extended dosing intervals (weekly, monthly, quarterly);

however, studies demonstrated antifracture benefits with daily dosing.
Adverse drug events

The most common adverse drug events are GI related: abdominal pain, dyspepsia, constipation,
diarrhea, flatulence, nausea, gastritis, esophageal ulceration (if not taken appropriately). Rarely,
patients experience osteonecrosis of the jaw (mostly in cancer patients on intravenous
bisphosphonates) or myalgia, arthralgia, or flu-like symptoms (especially with intravenous [IV]
zoledronic acid)

Interaction may result in decreased pharmacologic effect of bisphosphonates such as calcium
supplements and antacids. Separate administration by 1 hour.
Interaction may result in increased pharmacologic effect of bisphosphonates such as ranitidine. IV

ranitidine may double bioavailability of alendronate.
Interaction may result in increased toxicity of interacting drugs such as aspirin. Alendronate > 10
mg daily may increase risk of upper GI side effects of aspirin.
Estrogen replacement therapy
ERT has a beneficial effect on bone mineral density and fracture risk, but the risks of long-term
therapy appear to outweigh that benefit. ERT should be used at the lowest effective dose for the
shortest duration in women experiencing vasomotor symptoms or vulvovaginal atrophy.
Estrogen agonist-antagonist (selective estrogen receptor modulator): raloxifene (Evista)

Mechanism of action
Raloxifene is an estrogen receptor agonist in the bone. It decreases resorption of bone and overall
bone turnover. It acts as an antagonist in breast tissue.
• This medication may be taken without regard to food.
• Concomitant use with estrogen therapy is not recommended.
• This medication will not treat symptoms of menopause such as hot flashes and may aggravate
them.
• In the event of prolonged immobilization, discontinue raloxifene 3 days prior to and during the
immobile period when possible.
Adverse drug events

• Cardiovascular: Hot flashes, chest pain, syncope
• GI: Nausea, diarrhea, vomiting
• Musculoskeletal: Arthralgia, myalgia, nocturnal leg cramps
• Central nervous system (CNS): Insomnia, neuralgia
• Skin: Rash, sweating
• Thrombotic: deep-vein thrombosis, pulmonary embolism

For the following drugs, interaction may result in decreased pharmacologic effect of raloxifene:
• Ampicillin: Peak levels are reduced by 28% and overall absorption is reduced by 14%.
Coadministration is not contraindicated because of maintained systemic exposure and
elimination.
• Cholestyramine: Absorption and enterohepatic cycling are reduced. Do not administer together.
In the case of warfarin, interaction may result in decreased pharmacologic effect of the interacting
drug. Prothrombin time may decrease up to 10%. Patients with history of venous thromboembolism
should not be on raloxifene.
Calcitonin (Miacalcin, Fortical)
Mechanism of action
Calcitonin participates in the regulation of calcium and bone metabolism. It inhibits bone resorption
by binding to osteoclast receptors.
• If this medication is administered as an injection, it should be given in the upper arm, thigh, or
buttocks.
• Proper education regarding administration of the injection and the nasal spray preparation is
necessary.
• Patient should be advised that if a shot is missed, it should be administered as soon as possible,
but not if it is almost time for the next dose.
• Store the nasal spray in the refrigerator until time for use. Warm the spray to room temperature
prior to first use and then store at room temperature.
Adverse drug events

• Skin: Facial flushing and hand flushing (most common overall)
• GI: Nausea, diarrhea, vomiting, abdominal pain
• Taste disorder: Salty taste
• Genitourinary: Nocturia, urinary frequency
• Nasal (with nasal spray): Rhinitis, nasal dryness, irritation, itching, congestion
• Ophthalmic: Blurred vision, abnormal lacrimation

In the case of lithium, interaction may result in decreased pharmacologic effect of interacting drug.
Concomitant administration may decrease lithium levels.
Salmon calcitonin should be avoided in patients with a true allergy to seafood.
Parathyroid hormone: teriparatide (Forteo)
Mechanism of action
Teriparatide increases the rate of bone formation by stimulating osteoblasts, thereby increasing
bone mass density and decreasing fracture risk.
Because of limited long-term safety data (< 2 years) and risks of osteosarcoma in animal models,
this medication is recommended for use only in men and women at high risk of fracture.

Patients should be educated regarding appropriate use of the prefilled pen delivery device, storage
(refrigerator), and adverse effects (orthostasis with first dose).
Adverse drug events

• Musculoskeletal: Pain, arthralgia
• CNS: Paresthesias
• GI: Nausea, diarrhea, abdominal cramps
• Taste disorder: Metallic taste
• Skin: Injection pain, urticaria

No drug-drug or drug-disease interactions are known; however, teriparatide is contraindicated in
patients who are at increased risk of osteosarcoma, including those who have received radiation to
the bone, adolescents or young adults with open epiphyses, and individuals with Paget's disease.
Nondrug Therapy
Nondrug therapies include
• Weight-bearing exercise
• Limited alcohol consumption

• Calcium-rich diet
• Strategies to reduce the risk of falls
15-4. Key Points
Postmenopausal Hormone Replacement Therapy
Postmenopausal HRT must be selected on an individual basis taking into account the risks and
benefits, concomitant diseases, and medications. Important patient parameters to consider include
menopause symptoms, risk of coronary artery disease, risk of osteoporosis, risk of breast cancer,
and risk of thromboembolism.
The primary indication for initiating HRT is to relieve vasomotor and other menopause symptoms
to improve quality of life. Hormone replacement therapy is not recommended for use in the primary
prevention of any other disease states.
Hormone replacement therapy should be used at the lowest effective dose and for the shortest
duration possible. Estrogen plus progestin therapy is indicated in patients with a uterus. Estrogen
alone is indicated in women who no longer have a uterus.
Contraceptives
Oral contraceptives are highly effective and safe when used properly according to the
manufacturer's recommended dose and administration. Selection of prescription contraceptives
requires careful consideration of patient medical history, lifestyle, compliance, and preference.
In addition to the contraceptive benefit of these products, other menstrual-related health problems
may be resolved or lessened (e.g., menstrual pain, irregular menses, headache, and spotting).
Changes in dose or product are often necessary to achieve an appropriate balance of estrogen and
progestin that minimizes undesirable adverse effects associated with deficiencies or excess amounts
of the hormones.
Patients must be educated to report immediately the onset of severe abdominal pain, severe chest
pain, shortness of breath, severe headache, visual disturbances, or severe pain in the leg or calf.
Osteoporosis
Women should be counseled about the following preventive measures:
• Adequate calcium consumption, using dietary supplements if dietary sources are not adequate
• Adequate vitamin D consumption (400-1,000 IU daily) and the natural sources of this nutrient
• Regular weight-bearing and muscle-strengthening exercises to reduce falls and prevent fractures
• Moderation of alcohol intake
• Fall prevention strategies
Bone mineral density testing should be recommended to all postmenopausal women 65 years of age
or older and for postmenopausal women younger than 65 years who have one or more risk factors
for osteoporosis.
Therapy must be selected on an individual basis considering risks and benefits, concomitant
diseases, and medications.
Appropriate calcium and vitamin D intake is an important component of prevention and treatment.
If they are not obtained in the diet, supplementation is recommended for all individuals, especially
patients receiving prescription therapy for osteoporosis.
Bisphosphonates are first-line pharmacologic options for osteoporosis prevention and treatment.
They must be taken with a full glass of water 30-60 minutes prior to the first meal of the day or any
other medications. The patient must remain upright for at least 30 minutes after taking a dose.
Estrogen replacement therapy is not approved for the treatment of osteoporosis and should not be
initiated for this reason. It is approved for prevention of osteoporosis, but should be used only short
term for women who are experiencing vasomotor or vaginal atrophy symptoms.
15-5. Questions
A. J. is a 35-year-old premenopausal woman who is concerned about her family history of

osteoporosis. She does not eat dairy products because she is lactose intolerant. Her recent bone
mineral density screening revealed a T score of 1.0. Select the appropriate therapy
recommendation from the choices below.
1.
A. Daily estrogen replacement therapy
B. Daily calcium and vitamin D supplementation
C. Daily combined estrogen and progestin replacement therapy
D. Daily teriparatide injections
E. Daily calcitonin nasal spray

The pharmacist receives a prescription for Fosamax 70 mg daily for prevention of osteoporosis
with instructions to the patient to take with food and remain upright for at least 30 minutes
following ingestion. From the choices below, identify the errors in this prescription.
A. The dose of Fosamax should be 35 mg weekly for prevention.
2.
B. Fosamax should be taken at least 30 minutes prior to a meal; it should not be taken with
food.
C. Patients should lie down for 1 hour following administration of Fosamax.
D. Choices B and C are correct.
E. Choices A and B are correct.

What is the recommended dosage range of daily calcium intake for an adult?
A. 200-400 mg
3. B. 250-500 mg
C. 300-600 mg
D. 500-1,000 mg
E. 1,000-1,500 mg

Which of the following agents is considered first-line therapy for postmenopausal
osteoporosis?
A. Alendronate
4.
B. Calcitonin
C. Prempro
D. Denosumab
E. Teriparatide

Which of the following products is available in an injectable and nasal spray dosage form?
A. Raloxifene
5. B. Alendronate
C. Teriparatide
D. Calcitonin
E. Prempro

Which of the following drugs does not increase the risk of osteoporosis?
A. Anticonvulsants
6. B. Tamoxifen
C. Glucocorticoids
D. Estrogen
E. Depo-Provera

What is the recommended dose of raloxifene in the prevention and treatment of
postmenopausal osteoporosis?
A. 10 mg daily
7.
B. 15 mg daily
C. 40 mg daily
D. 60 mg daily
E. 120 mg daily

S. T. is a 32-year-old woman who wants to begin using a prescription contraceptive product.
She is a new mother and would like to know if any products are safe for use during breast-
feeding. S. T. states that she is not interested in using a device intravaginally and experiences
irritation and inflammation with condom use. Which of the following product(s) would be an
appropriate choice for S. T.?
8.
A. Ortho Tri-Cyclen
B. Micronor
C. Depo-Provera
D. A or B
E. B or C

T. H. is a 27-year-old woman currently taking Nordette oral contraceptive pills. She presents to
your pharmacy with a prescription of ampicillin 500 mg qid for 1 week. Which of the
following choices describes appropriate action taken by the pharmacist?
A. Call the physician and request a change to amoxicillin to avoid a drug interaction between
Nordette and ampicillin.
9. B. Dispense the ampicillin and counsel T. H. on the appropriate administration and duration of
therapy for the antibiotic.
C. Dispense the ampicillin and counsel T. H. regarding the potential for ampicillin to interfere
with the efficacy of Nordette. Instruct T. H. to use a backup method of contraception until
her next menstrual period begins.
D. Refuse to fill the ampicillin prescription, and counsel T. H. that she should never take
antibiotics while she is on oral contraceptives.

Which of the following oral contraceptives is a biphasic product?
A. Ortho Tri-Cyclen
10. B. Ortho-Novum 10/11
C. Ortho-Novum 1/35
D. Yasmin
E. Seasonale

Which of the following products is a progestin-only oral contraceptive?
A. Nordette
11. B. Ortho Tri-Cyclen
C. Nor-QD
D. Demulen 1/50
E. Necon 1/35

A 26-year-old female who is recently initiated on a combination hormonal oral contraceptive
complains of late-cycle breakthrough bleeding. Which of the following is she most likely
experiencing?
12. A. Too much estrogen

B. Too little estrogen
C. Too much progestin
D. Too little progestin
E. Too much androgen

What is the highest dose of estrogen (ethinyl estradiol) offered in an oral contraceptive?
A. 25 mcg
13. B. 30 mcg
C. 35 mcg
D. 40 mcg
E. 50 mcg

A progestin-only oral contraceptive would be preferable over a combination oral contraceptive
in all of the following cases except
14. A. a one pack per day smoker over 35 years old.

B. a patient with fibrocystic breast changes.
C. a lactating woman.
D. a patient with a history of thromboembolic disease.

A. J. is a 55-year-old woman who presents to your pharmacy with a prescription for Premarin
0.625 mg daily. She has an intact uterus and has been recently diagnosed with menopause.
Which of the following statements describes the appropriate action to be taken by the
pharmacist?
15. A. Refuse to fill the prescription and recommend a phytoestrogen supplement.

B. Call the physician and confirm that the patient has an intact uterus and recommend a
product containing estrogen plus progestin.
C. Fill the prescription and counsel the patient regarding administration instructions and
potential adverse effects.
D. None of the above.

Which of the following factors is a contraindication to the use of hormone replacement therapy
in postmenopausal women?
A. Diabetes
16.
B. Basal cell skin cancer
C. Thromboembolic disease
D. Depression
E. Obesity

From the choices below, select the most common side effect(s) associated with estrogen
replacement.
A. Breast tenderness
17.
B. Depression
C. Nausea
D. Brittle fingernails
E. A and C

The Women's Health Initiative study was terminated because HRT increased the risk of all of
the following conditions except
A. breast cancer.
18.
B. stroke.
C. cardiovascular disease.
D. uterine cancer.
E. pulmonary embolism.

Which of the following product dosing regimens is correct?
A. Climara Transdermal: apply to skin once daily.

19. B. Vagifem: 1 tablet vaginally once daily for 2 weeks; then 1 tablet vaginally twice weekly.
C. Estring: insert ring intravaginally once daily at bedtime.
D. Premarin tablets: 0.625-2.5 mg tid.
E. Premarin vaginal cream: 20-40 g vaginally once daily.

Which of the following drug interactions may result in increased pharmacologic effect of
estrogen?
A. Macrolide antibiotics
20.
B. Itraconazole
C. Ketoconazole
D. A and C
E. A, B, and C
15-6. Answers

15-6. Answers
B. A. J. has neither osteopenia nor osteoporosis with a T score of 1.0. At this point, preventive
1. therapy is appropriate, with adequate calcium and vitamin D intake. Prescription therapy is not
indicated at this time.

E. The appropriate use of Fosamax (alendronate sodium) for prevention of osteoporosis
includes a 35 mg weekly or 5 mg daily dose. The 70 mg weekly dose is for treatment of
2. osteoporosis. The medication should be taken with a full glass of water at least 30 minutes
prior to ingesting food or other beverages. Patients should remain in the upright position for at
least 30 minutes following ingestion of Fosamax.

E. According to the National Osteoporosis Foundation, adults < 50 years of age require 1,000
3. mg daily, and those 50 and older should have 1,200 mg daily. The recommended dosage range
of daily calcium intake for an adult is 1,000-1,500 mg.

A. Bisphosphonates are first-line therapy for osteoporosis because data demonstrates that they
4.
reduce the risk of fracture.

D. Injectable and nasal spray dosage forms of calcitonin are available. Teriparatide is available
5. as an injection only. Prempro, raloxifene, and alendronate are available only in oral dosage
forms.

6. D. Estrogen decreases rather than increases the risk of osteoporosis.

7. D. The approved and recommended dose of raloxifene is 60 mg once daily.

E. Micronor is a progestin-only (minipill) oral contraceptive and is considered compatible with
breast-feeding. Depo-Provera is an injectable progestin-only contraceptive option that is
considered safe and appropriate for women who desire to breast-feed because it does not affect
8.
milk production or adversely affect infant development. Ortho Tri-Cyclen is a combined oral
contraceptive that may decrease the quantity of breast milk available and may adversely affect
the infant.

C. Ampicillin may interact with combined oral contraceptives. Although clinical studies have
not consistently demonstrated an interaction, more than 25 case reports of unintended
pregnancies have been attributed to concomitant use of ampicillin and oral contraceptives.
Concomitant administration of ampicillin, as well as other antibiotics, may decrease the
9.
effectiveness of combined oral contraceptives, resulting in pregnancy. The American Medical
Association recommends that women be counseled about the potential risk of antibiotics
decreasing efficacy of oral contraceptives. If the patient desires, the pharmacist should
recommend a backup method of contraception until menses occurs.

10. B. Ortho-Novum 10/11 is a biphasic oral contraceptive.

11. C. Nor-QD is a progestin-only oral contraceptive.

D. Too little progestin may result in breakthrough bleeding late in the menstrual cycle. She
12.
should be changed to a product with a higher progestin content.

13. E. The highest dose of estrogen (ethinyl estradiol) offered in an oral contraceptive is 50 mcg.

14. B. Fibrocystic breast changes are not a contraindication to using combined oral contraceptives.

B. Unopposed estrogen is not recommended in women with an intact uterus because of an
15. increased risk of endometrial hyperplasia and endometrial cancer. Women with an intact uterus
should receive a product containing estrogen plus progestin.

C. Thromboembolic disease is a definite contraindication to the use of hormone replacement
16.
therapy in postmenopausal women.

E. Breast tenderness and nausea are the most common side effects associated with estrogen
17.
replacement.

18. D. The WHI study was not terminated because of an increased risk of uterine cancer.

B. Vagifem dosage is 1 tablet vaginally once daily for 2 weeks; then 1 tablet vaginally twice
19.
weekly.

E. Macrolide antibiotics, itraconazole, and ketoconazole may result in increased
20.
pharmacologic effect of estrogen by inhibiting CYP450 3A4.

15-7. References
Postmenopausal Hormone Replacement Therapy
Kalantaridou SN, Davis SR, Calis KA. Hormone replacement therapy in women. In: Dipiro JT,
Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New
York: McGraw-Hill; 2008:1351-68.
Klasco RK, ed. DRUGDEX® System (electronic version). Greenwood Village, Colo.: Thomson
Micromedex.
Loose DS, Stancel GM. Estrogens and progestins. In: Brunton LL, ed. Goodman and Gilman's the
Pharmacological Basis of Therapeutics. 11th ed. New York: McGraw-Hill; 2006:1541-71.
North American Menopause Society. Estrogen and progestogen use in postmenopausal women:
July 2008 position statement of the North American Menopause Society. Menopause.
2008;15:584-602. Available at: www.menopause.org.
O'Mara NB, Tom WC. Estrogen-containing hormone replacement products for postmenopausal
women. Pharmacist's Letter. 2008;24(12):240407.
O'Neil CK. Health issues in older women. In: Dunsworth T, Richadrson M, Chant C, et al., eds.
Pharmacotherapy Self-Assessment Program. 6th ed. Book 7: Women's and Men's Health.
Lenexa, Kans.: American College of Clinical Pharmacy, 2008;143-57.
Parent-Stevens L, Sagraves R. Gynecologic and other disorders of women. In: Koda-Kimble MA,
Young LY, eds. Applied Therapeutics: The Clinical Use of Drugs. 7th ed. Philadelphia:
Lippincott Williams & Wilkins; 2005:48-28 to 48-44.
Warren MP. A comparative review of the risks and benefits of hormone replacement therapy
regimens. Am J Obstet Gynecol. 2004;190:1141-67.
Contraception
Allen J, Cupp M. Hormonal contraception. Pharmacist's Letter. 2007;23(12):231207.
American College of Obstetricians and Gynecologists. The use of hormonal contraception in

women with coexisting medical conditions. Obstet Gynecol. 2006;107(6):1453-72.
Dickerson LM, Shrader SP, Diaz VA. Contraception. In: Dipiro JT, Talbert RL, Yee GC, et al., eds.
27.
Hardman JL. Contraception. In: Koda-Kimble MA, Young LY, eds. Applied Therapeutics: The
Clinical Use of Drugs. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2005:45-1 to 45-26.
Micromedex.
Osteoporosis
Micromedex.
MacLaughlin EJ, Raehl CL. ASHP therapeutic position statement on the prevention and treatment
of osteoporosis in adults. Am J Health-Syst Pharm. 2008;65:343-57.
National Osteoporosis Foundation. Clinician's Guide to Prevention and Treatment of Osteoporosis,

2008. Available at: www.nof.org/professionals/Clinicians_Guide.htm.
O'Connell MB, Vondracek SF. Osteoporosis and other metabolic bone diseases. In: Dipiro JT,
16. Kidney Disease - Joanna Q. Hudson, PharmD, BCPS, FASN
16-1. Acute Kidney Injury
Introduction
Acute renal failure, now increasingly referred to as acute kidney injury (AKI), is defined as rapid
(hours to days) deterioration of kidney function resulting in azotemia (retention of nitrogenous
waste products such as urea) and failure of the kidney to maintain fluid, electrolyte, and acid-base
homeostasis.
A reduced urine output is frequently seen: oliguria (urine output < 400 mL/d), anuria (urine output
< 50 mL/d), and nonoliguria (urine output > 400 mL/d).
The classification system proposed to distinguish between mild or severe and early or late cases of
AKI is known as RIFLE: Risk of kidney dysfunction, Injury to the kidney, Failure or Loss of kidney
function, and End-stage renal disease (ESRD):
• Risk: A 1.5-fold increase in the serum creatinine or a decrease of the glomerular filtration rate
(GFR) by 25 percent or urine output < 0.5 mL/kg/h for 6 hours
• Injury: A twofold increase in the serum creatinine or a decrease of GFR by 50% or urine output <
0.5 mL/kg/h for 12 hours
• Failure: A threefold increase in the serum creatinine, a decrease of GFR by 75% or urine output
of < 0.5 mL/kg/h for 24 hours, or anuria for 12 hours
• Loss: Complete loss of kidney function (e.g., need for renal replacement therapy) for more than 4
weeks
• ESRD: Complete loss of kidney function (e.g., need for renal replacement therapy) for more than
3 months
A modification of RIFLE that includes slightly adapted diagnostic criteria and a staging system was
proposed by the Acute Kidney Injury Network. The classification or staging system corresponds to
risk (stage 1), injury (stage 2), and failure (stage 3) of the RIFLE criteria. Loss and ESRD were
removed from the staging system and defined as outcomes.
Epidemiology
Incidence and prevalence
• Community-acquired AKI accounts for 1% of hospital admissions.

• Hospital-acquired AKI occurs in 5-7% of hospitalized patients.
Mortality
• The best prognosis is when renal replacement therapy is not required.
• The mortality rate is 40-50% for patients who require renal replacement therapy.
• The mortality rate is > 50% for patients with multiple organ failure.
Types and Classifications
AKI is classified according to the area of the kidney affected:
• Prerenal AKI is characterized by a decrease in perfusion to the kidney with or without systemic
arterial hypotension. It is the most common type of AKI and is usually reversible.
• Intrinsic or intra renal AKI is the result of structural damage to the parenchymal tissue of the
kidney. It is divided into vascular, glomerular, interstitial, and tubular disorders (most common).
• Postrenal AKI is an obstruction of urine flow occurring at any level of the urinary outflow tracts.
• Decreased urine output
• Signs of hypovolemia (prerenal causes), such as tachycardia, decreased venous and arterial
pressure, and orthostasis
• Unique color and composition of urine: cola-colored urine (suggesting bleeding) and foaming
(indicating proteinuria)
• Symptoms of uremia (a clinical syndrome resulting from azotemia), including weakness, shortness
of breath, fatigue, mental status changes, nausea and vomiting, bleeding, loss of appetite, and
edema
• Flank pain
• Increased weight (suggesting fluid accumulation)
• Increased blood pressure (suggesting fluid accumulation)
• Signs and symptoms of electrolyte abnormalities (hyperkalemia) and metabolic acidosis (see
Chapter 17 on fluids and electrolytes)
• Bladder distention or prostate enlargement (postrenal causes)
• Other findings specific to the cause of AKI (see section on pathophysiology)
Pathophysiology and Etiologies
Prerenal AKI
Prerenal AKI is caused by conditions that decrease glomerular hydrostatic pressure, leading to a
decrease in GFR (see discussion on etiologies). Hypoperfusion leads to increased sodium and water
reabsorption by the kidney and stimulates compensatory mechanisms.
The following compensatory mechanisms increase glomerular hydrostatic pressure and GFR:
• Vasodilation of the afferent arteriole (mediated primarily by prostaglandins)
• Vasoconstriction of the efferent arteriole (mediated primarily by angiotensin II)
Alterations in afferent and efferent arteriolar tone can affect compensatory mechanisms.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors can
prevent compensatory vasodilation of the afferent arteriole. Angiotensin-converting enzyme
inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and renin inhibitors can prevent
compensatory vasoconstriction of the efferent arteriole.
Etiologies of prerenal AKI are as follows:
• Intravascular volume depletion related to excessive diuresis, vomiting, excessive gastrointestinal

(GI) fluid loss, and bleeding
• Severe hypotension
• Decreased effective blood volume (volume sensed by arterial baroreceptors) as occurs with
congestive heart failure, cirrhosis, nephrotic syndrome, and hepatorenal syndrome
• Systemic vasodilatation as occurs with sepsis, liver failure, and anaphylaxis
• Large-vessel renal vascular disease, including renal artery thrombosis or embolism and renal
artery stenosis
• Medications (see
Table 16-1).
Intrinsic acute renal failure
The primary anatomic sites of the kidney are prone to structural damage from prolonged ischemia
and direct toxicity because of the high metabolic activity and concentrating ability of the kidney.
Etiologies by anatomic site are as follows:
• Vascular: Inflammation and emboli
• Glomerular (glomerulonephritis): Systemic lupus erythematosus and medications (see Table

16-1)
• Interstitial: Ischemia, allergic interstitial nephritis, infections, and medications (see Table 16-1)
• Tubular—accounts for 90% of intrinsic cases: Intrarenal vasoconstriction, direct tubular

toxicity, and intratubular obstruction; prolonged ischemia from prerenal causes; and toxins
• Endogenous: Myoglobin, hemoglobin, and uric acid
• Exogenous: Medications (see Table 16-1; aminoglycosides are common nephrotoxins leading to
nonoliguric AKI after 5-7 days of therapy); radiocontrast-induced AKI; other causes such as
ethylene glycol and pesticides
Postrenal acute kidney disease
This disease is an obstruction of urinary flow at any level from the urinary collecting system to the
urethra. It must involve both kidneys (or one kidney in a patient with a single functioning kidney).
Etiologies by anatomic site are as follows:
• Renal pelves or tubules: Crystal deposition
• Ureteral: Tumor, stricture, and stones
• Bladder neck obstruction: Prostatic hypertrophy and bladder carcinoma
• Medications: See Table 16-1.
[Table 16-1. Drug-Induced Causes of Kidney Disease]
Diagnostic Criteria
Table 16-2 shows the diagnostic tests and the findings associated with AKI. A diagnosis requires
the following steps:
• Evaluate physical findings: Assess for signs and symptoms listed in clinical presentation.
• Take medication history (including OTC medication and herbals): Identify potentially
nephrotoxic agents (Table 16-1).
• Estimate GFR: Normal is 100-125 mL/min/1.73 m2.
• Consider limitations in using serum creatinine as a marker of kidney function (e.g., conditions of
poor muscle mass) and in using equations to estimate GFR in patients with unstable kidney
function.
• Other assessment equations and methods (e.g., Jelliffe equation) are available to estimate GFR in
patients with unstable kidney function.
Creatinine clearance
Creatinine clearance (CrCl) is measured using urine collection methods:
where UCr = urinary creatinine concentration (mg/dL)

V = volume of urine (mL)

SCr = serum creatinine concentration (mg/dL)

t = time period of urine collection (minutes)

[Table 16-2. Laboratory Findings to Differentiate Prerenal and Intrinsic Kidney Disease]
CrCl is estimated using the Cockcroft-Gault equation (assumes stable kidney function):
where BW = body weight in kg. Ideal body weight is recommended if patient's body weight is more
than 30% above the ideal body weight. Multiply the result of the Cockcroft-Gault equation by 0.85
for females.
Blood tests
• Elevated: Blood urea nitrogen (BUN), serum creatinine, and electrolytes (potassium and
phosphorus)
• Decreased: Calcium (consider albumin concentration) and bicarbonate

Urinalysis
• An elevated specific gravity and osmolality are indicative of prerenal causes and stimulation of
sodium and water retention.
• Proteinuria includes microalbuminuria (> 30 mg/d), overt proteinuria (> 300 mg/d), and nephrotic
range proteinuria (> 3 g/d).
• Hematuria is indicated by red blood cells.
• Glucose and ketones may be present.
• Urine sediment consisting of granular casts and cellular debris suggests structural damage.
• White blood cells suggest inflammation.
• Eosinophils are associated with acute allergic interstitial nephritis.
• Consider whether fluids or diuretics were previously administered when interpreting urinalysis.
Urine chemistries
Evaluate urine sodium, potassium, chloride, creatinine, and urinary anion gap.
Fractional excretion of sodium (FENa) is useful to differentiate prerenal AKI from acute intrinsic
kidney injury. A low value (< 1%) suggests retention of sodium and water (prerenal etiology)
versus intrinsic cause.
where UNa = urine sodium

UCr = urine creatinine

PCr = plasma creatinine

PNa = plasma sodium

Other tests
Radiographic procedures include ultrasound, plain film radiograph, radioisotope scan, and
computed tomography.
Renal biopsy is indicated for patients without cause of AKI identified by other diagnostic tests.
Prevention
Risk factors must be identified:
• Volume depletion
• Exposure to nephrotoxic medications
• Preexisting kidney or hepatic disease
Surgical procedures can be a risk factor. Consider baseline kidney function, age, cardiovascular
status, and volume status.
Diagnostic tests requiring radiocontrast media can put patients at risk. Risk factors for contrast
nephropathy are diabetes, heart failure, age > 75, and an estimated GFR < 60 mL/min/1.73 m2. In
addition to being given hydration, high-risk patients should receive oral acetylcysteine (Mucomyst)
600 mg twice daily for 2 days beginning the day before exposure to radiocontrast dye. Bicarbonate
may also be added to the hydration fluid.
Treatment Goals
• Correct underlying causes of AKI (e.g., discontinue nephrotoxic agents, correct fluid status, treat
underlying infection, and address cause of urinary tract obstructions).
• Return to baseline kidney function or highest kidney function possible.
• Prevent development of chronic kidney disease and the need for chronic renal replacement
therapies (dialysis or transplantation).
• Avoid nephrotoxic agents or take measures to reduce exposure if possible.
• Adjust doses of medications on the basis of kidney function.
• Avoid agents contraindicated in patients with kidney disease, such as metformin (Glucophage).
• Address complications of AKI, such as electrolyte abnormalities (hyperkalemia), fluid overload,

metabolic acidosis (see Chapter 17 on fluids and electrolytes), hyperphosphatemia (see Section
16-2 on chronic kidney disease).
Strategies for treatment
• Address underlying cause of AKI.
• Provide supportive care with diuretic therapy (loop diuretics) and replacement fluids as needed to
maintain hemodynamic stability.
Drug Therapy
Diuretics
Select diuretics are shown in

Table 16-3.
Mechanism of action
Loop diuretics are delivered to the tubular lumen of the kidney by proximal tubular cells and cause
inhibition of sodium and chloride reabsorption in the thick ascending limb of the loop of Henle to
promote water excretion.
Osmotic diuretics are freely filtered into the tubular lumen in the proximal tubule and increase the
osmolarity of the glomerular filtrate, which inhibits tubular reabsorption of water and electrolytes
and increases urinary output.
Thiazide and thiazide-like diuretics inhibit the Na+-Cl- cotransport in the early distal convoluted
tubules. They are generally used in combination with loop diuretics for resistant edema and fluid
overload, particularly metolazone, which is effective at GFRs < 30 mL/min. Other thiazide diuretics
are generally not effective when GFR is < 30 mL/min.
Adverse drug events

Loop diuretics
Adverse drug events are as follows:
• Hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, hyperuricemia, and hyperglycemia
• Hypercalciuria
• Orthostatic hypotension and dehydration
• Metabolic alkalosis (partly attributable to extracellular fluid volume contraction)
• Ototoxicity
• Diarrhea and nausea

Furosemide, bumetanide, and torsemide have a sulfonamide substituent (potential for
hypersensitivity reactions). Ethacrynic acid is generally reserved for patients allergic to sulfa
compounds.
[Table 16-3. Diuretics as Drug Therapy for AKI by Drug Classification]
Osmotic diuretics
The following adverse drug events may occur:
• Acute expansion of extracellular fluid volume and increased risk of pulmonary edema
• Acute rise in serum K+, nausea and vomiting, headache, blurred vision, and rash

Adverse drug events include the following:
• Hypokalemia, hyponatremia, and hypercalcemia
• Hypovolemia and orthostatic hypotension
• Hyperglycemia, hypochloremic alkalosis, and hyperlipidemia
• Hypersensitivity reactions from sulfonamide substituents
• Chest pain (metolazone; more common with Mykrox, which is more rapidly and extensively
absorbed than Zaroxolyn)
• Loop diuretics and aminoglycosides have an increased potential for ototoxicity.
• Diuretics and other nephrotoxins have an increased risk of nephrotoxicity if hypovolemia occurs.
• Diuretics and lithium used concomitantly may result in decreased renal clearance of lithium.
Monitor lithium concentrations more closely.
• For diuretics and digoxin, hypokalemia from diuretic use may increase risk of toxicity with
digoxin. Monitor potassium and digoxin.
• Loop and thiazide diuretics may increase gout attacks because of hyperuricemia.
• For thiazide diuretics and diabetes, hyperglycemia may result from thiazides. Increase glucose
monitoring.
• The following conditions decrease secretion of the diuretic to its site of action in the renal tubule:
• Proteinuria (diuretic binds to protein and is not available at its site of action)
• Decreased renal blood flow
• Competitive inhibition of transport system (NSAIDs, probenecid, and cephalosporins)
• Blood pressure (sitting and standing), pulse, urine output, fluid intake, serum creatinine, serum
electrolytes, blood urea nitrogen, bicarbonate, calcium, glucose, and uric acid
• In the case of osmotic diuretics, serum osmolality (310-320 mOsm/kg); assess urine output after
initial test dose (goal urine flow is at least 30-50 mL/h)
Pharmacokinetics
Loop diuretics
• Oral bioavailability: Furosemide (60%), bumetanide (85%), and torsemide (85%)
• Oral:intravenous dose ratios: Furosemide (1.5), bumetanide (1), and torsemide (1)
• Equivalent doses: 1 mg bumetanide = 20 mg torsemide = 40 mg furosemide
• Elimination route: Furosemide (primarily renal), bumetanide (hepatic and renal), torsemide
(primarily hepatic), and ethacrynic acid (hepatic and renal)

Metolazone absorption differs between brands. Mykrox (available outside the United States) is
more rapidly and extensively absorbed than Zaroxolyn.
Other factors
Patients with kidney disease generally require larger doses of diuretics to achieve adequate
concentrations of the drug at the site of action in the kidney.
The brands of metolazone (Zaroxolyn and Mykrox) are not bioequivalent and should not be
interchanged.
Dopamine
The use of dopamine in AKI is controversial because benefits have not consistently been
demonstrated.
Nondrug Therapy
Fluid management
Fluid intake and output should be evaluated and adjustments made to maintain hemodynamic
stability (consider sensible and insensible losses).
Fluid selection (e.g., crystalloids, colloids, or normal saline) and rate of correction depend on the
clinical condition of the patient.
Nutritional therapy
A high-calorie diet is generally required (patient-specific).
Restriction of sodium, potassium, and phosphorus should be considered.
Renal replacement therapies
Renal replacement therapies are procedures by which the blood is artificially cleared of waste and
some essential metabolic products to augment the function of failed or failing kidneys. They include
hemodialysis and hemofiltration, in which the semipermeable membrane is a dialyzer, and
peritoneal dialysis, in which the peritoneal cavity serves as this membrane. Procedures may be
intermittent or continuous. Hemodialysis and hemofiltration are the most common modalities for
patients with AKI. Kidney transplantation is also considered a form of renal replacement therapy.
The potential for drug removal by dialysis must be considered.
Indications for renal replacement therapy

Any of the following refractory to more conservative measures are indications for renal replacement
therapy:
• Acidosis
• Electrolyte abnormalities (hyperkalemia)
• Intoxication (drug-induced kidney failure), if drug can be removed by dialysis
• Volume overload
• Uremia (BUN >100 mg/dL) or uremic symptoms (pericarditis, encephalopathy, bleeding,

dyscrasia, nausea, vomiting, and pruritus)
16-2. Chronic Kidney Disease
Introduction
Chronic kidney disease (CKD) is kidney damage with or without a decrease in GFR or a GFR < 60
mL/min/1.73 m2 for 3 months. Kidney damage is defined as pathologic abnormalities or markers
of damage, including abnormalities in blood or urine tests or in imaging studies.
CKD is classified into five stages on the basis of kidney damage and GFR (
Table 16-4). End-stage renal disease occurs when patients require renal replacement therapy (either
dialysis or transplantation) to sustain life.
Epidemiology of Chronic Kidney Disease
Incidence and prevalence
Approximately 26 million American adults have CKD. The number of patients with CKD continues
to increase, with a 50% increase in the number of patients with ESRD expected by 2020. The
incidence of CKD is approximately four times higher in the African American population. The
incidence is greatest in individuals age 45-64.
Approximately 500,000 patients are being treated for ESRD (including patients receiving
hemodialysis, peritoneal dialysis, and transplantation).
Mortality
Life expectancy is four to five times shorter in dialysis patients than in the general population. The
primary causes of death in the ESRD population are cardiovascular diseases and infection.
Comorbidities, estimated GFR, and albumin at initiation of dialysis are strong predictors of
mortality in the dialysis population.
• Changes in urine output (may not occur in earlier stages of CKD)
• Foaming of urine, which indicates proteinuria (

Table 16-5):
• Microalbuminuria: Albumin in the urine in amounts of 30-300 mg/d
[Table 16-4. Stages of Chronic Kidney Disease]
[Table 16-5. Definitions of Proteinuria and Albuminuria]
• Albuminuria: Albumin in the urine in amounts > 300 mg/d
• Clinical proteinuria: Total protein (in addition to albumin) in the urine in amounts > 300 mg/d
• Increased blood pressure (hypertension is a common etiology and result of CKD)

• Signs and symptoms of hyperglycemia and glucosuria (diabetes is a common etiology)
• Signs and symptoms associated with fluid and electrolyte abnormalities (e.g., hyperkalemia and
fluid overload; see Chapter 17 on fluids and electrolytes)
• Development of secondary complications of CKD:
• Anemia: Decreased hemoglobin and hematocrit, iron deficiency common
• CKD mineral and bone disorder: Increased serum phosphorus, decreased serum calcium (at
risk for hypercalcemia as kidney disease progresses), increased intact parathyroid hormone
(iPTH), and vitamin D deficiency
• Metabolic acidosis: Decreased serum bicarbonate and increased anion gap
• Malnutrition: Decreased albumin and prealbumin (see Chapter 19 on nutrition)
• Signs of uremia (see Section 16-1) in later stages of CKD (stages 4 and 5 CKD)
Pathophysiology of Progressive Kidney Disease and Selected Secondary Complications
Progressive kidney disease
Progressive loss of nephron function results in adaptive changes in remaining nephrons to increase
single nephron glomerular filtration pressure. Over time, the compensatory increase in single
nephron GFR leads to hypertrophy from sustained increases in pressure and loss of individual
nephron function.
Proteinuria, one of the initial diagnostic signs, may also contribute to the progressive decline in
kidney function. Loss of kidney function is usually irreversible.
Etiology of progressive kidney disease

Each of the following may result in damage to the kidney that leads, over time, to a decrease in
functioning nephrons and in total GFR:
• Diabetes (accounts for primary cause in 44% of patients with ESRD)
• Hypertension (accounts for primary cause in 26% of patients with ESRD)
• Glomerulonephritis
• Cystic kidney disease
• HIV (human immunodeficiency virus) nephropathy

• Other contributing factors (smoking, obesity, genetic factors, and gender differences)
Anemia of chronic kidney disease
The primary etiology is a decrease in production of the hormone erythropoietin by the kidney as
kidney disease progresses. More than 90% of erythropoietin production occurs in the kidney and
approximately 10% in the liver.
CKD results in a normochromic, normocytic anemia. Red blood cell lifespan is also decreased from
120 days to approximately 60 days in patients with kidney failure. Other contributors include iron
deficiency and blood loss (e.g., from uremic bleeding, dialysis).
CKD Mineral and Bone Disorder
As kidney function declines, phosphorus elimination decreases. Hyperphosphatemia causes a

reciprocal decrease in serum calcium concentrations (hypocalcemia). Hypocalcemia stimulates the
release of iPTH by the parathyroid glands.
Conversion of the vitamin D precursor to the active form (1,25-dihydroxyvitamin D3) occurs in the
kidney. As kidney disease progresses, there is a decline in the 1±-hydroxylase enzyme that promotes
the final hydroxylation step in the kidney, resulting in a deficiency in active vitamin D. Deficiencies
in the precursor form of vitamin D have also been observed in stages 3 and 4 CKD. Active vitamin
D (1,25-dihydroxyvitamin D3) promotes increased intestinal absorption of calcium and suppresses
production of parathyroid hormone by the parathyroid gland; therefore, vitamin D deficiency leads
to worsening secondary hyperparathyroidism.
Increased iPTH promotes the following:
• Decreased phosphorus reabsorption within the kidney
• Increased calcium reabsorption by the kidney
• Increased calcium mobilization from bone
As kidney disease progresses, the following occur:
• Hyperphosphatemia and subsequent hypocalcemia progressively worsen, and secondary

hyperparathyroidism becomes more severe.
• The renal effects of PTH on phosphorus and calcium are no longer maintained, and PTH
predominantly stimulates calcium resorption from bone.
• Decreased production of active vitamin D worsens hypocalcemia and secondary

hyperparathyroidism.
• In more severe CKD (stages 4 and 5), patients are prone to develop hypercalcemia, in part
because of the use of calcium-containing phosphate binders.
• Patients with stage 5 CKD are at risk for calcifications and calciphylaxis.
• Uncontrolled secondary hyperparathyroidism leads to hyperplasia of the parathyroid gland and

renal osteodystrophy (from sustained effects of iPTH on bone).
Metabolic acidosis
• Decreased excretion of acid by the kidney
• Accumulation of endogenous acids attributable to impaired kidney function (e.g., phosphates and
sulfates)
Diagnostic Criteria
There is a progressive increase in serum creatinine: > 1.1-1.2 mg/dL for females and > 1.2-1.3
mg/dL for males. Consider factors that may alter serum creatinine, such as decreased muscle mass
and nutritional status.
There is a decreased GFR (see Table 16-4 for CKD classifications). Consider the assessment
method used:
• Measured creatinine clearance (see discussion of diagnostic criteria for acute kidney injury in
Section 16-1)
• Cockcroft-Gault equation (see discussion of diagnostic criteria for acute kidney injury in Section
16-1)
• Modification of diet in renal disease abbreviated equation
GFR = 186 × (serum creatinine)- 1.154

× (age in years)-0.203

× 1.210(if patient is black)

× 0.742(if patient is female)

• Schwartz equation (children)
where k = 0.55 for children aged 1-13 years
• Microalbuminuria, albuminuria, or clinical proteinuria (Table 16-5)
• Abnormal serum chemistries:
• Increased serum creatinine and BUN
• Increased potassium, decreased serum bicarbonate, increased phosphorus, and decreased

calcium (indicative of secondary complications)
• Development of secondary complications (e.g., anemia, CKD mineral and bone disorder, and
fluid and electrolyte abnormalities)
Testing for anemia is recommended in all patients with CKD. Guidelines for anemia management
in patients with CKD recommend further evaluation for anemia when hemoglobin is < 12 g/dL in
females and < 13.5 g/dL in males.
For iron deficiency, evaluate red blood cell indices and iron indices to identify iron deficiency as a
contributing factor; iron deficiency manifests as a microcytic anemia.
• Red blood cell count: < 4.2 × 106 cells per mm2
• Mean corpuscular volume: < 80 femoliters
• Serum iron: < 50 mg/dL
• Total iron binding capacity: < 250 mg/dL
• Transferrin saturation (TSat): < 16%
• Serum ferritin: < 12 ng/mL
Transferrin saturation and serum ferritin should be maintained at higher values for CKD patients
receiving erythropoietin therapy (TSat > 20% and serum ferritin >100 ng/mL for CKD patients not
on dialysis and for peritoneal dialysis patients; and TSat > 20% and serum ferritin >200 ng/mL for
hemodialysis patients).
Evaluate for folate and vitamin B12 deficiencies (manifests as a macrocytic anemia), sources of
blood loss (e.g., GI bleeding), and confounding disease states (e.g., cancer and HIV).
• Serum phosphorus: > 4.6 mg/dL (> 5.5 mg/dL in stage 5 CKD)
• Calcium abnormalities:
• Hypocalcemia: Corrected serum calcium < 8.5 mg/dL
• Hypercalcemia (a concern in stages 4 and 5 CKD): Corrected calcium = measured serum

calcium + 0.8 × (normal serum albumin - measured serum albumin); normal serum albumin =
4.0 g/dL
• Elevated calcium × phosphorus product: > 55 mg2/dL2 (elevated product increases risk for
metastatic calcifications)
• Intact parathyroid hormone: > 70 pg/mL (stage 3 CKD), > 110 pg/mL (stage 4 CKD), and > 300
pg/mL (stage 5 CKD)
• Radiographic evidence of bone abnormalities (e.g., osteitis fibrosa cystica)
Metabolic acidosis
Serum bicarbonate (HCO3-) is < 20 mEq/L.
Typically have an increased anion gap: anion gap = [Na+] - ([Cl-] + [HCO3-]).
Signs and symptoms of chronic metabolic acidosis that develop as CKD progresses are generally
not of the same magnitude as those of acute metabolic acidosis (e.g., hyperventilation,
cardiovascular and central nervous system manifestations).
• Control underlying cause of progressive CKD (e.g., diabetes and hypertension; see Chapters 8 and
13, respectively).
• Meet blood pressure goal: < 130/80 mm Hg for patients with evidence of kidney disease and/or
diabetes.
• Prevent or minimize microalbuminuria or proteinuria.
• Slow the rate of progression of CKD (by achieving diabetes and hypertension goals and
minimizing proteinuria).
• Prevent drug-induced causes of kidney disease:
• Avoid chronic use of combinations of analgesics.
• Minimize use of agents known to cause AKI (patients can develop an acute-on-chronic
kidney disease).
• Manage secondary complications of CKD (anemia, mineral and bone disorders, and electrolyte
abnormalities).
• Control hyperlipidemia.
• Address cardiovascular risk factors (cardiovascular disease is the leading cause of death in the
CKD population).
• Adjust drug doses on the basis of kidney function.
• Avoid medications contraindicated in patients with reduced kidney function. For example,
metformin (Glucophage) is contraindicated in patients with elevated serum creatinine (> 1.5
mg/dL for men and > 1.4 mg/dL for women) because of the increased risk of lactic acidosis.
• Prepare patient for renal replacement therapy (i.e., dialysis and transplantation) as needed.
• Start dialysis if stable GFR < 15 mL/min/1.73 m2 and based on other indications (see Section
16-2 on indications for renal replacement therapy).
• Recommend smoking cessation.
Treatment strategies
• Diuretics for fluid balance and management of hypertension (diuretic selection based on kidney
function)
• Antihypertensives with diet and lifestyle modifications for control of blood pressure (see Chapter
8 on hypertension)
• Antidiabetic agents with diet and lifestyle modifications for control of blood glucose (see Chapter
13 on diabetes)
• ACEIs and ARBs to delay progression of kidney disease (recommended for patients with diabetes
and individuals with hypertension and proteinuria; see Table 16-5)
• Protein restriction to 0.6-0.8 g/kg/d:
• Consider for patients with > 1 g/d proteinuria despite optimal blood pressure control with a
regimen that includes an ACEI or ARB.
• Be cautious about maintaining adequate caloric intake and avoid malnutrition.
• Do not implement for patients < 80% of their ideal body weight or with > 10 g/d proteinuria.
• Renal replacement therapy:
• Consider plans for dialysis therapy (hemodialysis or peritoneal dialysis) during stage 4 CKD
(when GFR < 30 mL/min) (see Section 16-2 for general description of dialysis).
• Evaluate candidacy for kidney transplantation.
Target hemoglobin is 11-12 g/dL, and target hematocrit is 33-36% (based on the Kidney Disease
Outcome Quality Initiative Guidelines). Note: The FDA labeling for all erythropoietic stimulating
agents states the goal hemoglobin as 10-12 g/dL.
Iron indices are transferrin saturation > 20% and serum ferritin > 100 ng/mL for CKD patients not
on dialysis and for peritoneal dialysis patients. The goal for serum ferritin in hemodialysis patients
is > 200 ng/mL). Note: Ferritin is an acute phase reactant and may be elevated during conditions of
infection or inflammation.
Erythropoietic stimulating agents
Erythropoietic stimulating agents (ESAs) stimulate red blood cell production in the bone marrow.
ESAs may be administered subcutaneously (SC) or intravenously (IV). SC is generally preferred for
patients not on hemodialysis (i.e., peritoneal dialysis and early stage CKD patients who do not have
IV access).
Epoetin alfa (Epogen and Procrit): Initial doses are 50-100 units/kg IV or SC three times per week.
Darbepoetin alfa (Aranesp): Initial dose is 0.45 mcg/kg IV or SC administered once weekly.
Alternatively, for patients not on dialysis, an initial dose of 0.75 mcg/kg may be administered SC
every two weeks.
Dose conversion is from epoetin alfa (units/week) to darbepoetin alfa (mcg/week)(

Table 16-6).
The darbepoetin package insert states that for patients receiving epoetin alfa 2-3 times per week,
darbepoetin alfa should be administered weekly. For patients receiving epoetin alfa once per week,
darbepoetin alfa should be administered once every two weeks. In this situation, the weekly epoetin
dose should be multiplied by 2 and that dose should be used in Table 16-6 to determine the
appropriate darbepoetin dose.
For dose titration, allow at least 2-4 weeks before making a change in the dose of epoetin alfa or
darbepoetin alfa based on the change in hemoglobin or hematocrit. If a change in hemoglobin is < 1
g/dL
[Table 16-6. Estimated Starting Doses of Darbepoetin Alfa Based on Previous Epoetin Alfa Dose]
in a 4-week period and iron stores are adequate, increase the ESA dose by 25%. If a change in
hemoglobin is > 1 g/dL in a 2-week period, or the hemoglobin is approaching 12 g/dL, reduce the
ESA dose by 25%.
Iron supplementation
Iron supplementation prevents iron deficiency as a cause of resistance to therapy with erythropoietic
stimulating agents. Iron deficiency should be corrected prior to making changes in the dose of the
erythropoietic stimulating agent.
Oral iron supplementation is limited by poor absorption and is often inadequate to achieve goal iron
indices. It may be reasonable for stages 3 and 4 CKD patients and the peritoneal dialysis population
(patients without IV access). The recommended dose is 200 mg elemental iron per day.
Intravenous iron supplementation is preferred for treatment of absolute iron deficiency and in
hemodialysis patients with regular intravenous access. One may administer a full course of iron,
typically a total dose of 1 g divided over 8-10 hemodialysis sessions (100 mg per dose for iron
sucrose [Venofer] and iron dextran [InFeD and Dexferrum] or 125 mg per dose for sodium ferric
gluconate [Ferrlecit]). Weekly doses of 25-125 mg may be administered as maintenance doses of
iron in hemodialysis patients.
• Iron sucrose: The 100 mg dose may be diluted in 100 mL of 0.9% NaCl (sodium chloride)
administered IV over at least 15 minutes or administered undiluted over 2-5 minutes.
• Iron dextran: The 100 mg dose may be administered over 2 minutes IV push. One must
administer a 25 mg test dose because of the risk of anaphylactic reactions.
• Sodium ferric gluconate: The 125-mg dose may be diluted in 100 mL of 0.9% NaCl and
administered IV over 1 hour or administered undiluted as an IV injection at a rate up to 12.5
mg/min. Dosing in pediatric patients is 1.5 mg/kg in 25 mL of 0.9% NaCl over 60 minutes
(maximum dose 125 mg).
IV iron regimens differ in peritoneal dialysis patients and patients with CKD not requiring dialysis.
A total dose of 1 g is recommended for iron-deficient patients, administered in divided doses. Iron
sucrose has an approved regimen in these populations.
The approved dosing regimen for iron sucrose in nondialysis CKD patients is 200 mg over 2-5
minutes on five different occasions within a 14-day period. Peritoneal dialysis patients should
receive 300 mg in 0.9% NaCl administered IV over 1.5 hours, followed by a second infusion of 300
mg 14 days later and then by a 400 mg dose administered over 2.5 hours 14 days later.
Ferumoxytol (Feraheme) is an IV form of iron approved in 2009 for treatment of iron deficiency
anemia in adults with chronic kidney disease. The approved dose is 510 mg (17 mL) as a single
dose, followed by a second 510 mg dose 3-8 days after the initial dose.
Blood transfusions may be required for more severe anemia or when blood loss is a major
contributing factor.
• Goal serum phosphorus is 2.7-4.6 mg/dL for stages 3 and 4 CKD and 3.5-5.5 mg/dL for stage 5
CKD.
• Goal serum corrected calcium is approximately 8.5-10 mg/dL (normal range) for stages 3 and 4
CKD and 8.4-9.5 mg/dL for stage 5 CKD (recommend a lower range in stage 5 CKD because of
risk of hypercalcemia and calcifications).
• Calcium × phosphorus product is < 55 mg2/dL2.
• Goal iPTH is as follows:
• Stage 3 CKD: iPTH 35-70 pg/mL
• Follow a dietary phosphorus restriction of 800-1,000 mg/d phosphorus (consult with dietitian).
• Use phosphate binding agents—elemental (calcium, lanthanum, aluminum, and magnesium)

and nonelemental (sevelemer):
• Titrate doses on the basis of phosphorus and calcium × phosphorus product.
• Limit use of calcium-containing phosphate binders if hypercalcemia occurs.

• Aluminum is not a first-line agent; prescribe it only if needed for short-term use (< 30 days)
to minimize the risk of accumulation.
• Remove phosphorus by dialysis for ESRD patients. Continue phosphorus restriction and use of
phosphate binding agents with dialysis.
• Maintain goal calcium and phosphorus concentrations.
• Provide vitamin D supplementation depending on the stage of CKD. Supplementation with the
active form (calcitriol) or a vitamin D analog (doxercalciferol or paricalcitol) may be necessary
in more severe stages of CKD (stages 4 and 5). Supplementation with a vitamin D precursor
(e.g., ergocalciferol) may be sufficient in earlier stages.
• Use a calcimimetic agent (cinacalcet [Sensipar]) to help control iPTH in ESRD patients. Initial
dose is 30 mg po daily. The dose of cinacalcet should be titrated no more frequently than every
2-4 weeks through sequential doses of 60, 90, 120, and 180 mg once daily to target iPTH (150-
300 pg/mL).
• Control metabolic acidosis (which causes bone demineralization if not controlled).
Metabolic acidosis
• Serum bicarbonate: 22-26 mEq/L
• pH: 7.35-7.45
• Administration of sodium bicarbonate or other alkali preparation: Gradual correction (over

days to weeks) is usually appropriate for asymptomatic patients with mild to moderate acidosis
(serum bicarbonate 12-20 mEq/L and pH 7.2-7.4).
• Dialysis: Bicarbonate or lactate contained within the dialysate solution diffuses from dialysate to
plasma and effectively treats metabolic acidosis.
Monitoring
• Patients at high risk for CKD (e.g., patients with diabetes or hypertension) or patients diagnosed
with CKD should have the following monitored regularly:
• Serum creatinine: Consider limitations.
• Estimated GFR: Assess rate of progression (mL/min per year).

• Proteinuria: Monitor annually in patients with type 1 diabetes with diabetes duration of e 5 years
and at diagnosis for patients with type 2 diabetes.
• Serum electrolytes: Assess levels.
• Blood pressure: Assess in individuals with hypertension.
• Blood glucose: Assess in individuals with diabetes.
• Drug regimens: Evaluate and adjust on the basis of kidney function.
• Monitor hemoglobin and hematocrit every 1-2 weeks after initiation of erythropoietic therapy or
following a dose change and every 2-4 weeks once stable target hemoglobin and hematocrit are
achieved.
• Monitor iron indices (transferrin saturation and serum ferritin).
• Evaluate patient for signs and symptoms of anemia.
• Phosphorus
• Calcium
• Parathyroid hormone
• Vitamin D (measure precursor levels, 25 hydroxyvitamin D, in patients with stages 3 and 4 CKD)
Metabolic acidosis
• Serum bicarbonate
• Potassium
Drug Therapy
• ACEIs and ARBs (see Chapter 8 on hypertension and Chapter 13 on diabetes)
• Antihypertensive agents (see Chapter 8 on hypertension)

• Antidiabetic agents (see Chapter 13 on diabetes)
Anemia
Anemia is treated with erythropoietic stimulating agents (

Table 16-7).
Mechanism of action
These agents stimulate the division and differentiation of erythroid progenitor cells and induce the
release of reticulocytes from the bone marrow into the bloodstream, where they mature into
erythrocytes.
Adverse drug events

Adverse drug events include the following:
• Hypertension
• Red blood cell aplasia
• Seizures (rare)
• Polycythemia
• Thrombocytosis

Causes of resistance to erythropoietic therapy are as follows:
• Iron deficiency
• Secondary hyperparathyroidism
• Inflammatory conditions
• Aluminum accumulation
• Other disease states causing anemia (e.g., cancer and HIV)
The following should be monitored:
• Hemoglobin and hematocrit
• Iron indices
• Blood pressure
[Table 16-7. Erythropoietic Stimulating Agents]
Pharmacokinetics
Erythropoietic stimulating agents have the following half-lives:
• Epoetin alfa: Approximately 8.5 hours IV and 24 hours SC
• Darbepoetin alfa: Approximately 25 hours IV and 48 hours SC
The effect on hematologic parameters is observed over approximately 7 days to 6 weeks.
Steady-state conditions depend on the lifespan of red blood cells and the rate of red blood cell
production.
Strengths and dosage forms

Epoetin alfa is supplied as single-dose, preservative-free solution (in vials of 2,000, 3,000, 4,000,
10,000, and 40,000 units/mL) and as a multidose, preserved solution (in vials of 10,000- and 20,000
units/mL).
Darbepoetin alfa is available in two solutions. A polysorbate solution and an albumin solution are
supplied as single-dose vials (of 25, 40, 60, 100, 200, 300, and 500 mg/mL and of 150 mg/0.75
mL); as single-dose prefilled syringes; and as prefilled autoinjectors (syringes and autoinjectors
available in doses of 25, 40, 60, 100, 150, 200, 300, and 500mcg). They contain no preservatives.
Iron supplementation
Iron supplements are described in

Table 16-8.
Mechanism of action
Supplies a source of elemental iron necessary for the function of hemoglobin, myoglobin, and
specific enzyme systems, and allows transport of oxygen via hemoglobin.
• Oral iron may cause stools to be dark in color.
• Take between meals to increase absorption.
• Oral iron may be taken with food if GI upset occurs.
• Do not take with dairy products or antacids.

Adverse drug events
• Oral iron may cause stomach cramping, constipation, nausea, vomiting, and dark stools.
• In the case of intravenous iron, anaphylactic reactions have occurred with iron dextran (InFed and
Dexferrum); administer a 25 mg test dose prior to administration of the full dose. A reduced
incidence of hypersensitivity reactions exists with sodium ferric gluconate (Ferrlecit), iron
sucrose (Venofer), and ferumoxytol (Feraheme). For all preparations, observe patients for
diaphoresis,
[Table 16-8. Iron Supplements]
nausea, vomiting, lower back pain, dyspnea, and hypotension.
• Iron overload may be treated with deferoxamine (Desferal).

GI absorption of oral iron is decreased when given with antacids, quinolones, and tetracycline and
increased when administered with vitamin C.
Intravenous iron has a potential to increase risk of infection. Administration to patients with severe
systemic infections is controversial.
• Ferritin and transferrin saturation.
• Hemoglobin and hematocrit.
• Monitor for anaphylactic or hypersensitivity reactions after IV administration.
• Ferumoxytol (Feraheme) is supplied in 17 mL single-dose vials containing 30 mg of elemental

iron per milliliter.
• Iron dextran (InFeD and Dexferrum) is supplied in 2 mL single-dose vials containing 50 mg of

elemental iron per milliliter.
• Iron sucrose (Venofer) is supplied in 5 mL single-dose vials containing 100 mg elemental iron (20
mg/mL).
• Sodium ferric gluconate (Ferrlecit) is supplied as colorless glass ampules containing 62.5 mg
elemental iron in 5 mL (12.5 mg/mL).
Phosphate binding agents are used to treat this disorder (

Table 16-9).
Mechanism of action
These agents combine with dietary phosphate in the GI tract to form an insoluble complex that is
excreted in the feces.
• Take with meals and snacks.
• Do not take with oral iron salts or certain antibiotics (quinolones, tetracyclines).
• Aluminum and magnesium products are generally for short-term use because of concern of
accumulation in patients with kidney disease.
• Use in conjunction with dietary phosphorus restriction.
Adverse drug events
• Calcium products can result in hypercalcemia, nausea, vomiting, abdominal pain, and
constipation.
• Sevelamer hydrochloride (Renagel) and sevelamer carbonate (Renvela) can result in decreased
LDL (low-density lipoprotein) cholesterol, increased HDL (high-density lipoprotein) cholesterol
(may be a beneficial effect), nausea, and vomiting. Note: Sevelamer carbonate (Renvela) has less
risk of lowering serum bicarbonate levels than does sevelamer hydrochloride (Renagel). The new
formulation will eventually replace Renagel.
[Table 16-9. Phosphate Binding Agents]
• Lanthanum carbonate (Fosrenol) may cause nausea, vomiting, diarrhea, abdominal pain, and
constipation.
• Aluminum may cause constipation, aluminum toxicity, chalky taste, cramps, nausea, and
vomiting.
• Magnesium products may cause diarrhea, hypermagnesemia, cramps, and muscle weakness.
• All products may cause hypophosphatemia.

Calcium, lanthanum, aluminum, and magnesium are elemental compounds that may bind with
antibiotics (quinolones and tetracyclines) in the GI tract, thus decreasing their absorption.
Sevelamer hydrochloride (Renagel) may contribute to metabolic acidosis and decreased LDL
cholesterol. There is less risk of metabolic acidosis with sevelamer carbonate (Renvela).
• Phosphorus, calcium, and iPTH
• Aluminum and magnesium (if receiving aluminum or magnesium-containing products)
• For sevelamer (Renvela and Renagel), serum bicarbonate and LDL cholesterol
Vitamin D therapy
Vitamin D therapy is described in

Table 16-10.
Mechanism of action (active vitamin D)

This therapy increases intestinal absorption of calcium, increases tubular reabsorption of calcium by
the kidney (in patients with sufficient kidney function), suppresses synthesis of parathyroid
hormone, and increases intestinal phosphorus absorption.
• Use in conjunction with dietary phosphorus restriction and phosphate binding agents; therapy may
need to be temporarily discontinued if calcium and phosphorus are elevated.
• Notify health care provider of any of the following signs of hypercalcemia: weakness, headache,
decreased appetite, and lethargy.
Adverse drug events
• Hypercalcemia: Decreased incidence with vitamin D analogs (paricalcitol, doxercalciferol)
• Hyperphosphatemia: Decreased incidence with vitamin D analogs
• Adynamic bone disease: Caused by oversuppression of PTH
• Cholestyramine may decrease intestinal absorption of oral products.
• Magnesium absorption may be increased with concomitant administration.

[Table 16-10. Vitamin D Therapy]
• iPTH
• Calcium
• Phosphorus
• Calcium × phosphorus product (vitamin D therapy may need to be temporarily discontinued or the
dose decreased if the calcium × phosphorus product is elevated)
• Alkaline phosphatase
• Signs of vitamin D intoxication and hypercalcemia (e.g., weakness, headache, somnolence,

nausea, vomiting, bone pain, and polyuria)
Pharmacokinetics
• Calcitriol (Calcijex):
• Half-life 3-8 hours; protein binding 99.9%
• Paricalcitol (Zemplar):
• Half-life: Healthy subjects 4-6 hours (oral); Stage 3 and 4 CKD 17-20 hours (oral); Stage 5
CKD 14-15 hours (IV)
• Protein binding: > 99%
• Doxercalciferol (Hectorol):
• Half-life of active metabolite: 32-37 hours
Ergocalciferol requires hydroxylation within the liver to form calcifediol and a second
hydroxylation within the kidney to form active vitamin D.
Doxercalciferol requires conversion to its active form 1±, 25-dihydroxyvitamin D2 in the liver.
• Calcitriol (Calcijex): 1 mcg/mL ampules

• Calcitriol (Rocaltrol): 0.25 and 0.5 mcg capsules and 1 mcg/mL oral solution
• Paricalcitol (Zemplar): IV—2 and 5 mcg/mL vials; po—1, 2, and 4 mcg capsules
• Doxercalciferol: IV—2 mcg/mL ampules; po—0.5 and 2.5 mcg capsules
Calcimimetics: Cinacalcet (Sensipar)
Cinacalcet is approved for patients with stage 5 CKD who are on dialysis. It is used in conjunction
with phosphate binder therapy and vitamin D. The dose range is 30-180 mg/d; initial dose is 30 mg
titrated every 2-4 weeks on the basis of iPTH levels. Do not start therapy if corrected serum calcium
is < 8.4 mg/dL.
Mechanism of action
Cinacalcet binds with the calcium-sensing receptor on the parathyroid gland and increases
sensitivity of the receptor to extracellular calcium, thereby decreasing the stimulus for PTH
secretion.
• Cinacalcet should be taken with food or shortly after a meal.
• Tablets should be taken whole and should not be divided.
Adverse drug events
• Hypocalcemia (use with caution in patients with seizure disorder)
• Nausea and vomiting
• Diarrhea
• Myalgias

Cinacalcet is metabolized by multiple cytochrome P450 (CYP) enzymes, primarily CYP3A4,
CYP2D6, and CYP1A2. Adjustments in dose may be required for patients taking agents that inhibit
metabolism of cinacalcet (e.g., ketoconazole). Dose reductions of drugs with a narrow therapeutic
range and with a metabolism dependent on these enzymes may also be required (e.g., tricyclic
antidepressants, flecainide, and thioridazine).
Serum calcium and serum phosphorus should be measured within 1 week and iPTH should be
measured 1-4 weeks after initiation or dose adjustment of cinacalcet. The dose of cinacalcet should
be titrated no more frequently than every 2-4 weeks through sequential doses of 60, 90, 120, and
180 mg once daily to target iPTH (150-300 pg/mL).
Pharmacokinetics
• The maximum concentration is achieved in approximately 2-6 hours following administration and
is increased with food.
• Half-life is 30-40 hours.
• Volume of distribution is approximately 1,000 L.
• Cinacalcet is approximately 93-97% bound to plasma proteins.
• Cinacalcet is metabolized primarily by CYP3A4, CYP2D6, and CYP1A2.

Cinacalcet is available in 30-, 60-, and 90-mg tablets.
Metabolic acidosis
See Chapter 17 on critical care.
Vitamin supplementation (specific to the dialysis population)
Water-soluble vitamins for dialysis patients are described in

Table 16-11.
Mechanism of action
Vitamin supplementation replaces water-soluble vitamins lost during dialysis without providing
supratherapeutic amounts of fat-soluble vitamins.
• Take daily to replace water-soluble vitamins.
• Hemodialysis patients should take after dialysis.
Adverse drug events
• General: Nausea, headache, pruritus, and flushing (depending on specific vitamin)
• Vitamin B6 (pyridoxine): Neuropathy and increased aspartate transaminase
• Vitamin C (ascorbic acid): Hyperoxaluria, dizziness, diarrhea, fatigue, and nausea

• Folic acid: Headache, rash, and pruritus

Folic acid may decrease phenytoin concentrations by increasing the metabolism.
Nondrug Therapy
• Preparation for renal replacement therapy when patients reach stage 4 CKD:
• Choice of chronic dialysis (hemodialysis or peritoneal dialysis) if patient is a candidate for both
modalities and discussion of transplantation
• Placement of dialysis access (fistula or graft for hemodialysis, catheter for peritoneal dialysis)
[Table 16-11. Water-Soluble Vitamin Supplements for Dialysis Patients]
• Patient education regarding choice of renal replacement therapy and complications of CKD
Diet
• Risks and benefits of protein restriction (0.6-0.8 g/kg/d) should be considered in patients with
stage 4 CKD.
• Increased protein requirements should be considered for patients on dialysis (approximately 1.2
g/kg/d) and even greater requirements for peritoneal dialysis patients because of increased protein
loss with the dialysis procedure.
• Nutritional supplementation should be taken as needed.
• Counseling by a renal dietitian may be beneficial to tailor a diet based on the stage of CKD.
Renal replacement therapies
Hemodialysis
The intermittent hemodialysis procedure is generally performed three times per week for 3-5 hours
for patients with stage 5 kidney disease (end-stage renal disease). It requires a viable permanent
access site (graft or fistula) or a temporary site for patients requiring immediate dialysis or
experiencing failed permanent access sites. Fistulas are the preferred access for chronic
hemodialysis.
Complications include infection, hypotension during dialysis, clotting, and dialyzer reactions. Drug
removal by hemodialysis is most likely to occur for drugs with small molecular weight, low protein
binding, and small volume of distribution.
Peritoneal dialysis
Peritoneal dialysis requires insertion of a catheter into the peritoneum. Types include continuous
ambulatory peritoneal dialysis and automated peritoneal dialysis (which includes continuous
cycling, nocturnal tidal, and nightly intermittent peritoneal dialysis).
Several complications are possible:
• Peritonitis
• Most common gram-positive organisms are Staphylococcus epidermidis and Staphylococcus

aureus.
• Most common gram-negative organisms are Enterobacteriacae and Pseudomonas aeruginosa.
• Empiric therapy should include gram-positive coverage (first-generation cephalosporin or

vancomycin if MRSA [methicillin-resistant Staphylococcus aureus] is prevalent) and gram-
negative coverage (e.g., ceftazidime and aminoglycoside).
• Intraperitoneal administration of antibiotics is recommended.
• Hyperglycemia from glucose content of dialysate solution
• Malnutrition from increased protein loss
Transplantation
See Chapter 20 for information on transplantation.
16-3. Key Points
Acute Kidney Injury
• Prevention of kidney dysfunction in high-risk patients is the most effective strategy to address
AKI.
• Conditions that put patients at increased risk of AKI include decreased perfusion of the kidney
(attributable to dehydration or poor effective circulating volume such as with congestive heart
failure) and administration of potentially nephrotoxic agents, particularly under conditions of
decreased perfusion.
• Nephrotoxic agents should be avoided when possible in patients at risk for AKI.
• Immediate recognition and treatment of AKI may prevent irreversible kidney damage.
• Goals of treatment for patients with AKI are achievement of baseline kidney function and
prevention of both chronic kidney disease and the need for chronic renal replacement therapy.
• Diuretics are often used in patients with AKI to maintain fluid balance and hemodynamic stability.
• A review of medications is frequently necessary to ensure appropriate dose adjustments based on

kidney function (see Appendix B for drugs in renal failure).
Chronic Kidney Disease
• Chronic kidney disease is classified in stages 1 through 5 on the basis of estimated glomerular
filtration rate and evidence of pathological abnormalities or markers of kidney damage, including
abnormalities in blood or urine tests or in imaging studies.
• Screening for microalbuminuria and proteinuria is important for identifying patients with kidney
disease and monitoring progression of the disease.
• Therapy to delay progression of kidney disease includes control of diabetes and hypertension,
initiation of therapy with angiotensin-converting enzyme inhibitors or angiotensin receptor
blockers, and protein restriction if indicated.
• Common secondary complications of CKD include anemia, fluid and electrolyte abnormalities,
hyperphosphatemia, secondary hyperparathyroidism, and malnutrition.
• Management of anemia includes administration of erythropoietic stimulating agents (epoetin alfa

[Epogen and Procrit] and darbepoetin alfa [Aranesp]) and iron supplementation with oral iron
(multiple preparations) or intravenous iron (sodium ferric gluconate [Ferrlecit], iron sucrose
[Venofer], ferumoxytol [Feraheme], or iron dextran [InFeD and Dexferrum]) to achieve target
hemoglobin (11-12 g/dL), while preventing iron deficiency.
• Hyperphosphatemia is managed by dietary phosphorus restriction; use of phosphate binding

agents (calcium-containing products, lanthanum carbonate [Fosrenol], or sevelemer carbonate
[Renvela]); and dialysis.
• Management of secondary hyperparathyroidism includes control of serum calcium and

phosphorus and administration of vitamin D therapy—including vitamin D precursors in early
CKD based on kidney function (ergocalciferol [Drisdol and Calciferol])—and active vitamin D
therapy for more severe kidney disease (calcitriol [Calcijex and Rocaltrol], paricalcitol
[Zemplar], or doxercalciferol [Hectorol]). The calcimimetic agent cinacalcet (Sensipar) is
indicated for management of secondary hyperparathyroidism in patients with stage 5 CKD who
are on dialysis and is used in conjunction with phosphate binders and vitamin D.
• Nutritional requirements must be reevaluated on the basis of severity of kidney disease (e.g.,
protein restriction to delay progression of CKD versus increased protein requirements for patients
on dialysis).
16-4. Questions
R. T. is a 45-year-old female admitted to the hospital after fainting at work. Her past medical
history includes type 2 diabetes and rheumatoid arthritis. Her only complaint is that she has had
difficulty over the past 5 days keeping down anything she eats or drinks. She has also noticed a
decrease in urination over the past 24 hours. Regular medications include aspirin 325 mg qd,
ibuprofen 600 mg qd for arthritis, metformin 500 mg qd, glyburide 5 mg qd, and Tylenol prn
for headache. Laboratory values in the emergency department showed a serum creatinine of 2.0
mg/dL and BUN of 56 mg/dL, consistent with acute kidney injury. Her lab tests from 1 month
1.
ago at a regular checkup were normal. The most likely etiology of R. T.'s acute kidney injury is
A. dehydration from poor oral intake.

B. trauma from fainting.
C. age-related decreases in kidney function.
D. kidney failure caused by diabetes.
E. obstruction of urine outflow.

Which of the following medications may have contributed to R. T.'s acute kidney injury?
A. Aspirin
2. B. Ibuprofen
C. Metformin
D. Glyburide
E. Tylenol

Which of the following diuretics may retain its effectiveness at a glomerular filtration rate < 30
mL/min?
A. Hydrochlorothiazide
3.
B. Chlorothiazide
C. Metolazone
D. Spironolactone
E. Aldactone

Which of the following fluid and electrolyte abnormalities typically occur in patients with
severe kidney dysfunction (i.e., creatinine clearance < 15 mL/min)?
I. Metabolic alkalosis
II. Hyperkalemia
III. Hyperphosphatemia
4.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Which set of laboratory values is most consistent with a patient in acute intrinsic kidney
disease?
A. Urinary granular casts absent, FENa < 1, urinary osmolality 600 mOsm/kg
5.
B. Urinary granular casts absent, FENa > 1, urinary osmolality 600 mOsm/kg
C. Urinary granular casts present, FENa < 1, urinary osmolality 300 mOsm/kg
D. Urinary granular casts present, FENa > 1, urinary osmolality 300 mOsm/kg
E. Acute intrinsic kidney failure can only be diagnosed by biopsy.

Which of the following diuretics would be most appropriate for the initial treatment of a
patient with acute kidney injury?
I. Metolazone
II. Spironolactone
III. Furosemide
6.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

A patient with nephrotoxicity caused by tobramycin would likely present with an increase in
serum creatinine
A. immediately after starting therapy and with nonoliguria.

7.
B. immediately after starting therapy and with oliguria.
C. 5-7 days after starting therapy and with oliguria.
D. 5-7 days after starting therapy and with nonoliguria.
E. within 24 hours with excessive diuresis.

Lisinopril may cause hemodynamically mediated kidney disease by preventing which of the
following compensatory mechanisms by the kidney?
A. Vasodilation of the afferent arteriole

8.
B. Vasoconstriction of the afferent arteriole
C. Vasodilation of the efferent arteriole
D. Vasoconstriction of the efferent arteriole
E. Vasodilation of both the afferent and the efferent arterioles

The estimated creatinine clearance for a 47-year-old male patient with an ideal body weight of
176 pounds (slightly less than actual body weight) and a serum creatinine of 2.2 mg/dL is
A. 32 mL/min.
9.
B. 40 mL/min.
C. 47 mL/min.
D. 93 mL/min.
E. 120 mL/min.

D. K. is a 53-year-old black female (body weight = 65 kg) with hypertension and
hypercholesterolemia who is seen in the outpatient nephrology clinic for evaluation of kidney
disease progression. Her current blood pressure is 156/82 mm Hg, SCr is 2.6 mg/dL (stable for
the past 4 months), BUN is 44 mg/dL, and urinary protein is 800 mg/d. Her medications are
enalapril 20 mg/d × 1 year and simvastatin 20 mg qd × 2 years. On the basis of D. K.'s
estimated creatinine clearance, she would be classified in which of the following stages of
10. chronic kidney disease?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
E. Stage 5

The recommended target blood pressure for D. K. is
A. < 110/70 mm Hg.

11. B. < 130/90 mm Hg.
C. < 130/80 mm Hg.
D. < 140/95 mm Hg.
E. < 140/90 mm Hg.

Which of the following would be most beneficial in a patient with type 1 diabetes and
microalbuminuria to delay progression of CKD?
I. Angiotensin-converting enzyme inhibitor

II. Angiotensin receptor blocker
III. Loop diuretic
12.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Epoetin alfa and darbepoetin alfa stimulate erythropoiesis by which of the following?
A. Prevention of excessive red blood cell destruction
13. B. Prevention of degradation of bone marrow stem cells
C. Differentiation of peritubular interstitial cells of the kidney
D. Increase in size of red blood cells produced in the bone marrow
E. Differentiation of erythroid progenitor stem cells in the bone marrow

When administered intravenously, darbepoetin alfa has a terminal half-life approximately
__________ that of epoetin alfa.
A. equal to
14.
B. twofold longer than
C. twofold shorter than
D. threefold longer than
E. threefold shorter than

One of the most commonly reported adverse reactions with epoetin alfa and darbepoetin alfa is
A. nausea.
15. B. hypertension.
C. constipation.
D. anemia.
E. anaphylaxis.

At least _________ should be allowed to lapse before a change in dose of epoetin alfa or
darbepoetin alfa is made on the basis of a change in hemoglobin and hematocrit.
A. 1 week
16.
B. 2-4 weeks
C. 6-8 weeks
D. 2 months
E. 4 months

R. A. is a 42-year-old 70-kg male on hemodialysis tiw who receives epoetin alfa for treatment
of anemia. He has been stable on an epoetin dose of 4,000 units intravenously tiw with an
average hemoglobin of 11 g/dL (hematocrit of 33%). Over the past 3 months, his hematocrit
has dropped to 28%. Iron indices reveal the following: serum ferritin 78 ng/mL and transferrin
saturation 12%. The best initial treatment for R. A. is to
17. A. increase the dose of epoetin alfa to maintain a hemoglobin of 11-12 g/dL (hematocrit of 33-
36%).
B. withhold epoetin alfa therapy until hemoglobin increases to 12 g/dL.
C. administer intravenous iron (sodium ferric gluconate) at a maintenance dose of 125 mg per
week.
D. administer a 1 g total dose of intravenous iron in divided doses.
E. begin oral ferrous sulfate 325 mg tid.

In the gastrointestinal tract, calcitriol
A. promotes absorption of calcium and inhibits absorption of phosphorus.

18. B. promotes absorption of phosphorus and inhibits absorption of calcium.
C. promotes absorption of both calcium and phosphorus.
D. promotes decreased binding of calcium and phosphorus.
E. promotes increased elimination of calcium and phosphorus.

J. T. is a 63-year-old female with stage 5 CKD (end-stage kidney disease) receiving peritoneal
dialysis. Her most recent laboratory analysis reveals the following: BUN 58 mg/dL, SCr 5.2
mg/dL, phosphorus 7.4 mg/dL, calcium 9.0 mg/dL, albumin 2.5 g/dL, and iPTH 542 pg/mL. In
addition to dietary restriction of phosphorus, which of the following agents is best for initial
management of J. T.'s hyperphosphatemia?
I. Sevelamer carbonate
19. II. Lanthanum carbonate
III. Calcium carbonate
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

J. T. should be instructed to take her phosphate binder
A. with meals to enhance systemic absorption of phosphorus.

20. B. with meals to minimize systemic absorption of phosphorus.
C. between meals to avoid food-drug interactions.
D. between meals to minimize GI side effects.
E. There are no specific instructions to follow with regard to meals.

Which of the following agents is appropriate for a patient with stage 5 CKD and secondary
hyperparathyroidism requiring treatment to reduce iPTH?
I. Calcitriol
II. Paricalcitol
III. Ergocalciferol
21.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Cinacalcet is a calcimimetic that works by which of the following mechanisms?
A. It decreases the sensitivity of the calcium-sensing receptors on the parathyroid gland to

calcium, which prevents secretion of PTH.
B. It increases the sensitivity of the calcium-sensing receptors on the parathyroid gland to
22. calcium, which prevents secretion of PTH.
C. It stimulates the breakdown of iPTH and prevents the effects of PTH on bone turnover.
D. It inhibits the breakdown of iPTH to provide a negative feedback system and suppress PTH
synthesis.
E. It increases calcium concentrations, which suppresses secretion of PTH from the parathyroid
gland.

A drug with which of the following characteristics is most likely to be removed by
hemodialysis (Vd = volume of distribution)?
A. fu 0.05, Vd 0.2 L/kg

23.
B. fu 0.05, Vd 0.6 L/kg
C. fu 0.30, Vd 0.6 L/kg
D. fu 0.95, Vd 0.2 L/kg
E. fu 0.95, Vd 6 L/kg

The best antibiotic selection for empiric treatment of peritonitis in a peritoneal dialysis patient
is
A. cefazolin + vancomycin.
24.
B. cefazolin + ceftazidime.
C. vancomycin alone.
D. cefazolin alone.
E. gentamicin alone.

Which of the following supplements should be recommended daily in a patient with stage 5
CKD requiring chronic hemodialysis?
A. Multivitamin
25.
B. Nephrocaps
C. Vitamin A
D. Nephrocaps + vitamin A
E. Folic acid only

16-5. Answers
A. Dehydration is the most likely cause of AKI in R. T. because she has had a decrease in oral
intake over the past 5 days. Dehydration would be classified as a prerenal cause of AKI.
Fainting was likely a result of dehydration and not the cause of her decline in kidney function.
A serum creatinine of 2.0 mg/dL would not be considered normal in a 45 year old, eliminating
1.
age as a rationale for kidney disease. Diabetes would be more likely to cause a chronic
decrease in her kidney function as opposed to an acute change (lab tests from 1 month ago
were normal, ruling out evidence of chronic kidney disease). She has had some urine output in
the past 24 hours, which rules out obstruction.

B. NSAIDs are associated with hemodynamic changes (in particular, they prevent the
compensatory vasodilation of the afferent arteriole that occurs in conditions of prerenal acute
2. kidney disease). Metformin is not a cause of AKI in this case but would need to be
discontinued at this time because of the risk of lactic acidosis in a patient with decreased
kidney function (serum creatinine > 1.4 mg/dL in females and > 1.5 mg/dL in males).

C. There is some evidence that metolazone is beneficial in patients with kidney disease and a
GFR < 30 mL/min. This is not the case with other thiazide or thiazide-like diuretics or with
3.
potassium-sparing diuretics. Metolazone is frequently used in combination with loop diuretics
for this reason.

D. Hyperkalemia and hyperphosphatemia are common electrolyte abnormalities observed as
4.
kidney function decreases. Metabolic acidosis is also common, but not metabolic alkalosis.

D. Acute intrinsic kidney disease is generally characterized by the presence of granular casts
5. (indicating structural damage), a fractional excretion of sodium > 1, and a urine osmolality
similar to that of plasma osmolality (indicating changes in concentrating ability of the kidney).

B. A patient with acute kidney disease generally requires aggressive diuresis (while avoiding
dehydration). Furosemide is a loop diuretic that is more potent than a thiazide-like diuretic
6.
(metolazone) or a potassium-sparing diuretic (spironolactone) and would be a rational choice
for initial therapy of AKI. Spironolactone may also cause hyperkalemia in a patient with AKI.

D. Aminoglycoside-induced nephrotoxicity is characterized by a delay in changes in serum
7.
creatinine (approximately 5-7 days) and relatively normal urine output (nonoliguria).

D. Angiotensin-converting enzyme inhibitors may contribute to development of AKI in
patients with conditions resulting in prerenal kidney disease (e.g., conditions resulting in
8. decreased perfusion of the kidney, hypovolemia, heart failure, liver disease, and so forth).
ACEIs (and angiotensin receptor blockers) prevent the compensatory vasoconstriction of the
efferent arteriole mediated by angiotensin II that occurs in an attempt to increase GFR.

C. Using the Cockcroft-Gault equation to estimate creatinine clearance, one finds that this
patient has an estimated creatinine clearance of 47 mL/min. For females, multiply the
calculated value by 0.85.
9.
BW (kg) = 176 lbs/2.2 = 80 kg
SCr = 2.2 mg/dL

D. D. K.'s estimated creatinine clearance determined using the Cockcroft-Gault equation is 26
mL/min, classified as stage 4 CKD (GFR 15-29 mL/min/1.73 m2).
10.
with the result multiplied by 0.85 for a female. Note: The estimated GFR determined using the
Modification of Diet in Renal Disease equation is 25 mL/min/1.73m2.

C. The recommended blood pressure for D. K. is < 130/80 mm Hg because she has stage 4
11.
CKD.

C. ACEIs and ARBs are advocated for patients with diabetes and microalbuminuria. The
decreases in glomerular pressure caused by these agents that are detrimental in patients with
12.
AKI are beneficial in a chronic condition such as diabetes, in which sustained elevations in
glomerular pressure result in worsening kidney disease over time.

E. Erythropoietic agents including epoetin alfa and darbepoetin alfa work in the bone marrow
13. to stimulate differentiation of erythroid progenitor stem cells and result in an increase in red
blood cell production (increase erythrocytes).

D. The half-life of darbepoetin alfa is three times longer than that of epoetin alfa, giving this
14.
agent the added benefit of reduced frequency of administration.

15. B. Hypertension is the most common adverse effect in patients receiving erythropoietic agents.

B. Stimulation of erythropoiesis by epoetin alfa and darbepoetin alfa occurs immediately;
16. however, it will take at least 2-4 weeks before substantial changes in hemoglobin and
hematocrit are observed as a result of any change in dose of erythropoietic therapy.

D. R. A. is iron deficient, as indicated by his low serum ferritin (< 100 ng/mL) and transferrin
saturation (< 20%). No change in epoetin alfa should be made until the iron deficiency is
corrected (this is the leading cause of resistance to epoetin alfa and darbepoetin alfa therapy).
R. A. will require a full course of iron (1 g administered intravenously in divided doses with
each dialysis session) as opposed to a maintenance dose, which should be administered once R.
17.
A. is iron replete. Sodium ferric gluconate may be administered in doses of 125 mg per dialysis
session for eight sessions to give the total 1 g dose (iron sucrose would be administered in 100
mg increments over 10 hemodialysis sessions). Ferumoxytol would be administered as two 510
mg doses given 3-8 days apart. Absorption of oral iron is poor, making intravenous iron
preferred in this hemodialysis patient.

C. Active vitamin D (calcitriol) promotes absorption of both calcium and phosphorus in the GI
18. tract. This is one reason that therapy with calcitriol or a vitamin D analog may need to be
withheld if the calcium × phosphorus product is elevated.

C. Sevelamer carbonate (Renvela) or lanthanum carbonate would be better options than a
calcium-containing binder for initial management because J. T. has a corrected calcium of 10.2
mg/dL [corrected calcium = measured serum calcium + 0.8 × (normal serum albumin -
19.
measured serum albumin)] and a calcium × phosphorus product of 75 mg2/dL2. This elevated
product increases the risk of metastatic calcifications. She requires a phosphorus binding agent
without calcium to minimize calcium absorbed in the GI tract.

B. Phosphate binders should be taken with meals to minimize systemic absorption of
20.
phosphorus from the GI tract.

C. Calcitriol and paricalcitol are active forms of vitamin D that do not require conversion in
the liver or kidney. Ergocalciferol is a vitamin D precursor that does require activation and
21.
would not be recommended for a patient with stage 5 CKD without the necessary activity of
the enzyme in the kidney (1 -hydroxylase) responsible for final conversion to the active form.

B. The calcimimetic agent cinacalcet (Sensipar) works by binding with the calcium-sensing
22. receptor on the parathyroid gland and increases the sensitivity of this receptor to calcium,
thereby suppressing secretion of PTH.

D. Drug characteristics that make an agent more likely to be removed by dialysis include low
protein binding, small volume of distribution, and low molecular weight. Among the choices
23.
given, the agent that best meets these criteria is choice D, which has a high fraction unbound in
the plasma and a low volume of distribution.

B. Empiric therapy should include antibiotics with gram-positive and gram-negative coverage.
24.
Choice B is most appropriate.

B. Nephrocaps include water-soluble vitamins (vitamin B complex + vitamin C + folic acid)
recommended for a patient with kidney failure. Supplementation with fat-soluble vitamins is
25.
not recommended in patients with kidney failure because of toxicities associated with
accumulation.

16-6. References
Acute Kidney Injury and Drug-Induced Kidney Disease
Lameire N, Van Viesen W, Vanholder R. Acute renal failure. Lancet. 2005;365(9457):417-30.
Nolin TD, Himmelfarb J. Drug-induced kidney disease. In: DiPiro J, Talbert RL, eds.
810.
Ricci Z, Cruz D, Ronco C. The RIFLE criteria and mortality in acute kidney injury: A systematic
review. Kidney International. 2008;73:538-46.
Wood AJJ. Diuretic therapy. N Engl J Med. 1998; 339:387-95.
Chronic Kidney Disease and Progression
Abosaif NY, Arije A, Atray NK, et al. K/DOQI clinical practice guidelines on hypertension and
antihypertensive agents in chronic kidney disease. Am J Kidney Dis. 2004;43(suppl 1):S1-290.
Chobanian AV, Bakris GL, Black HR, et al. and the National High Blood Pressure Education
Program Coordinating Committee. The seventh report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report.
JAMA. 2003;289: 2560-72.
Levey AS, Beto JA, Coronado BE, et al. Controlling the epidemic of cardiovascular disease in
chronic renal disease: What do we know? What do we need to learn? Where do we go from here?
Am J Kidney Dis. 1998;32:853-906.
National Kidney Foundation. NKF-K/DOQI clinical practice guidelines for chronic kidney disease:
Evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(suppl 1):S1-266.
U.S. Renal Data System. USRDS 2008 Annual Data Report: Atlas of End-Stage Renal Disease in
the United States. Bethesda, Md.: National Institutes of Health, National Institute of Diabetes and
Digestive and Kidney Diseases; 2008.
Anemia
American Reagent Laboratories. Venofer (iron sucrose injection) package insert. Shirley, N.Y.:
American Reagent Laboratories; 2007.
Amgen. Aranesp (darbepoetin alfa) package insert. Thousand Oaks, Calif.: Amgen; 2008.
Macdougall IC, Gray SJ, Elston O, et al. Pharmacokinetics of novel erythropoiesis stimulating
protein compared with epoetin alfa in dialysis patients. J Am Soc Nephrol. 1999;10:2392-95.
National Kidney Foundation. K/DOQI clinical practice guidelines and clinical practice
recommendations for anemia in chronic kidney disease. Am J Kidney Dis. 2006 May;47(5 suppl
3):S1-145.
Watson Pharmaceuticals. Ferrlecit (sodium ferric gluconate complex in sucrose injection) package
insert. Corona, Calif.: Watson Pharmaceuticals; 2006.
Hyperphosphatemia and Secondary Hyperparathyroidism
Amgen. Sensipar (cinacalcet HCl) tablets package insert. Thousand Oaks, Calif: Amgen; 2007.
Eknoyan G, Levin A, Levin NW. Bone metabolism and disease in chronic kidney disease. Am J
Kidney Dis. 2003;42(4 suppl 3):S1-201.
Nutrition
National Kidney Foundation. K/DOQI clinical practice guidelines for nutrition in chronic renal
failure. Am J Kidney Dis. 2000;35(suppl 2):S1-140.
Other
Aronoff GR, Bennett WM, Berns JS, et al. Drug Prescribing in Renal Failure: Dosing Guidelines
for Adults and Children. 5th ed. Philadelphia: American College of Physicians; 2007.
Ifudu O. Care of patients undergoing hemodialysis. N Engl J Med. 1998;339:1054-62.
National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Clinical Practice
Guidelines for Peritoneal Dialysis Adequacy: Update 2006. New York: National Kidney
Foundation. Available at: http://www.kidney.org/professionals/kdoqi/index.cfm.
17. Critical Care, Fluids, and Electrolytes - G. Christopher Wood, PharmD, FCCP, BCPS with
Added Qualifications in Infectious Diseases
17-1. Sedation, Analgesia, and Neuromuscular Blockade
Definition and Classifications
• Pain: Critically ill patients may experience acute pain, chronic pain, or both.
• Anxiety or agitation: Patients may experience psychophysiological response to real or imagined

danger. The term agitation is used in this chapter.
• ICU delirium: Delirium presented in the intensive care unit (ICU). See discussion of clinical
presentation. The term delirium is used in this chapter.
• Pain, agitation, or both in patients with impaired consciousness: pulling of tubes or lines, writhing,
kicking, restlessness, hypertension, tachycardia, tachypnea, diaphoresis, moaning
• Delirium: fluctuating, disorganized thinking or inattentiveness not caused by an obviously

reversible cause; with or without agitation
Pathophysiology
• Injuries
• Medical procedures and equipment (e.g., mechanical ventilation equipment or catheters)
• Mental status changes (e.g., fear, infection, hypoxia, sleep deprivation, or adverse drug effects or
withdrawal)
• Preexisting medical conditions (e.g., chronic pain)
Diagnostic Criteria
• Pain: Use a verbal or visual scale to assess severity. For unconscious patients, use physical signs
and symptoms.
• Agitation: Use a validated scale to assess (e.g., Riker Sedation-Agitation Scale).
• Delirium: Use Confusion Assessment Method for the ICU (CAM-ICU) scale.
Treatment Goals
• Find and remove the cause of pain, agitation, and delirium.
• Achieve a balance between patient comfort, adverse effects, and ability to provide care.
• Reserve neuromuscular blocking (NMB) agents for patients who are not controlled with
maximum doses of sedation and analgesia.
Drug Therapy
Selected drug therapy is described in

Table 17-1.
Mechanism of action
• Opiates, nonsteroidal anti-inflammatory drugs (NSAIDs): See Chapter 23 on pain

management.
• Benzodiazepines, haloperidol: See Chapter 25 on psychiatric disease.
• Propofol: Mechanism of action is unknown—possibly -aminobutyric acid (GABA)-related

activity.
• NMB agents: These are postsynaptic cholinergic receptor antagonists; they do not provide
analgesia or sedation.
[Table 17-1. Selected Drug Therapy Based on Guidelines for Use in ICU Patients]
When patient-controlled analgesia pumps are used, make sure the patient understands how to
activate the device.
Adverse drug events
• Opiates, NSAIDs: See Chapter 23 on pain management.
• Propofol: Adverse events include respiratory depression, hypotension, and hypertriglyceridemia.

The maximum dose is 5 mg/kg/h.
• NMB agents: Adverse events include respiratory depression, prolonged weakness or paralysis
after discontinuation, and tachycardia with pancuronium.
Drug interactions
• Propofol: Actions are potentiated by other sedatives.
• NMB agents: Actions are potentiated by corticosteroids, aminoglycosides, clindamycin, calcium

channel blockers, anesthetics; actions are inhibited by anticholinesterase inhibitors (e.g.,
neostigmine).
• Opiates, NSAIDs: Use a visual or verbal scale to assess efficacy. Also monitor heart rate (HR),
blood pressure (BP), and respiratory rate (RR). See also Chapter 23 on pain management.
• Benzodiazepines, haloperidol: Use a validated scale. Also monitor HR, BP, and RR. See also
Chapter 25 on psychiatric disease.
• Propofol: Use a validated scale. Also monitor BP, HR, RR, intracranial pressure (ICP), and serum
triglycerides at baseline and 1-2 times a week during long-term use.
• NMB agents: Monitor movement and spontaneous breathing. Also monitor BP, HR, and ICP
(acute increases may indicate suboptimal sedation or analgesia). Peripheral nerve stimulation
monitoring ("train of four") is highly recommended.
• Note: In patients with continuous sedation, a daily wakening and assessment period results in
decreased sedative use and a shorter length of stay in ICU.
Kinetics
• Propofol: Medication is highly lipophilic (may accumulate long term), has a rapid onset (1
minute), and has a short duration (about 10 minutes).
• NMB agents: Onset for all NMB agents is < 5 minutes. Duration is 60-90 minutes for
pancuronium and 30-60 minutes for vecuronium and cisatracurium. Excretion of pancuronium is
mostly renal; for vecuronium, it is about 50:50, hepatic:renal. Excretion of cisatracurium is not
organ dependent.
Other aspects
Propofol
Propofol is in a lipid vehicle (provides 1 kcal/mL). It should be used with caution in patients with
egg allergy. It is a potential growth medium for bacteria; the maximum hang time for a bottle is 12
hours.
Dexmedetomidine
A newer agent (not discussed in depth in current guidelines), dexmedetomidine (Precedex), is
available. It is a central alpha-2 agonist administered as a continuous IV infusion for up to 24 hours.
The potential advantage of dexmedetomidine is less respiratory depression than found with other
agents. Adverse events include hypotension and bradycardia.
Newer data suggest the agent is safe for use longer than 24 hours and results in less delirium and
shorter ICU stay than midazolam.
17-2. Traumatic Brain Injury
Definition
Traumatic brain injury is defined as neurologic deficit secondary to brain trauma.
Classifications
• Severe
• Mild or moderate
• Use the Glasgow Coma Scale (GCS) for assessment: sum of eye, motor, and verbal scores (range
3-15).
• Traumatic brain injury has a wide range of presentation from mild confusion to totally
nonresponsive coma.
Pathophysiology
• Traumatic brain injury results from motor vehicle accidents (most common), falls and accidents,
assaults, and gunshot wounds.
• It is most common in 15- to 24-year age group.
• Every year 375,000 cases and 75,000 deaths occur.

• Traumatic brain injury consists of direct neuronal damage ± edema ± secondary ischemia-related
neuronal death.
Diagnostic Criteria
• Computed tomography (CT) scan
• GCS
• ICP monitoring in severe patients (GCS score 3-8)
Treatment Goals
• Keep ICP < 20 mm Hg and cerebral perfusion pressure (CPP) > 50 mm Hg (CPP = mean arterial
pressure - ICP).
• Prevent seizures.
Strategies to decrease ICP
• Osmotic agents and diuretics
• Mannitol 0.25-1.0 g/kg intravenous (IV) q4h
• Loop diuretics IV (e.g., furosemide)
• Hypertonic NaCl IV (e.g., 3.0%, 7.5%)
• Sedation
• Short-acting agents are preferred to allow frequent patient assessment (e.g., propofol, fentanyl).
• Pentobarbital (1-3 mg/kg/h IV) is a long-acting agent for refractory intracranial hypertension.
• NMB agents:
• A short-acting agent is preferred (vecuronium).
• Such agents are used for refractory intracranial hypertension.
Nondrug interventions
• Raising of the head of the bed (30 degrees)
• Ventricular drainage of cerebrospinal fluid via ventriculostomy

• Mild or moderate hyperventilation (pCO2 30-35 mm Hg)
• Surgery
Strategies to increase mean arterial pressure
• Maximize fluid status. The overall goal is euvolemia.
• Vasopressors and inotropes may be used in shock after fluid status is optimized.
Seizure prevention
• Seizure prevention may be started on the basis of severity and type of injury.
• Phenytoin (Dilantin, generic) can be used: 20 mg/kg IV loading dose plus 4-8 mg/kg/d for 7 days.
• Continue beyond 7 days if the patient has a seizure.
• An alternative agent is carbamazepine.
• See Chapter 24 on seizure control for the mechanism of action, adverse drug events, drug
interactions, and kinetics.
The overall goal is CPP > 50 mm Hg and ICP < 20 mm Hg. Drug classes are covered elsewhere.
Other Aspects
Nimodipine (Nimotop) is a calcium channel blocker given for 21 days. It is indicated for treating
aneurysmal subarachnoid hemorrhage. It may also provide some benefit in traumatic subarachnoid
hemorrhage.
17-3. Acute Spinal Cord Injury
Definition
Acute spinal cord injury is traumatic spinal cord injury with neurologic impairment.
Classifications
• Complete: Total loss of motor and sensory function occurs in affected areas.
• Incomplete: Some motor or sensory function is retained in affected areas.

• Paraplegia: Neurologic deficit occurs in the lower extremities.
• Quadriplegia: Neurologic deficit occurs in the upper and lower extremities.
• Central cord syndrome: Symptoms are atypical.
• Loss of motor function, loss of sensory function, or both, from nerves distal to level of vertebral
injury
• Usually bilaterally symmetrical symptoms
Pathophysiology
See discussion of traumatic brain injury in Section 17-2.
Diagnostic Criteria
• Physical examination consistent with spinal cord injury
• CT or radiographic evidence of injury
Treatment Goals
Treatment goals are the reservation or restoration of motor and sensory function.
Drug Therapy
Drug therapy is considered optional in current treatment guidelines:
• A loading dose of methylprednisolone 30 mg/kg IV is given.
• If the loading dose is given within 3 hours of the injury, a 5.4 mg/kg/h IV infusion is continued for
a total of 24 hours.
• If the loading dose is given within 3 hours of the injury, a 5.4 mg/kg/h IV infusion is continued for
a total of 48 hours.
• No methylprednisolone is if > 8 hours have passed from the injury or in the case of penetrating
injuries.
Mechanism of action
The mechanism of action is unknown. The medication is thought to protect neurons by inhibiting
lipid peroxidation.
Adverse drug effects
• Increased infections (48 hours worse than 24 hours)
• Hyperglycemia
• Neurologic status
• Serum glucose
17-4. Venous Thromboembolism Prophylaxis
Definition
Venous thromboembolism (VTE) is pathogenic blood clot formation.
Classifications
• Deep venous thrombosis (DVT): VTE in a large vein, generally in a lower extremity
• Pulmonary embolism (PE): DVT that has embolized to the pulmonary vasculature (much less
common)
Clinical Presentations
• DVT is often asymptomatic:
• Unilateral leg symptoms such as swelling, pain, tenderness, erythema, warmth, ± palpable cord
• Pain behind the knee upon dorsiflexion (Homans' sign)
• PE is often asymptomatic:
• Pulmonary symptoms such as chest pain, cough, dyspnea, tachypnea, hemoptysis
• May proceed rapidly to life-threatening shock and hypoxia
Pathophysiology
Three general risk factors can be identified:

• Hypercoagulable states:
• Clotting factor deficiencies or abnormalities (e.g., protein C or S deficiency)
• Malignancy, pregnancy, estrogen use
• Direct vessel trauma
• Venous stasis (i.e., poor blood flow allows clot formation)
Specific Risk Factors
• Risk increases with age (see

Table 17-2).
• Immobility, previous VTE, cancer, obesity, congestive heart failure, pregnancy, estrogen therapy,
and smoking are risk factors.
• Major surgery or trauma are risk factors, particularly in the case of lower extremities or the pelvis,
genito-urinary injury, and neurologic injury.
Epidemiology
• About 600,000 hospitalizations take place in the United States yearly with about 60,000 deaths
(10% mortality).
• Incidence of DVT ranges from 2% to 80% depending on risk factors.
Diagnostic Criteria
• Radiocontrast dye studies: Such studies (venography for DVT, pulmonary angiography for PE)
are invasive, are expensive, and require expertise, and adverse events common (e.g.,
nephropathy). A ventilation/perfusion scan (for PE) is less invasive, but inconclusive results are
common.
• Ultrasonography: Used for DVT, ultrasonography is noninvasive, is inexpensive, is performed at

the bedside, but is less sensitive.
• Serum D-dimer concentrations: Normal levels may rule out VTE.
Treatment Goals
• Goals are to decrease morbidity (VTE recurrence, progression to PE); mortality; and costs of
VTE.
• VTE prophylaxis is underused: only 35% to 50% of at-risk patients receive it.
Drug Therapy to Treat VTE
Heparin
Therapy consists of full-dose IV heparin (80 units/kg load + 18 units/kg/h) or full-dose low
molecular weight heparin (LMWH) subcutaneous (SC) (e.g., enoxaparin 1 mg/kg q12h or 1.5
mg/kg qd). LMWH may be used on an outpatient basis in stable DVT patients. Full-dose heparin
may be given SC bid, but this is rarely done.
Warfarin
Begin warfarin concurrently. Discontinue heparin or LMWH when the international normalized
ratio (INR) is therapeutic (usually 2-3) and stable. Duration is as follows:
• Reversible, 3 months
• Idiopathic, 6-12 months (consider longer)
• High risk, 12 months to indefinite
Direct thrombin inhibitors
Use direct thrombin inhibitors in place of heparin for heparin-induced thrombocytopenia.
Thrombolytic therapy
Reserve thrombolytic therapy for very severe cases. Therapy is highly individualized.
Inferior vena cava filter
Reserve this treatment for selected patients with contraindication to anticoagulation.
Drug Therapy to Prevent VTE
Drug therapy for prevention of VTE is described in Table 17-2.
Mechanism of action
• Heparin binds to antithrombin and potentiates its anticoagulation (anti-IIa activity > anti-Xa
activity).
[Table 17-2. Drug and Nondrug Therapy for Prevention of Venous Thromboembolism]
• LMWHs are the same as heparin but anti-Xa activity is > anti-IIa activity. Some controversy
exists over the interchangeability of these drugs because of differences in Xa:IIa activity ratios.
• Fondaparinux is a factor Xa inhibitor.
• For warfarin, see Chapter 10 on cardiac arrhythmias.
• Direct thrombin inhibitors (lepirudin [Refludan], bivalirudin [Angiomax], argatroban) directly

inhibit thrombin.
• For heparin, fondaparinux, thrombin inhibitors, and thrombolytics, patient instructions and
counseling are not necessary.
• For LMWHs and fondaparinux, patients can be taught to self-inject after hospital discharge:
• Monitor for signs and symptoms of bleeding or VTE recurrence.
• Avoid NSAIDs.
Adverse drug events
• Bleeding: Occurs with all agents:
• Low-dose unfractionated heparin (LDUH) and low-dose LMWH have similar bleeding risks.
• Protamine sulfate reverses heparin and LMWH.
• Heparin-induced thrombocytopenia (HIT): Occurs with heparin, LMWH:
• Early onset occurs around the first week of therapy. It is transient, and no therapy is needed.
• Late onset (> 50% decrease from baseline) is immune mediated. If the event is severe, heparin
or LMWH must be discontinued:
• Switch to direct thrombin inhibitor until platelets > 150,000/mcL, then possibly short-term
warfarin (4 weeks).
• Adverse events are less frequent with LMWH.
• HIT may result in severe thrombosis or limb amputation.

• HIT may happen immediately upon rechallenge with heparin or LMWH.
• Spinal hematoma can occur with epidural catheters. LMWH or full anticoagulation is worse
than LDUH; do not use LMWH.
• Osteoporosis can occur with long-term therapy. Heparin is worse than LMWH.
• Hypersensitivity (reexposure): Occurs with lepirudin.
Drug interactions
• NSAIDs may increase bleeding risk with all agents.
• Heparin (full-dose IV) and thrombin inhibitors:
• Goal is partial thromboplastin time (PTT) that corresponds to an anti-Xa level of 0.3-0.7
units/mL (check with each lab for therapeutic range).
• Monitor q6h until therapeutic; then once or twice daily.
• LDUH does not affect PTT.
• LMWHs:
• Goal is an anti-Xa level of 0.6-1 units/mL.
• No routine monitoring is needed, but monitoring may be necessary in cases of renal

impairment, obesity, prolonged use, and pregnancy.
• Fondaparinux:
• No monitoring is necessary.
• Fondaparinux affects anti-Xa levels.
• Direct thrombin inhibitors:
• Argatroban: Goal is PTT that is 1.5-3.0 times control. Argatroban falsely elevates INR.
• Bivalirudin: There are no recommendations in HIT. Bivalirudin elevates PTT and INR.
• Lepirudin: Goal PTT is 1.5-2.5 times control.
• Warfarin (see Chapter 10 on cardiac arrhythmias).
Kinetics
• Heparin: Cleared by endothelial cell enzymes (half-life about 90 minutes); higher doses also
renally cleared.
• LMWHs: Renally cleared; half-life 2-4 times longer than heparin.
• Fondaparinux: Renally cleared; longer half-life (about 24 hours).
• Direct thrombin inhibitors: Half-life 30-90 minutes; lepirudin renally cleared; others hepatically
cleared.
17-5. Stress Ulcer Prophylaxis
Definition
Stress ulcer prophylaxis refers to gastrointestinal (GI) mucosal damage related to metabolic stress in
the ICU.
Presentation is similar to that of peptic ulcer disease (see Chapter 21 on gastrointestinal disorders).
Pathophysiology
Shunting of blood from the GI tract to vital organs during critical illness results in breakdown of
gastric mucosal defenses (e.g., bicarbonate production, epithelial cell turnover).
Risk Factors
• Mechanical ventilation > 48 hours
• Coagulopathy
• Other disease states or organ dysfunction where GI perfusion may be compromised (e.g., sepsis,
burns, traumatic brain injury)
Diagnostic Criteria
Diagnosis is based on signs and symptoms and can be confirmed with endoscopy.
Treatment Goals
The goal is to prevent stress ulcers.
Drug Therapy
• See Chapter 21 on GI disorders for full drug information.
• Histamine-2 (H2) antagonists or sucralfate are traditional standards of therapy; H2 antagonists

may be more effective. Sucralfate administration can be difficult in ICU patients.
• Proton pump inhibitors are equivalent to H2 antagonists.
• Optimal duration of therapy is unknown (usually until risk factors have resolved or transfer from
ICU).
• Antacids are less effective and are not recommended. They have higher aspiration risk and require
frequent dosing.
17-6. Severe Sepsis and Septic Shock
Definition and Classifications
Severe sepsis is sepsis (see Chapter 29 on infectious disease) plus dysfunction of one or more major
organs (e.g., hypotension responsive to fluids, oliguria, acute mental status change, lactic acidosis,
respiratory insufficiency, coagulopathy).
Septic shock is severe sepsis plus hypotension that is not fully responsive to fluids (i.e., requires
vasopressor therapy).
See sepsis criteria (in Chapter 29) and the definitions of severe sepsis and septic shock.
Pathophysiology
Progression is seen in the systemic manifestations of sepsis. Imbalances in the inflammatory,

immune, and coagulation systems lead to organ hypoperfusion and organ dysfunction with or
without refractory hypotension.
Causative organisms vary by institution, but broad patterns are known:
• Common community-acquired organisms include Streptococcus pneumoniae, Staphylococcus

aureus, Haemophilus influenzae, Escherichia coli, and "atypicals" (Mycoplasma pneumoniae,
Chlamydia pneumoniae, Legionella spp.).
• Common nosocomial or health care-associated organisms include Pseudomonas aeruginosa, S.

aureus (methicillin resistance more common), Enterobacter spp., Klebsiella spp., Proteus spp.,
Citrobacter spp., Serratia spp., and Candida spp.
Diagnostic Criteria
See sepsis criteria (in Chapter 29) and the definitions of severe sepsis and septic shock.
Treatment Goals
• Rapidly stabilize hemodynamic parameters and organ dysfunction within 6 hours.
• Identify causative organism or organisms, start appropriate antimicrobial therapy within 1 hour,
and eliminate the source of infection, if applicable (e.g., vascular or urinary catheter, abscess).
Duration of antimicrobial therapy is typically 7-14 days.
• Modulate inflammatory, coagulating, and hormonal derangements, if applicable.
Drug and Nondrug Therapy
See Chapter 29 on infectious disease for antimicrobial information (mechanism of action, dosing,
adverse effects, etc.). Empiric antimicrobial selection is also covered in Chapter 29. Definitive
therapy should be streamlined to a narrower spectrum agent, if possible, on the basis of the final
culture and sensitivity reports.
See Section 17-7 for details on fluid therapy. Fluid therapy for severe sepsis and septic shock can be
colloids, isotonic crystalloids, or both. Vasopressors should be used only after appropriate fluid
therapy fails to adequately normalize BP (
Table 17-3).
Mechanism of action
• Vasopressors and inotropes are adrenergic-receptor agonists.
• Drotrecogin alfa is recombinant human-activated protein C (an endogenous anticoagulant). The

exact method of action is unknown, but it modulates coagulation and inflammatory cascades.
Adverse drug events
• Vasopressors and inotropes: Tachycardia, arrhythmias, organ and extremity ischemia,

hypertension
• Drotrecogin alfa: Bleeding (contraindicated in active internal bleeding, recent trauma, stroke, or
other clinical condition at high bleeding risk or presence of epidural catheter)
• Vasopressors and inotropes: None
• Drotrecogin alfa: Increased bleeding risk with concomitant anticoagulation or antiplatelet

therapy
• Vasopressors and inotropes: Monitor BP, HR, cardiac output, urine output, and extremity
perfusion on physical exam.
• Drotrecogin alfa: Note signs and symptoms of bleeding on physical exam and monitor BP and
HR. Monitor improvement in signs and symptoms of infection, temperature, white blood count
(WBC), and organ dysfunction. Drotecogin alfa may prolong activated PTT.
[Table 17-3. Vasopressors and Inotropes Used in Severe Sepsis and Septic Shock]
Kinetics
For drotrecogin alfa, dose adjustment is not required in renal or hepatic dysfunction.
Other aspects
Low-dose hydrocortisone (200-300 mg × 7 days ± fludrocortisone 50 mcg/d) is recommended for

patients with septic shock who are not responsive to fluids and vasopressors. Patients with a poor
response to cosyntropin stimulation testing (serum cortisol increase of < 9 mcg/dL) may respond
better to corticosteroid supplementation.
Vasopressin infusion (0.03 units/min) may be used to increase BP in patients refractory to high
doses of traditional pressors. Doses > 0.04 units/min are associated with severe adverse events (e.g.,
cardiac arrest). New data suggest that patients receiving lower doses of catecholamine vasopressors
(i.e., < 15 mcg/min of norepinephrine) benefit more from vasopressin than do patients on higher
doses of norepinephrine.
17-7. Fluid and Electrolyte Abnormalities in Critically Ill Patients
Introduction
See also Chapter 16 on kidney disorders (for hyperphosphatemia), Chapter 18 on nutrition, and
chapter 19 on oncology (for hypercalcemia).
Definition
Fluid and electrolyte abnormalities are pathologic alterations in fluid and electrolyte homeostasis.
Classifications
Fluid and electrolyte abnormalities are classified by electrolyte (see the discussion on clinical
presentation).
In all cases, mild to moderate abnormalities are usually asymptomatic.
Sodium (normal range: 135-145 mEq/L)
In cases of hyponatremia or hypernatremia, lethargy, nausea, headache, dry mucous membranes,

poor skin turgor (depends on hydration status), and confusion may occur.
Coma, seizures, or central pontine myelinolysis may occur in severe hyponatremia or if sodium
increases or decreases rapidly (> 12 mEq/L/d).
Chloride (normal range: 96-106 mEq/L)
Symptoms are related to acid-base or fluid abnormalities, not chloride itself.
Water (moves osmotically with sodium)
In cases of dehydration, dry mucous membranes, poor skin turgor, lethargy, nausea, headache,
hypotension, and tachycardia occur. Seizures, coma, or death can occur if dehydration is severe.
Decreased urine output, metabolic acidosis, and hypotension are also found.
For edema or fluid overload, see Chapter 9 on heart failure.
Potassium (normal range: 3.5-5.0 mEq/L)
In cases of hypokalemia, confusion, muscle cramps, weakness, and cardiac arrhythmias occur.
In cases of hyperkalemia, muscle cramps, weakness, and cardiac arrhythmias occur.
Magnesium (normal range: 1.5-2.2 mEq/L)
With hypomagnesemia, presentation is similar to that of hypocalcemia.
In cases of hypermagnesemia, lethargy, weakness, and cardiac arrhythmias occur. Coma is possible
in severe cases.
Phosphorus (normal range: 2.6-4.5 mg/dL)
In cases of hypophosphatemia, confusion, anxiety, weakness, respiratory depression, paresthesias,

and lethargy occur. Seizures and coma are possible if hypophosphatemia is severe.
For hyperphosphatemia, see Chapter 16 on kidney disorders.
Calcium (normal range: 8.5-10.5 mg/dL)
In cases of hypocalcemia, confusion, anxiety, paresthesias, muscle cramps, and tetany occur. Coma
and cardiac arrhythmias may occur in severe cases.
For hypercalcemia, see Chapter 19 on oncology.
Pathophysiology
Normal distribution of fluids and electrolytes
• Electrolytes with high serum concentrations are primarily extracellular (Na, Cl); those with low
serum concentrations are mostly intracellular or in bone (K, P, Mg, Ca).
• Total body water is approximately 60-70% of total body weight (differs by age, gender, disease
states).
• Of all water, intracellular is approximately two-thirds; extracellular is approximately one-third.
• Of extracellular water, approximately three-fourths is interstitial; approximately one-fourth is

intravascular (plasma).
• Typical fluid requirements for adults are approximately 35 mL/kg/d; they can be much higher in
critical illness because of extrarenal losses (GI tract, wounds) and fluid shifts (trauma, sepsis).
• Primary hormonal controls are aldosterone (sodium retention) and antidiuretic hormone (water
retention).
Hyponatremia
The first three forms of hyponatremia listed below are hypotonic:
• Hypovolemic (sodium and water loss): This condition is characterized by high urine osmolality.
It is related to extrarenal fluid losses (GI, wounds); diuretics; and adrenal insufficiency.
• Euvolemic (moderate water retention): This condition occurs with syndrome of inappropriate
antidiuretic hormone (SIADH) release, renal failure, carbamazepine, NSAIDs, chlorpropamide.
• Hypervolemic (sodium and water retention): This condition occurs with congestive heart
failure, cirrhosis, nephrotic syndrome, and glucocorticoids.
• Hypertonic: This condition is the dilutional effect of abnormal osmotic agents in the vasculature
(severe hyperglycemia).
Hypernatremia
Hypernatremia occurs in cases of water loss or excessive sodium intake (e.g., from IV fluids). It is
related to extrarenal fluid losses (GI, wounds) and diabetes insipidus.
Hypochloremia
Hypochloremia occurs with GI losses.
Hypokalemia
Hypokalemia is related to diuretics, ²2-agonists, amphotericin B, glucocorticoids, cisplatin, and GI

losses.
Hyperkalemia
Hyperkalemia is related to renal dysfunction, acidosis, angiotensin-converting enzyme (ACE)

inhibitors, potassium-sparing diuretics, trimethoprim, orally taken salt substitutes, and adrenal
insufficiency.
Hypomagnesemia
Hypomagnesemia occurs with GI losses, diuretics, amphotericin B, alcohol, and cisplatin. It should
be treated prior to treating hypokalemia; Na/K-ATPase pumps require magnesium to work.
Hypermagnesemia
Hypermagnesemia is related to renal dysfunction, magnesium-containing antacids, adrenal

insufficiency, and hyperparathyroidism.
Hypophosphatemia
Hypophosphatemia is related to refeeding syndrome, phosphate binders, diuretics, hypercalcemia,

vitamin D deficiency, and glucocorticoids.
Hypocalcemia
Hypocalcemia occurs with hypoparathyroidism, hypomagnesemia, vitamin D deficiency, and loop

diuretics. Total calcium is artificially low in hypoalbuminemia (calcium is highly albumin bound).
Diagnostic Criteria
• Criteria include serum concentration, signs, and symptoms.
• Sodium analysis may use urine sodium and urine osmolality.
Treatment Goals
• Find and treat the underlying cause of abnormality.
• Treat abnormality to avoid sequelae.
Drug and Nondrug Therapy
Fluid replacement
Administer fluids as follows:
• Crystalloids: Salt solutions — 1/2 or 1/4 normal saline (NS) ± dextrose 5% ± KCl 20 mEq/L
(approximates urine electrolytes), NS (154 mEq/L of Na), lactated Ringer's (LR), 1/4 NS, or
dextrose 5%—are chosen on the basis of sodium and fluid needs. NS or LR are typically used for
fluid resuscitation (sodium is the major osmotic cation in plasma).
• Colloids: Osmotic agents—albumin 5-25% or hetastarch—are used for fluid resuscitation or to

raise oncotic pressure (e.g., cirrhosis).
• Vasopressors ± isotropic activity: After fluids are optimized, vasopressors ± isotropic activity
may be used (see Chapter 9 on heart failure).
Edema
Fluid restriction ± diuretics may be used. See Chapter 9 on heart failure and and Chapter 16 on
kidney disorders.
Hyponatremia
If the case is severe, titrate 3% NaCl to maximum serum sodium increase of 12 mEq/d. Treat
specific forms as follows:
• Hypovolemic: Replace fluid losses with IV NS (0.9% NaCl, 154 mEq/L).
• Euvolemic (SIADH): Use fluid restriction ± demeclocycline.
• Hypervolemic: Use fluid restriction ± diuretics.

• Hypertonic: Correct hyperglycemia.
Hypernatremia
Titrate low-sodium fluids (e.g., dextrose 5%, 1/4NS) to a normal serum sodium. In cases of
diabetes insipidus, use DDAVP (desmopressin).
Hyperchloremia
Give sodium acetate or LR instead of NS, especially if acidemic (acetate is converted to bicarbonate
by the liver).
Hypokalemia
Administer IV (KCl) or po (KCl, K phosphate, or K acetate). Each 10 mEq dose increases serum
potassium by about 0.1 mEq/L. IV administration faster than 10 mEq/h requires electrocardiogram
(ECG) monitoring for arrhythmias.
Hyperkalemia
Treat hyperkalemia as follows:
• Potassium removal (slower onset of action): Use Na polystyrene sulfonate (Kayexalate) po or

PR (per rectum), loop diuretics, or hemodialysis (if severe).
• Intracellular potassium shifting (rapid onset of action): Administer regular insulin + dextrose
IV, albuterol, or Na bicarbonate.
• Potassium antagonism of cardiac effects (rapid onset of action): Administer IV calcium.
Hypomagnesemia
Dosages are described below. A large percentage of the dose is renally wasted. Repletion requires
3-days of treatment.
• IV: 0.5-1 mEq/kg/d (8 mEq = 1 g); administration rate = 8 mEq/h
• IM: Can give IM but painful
• po: Magnesium-containing antacid or laxative tid-qid as tolerated or magnesium oxide 300-600

mg bid-qid
Hypermagnesemia
Treat with diuretics, IV calcium, or hemodialysis (similar to hyperkalemia).
Hypophosphatemia
If the case is severe, use IV sodium or potassium phosphate 0.16-0.64 mmol/kg at 7.5 mmol/h to
avoid potassium overdose (if potassium phosphate is used), calcium precipitation, or both.
Administer po 1-2 g/d (5-60 mmol/d), for example, Neutra-Phos, Neutra-Phos-K, or Fleet Phospho-
soda.
Hyperphosphatemia
See Chapter 16 on kidney disorders for information about hyperphosphatemia.
Hypocalcemia
If patient is symptomatic, administer IV calcium gluconate (2-3 g) or IV calcium chloride (1 g) over

10 minutes. In addition, the following may be administered:
• IV infusion of 0.5-2.0 mg/kg/h of elemental calcium
• Calcium salts such as calcium carbonate (po 1-3 g elemental calcium/d ± vitamin D)
Patient counseling
In cases of po administration, advise patient about potential adverse events.
Adverse drug events
• Sodium: Edema or central pontine myelinolysis can occur if serum Na changes rapidly (> 12
mEq/d).
• Crystalloids: Vein irritation is possible with hypotonic (1/4 NS, 1/2 NS) or hypertonic fluids (3%
NaCl). Dextrose 5% is approximately isotonic and is often added to low-sodium fluids.
• Potassium: Events include cardiac arrhythmias (> 10 mEq/h), vein irritation (IV), GI upset (po;
worse with wax matrix controlled-release tablets), and bad taste (po liquid). With sodium
polystyrene sulfonate, constipation may occur (medication is usually mixed with sorbitol).
• Magnesium: Events include diarrhea (po), flushing, sweating (IV), and vein irritation (IV).
• Phosphorus: Events include diarrhea (po) and calcium phosphate precipitation (IV).
• Calcium: IV calcium gluconate is less irritating than calcium chloride. Cardiac dysfunction can
occur if medication is administered > 60 mg/min (elemental calcium). Events also include
calcium phosphate precipitation (IV) and constipation (po).
Drug interactions
• Hypokalemia and hypomagnesemia can predispose the patient to digoxin toxicity.
• Binding of drugs in the GI tract by calcium or magnesium is possible (see Chapter 18 on

nutrition).
• Serum concentrations
• Resolution of signs and symptoms
• With fluid replacement, normalization of the following: BP, HR, urine output (goal > 0.5
mL/kg/h), skin turgor, mucous membrane hydration, edema, cardiac output, pulmonary artery
wedge pressure (see Chapter 9 on heart failure), and serum lactate/base deficit
Other aspects
Glucose control in critically ill patients

Tight glucose control (80-110 mg/dL) with insulin infusion was originally shown to reduce
mortality in one large trial; however, recent large trials have not seen such a benefit. Hypoglycemia
is common with intensive glucose control.
Anemia of critical illness

This common complication is caused by blood loss, bone marrow dysfunction (e.g., erythropoietin
resistance), and hemodilution. Red blood count (RBC) transfusion is not recommended until
hemoglobin is < 7.0 g/dL (unless patient is symptomatic). No benefit is gained from transfusing
sooner, and transfusions are associated with increased infections and higher mortality.
Recombinant erythropoietin (40,000 units SC per week) has been shown to decrease the need for
RBC transfusions by about 20% in a large trial; however, this benefit was not seen in a large
follow-up trial. Until further data are available, erythropoietin is not recommended for routine use
in the ICU, but it may be used if the patient has another indication for it (e.g., renal failure).
17-8. Key Points
• Appropriate sedation and analgesia are essential because pain and agitation are common in
critically ill patients. Drug selection should be based on clinical guidelines and patient
parameters.
• Sedation and analgesia should be monitored using a validated assessment tool.

• NMB agents should be used only after sedation and analgesia have been maximized.
• Neuromuscular blockade should be monitored using peripheral nerve stimulation in addition to

observation of clinical signs and symptoms.
• Appropriate stress ulcer prophylaxis is recommended for patients at risk.
• Appropriate VTE prophylaxis is recommended for patients at risk. Optimal therapy is determined
by clinical guidelines and patient risk factors.
• High-dose methylprednisolone therapy within 8 hours of injury may improve outcomes after acute
spinal cord injury.
• ICP and CPP should be optimized after severe traumatic brain injury using drug and nondrug
therapies. Phenytoin is effective at preventing early post-traumatic seizures.
• Severe sepsis and septic shock are progressions of sepsis. Therapy includes hemodynamic
stabilization, appropriate antimicrobial agents, and removal of infectious foci, if possible.
• Drotrecogin alfa may decrease mortality as an adjunctive agent in patients with severe sepsis and a
high severity of illness.
• Maintaining adequate fluid status is vital to maintaining tissue perfusion and organ function.
However, many clinical factors can affect fluid and electrolyte status in critically ill patients.
Finding and treating underlying causes of fluid and electrolyte abnormalities are essential.
• Fluid and electrolyte abnormalities are generally asymptomatic unless severe.
• Fluid and electrolyte therapy should be monitored closely because of patient instability and the
risk of iatrogenic abnormalities (e.g., cardiac arrhythmias, fluid overload).
17-9. Questions
In most critically ill patients, the opiate of choice for analgesia is
A. morphine.
1. B. hydromorphone.
C. fentanyl.
D. acetaminophen.
E. ketorolac.

In which situations should hydromorphone or fentanyl be used for analgesia in critically ill
patients?
I. Morphine allergy
II. Renal dysfunction
III. Hemodynamic instability
2.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

What is the maximum duration of therapy for ketorolac?
A. 5 days
3. B. 7 days
C. 14 days
D. 30 days
E. There are no restrictions on length of use.

Which agent is recommended for general long-term sedation in the ICU (> 24-72 hours)?
A. Diazepam
4. B. Propofol
C. Midazolam
D. bentobarbital
E. Lorazepam

In most critically ill patients, which of the following is the NMB agent of choice?
A. Propofol
5. B. Vecuronium
C. Cisatracurium
D. Pancuronium
E. Any agent may be used first line.

The primary advantage of cisatracurium over pancuronium and vecuronium is that
A. elimination is not organ dependent.

6. B. it has a shorter duration of action.
C. it has a longer duration of action.
D. it is more effective.
E. it does not require monitoring.

Which of the following is preferred as a first-line sedative agent for ICP control in patients with
traumatic brain injury?
A. Pentobarbital
7.
B. Lorazepam
C. Propofol
D. Vecuronium
E. Sedation is not recommended.

The regimen of choice for post-traumatic seizure prophylaxis is
A. phenytoin indefinitely.
8. B. phenytoin × 7 days.
C. carbamazepine × 7 days.
D. benzodiazepines prn if seizures occur.
E. propofol × 7 days.

Which of the following best describes the use of high-dose methylprednisolone in acute spinal
cord injury?
A. Duration of therapy is 24 hours if started within 12 hours of injury.

B. Duration of therapy is 48 hours if started within 8 hours of injury.
9.
C. Duration of therapy is 24 hours if started 0-3 hours from injury and 48 hours if started 3-8
hours from injury.
D. High-dose methylprednisolone may be started at any time after injury.
E. Both blunt and penetrating spinal cord injuries should be treated with high-dose
methylprednisolone.


Patient Profile 1—City Hospital

Address: 42 Spring Street
Patient name: Dennis Green
Height: 5´103
Age: 24 years
Weight: 70 kg
Sex: M
Allergies: NKDA
Race: Caucasian
Medication orders:
Diagnosis:
Cimetidine 300 mg IV q8h
Injury from motor vehicle accident:
Morphine 1-4 mg IV q1h prn pain
Multiple rib fractures
Dietary: N/A
Moderate liver contusion
Additional orders: Pharmacy consult for
Lab/diagnostic tests: CT scan of liver shows no VTE prophylaxis
active bleeding
Pharmacist notes: N/A
Which of the following is the most appropriate VTE prophylaxis regimen for Mr. Green?
A. Low-dose LMWH
10. B. Heparin 5,000 units SC q12h
C. Full-dose IV heparin infusion
D. Warfarin to INR 2-3
E. Intermittent pneumatic compression and elastic stocking

The following day, Mr. Green requires placement of an epidural catheter for pain control for
his rib fractures. Which of the following is true regarding VTE prophylaxis in Mr. Green?
A. LMWH should be started and monitored closely with anti-Xa levels.

11.
B. LMWH should be avoided because of the risk of perispinal hematoma.
C. Full-dose IV heparin should be used for VTE prophylaxis.
D. Warfarin should be started.
E. A full-dose direct thrombin inhibitor should be started.

Use Patient Profile 2 to answer questions 12 and 13:

Patient Profile 2—Suburb Hospital

Address: 34 Summer Street
Height: 5´4"
Patient name: Ann Collins
Weight: 60 kg
Age: 65 years
Allergies: Penicillin (rash)
Sex: F
Medication orders:
Race: Caucasian
Ranitidine 50 mg IV q8h
Diagnosis:
Heparin 5,000 units SC q12h changed to IV heparin
Severe community-acquired pneumonia
infusion 1,100 units/h after DVT is diagnosed
Acute pain and swelling in left leg 7 days
Gatifloxacin 400 mg IV qd
after admission
Dietary: N/A
Lab/diagnostic tests: Bedside ultrasound
shows acute DVT in left leg
Additional orders: N/A
Pharmacist notes: N/A
A comparison of Mrs. Collins's complete blood count (CBC) on admission and day 7 follows:
Admission Day 7

WBC 18.0 4.0

% neutrophils/% bands 80/10 60/0

Hematocrit (%) 42 48

Platelets 175,000 8,000

Which of Mrs. Collins's hematologic changes over time is most likely due to heparin?
A. Leukopenia
12. B. Leukocytosis
C. Increased hematocrit
D. Bandemia (left shift)
E. Thrombocytopenia

What should be done regarding heparin therapy in Mrs. Collins?
A. Switch to a direct thrombin inhibitor.

13. B. Continue heparin; monitor CBC closely.
C. Switch to high-dose LMWH.
D. Switch to aspirin.
E. Discontinue heparin; do not anticoagulate.

In most patients with an acute DVT who are hemodynamically stable, what is the initial
treatment of choice?
A. Heparin 5,000 units SC q12h

14.
B. Full-dose IV heparin or full-dose LMWH
C. Thrombolytic therapy (e.g., recombinant tissue plasminogen activator)
D. Aspirin
E. Low-dose LMWH

All of the following are risk factors for the development of stress ulcers except
A. sepsis.
15. B. coagulopathy.
C. mechanical ventilation.
D. age > 40 years.
E. burns.

Which of the following is correct regarding stress ulcer prophylaxis?
A. H2 antagonists or sucralfate are equally effective and considered drugs of choice.

B. Proton pump inhibitors are more effective than H2 antagonists or sucralfate.
16.
C. Antacids have the most direct effect on gastric pH and are considered drugs of choice.
D. Sucralfate is more effective and causes less pneumonia than do H2 antagonists.
E. All agents (H2 antagonists, sucralfate, proton pump inhibitors, and antacids) are equally
effective.

Which of the following is the most likely adverse event associated with drotrecogin alfa use in
severe sepsis?
A. Renal dysfunction
17.
B. Allergy and anaphylactic shock
C. Tachycardia
D. Bleeding
E. Rash

Which of the following will not increase blood pressure via ± 1-adrenergic activation?
A. Phenylephrine
18. B. Dopamine
C. Epinephrine
D. Norepinephrine
E. Dobutamine

M. W. is a 25-year-old pregnant female who is admitted to the medical ICU following several
days of severe nausea and vomiting. She is hypotensive, tachycardic, and confused, and her
urine output is very low. Her serum sodium is 128 mEq/L. Which of the following should be
given to treat her fluid and sodium abnormality?
19.
A. IV normal saline or lactated Ringer's
B. IV 5% dextrose in water
C. po water
D. IV furosemide
E. Desmopressin

Common fluid and electrolyte abnormalities associated with loop diuretics include all of the
following except
A. hypokalemia.
20.
B. hyperkalemia.
C. hypomagnesemia.
D. dehydration.
E. hypocalcemia.

R. T. is a 40-year-old male admitted to the medical ICU following a severe asthma
exacerbation. RT's serum phosphorus is 0.9 mEq/L and his body weight is 70 kg (100% of
ideal). Which of the following acute phosphorus supplementation regimens is most
appropriate?
21.
A. 45 mmol of sodium phosphate IV over 6 hours
B. 45 mmol of sodium phosphate IV over 10 minutes
C. 15 mmol of po phosphorus (e.g., Neutraphos) over the next 24 hours
D. 15 mmol of IV sodium phosphate over 2 hours
E. No acute phosphorus therapy is required.

The most common electrolyte abnormality associated with ACE inhibitors is
A. hypomagnesemia.
22. B. hypokalemia.
C. hyperkalemia.
D. hyperphosphatemia.
E. hypernatremia.

All of the following are useful in the rapid treatment of severe hyperkalemia except
A. potassium restriction.
23. B. IV calcium.
C. IV regular insulin and dextrose.
D. IV sodium bicarbonate.
E. Oral Kayexalate.

Which of the following electrolyte abnormalities are most commonly associated with
amphotericin?
I. Hypokalemia
II. Hypomagnesemia
III. Hypocalcemia
24.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

All of the following are side effects of potassium replacement therapy except
A. constipation (po).
25. B. GI upset (po).
C. cardiac arrhythmias (IV).
D. vein irritation (IV).
E. poor taste (po liquid).

Which of the following best describes GI side effects of antacids containing magnesium and
calcium salts?
A. Mg causes constipation; Ca causes diarrhea.

26.
B. Mg causes diarrhea; Ca causes constipation.
C. Both cause diarrhea.
D. Both cause constipation.
E. Neither has GI side effects.

17-10. Answers
A. Morphine is recommended by the current Society of Critical Care Medicine (SCCM)

1. guidelines on sedation and analgesia as the opiate of choice for most critically ill patients.
Morphine is inexpensive, relatively short acting, and well tolerated by many patients.

E. Under SCCM guidelines, hydromorphone or fentanyl is recommended for critically ill
patients with any of the three conditions mentioned. Morphine may cause more hemodynamic
instability than does hydromorphone or fentanyl because of more histamine release. In
2.
addition, morphine has a renally excreted, partially active metabolite that may accumulate in
renal dysfunction. Hydromorphone and fentanyl do not have such a metabolite. The reason for
using these agents in morphine allergy is self-explanatory.

A. According to the manufacturer, ketorolac should not be used longer than 5 days because of
3.
the high risk of GI bleeding with this drug.

E. According to SCCM guidelines, lorazepam is the sedative of choice in most critically ill
4. patients requiring long-term sedation. Lorazepam is less expensive than propofol and has a
longer duration of action than propofol or midazolam.

D. Under SCCM guidelines, pancuronium is the NMB agent of choice for most critically ill
5.
patients. Pancuronium is less expensive than the other agents.

A. Cisatracurium is metabolized by nonspecific plasma esterases, whereas pancuronium and
6. vecuronium have varying degrees of hepatic and renal elimination. Thus, SCCM guidelines
recommend cisatracurium for use in patients with renal and hepatic dysfunction.

C. According to SCCM guidelines, propofol is the sedative of choice for patients who require
7. neurologic assessment often. Patients with traumatic brain injury may require multiple
neurologic assessments daily. The short duration of action of propofol allows rapid wakening.

B. According to the Brain Trauma Foundation guidelines, phenytoin for 7 days postinjury is
8.
the regimen of choice for post-traumatic seizure prophylaxis in patients requiring such therapy.

C. This regimen is based on the results of the National Acute Spinal Cord Injury Study III trial.
Some controversy exists regarding the study design of this trial and the actual efficacy of the
9.
drug for this indication; however, most clinicians treat acute spinal cord injury with high-dose
methylprednisolone.

A. According to American College of Chest Physicians (ACCP) guidelines, low-dose LMWH
is the drug of choice for VTE prophylaxis in a patient with multiple trauma. LMWH is
10. acceptable in this patient because the organ injury is not actively bleeding. If the patient had
active bleeding, then mechanical methods (intermittent pneumatic compression and elastic
stocking) would be indicated instead of LMWH.

B. Manufacturers of LMWHs do not recommend using these agents in patients with epidural
11. catheters because of case reports of clinically significant spinal hematomas. Full
anticoagulation should also be avoided.

E. Thrombocytopenia is a common hematologic side effect of heparin. A severe drop in
12.
platelets during the first 7-14 days is a typical presentation.

A. According to ACCP guidelines, all forms of heparin must be discontinued. However, this
patient requires acute, full anticoagulation for treatment of an active DVT. A direct thrombin
13.
inhibitor should be started. These agents do not cross react with heparin and potentiate
thrombocytopenia.

B. According to ACCP guidelines, rapid, full anticoagulation with IV heparin or SC LMWH is
14. recommended in most patients with uncomplicated DVT. Thrombolytic therapy is
recommended only in selected patients with hemodynamic instability or a massive VTE.

15. D. Increased age is not an independent risk factor for stress ulcers.

A. According to American Society of Health-System Pharmacists guidelines, H2 antagonists
and sucralfate are generally considered to be equally effective and are the drugs of choice.
16.
However, some controversy exists over the effect of H2 antagonists on pneumonia
development. Therefore, some clinicians prefer sucralfate.

D. Drotrecogin alfa is a recombinant form of the endogenous anticoagulant activated protein C.
17.
The anticoagulant activity increases the risk of bleeding.

18. E. Dobutamine has no ±1-adrenergic (vasoconstriction) activity.

A. M. W. is hyponatremic, and her clinical signs and symptoms indicate severe dehydration
from GI losses of water and sodium. She requires rapid fluid resuscitation with a fluid that has
an approximately physiologic amount of sodium (either NS 154 mEq/L or LR 130 mEq/L).
19.
This amount of sodium will increase her serum sodium into the normal range over time, and
the osmotic effect will hold water in the extracellular compartment (the vasculature and
interstitium) to help restore organ perfusion.

20. B. Loop diuretics enhance renal excretion of water, potassium, magnesium, and calcium.

A. R. T. is severely hypophosphatemic and requires high-dose IV therapy (0.64 mmol/kg × 70
21. kg = 44.8 mmol). The dose should be infused at 7.5 mmol/h (total time: 6 hours) to avoid
precipitation with calcium.

22. C. ACE inhibitors cause hyperkalemia because of aldosterone inhibition.

E. Oral Kayexalate (sodium polystyrene sulfonate) does not act very quickly. It requires transit
23. time through the intestines to bind potassium and create a gradient that pulls more potassium
into the lumen of the GI tract.

24. C. Amphotericin B causes renal wasting of potassium and magnesium.

A. Oral potassium replacement therapy does not normally cause constipation. Cardiac
25.
arrhythmias are a concern if IV potassium is given faster than 10 mEq/h.

B. Magnesium salts (e.g., milk of magnesia) are often used as osmotic laxatives and may cause
26.
diarrhea. Calcium salts may cause constipation.

17-11. References
Allen ME, Kopp BJ, Erstad BL. Stress ulcer prophylaxis in the postoperative period. Am J Health
Syst Pharm. 2004;61:588-96.
American Association of Neurological Surgeons and Congress of Neurological Surgeons.

Pharmacological therapy after acute cervical spinal cord injury. Neurosurgery. 2002;50(3
suppl):S63-72.
American Society of Health-System Pharmacists Commission on Therapeutics. ASHP therapeutic

guidelines on stress ulcer prophylaxis. Am J Health Syst Pharm. 1999;56:347-79.
Boucher BA, Clifton GD, Hanes SD. Critical care therapy. In: Helms RA, Quan DJ, Herfindal ET,
Gourley DR, eds. Textbook of Therapeutics: Drug and Disease Management. 8th ed.
Philadelphia: Lippincott Williams & Wilkins; 2006:655-73.
Boucher BA, Timmons SD. Acute management of the brain injury patient. In: DiPiro JT, Talbert
RL, Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York:
McGraw-Hill; 2008:965-76.
Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of

Neurological Surgeons. Guidelines for the Management of Severe Traumatic Brain Injury. New
York: Brain Trauma Foundation; 2003.
Brophy DF, Gehr TWB. Disorders of potassium and magnesium homeostasis. In: DiPiro JT,
Corwin HL, Gettinger A, Fabian TC, et al. Efficacy and safety of epoetin alfa in critically ill
patients. New Engl J Med. 2007;357:965-76.
Coyle JD, Joy MS. Disorders of sodium, water homeostasis. In: DiPiro JT, Talbert RL, Yee GC, et
al., eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-Hill;
2008: 845-60.
Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines for
management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36:296-327.
Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American
College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest.
2008;133(suppl): 381S-453S.
Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of
sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30:119-41.
Kang-Birken SL, DiPiro JT. Sepsis and septic shock. In: DiPiro JT, Talbert RL, Yee GC, et al., eds.
56.
Lau A, Chan LN. Electrolytes, other minerals, and trace elements. In: Lee M, ed. Basic Skills in
Interpreting Laboratory Data. 3rd ed. Bethesda, Md.: American Society of Health-System
Pharmacists; 2004:183-232.
Murray MJ, Cowen J, DeBlock H, et al. Clinical practice guidelines for sustained neuromuscular
blockade in the critically ill patient. Crit Care Med. 2002;30:142-56.
Pai AB, Rohrscheib, Joy MS. Disorders of calcium and phosphorus homeostasis. In: DiPiro JT,
18. Nutrition - Rex O. Brown, PharmD, BCNSP
18-1. Overview
General Nutrition
U.S. dietary guidelines (food pyramid)
• Maintain a healthy weight.
• Maintain a low-fat diet (< 30% of total calories).
• Eat plenty of fruits, vegetables, and grain products.
• Use salt, sugar, and alcohol in moderation.
Malnutrition
• Causes of undernutrition (protein-calorie malnutrition):
• Depressed intake of nutrients (starvation, semistarvation)
• Alteration in nutrient metabolism (trauma, major infection)
• Causes of obesity:
• Excessive caloric intake (especially carbohydrate and fat)
• Alteration in nutrient metabolism (genetic predisposition)
• Sedentary lifestyle
Dietary reference intakes (DRIs) of selected nutrients
• Fiber: 20-35 g/d (many people find this goal unpalatable)
• Calcium: 1,200-1,500 mg/d in adolescents and young adults; 1,000 mg/d in men until age 65 and
women until age 50; 1,200-1,500 mg/d for life thereafter (usually requires supplements)
• Multivitamins: Helpful to meet daily requirements of pregnant and lactating women, elderly
persons, and those who eat vegetarian or low-calorie diets
Nutritional assessment components

History and physical examination
• Dietary intake (anorexia, bullemia, hyperphagia, taste alterations)
• Underlying pathology affecting nutrition (cancer, burns)
• End-organ effects (diarrhea, constipation)
• General appearance (edema, cachexia)
• Skin appearance (scaling skin, decubitus ulcers)
• Musculoskeletal effects (depressed muscle mass, growth retardation)
• Neurologic effects (depressed sensorium, encephalopathy)
• Hepatic effects (jaundice, hepatomegaly)
Anthropometrics
• Skinfold measurements for assessment of fat (triceps, calf)
• Arm muscle circumference for assessment of skeletal muscle
• Weight for height to determine undernutrition or obesity
• Head circumference in infants to document appropriate growth
• Percentage of ideal body weight (IBW) after calculation of IBW for patient:
• IBW of males (kg) = 50 + (2.3 × height in inches over 5 feet)
• IBW of females (kg) = 45.5 + (2.3 × height in inches over 5 feet)
• Body mass index (BMI) for assessment of undernutrition or obesity calculated from body weight
(kg) and height (m): BMI = weight (kg)/height2 (m2)
Biochemical assessment
Serum albumin concentration
• Good prognostic indicator and good for assessment of long-term nutritional status
• Poor for repletion marker because of long half-life (21 d) and large body pool
Serum prealbumin concentration

• Good for short-term assessment of nutrition support because of short half-life (2 d) and small
body pool
Serum transferrin concentration
• Good for short-term assessment of nutrition support because of short half-life (7 d) and small
body pool
• Elevated in iron-deficiency anemia
Creatinine height index
• Requires 24-hour urine collection to determine levels of creatinine
Other methods of nutritional assessment
• Muscle strength testing
• Bioelectrical impedance (i.e., a low-grade electrical current runs through the body to identify body
protein stores and fat stores)
Types of malnutrition
• Marasmus: Features depleted fat and muscle stores, normal biochemical measurements, and
intact immune status
• Kwashiorkor: Features normal or elevated fat and body weight with abnormally low biochemical
measurements and depressed immune function
• Kwashiorkor-marasmus mix: All measurements depressed
• Obesity: Demonstrated as elevated body weight to at least 120% of IBW or BMI > 27.8 (male) or
> 27.3 (female)
• Class I obesity: BMI > 30 and < 35
• Class II obesity: BMI > 35 and < 40
• Class III obesity: BMI > 40
Selected definitions
• Hypermetabolism: An increase in energy expenditure above normal (usually > 10% above
normal)
• Hypercatabolism: An increase in protein losses above normal (usually via urinary excretion of
urea nitrogen)
• Specialized nutrition support: Parenteral nutrition (PN) or enteral nutrition (EN)
• Basal energy expenditure (BEE): A calculation of the normal energy needs of healthy adult men
or women using sex, age, height, and weight
• Harris-Benedict equations for BEE:
• Male (kcal/d) = 66 + 13.7 (weight in kg) + 5 (height in cm) - 6.8 (age in years)
• Female (kcal/d) = 655 + 9.6 (weight in kg) + 1.8 (height in cm) - 4.7 (age in years)
• Mifflin equations for energy expenditure:
• Male (kcal/d) = 10 (weight in kg) + 6.25 (height in cm) - 4.9 (age in years) + 5
• Female (kcal/d) = 10 (weight in kg) + 6.25 (height in cm) - 4.9 (age in years) - 161
• Resting energy expenditure (REE): A measured value of energy expenditure (generally ~10%
above BEE or Mifflin in health, but can be 100% above BEE in severe burns)
• Respiratory quotient (RQ): The value that results when carbon dioxide production (VCO2) is
divided by oxygen consumption (VO2)
• RQ for carbohydrate oxidation = 1.0
• RQ for fat oxidation = 0.7
• RQ for protein oxidation = 0.8
• RQ for fat synthesis = 8.0
• Body cell mass: Lean, metabolically active tissue (skeletal muscle, body organs)
• Lean body mass: Body cell mass, extracelluar fluid, and extracellular solids (bone, serum
proteins)
• RDI: Recommended daily intake
18-2. Nutritional Requirements
Calorie Requirements
• Most clinicians dose specialized nutrition support in total calories (i.e., using carbohydrate, fat,
and protein-calorie contributions to obtain the desired dose).
• 25 kcal/kg/d for adults with little stress (e.g., elective surgery)
• 30 kcal/kg/d for patients with infections, skeletal trauma
• 35 kcal/kg/d for patients with major trauma (head injury, long-bone fractures)
• 40 kcal/kg/d for patients with major thermal injury (> 50% total body surface area burn)
• Multiply BEE by the stress factor to determine calorie requirements:
• 1.0 × BEE for patients with little stress
• 1.3 × BEE for patients with minor trauma, infections
• 1.5 × BEE for patients with major trauma
• 2 × BEE for patients with severe thermal injury
• Measure the REE via indirect calorimetry for calorie requirements.
Caloric Contribution of the Major Macronutrients
• Glucose: 3.4 kcal/g because hydrated glucose is used in PN (glucose powder would be 4 kcal/g)
• Fat: 9 kcal/g
• Protein: 4 kcal/g
• Protein requirements are usually dosed in grams per kilogram per day.
• 0.8 g/kg/d is the adult recommended daily allowance (RDA) for protein in the United States.
• 1.0 g/kg/d is the adult RDA for patients with minor stress (elective operations).
• 1.5 g/kg/d is the adult RDA for patients with major trauma or infection.
• 2.0 g/kg/d is the adult RDA for patients with severe head injury, sepsis, or severe thermal
injury.
Measurement of Nutritional Efficacy Using Nitrogen Balance (NB)

NB = nitrogen in - nitrogen out
• Nitrogen in (grams) is determined by dividing the grams of protein taken in on the day of balance
by 6.25.
• Nitrogen out (grams) is determined by measuring the grams of urea nitrogen excreted during a 24-
hour urine collection and then adding a factor of 2 or 4 g for insensible nitrogen loss or stool loss.
• Positive NB can be used to document adequacy of nutritional support:
• In undernourished patients, +4 to +6 g/d is desired.
• Nitrogen equilibrium (-2 to +2 g/d) is usually adequate in critically ill patients.
Other Requirements during Nutrition Support
Water
• Up to 35 mL/kg/d for average-sized adults
• 40 mL/kg/d for smaller adults and adolescents
• > 40 mL/kg/d for patients with extrarenal losses (e.g., gastrointestinal drains)
Electrolytes
• Sodium requirements:
• 60-100 mEq/d in adults
• 2-6 mEq/kg/d in children
• Chloride requirements:
• Potassium requirements:
• Calcium requirements:
• Phosphorus requirements:
• 20-45 mmol/d in adults
• 1-2 mmol/kg/d in children
• Magnesium requirements:
• 0.25-1.00 mEq/kg/d in children
Vitamins
• Vitamins are provided daily in both PN (added) and EN (endogenous).
• Most enteral formulations provide the DRI for vitamins in a volume of 1,000-1,500 mL.
• For parenteral vitamin products:
• Adult products contain 12 (MVI-12) or 13 vitamins (Infuvite Adult, MVI-Adult); vitamin K is

added separately when the product with 12 vitamins is used.
• Pediatric products (MVI-Pediatric, Infuvite Pediatric) contain all 13 vitamins.
Trace elements
• Zinc: 3-5 mg/d in adults with PN; 50-250 mcg/kg/d in children with PN
• Copper: 0.5-1.2 mg/d in adults with PN; 20 mcg/kg/d in children with PN (maximum of 300
mcg/d)
• Chromium: 10-15 mcg/d in adults with PN; monitored but not given to children
• Manganese: 50-100 mcg/d in adults with PN; monitored but not given to children
• Selenium: 40-80 mcg/d in adults with PN; 1.5-3.0 mcg/kg/d in children with PN
18-3. Specialized Nutrition Support

Parenteral Nutrition
Indications
PN is generally used for patients who cannot be fed via the gastrointestinal tract.
Severe acute pancreatitis
• Oral or tube feeding will usually exacerbate this condition unless given via the jejunum (e.g.,
nasojejunal feeding tube or jejunostomy).
Short bowel syndrome
• This condition requires PN from a few weeks to lifelong, as needed.
Ileus
• This condition is secondary to lack of bowel function (e.g., acute renal failure secondary to sepsis)
Other indications
• Crohn's disease exacerbation with fistula or obstruction
• Neonates who cannot eat in the first day of life
• Preoperatively for undernourished patients who are undergoing an elective operation and for
whom there is no direct access to the gastrointestinal tract (e.g., partial small bowel obstruction
from cancer)
• Pregnancy with severe hyperemesis gravidarum (i.e., there is an inability to tolerate oral or enteral
nutrition)
• Gastrointestinal fistulae where oral or enteral nutrition should be restricted
Components of parenteral nutrition
Protein
• Protein should be included in all PN formulations.
• Standard amino acids from 10%, 15%, or 20% stock solutions can be used for most patients.
• Final concentrations in the PN formulation vary from 2% to 7%.
• Doses > 2 g/kg/d are rarely needed.

Fat
• Fat is provided as intravenous fat emulsion either as a separate infusion or admixed with the rest
of the PN formulation, making a total nutrient admixture (TNA).
• Products are manufactured as 10%, 20%, and 30% fat emulsions. (In the United States, 30% can
be used only for TNAs, not for direct infusion.)
• Fat provides essential fatty acids to the patient who is most likely not eating by mouth.
• Fat provides nonprotein calories other than glucose.
• Common doses used in adults are ~1 g/kg/d (9-10 kcal/kg/d).
• Intravenous fat emulsions contain phospholipid to emulsify the product and glycerol to make the
emulsion isotonic. (Both of these components provide modest calories.)
Dextrose
• Common doses of dextrose in critically ill patients are 3-4 mg/kg/min (~15-20 kcal/kg/d).
• Dextrose is in all PN formulations for obligate needs (central nervous system, renal medulla,
white blood cells, red blood cells, and wound healing)
• PN formulations are usually made from 70% dextrose in water.
• Final concentrations in the PN formulation vary from D10W to D35W.
• Dextrose should never exceed a dose of 5 mg/kg/min (~25 kcal/kg/d).
Sodium
• Sodium can be provided as chloride, acetate, or phosphate salts in PN.
• After phosphate addition, the remaining anions are added on the basis of acid-base status. They
are split between chloride and acetate with a normal pH, predominantly acetate with metabolic
acidosis, and predominantly chloride with metabolic alkalosis.
• Requirements can be increased when the patient has extrarenal losses from nasogastric suction,
abdominal drains, or ostomy losses.
Potassium
• Potassium can be provided as chloride, acetate, or phosphate salts in PN

• Requirements can be increased with administration of potassium-wasting drugs (diuretics,
steroids) or in severe undernutrition.
• Like sodium, the remaining potassium can be added as acetate or chloride on the basis of acid-
base status after the proper dose of phosphate is determined.
Calcium
• Most practitioners add calcium as the gluconate salt.
• Higher doses of calcium (~20-25 mEq/d) are needed in patients receiving long-term PN to help
prevent metabolic bone disease.
• Addition of calcium is limited in PN formulations because of the potential to precipitate with

phosphate salts, which ultimately results in insoluble calcium phosphate.
Phosphate
• Phosphate is added as the sodium or potassium salt.
• Higher doses of phosphorus (e.g., 30 mmol/L) are needed to prevent refeeding syndrome in
severely undernourished patients.
• Phosphorus should be decreased or removed in patients with renal failure.
• Most practitioners prefer sodium phosphate over potassium phosphate because of the higher
concentration of aluminum in the latter product, especially in chronic use of PN.
• Addition of phosphorus is limited in PN formulations because of the potential to precipitate with

calcium or magnesium salts to form an insoluble compound.
Magnesium
• Most practitioners add magnesium as the sulfate salt.
• Higher doses should be used in patients with alcoholism or large bowel losses or in patients
receiving drugs causing renal wasting of magnesium (cisplatin, amphotericin B,
aminoglycosides, loop diuretics).
• Magnesium should be restricted or deleted in patients with renal failure.
Multivitamins
• Multivitamins are given daily as part of PN.

• Parenteral multivitamin preparations contain 12 or 13 vitamins. (Vitamin K should be
administered separately if the 12-vitamin preparation is used.)
• Additional thiamine and folic acid are often given to alcoholic patients who are receiving PN.
• Additional folic acid (at least 600 mcg/d) should be given to pregnant patients receiving PN.
Trace elements
• Trace elements are given daily as a cocktail of four or five trace metals.
• Extra zinc should be given in patients with ostomy or diarrhea losses.
• Copper and manganese should be reduced or eliminated in patients with cholestasis.
• Extra selenium is usually needed in homebound PN patients.
Total nutrient admixtures versus two-in-one admixtures
Advantages of TNAs
• Decreased nursing time for administration
• Potentially decreased touch contamination
• Decreased pharmacy preparation time (assuming a 24-hour hang time)
• Financial savings (use of only one pump and one intravenous administration set)
Disadvantages of TNAs
• TNAs are better media for bacterial growth than are two-in-one admixtures.
• It is impossible to visualize particulate matter.
• Filter formulation with a 0.22-micron filter is not possible.
• Some additives like calcium and phosphorus are less compatible in TNAs.
Central vein PN versus peripheral vein PN
Advantages of central vein PN
• Central vein PN can maximize caloric intake.

• Volume restriction of patients is possible.
• Long-term catheter can be maintained.
Disadvantages of central vein PN
• Mechanical complications during catheter placement (e.g., pneumothorax)
• Potential hyperosmolar complications (e.g., from using hypertonic dextrose)
• Potential septic catheter complications
Advantages of peripheral vein PN
• It is easier to place the catheter (i.e., peripheral vein stick).
• Hyperosmolar complications are avoided because dilute formulations must be used.
Disadvantages of peripheral vein PN
• Incidence of thrombophlebitis is high.
• Frequent vein rotation is necessary.
• Energy intake is limited.
• Volume restriction is not possible (using dilute formulations).
• Cost is higher because more lipid calories are generally used. (Lipids are isotonic.)
Parenteral nutrition calculations
D20W (final concentration of PN formulation)
• D20W = 20% dextrose = 20 g/100 mL = 200 g/L × 3.4 kcal/g = 680 dextrose kcal/L
• 2 L/d of D20W (final concentration of PN formulation) = 1,360 dextrose kcal/d
Amino acids 5% (final concentration of PN formulation)
• 5% amino acids = 5 g/100 mL = 50 g/L × 4 kcal/g = 200 protein kcal/L
• 2 L/d of 5% amino acids = 100 g/d = 400 protein kcal/d

Lipid 2% (final concentration of TNA formulation)
• 2% lipid will deliver 200 kcal/L (includes calories from glycerol/phospholipid)
• 2 L/d of lipid 2% = 400 fat kcal/d
Lipid 20% infused at 20 m L/h × 24 h (separate infusion given with two-in-one PN

formulations)
• 20% lipid = 2 kcal/mL
• 20 mL/h × 24 h = 480 mL/d
• 480 mL/d × 2 kcal/mL = 960 fat kcal/d
Example: D30W; amino acids 4%; lipid 3%, at 60 mL/h
• 60 mL/h × 24 h/d = 1,440 mL/d (1.44 L/d)
• D30W = 30% dextrose = 300 g/L × 3.4 kcal/g = 1,020 kcal/L × 1.44 L = 1,469 dextrose kcal
• 4% amino acids = 40 g/L = 160 kcal/L × 1.44 L = 230 protein kcal
• 3% lipid = 300 kcal/L × 1.44 L = 432 fat kcal
• 1,469 kcal + 230 kcal + 432 kcal = 2,131 total kcal/d from the above PN formulation
Example: dextrose 400 g; amino acids 100 g; lipids 40 g; at 85 mL/h
• Dextrose 400 g × 3.4 kcal/g = 1360 kcal/d
• Amino acids 100 g × 4 kcal/g = 400 kcal/d
• Lipids 40 g × 10 kcal/g (includes phospholipid and glycerol) = 400 kcal/d
General principles of compounding parenteral nutrition
• Each component of the PN prescription should be reviewed to ensure a balanced PN formulation

is provided.
• Each component should be assessed for dose and potential compatibility programs.
• All compounded PN formulations should be visually inspected to ensure no gross contamination

or precipitation is present.
• Manufacturers of automated compounders should provide the additive sequence to ensure safety
in PN preparation.
General principles of stability and compatibility of parenteral nutrition
• Parenteral multivitamins should be added shortly before dispensing and administering the PN
formulation because vitamins A and C degrade fairly quickly.
• Preparation of TNAs using dual-chambered bags (lipid is kept in a separate compartment until
administration) can enhance the shelf life of a PN formulation.
• Dibasic calcium phosphate (CaHPO4) can precipitate in PN formulations if the amounts of

calcium gluconate and sodium or potassium phosphate are excessive.
• Generally, phosphate should be added first to the PN formulation.
• Generally, calcium should be added last to the PN formulation.
• Calcium chloride should not be used in PN because it is highly reactive with phosphate.
• Iron dextran can be added to two-in-one PN formulations but should not be added to TNAs.
Parenteral nutrition filtration
• Filters are used to prevent administration of particulate matter, microorganisms, and air.
• Use a new 0.22-micron filter each day with two-in-one PN formulations (0.22-micron filters with
positive charged nylon can be used for up to 96 hours in two-in-one PN formulations).
• Use a new 1.2-micron filter each day with TNAs.
Complications of parenteral nutrition
Metabolic
Hyperglycemia
• Patients with stress of trauma or infection or those with diabetes often need regular human insulin
added to the PN formulation to control hyperglycemia.
• Regular insulin continuous infusions are often needed to control hyperglycemia.
Electrolyte disorders
Hypokalemia
• Patients often require extra potassium in PN (e.g., 60 mEq/L).

Hypophosphatemia
• Patients often require extra phosphorus in PN (e.g., 30 mmol/L).
Hypomagnesemia
• Patients often require extra magnesium in PN (e.g., 16 mEq/L).
Hyponatremia
• Diagnosis of sodium disorders must include an assessment of extracellular fluid status (i.e.,
volume status).
• Volume depleted: Add sodium and water to PN, or increase intravenous fluid administration.
• Volume overloaded: Remove sodium from PN and concentrate the formulation.
• Euvolemic: Generally, water restriction is first-line therapy (concentrate the PN formula).
Acid-base disorders
• Increase acetate and decrease chloride anions if the patient has metabolic acidosis.
• Increase chloride and decrease acetate anions if the patient has metabolic alkalosis.
Essential fatty acid deficiency
• During PN, at least 4% of total calories need to be provided as intravenous lipid (easily attained
when lipid is used daily as a calorie source).
Trace element disorders
• Patients with increased ostomy output or chronic diarrhea need extra zinc.
• Hold copper and manganese in patients with cholestasis.
Hepatic steatosis
• Fatty infiltration of the liver has been reported with long-term PN.
• Hepatic steatosis is thought to be primarily caused by administration of excessive dextrose

calories.
• The key to prevention is through administration of an appropriate dose of dextrose (e.g., < 5
mg/kg/min).
Mechanical complications
• Pneumothorax (punctured lung) can occur during central vein canulation.
• Subclavian artery injury can occur when the artery is cannulated instead of the vein.
• Subclavian vein thrombosis can occur with long-term central vein access. (Heparin is used in
some PN patients to prevent this condition.)
Infectious complications
• Such complications are usually due to catheter-related breakdown in sterile technique.
• They are rarely solution related.
Monitoring of parenteral nutrition
Frequency and intensity of monitoring is based on the patient's condition, as assessed by
• Electrolyte balance and glucose control
• Acid-base status via arterial blood gases
• Intake and output for assessment of fluid balance
• Serum prealbumin concentrations, nitrogen balance, or both to document efficacy
Enteral Nutrition
Indications
• EN is generally used in patients who cannot or will not eat but have a functional and accessible
gastrointestinal tract.
• Neonates should begin EN as early as possible, even if receiving PN.
• EN is used in elderly patients who lack the ability to ingest food orally.
Cardiac
• Cardiac patients may need fluid-restricted EN with fluid overload.
Pulmonary failure
• EN is used frequently in patients receiving mechanical ventilation.
Hepatic failure
• EN is used frequently in this population.
• In severe hepatic encephalopathy, use a formulation with high branched-chain amino acids and
low aromatic amino acids.
• In the absence of encephalopathy or mild encephalopathy, use EN with standard protein.
Gastrointestinal failure
• In short bowel syndrome, EN is used to enhance small bowel hypertrophy after major bowel
resection.
• In inflammatory bowel syndrome, EN is the preferred method of nutrition support.
Neurologic impairment
• EN is preferred because the patient may not be able to eat, but the gastrointestinal tract is
functional and accessible.
Cancer or HIV infection
• Use EN (if possible) in these patients to prevent or treat undernutrition.
Types of enteral access
• Feeding enterostomy
• Feeding enterostomy is used for long-term EN.
• Gastrostomy requires a G-tube or PEG (percutaneous endoscopic gastrostomy).
• Jejunostomy requires an exploratory laparotomy to place.
• Oral route (by drinking supplements)
• Nasal tube feeding
• Nasal tube feeding is usual for short-term EN.
• Nasogastric, nasoduodenal, or nasojejunal tubes are used.

Products for enteral nutrition
• Polymeric, nutritionally complete tube feeding is used for patients with normal digestive processes
(e.g., 1 kcal/mL).
• Concentrated, nutritionally complete tube feeding is used for patients who need severe fluid
restriction (e.g., 2 kcal/mL).
• Polymeric, nutritionally complete, oral supplements are used to supplement an oral diet (e.g., 1.0
or 1.5 kcal/mL).
• Chemically defined, nutritionally complete tube feeding is used for patients with impaired
digestive processes such as short bowel syndrome or pancreatic insufficiency (e.g., 1 kcal/mL).
• Fiber-containing, nutritionally complete tube feeding is beneficial in patients who receive long-
term tube feeding (can prevent diarrhea and constipation; e.g., 1.0 or 1.2 kcal/mL).
• Concentrated, low-protein, low-electrolyte tube feeding is generally used for patients with renal
failure.
• A high branched-chain amino acid, low aromatic amino acid EN formula is used for patients with
liver failure and severe hepatic encephalopathy (e.g., 1.0 or 1.5 kcal/mL).
• High-fat, low-carbohydrate, nutritionally complete tube feeding is helpful in management of

diabetic or other glucose-intolerant patients (e.g., 1.0 or 1.2 kcal/mL).
• Immune-enhancing formulas that contain arginine, glutamine, and omega-3 fatty acids are
marketed and used in patients with high metabolic stress (e.g., severe trauma or infection; 1.0 or
1.3 kcal/mL).
Complications of enteral nutrition
Pulmonary (e.g., aspiration pneumonia)
• The most severe complications of EN are pulmonary.
• Pulmonary complications are caused by regurgitation of gastric contents into the lung (with or
without tube feeding).
• Prevention is important.
• Elevate the head of the bed to 30° if possible.
• Frequently assess the patient's abdomen to ensure tolerance.

• Frequently assess the placement of the feeding tube (especially nasally placed tubes).
Gastrointestinal
• Diarrhea is often associated with the administration of EN, but EN is not necessarily the cause of
the diarrhea.
Increased frequency or volume of stools
• Pharmacotherapy is often the cause, because of sorbitol in liquid vehicles.
• Lack of fiber and excessive infusion rate advancements can also be causes.
• Decreasing (or at least not advancing) the infusion rate is appropriate.
• Change to a fiber-containing formulation if the patient is not receiving one.
• Pseudomembranous enterocolitis can occur from antibiotic therapy.
• Use pharmacotherapeutic treatment if the above factors are ruled out (bismuth subsalicylate,
loperamide, diphenoxylate).
Constipation (decrease in stool frequency)
• Lack of fiber can be a cause.
• Lack of water can be a cause.
• Poor mobility and drugs with anticholinergic activity can contribute.
• Keep patient well hydrated and use a fiber-containing EN formulation.
Mechanical
• In the event of nasal necrosis, use a small-bore feeding tube and do not tape it too firmly to the
nose.
• To prevent esophageal injury, use a small-bore feeding tube.
• To prevent it from clogging, frequently flush the feeding tube with warm water.
• In the event of tube displacement, discourage removing the tube; the tube may have to be
anchored with a bridle.
Metabolic
Hyperglycemia
• Use regular human insulin.
• Consider a high-fat, low-carbohydrate EN formulation.
• Regular insulin continuous infusions are sometimes necessary
Hypokalemia
• Provide additional potassium as an intravenous (IV) or per tube supplement.
• Some institutions allow the addition of potassium salts to the EN formulation.
Hypophosphatemia
• Provide additional phosphorus as an IV supplement (e.g., potassium phosphate).
• Some institutions allow the addition of phosphorus salts to the EN formulation (e.g., injectable
sodium or potassium phosphate).
Monitoring of enteral nutrition
The intensity of monitoring will be dictated by the condition of the patient:
• Electrolyte balance and glucose control
• Acid-base status via arterial blood gases (critical care only)
• Intake and output for assessment of fluid balance
• Assessment of the patient's abdomen is required:
• Positive bowel sounds usually should be present.
• The abdomen should be soft, nontender, and nondistended in most cases.
• A profoundly distended abdomen usually requires the EN to be decreased or discontinued

temporarily.
• Serum prealbumin concentrations, nitrogen balance, or both should be assessed to document

efficacy.
Home Nutrition Support

Parenteral nutrition
• PN can be given from weeks to a lifetime (e.g., severe short bowel syndrome).
• PN is usually cycled at night over 10-16 hours.
• Patient must be monitored closely for iron deficiency because iron supplementation is not
routinely added to PN.
• Regular assessment of hemoglobin, hematocrit, and mean corpuscular volume is required.
• Serum iron, total iron-binding capacity, and ferritin are commonly used in the diagnosis of iron
deficiency.
• Metabolic bone disease is another long-term complication of home PN.
• Supplemental calcium in the PN formulation is usually required (15-25 mEq/d).
• Adequate vitamin K for osteocalcin is important on a long-term basis.
Enteral nutrition
• EN can be given indefinitely as full nutrition support or as a supplement to an oral diet.
• Permanent feeding ostomies are used almost exclusively in home EN.
• Patients in nursing homes and extended care facilities usually receive EN as a continuous (24
hours) or intermittent (e.g., 12 hours) infusion.
• Patients who receive home EN via gastrostomy usually receive bolus feeding (e.g., two 240-mL
cans tid via PEG).
• Patients who receive home EN as a supplement to oral intake are often cycled at night (e.g., 1,000
mL at 85 mL/h from 7:00 pm to 7:00 am each night).
18-4. Major Drug-Nutrient Interactions
Phenytoin and Enteral Tube Feeding
• It has been demonstrated that enteral feeding will bind to phenytoin, thus impairing the absorption
dramatically, possibly because of the protein component of EN (caseinates).
Management of Phenytoin-Enteral Nutrition Interaction

• Hold the EN 2 hours before and after the daily dose of phenytoin capsules.
• Hold the EN 1 hour before and after each dose of phenytoin suspension (usually given bid or tid).
• Increase the EN infusion rate to allow the desired nutritional dose of EN to be given (i.e., to make
up for the lost time while the EN is being held for drug administration).
Warfarin and Enteral Tube Feeding
• It has been reported that adequate anticoagulation with warfarin is very difficult to achieve with
concurrent EN (low international normalized ratios).
Management of Warfarin-Enteral Nutrition Interaction
• Hold EN 1 hour before and after the daily warfarin dose. If this is done, the EN rate should be
increased to attain the desired nutritional dose.
Management of Grapefruit Juice-Drug Interaction
• Grapefruit juice interacts with many drugs (e.g., amlodipine, carbamazepine, cyclosporine)
• Grapefruit juice from frozen concentrate has been reported to inhibit gastrointestinal cytochrome
P450-3A4, resulting in enhancement of oral absorption of some drugs (toxicity).
• When taking drugs that are known to interact with grapefruit juice, patients should be advised to
avoid these grapefruit products (i.e., substitute another fruit juice such as apple or orange juice).
18-5. Key Points
• Malnutrition can present as either undernutrition or obesity.
• The components of a nutritional assessment include a history and physical exam, anthropometric
measurements, and biochemical tests.
• An increase in energy expenditure (energy needs) is defined as hypermetabolism, and an increase

in nitrogen excretion (protein needs) is defined as hypercatabolism.
• Most patients receiving specialized nutrition support (parenteral or enteral nutrition) require 25-30
kcal/kg/d and 1-2 g protein/kg/d.
• The water requirement for most adult patients without substantial extrarenal losses is 30-40
mL/kg/d.
• PN should be reserved for patients whose gastrointestinal tracts are not functional or accessible
(e.g., severe acute pancreatitis, severe short bowel syndrome).
• TNAs contain dextrose, amino acids, lipid emulsion, electrolytes, vitamins, and trace elements in
one container.
• The advantages of TNAs include decreased nursing administration time, decreased potential for
touch contamination, and reduced expense (the patient needs only one pump and one intravenous
administration set).
• The advantages of central vein PN over peripheral vein PN include the ability to concentrate the
formulation, administer adequate calories and protein, and use the catheter for long-term
administration.
• For PN calculations: 1 g hydrated dextrose = 3.4 kcal, 1 g amino acids = 4 kcal, and 1 g lipid = 9
kcal. (Intravenous fat emulsion actually provides 10 kcal/g because it includes calories provided
as glycerol and phospholipid.)
• All PN formulations should be filtered during administration (0.22-micron filter for two-in-one
PN formulations and 1.2-micron filter for TNAs).
• Enteral nutrition support is generally used in patients who cannot or will not eat but have a
functional and accessible gastrointestinal tract.
• Enteral tube feeding can be provided by one of the following methods: nasogastric, nasoduodenal,
nasojejunal, gastrostomy, or jejunostomy.
• Diarrhea associated with enteral tube feeding is often caused by pharmacotherapy (e.g., sorbitol in
liquid drug preparations as a vehicle).
• Patients receiving phenytoin or warfarin concurrently with enteral tube feeding should have the
tube feeding held at least 1 hour before and after each dose.
18-6. Questions
Introduction
What is the most appropriate calcium intake (mg/d) for adults over 65 years of age?
A. 600-800 mg
1. B. 800-1,000 mg
C. 1,000-1,200 mg
D. 1,200-1,500 mg
E. 1,500-1,800 mg

Case Study for Questions 2 and 3
A patient presents for a comprehensive nutritional assessment. She is 35 years old, is 5 feet 8
inches, and weighs 52 kg. She has a history of Crohn's disease involving both the small bowel and
colon. She has had no surgeries but has intermittent diarrhea.
Medications
• Prednisone 5 mg qod
• Mesalamine 1 g tid
• Loperamide 2 mg q6h prn diarrhea
Measurements
• Triceps skinfold = 3 mm (normal, 10-14 mm)
• Calf skinfold = 4 mm (normal, 10-15 mm)
• Serum albumin concentration = 2.5 g/dL
• Serum prealbumin concentration = 13 mg/dL (normal, 15-45 mg/dL)
The triceps skinfold measurement for this patient is an anthropometric measurement for
assessment of
A. somatic protein stores.

2.
B. fat stores.
C. visceral protein stores.
D. immune competence.
E. body cell mass.

What type of malnutrition does this patient have?
A. Kwashiorkor
3. B. Marasmus
C. Obesity
D. Kwashiorkor-marasmus mix
E. Fat overload syndrome

A patient with a bone fracture and gram-negative pneumonia excretes 15 g (normal, 6-8 g/d) of
urea nitrogen during a 24-hour urine collection. On the basis of these data, the patient is
A. hypercatabolic.
4.
B. hypermetabolic.
C. hypocatabolic.
D. hypometabolic.
E. euvolemic.

During nutritional assessment, the measurement of body cell mass includes
A. bone.
5. B. interstitial fluid.
C. skeletal muscle.
D. intravascular fluid.
E. extracellular fluid solids.

Case Study for Questions 6-9
Following major gastrointestinal resection, a patient with severe short bowel syndrome is started on
parenteral nutrition (PN). It is anticipated that this patient may need this therapy for 6 months to 1
year. The PN prescription for this patient includes
• D20W amino acids 5% (final concentrations) at 105 mL/h (2,500 mL/d)
• Intravenous fat emulsion 20% at 10 mL/h × 24 h (240 mL/d)
• 0.45% sodium chloride injection at 50 mL/h × 24 h (1,200 mL/d)
How many calories from dextrose will this patient receive each day?
A. 1,100
6. B. 1,300
C. 1,500
D. 1,700
E. 1,900

How many grams of protein will this patient receive each day?
A. 25
7. B. 50
C. 75
D. 100
E. 125

How many calories from intravenous lipid will this patient receive each day?
A. 240
8. B. 360
C. 480
D. 600
E. 720

Calculate the daily nitrogen balance (grams per day) in this patient if she excretes 12 g of urea
nitrogen during the urine collection and 4 g are used as insensible and stool loss each day.
A. -4
9.
B. -2
C. 0
D. 2
E. 4

What would be an appropriate water or fluid requirement for a 60-kg patient with no extrarenal
fluid losses?
A. 800 mL
10.
B. 1,200 mL
C. 2,400 mL
D. 3,600 mL
E. 4,800 mL

Which of the following disease states or clinical conditions would usually require the
administration of parenteral nutrition?
A. Severe acute pancreatitis

11.
B. Motor vehicle crash resulting in femur fracture and head injury
C. 20% body surface area burn from a house fire
D. Laparoscopic cholecystectomy
E. Acute exacerbation of hepatic encephalopathy

What is the maximum dose (in kilocalories per kilogram per day) of dextrose in parenteral
nutrition for adult patients?
A. 5
12.
B. 10
C. 15
D. 20
E. 25

In a patient with metabolic acidosis, what anion salt would you use to add the majority of
sodium and potassium to a PN formulation?
A. Chloride
13.
B. Gluconate
C. Phosphate
D. Acetate
E. Sulfate

If excessive amounts of calcium are added to a standard parenteral nutrition formulation, it will
likely precipitate with
A. phosphate.
14.
B. gluconate.
C. magnesium.
D. chloride.
E. sodium.

Which vitamin should be supplemented above standard amounts during nutrition support of a
pregnant patient?
A. Cyanocobalamin
15.
B. Folic acid
C. Biotin
D. Chromium
E. Pantothenic acid

Which of the following is an advantage of central vein parenteral nutrition over peripheral vein
parenteral nutrition?
A. Allows easier catheter placement

16.
B. Does not require a pump for administration
C. Allows for fluid restriction
D. Does not have to be filtered
E. Uses dilute formulations in most cases

Which component of a total nutrient admixture should be added last before storing it in a
refrigerator?
A. Phosphorus
17.
B. Magnesium
C. Trace elements
D. Calcium
E. Intravenous fat emulsion

Which of the following are advantages of using a 0.22-micron filter when administering a two-
in-one parenteral nutrition formulation?
I. Traps particulate matter

II. Prevents precipitates from entering the patient
III. Filters most bacteria
18.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Which trace element should be reduced or removed in patients with cholestasis who are
receiving parenteral nutrition?
A. Zinc
19.
B. Chromium
C. Selenium
D. Copper
E. Iodine

A 70-year-old female who has mild congestive heart failure, gastroesophageal reflux disease
(GERD), type II diabetes mellitus, and rheumatoid arthritis had a recent cerebral vascular
accident. She will not regain her premorbid degree of mental status, so a decision is made to
give her long-term nutritional support. Which method would be most appropriate for this
patient?
20.
A. Central parenteral nutrition
B. Nasogastric tube feeding
C. Peripheral parenteral nutrition
D. Jejunostomy tube feeding
E. Nasoduodenal tube feeding

A common cause of diarrhea in patients receiving enteral nutrition is from the
A. osmotic load of the enteral nutrition formulation.

21. B. sorbitol in drug vehicles.
C. addition of fiber to the enteral nutrition formulation.
D. solute load from the protein component of the enteral nutrition formulation.
E. improper placement of a nasogastric feeding tube.

What is the drug of choice for enhancing gastric emptying in a patient receiving enteral
nutrition support?
A. Bismuth subsalicylate
22.
B. Azithromycin
C. Metoclopramide
D. Loperamide
E. Acyclovir

A patient is receiving phenytoin capsules 300 mg each day for seizure control. She requires
tube feeding with a 1 kcal/mL formulation at 85 mL/h (2,000 mL/d). What would be the most
appropriate intervention to maintain a therapeutic drug concentration and maintain the required
nutrition support?
I. Increase the dose of phenytoin to 600 mg/d.

II. Hold the enteral nutrition 2 hours before and after the dose.
23.
III. Increase the enteral nutrition to 100 mL/h × 20 hours.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

What is the mechanism for grapefruit juice to inhibit the metabolism of some drugs that can
result in drug toxicity?
A. Decreased renal excretion of drug

24.
B. Inhibition of gastrointestinal cytochrome P450-3A4
C. Decreased systemic clearance of drug
D. Inhibition of hepatic cytochrome P450-3A4
E. Expanded apparent volume of distribution

18-7. Answers
D. Calcium requirements are 1,000 mg/d for male adults until age 65, when they increase to
1. 1,200-1,500 mg/d. Calcium requirements are 1,000 mg/d for female adults until age 50, when
they increase to 1,200-1,500 mg/d.

B. Skinfold measurements measure body fat stores, which assess the lipid component of the
body. Visceral protein stores are serum proteins. Body cell mass and somatic protein stores
2.
assess skeletal muscle and visceral organs. Immune competence assessment requires a skin test
with a common antigen.

D. All measurements of nutritional assessment are depressed (i.e., weight for height,
3.
anthropometric measurements, and biochemical serum markers of protein status).

A. Catabolism is related to loss of body protein. Because it is increased, the patient would be
4.
considered hypercatabolic in this case.

C. Lean body mass includes bone, skeletal muscle, visceral organs, and extracellular solids.
5. Body cell mass includes only the lean, metabolically active tissue such as skeletal muscle and
visceral organs (e.g., liver).

6. D. D20W = 20 g/100 mL = 200 g/L × 2.5 L/d = 500 g/d × 3.4 kcal/g = 1,700 kcal/d.

7. E. 5% amino acids = 5 g/100 mL = 50 g/L × 2.5 L/d = 125 g/d.

8. C. Intravenous lipid emulsion 20% = 2 kcal/mL × 240 mL/d = 480 kcal/d.

E. The nitrogen intake is calculated by dividing the protein intake (125 g) by 6.25, which
results in 20 g. The nitrogen output would be the sum of the urinary urea nitrogen and
9. insensible losses (12 g + 4 g = 16 g/d). Therefore, the nitrogen balance would be 20 g -16 g = 4
g. A nitrogen balance of +4 would be suggestive of nutritional adequacy with this PN
formulation.

C. Water requirements are 30-40 mL/kg/d for patients without extrarenal fluid losses: 60 kg ×
10.
40 mL/kg/d = 2,400 mL/d.

A. It is difficult to feed patients with severe pancreatitis enterally unless there is access to the
small bowel (e.g., jejunostomy). The other clinical conditions, such as trauma and burns,
would occur in patients in whom the gastrointestinal tract could and should be used for
11.
nutrition support. A patient receiving laparoscopic cholecystectomy would not need nutrition
support. Most patients with hepatic encephalopathy can be fed enterally if they require
nutrition support.

E. The dose of dextrose in PN should never exceed 5 mg/kg/min in adult patients. This dose
12.
can be converted to 25 kcal/kg/d.

D. Acetate is converted to bicarbonate in the liver and would thus help or at least not
13.
exacerbate the metabolic acidosis.

A. Calcium phosphate is a relatively insoluble compound, so manufacturer guidelines for the
14. concentrations of these two elements must be followed closely to prevent precipitation. The
order of mixing these components in the PN formulation is also important.

B. Folic acid should be given at a dose of at least 600 mcg/d during pregnancy. Many
15. practitioners administer 1 mg/d above what the patient is eating or receiving via nutrition
support. This practice has been shown to prevent neural tube defects in the newborn.

C. Hyperosmolar nutrients (dextrose, amino acids) can be used to concentrate the PN
16.
formulation, but the PN would have to be administered via a central vein.

D. If calcium is added last, the PN formulation will contain the final volume, including all
17. other nutrients. The chance of calcium causing a precipitate will be decreased because all other
components (e.g., phosphorus) are diluted in the entire volume of the PN.

E. A 0.22-micron filter will do all three. In contrast, a 1.2-micron filter (used with TNAs) will
18.
not filter most bacteria.

D. Copper is excreted via the biliary tract. Patients with severe cholestasis should have copper
removed during short-term parenteral nutrition. In long-term PN, copper may be required in
19.
reduced doses to prevent anemia. Serum copper concentrations should be monitored regularly
in long-term patients who have cholestasis.

D. She is not a candidate for long-term PN because her gastrointestinal tract would be
accessible and functional. Nasogastric and nasoduodenal methods are used only for short-term
20.
enteral nutrition. A jejunostomy would be ideal because she also has GERD and perhaps
gastroparesis from her diabetes.

B. Several liquid preparations for drugs contain sorbitol as a pharmaceutical vehicle. These
liquid preparations are commonly used in patients with tubes because the drugs can be given
21. easily this way, especially if the patient cannot swallow. Most enteral nutrition formulations
are close to being isotonic (i.e., the osmotic load or solute load is not a major factor causing
diarrhea). Fiber will prevent or improve diarrhea in most cases.

C. Metoclopramide enhances gastric emptying and is commonly used in patients with
22.
gastrointestinal intolerance. This is true in both diabetics and nondiabetics.

D. Phenytoin absorption is markedly impaired when it is given concurrently with enteral tube
feeding. The enteral tube feeding should be held 2 hours before and after the daily dose of
23.
phenytoin capsules. To maintain the current dose of enteral nutrition, the rate of feeding should
be increased to 100 mL/h × 20 h (2,000 mL/d).

B. Drugs such as amlodipine, carbamazepine, and cyclosporine are profoundly metabolized in
the gastrointestinal tract before absorption. Grapefruit juice from frozen concentrate has been
24.
shown to inhibit gastrointestinal cytochrome P 450-3A4 and thus allows more of the drug to be
absorbed, thereby causing drug toxicity for drugs with a narrow therapeutic index.

18-8. References
American Society for Parenteral and Enteral Nutrition Board of Directors and Clinical Guidelines
Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric
patients. J Parenter Enteral Nutr. 2002;26(suppl 1):1SA-138SA.
Brown RO. Parenteral and enteral nutrition in adult patients. In: Helms RA, Quan DJ, Herfindal
ET, Gourley DR, eds. Textbook of Therapeutics: Drug and Disease Management. 8th ed.
Philadelphia: Lippincott, Williams & Wilkins; 2006:749-66.
Brown RO, Dickerson RN. Drug-nutrient interactions. Am J Managed Care. 1999;5:345-51.
Chessman KH, Kumpf VJ. Assessment of nutrition status and nutrition requirements. In: Dipiro JT,
Talbert RL, eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-
Hill; 2008:2349-66.
Hodges BM, Delegge M. Nutritional considerations in major organ failure. In: Dipiro JT, Talbert
RL, eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-Hill;
2008: 2417-36.
Kumpf VJ, Chessman KH. Enteral nutrition. In: Dipiro JT, Talbert RL, eds. Pharmacotherapy: A
Mattox TW, Reiter PD. Parenteral nutrition. In: Dipiro JT, Talbert RL, eds. Pharmacotherapy: A
McCarter DN, Marshall LL. General nutrition and vitamins/minerals. In: Helms RA, Quan DJ,
Herfindal ET, Gourley DR, eds. Textbook of Therapeutics: Drug and Disease Management. 8th
ed. Philadelphia: Lippincott, Williams & Wilkins; 2006:721-48.
Sacks G, Crill CM. Prevalence and significance of malnutrition. In: Dipiro JT, Talbert RL, eds.
77.
Task Force for the Revision of Safe Practices for Parenteral Nutrition. Safe practices for parenteral
nutrition. J Parenter Enteral Nutr. 2004;28 (suppl):S39-70.
Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N
Engl J Med. 2001;345:1359-67.
19. Oncology - J. Aubrey Waddell, PharmD, FAPhA, BCOP Jaclyn S. King, PharmD
19-1. Overview
Definition
Oncology can be defined as the science dealing with the etiology, pathogenesis, and treatment of
cancers (synonymous with malignant neoplasms). It encompasses more than 100 different diseases
that share characteristics of uncontrollable cell proliferation, invasion of local tissues, and
metastases (e.g., spread from original site).
In the United States, men have roughly a one-intwo cumulative lifetime risk of developing cancer
and women have a one-in-three risk. In 2009, approximately 1,479,350 new cases of cancer will be
diagnosed, and about 562,340 cancer deaths will occur. The most common types of cancer are
prostate, lung, and colorectal in men and breast, lung, and colorectal in women.
Classifications
Neoplastic malignancies arise from four tissue types (epithelial, connective, lymphoid, and nerve)
and are classified on the basis of this origin.
Table 19-1 lists the tissue origin of each type of malignancy and the corresponding medical
terminology.
The first signs and symptoms of cancer (solid tumors) develop when the tumor has grown to
approximately 109 cells (1 cm in diameter or 1 g mass). The type of cancer determines the
presentation of signs and symptoms, which vary widely across tumor types.
Positive screening tests (see Section 19-3) or generalized signs of anorexia, fatigue, fever, weight
loss, and anemia must also be evaluated. Boxes 19-1 and 19-2 show the American Cancer Society's
seven warning signs of cancer for adults and the warning signs for children.
The following factors promote cancer:
• External factors: Tobacco, chemicals, radiation, infectious organisms, and diet
• Internal factors: Genetics, hormones, and immune conditions
Development of cancer is genetically regulated and is a multistage process:
• Initiation: Normal cells are exposed to chemical, physical, or biological carcinogens. Such
exposure results in irreversible damage, genetic mutations, and selective growth advantages.
• Promotion: Reversible environmental changes favor the growth of the mutated cells.
• Transformation: The cells become cancerous.
• Progression: Additional genetic changes occur, resulting in increased cancerous proliferation.

Tumors invade local tissues, and metastasis occurs.
Genetic alterations are necessary for the development and growth of cancer. Some of the most
common are the following:
• Oncogenes promote growth advantages in mutated cells and cause excessive proliferation (e.g.,
ras, c-myc).
• Inactivation of tumor suppressor genes (TSGs) results in inappropriate cell growth, because TSGs
normally regulate the cell cycle (e.g., p53).
[Table 19-1. Tissue Origin of Malignant Tumor Types]
• Anti-apoptotic genes are activated (e.g., bcl-2).
• DNA (deoxyribonucleic acid) repair genes experience reduced activity.
Malignant tumor cells do not resemble their tissue of origin (in contrast to benign tumors). They are
unstable and are incapable of performing normal cell functions.
Diagnostic Criteria
A sample of suspected malignant tissues or cells is needed for a definitive diagnosis. Sampling can
be done with a biopsy, fine-needle aspiration, or exfoliative cytology. This tissue sample is
examined by a pathologist, who assigns a stage to the cancer. This process is called pathological
staging.
Radiation or chemotherapy should not begin without proper clinical and pathological staging.
Clinical staging can be accomplished by imaging studies, which may include the following:
• A chest x-ray evaluates the spread of cancer to bones or lungs.
• Computed tomography (CT) assesses the size, shape, and position of tumor and detects masses in
lymph nodes, brain, or adrenal glands through a three-dimensional view.
• Magnetic resonance imaging (MRI) evaluates the spread of cancer to the brain or spinal cord.
• Positron emission tomography (PET) evaluates lymph and other metastatic involvement.
• A bone scan assesses for the presence of bone metastasis.
Laboratory work may include complete blood counts (CBCs), blood chemistries, and tumor markers
(see Section 19.3).
Box 19-1. Warning Signs of Cancer in Adults
Change in bowel or bladder habits
A sore that does not heal
Unusual bleeding or discharge
Thickening of lump in breast or elsewhere
Indigestion or difficulty swallowing
Obvious change in wart or mole
Nagging cough or hoarseness
Source: American Cancer Society, 2009
Box 19-2. Warning Signs of Cancer in Children
Continued, unexplained weight loss
Headaches with vomiting in the morning
Increased swelling or persistent pain in bones or joints
Lump or mass in abdomen, neck, or elsewhere
Development of a whitish appearance in the pupil of the eye
Recurrent fevers not caused by infection
Excessive bruising or bleeding
Noticeable paleness or prolonged tiredness
Source: American Cancer Society, 2009.

If a diagnosis of cancer is made, the malignancy will need to be staged or categorized on the basis
of severity of the disease and the results of the pathological staging tests. Staging guides the
oncology practitioner in determining the prognosis and the treatment regimen for the patient.
The tumor, node, metastasis (TNM) staging system is the most commonly used tool for solid
tumors. Tumors are scored numerically on the basis of the size of the tumor, the extent of lymph
node involvement, and presence or absence of metastases. This score allows classification of
tumors by stage, from 0 to IV, with stage IV denoting the presence of metastasis (e.g., most severe
disease). A stage 0 tumor is called a carcinoma in situ, where the malignancy has not yet invaded
the basement membrane of the epithelial surface.
Lymphoid tumors are staged differently and are beyond the scope of this review. Refer to Adams et
al. (2002) for more information.
Treatment regimens are based on the type of cancer, stage, the age of the patient, and other
prognostic factors (e.g., presence of a tumor marker, poor performance status, and ethnicity, among
others).
Primary therapy is the initial and mainstay approach to treat cancer. It usually consists of removal of
the tumor or debulking through surgery.
Neoadjuvant therapy is given prior to the primary therapy. The goal is to reduce the size of the
tumor, thereby increasing the efficacy of the primary treatment. Examples include chemotherapy or
radiation.
Adjuvant therapy is additional therapy given after the main treatment. The goal is to ensure that all
residual disease has been eradicated.
The four main cancer treatments are surgery, radiation, chemotherapy, and biologic therapy. Most
regimens are a combination of these modalities:
• Surgery alone is reserved for solid localized tumors, where the entire cancer can be resected. It
may also be combined with other modalities in later stages of disease. It is not an option for
patients with lymphoid-based disease (e.g., Hodgkin lymphoma).
• Radiation alone is also reserved for curing localized tumors because it treats a very focused area.
It also can be combined with other treatments as neoadjuvant or adjuvant therapy to reduce
disease-related symptoms or to reduce the incidence of disease recurrence.
• Chemotherapy is a means of systemic treatment, in contrast to the two types of local treatment just
described. It can be used to treat the primary tumor as well as metastases. Chemotherapy is
generally not administered to patients with local disease that can be fully resected.
• Biologic therapy is another systemic treatment and includes agents such as monoclonal antibodies,
interferons, interleukins, and tumor vaccines. It is a relatively new type of treatment and acts by
stimulating the host immune system.
The goals of cancer therapy are based on the type and stage of cancer, as well as on patient
characteristics (e.g., an older patient with a short life expectancy may not be offered intense
treatment that may impair quality of life). Goals may be as follows:
• Localized or regional disease (i.e., stages 0, I, II, and early III): Provide curative intent and
inhibit recurrence of disease. Stage 0 diseases are often not treated, but monitored until clinically
apparent.
• Advanced or metastasized disease (i.e., advanced stage III and all stage IV): Palliate symptoms,
reduce tumor load, prolong survival, and increase quality of life.
Survival and response to treatment
In 2009, more than 1,500 people per day will die of a cancer-related cause, which accounts for one
in four deaths. Survival depends on patient characteristics, type of disease, stage of disease, and
treatment regimen. Older patients with more severe disease, a poor performance status, and faster-
growing tumors have a poor prognosis.
Response to treatment modalities for solid tumors are classified as follows:
• Cure: 5 years of cancer-free survival for most tumor types
• Complete response: Absence of all neoplastic disease for a minimum of 1 month after cessation
of treatment
• Partial response: 50% decrease in tumor size or other disease markers for a minimum of 1
month
• Stable disease: No change or no meeting of criteria for partial response or progression
• Progression: 25% increase in tumor size or new lesion
Response to treatment for hematologic cancers is measured by the elimination of abnormal cells, a
decrease in tumor markers to normal, and the improved function of affected cells.
19-2. Drug Therapy
Chemotherapy
Chemotherapeutic agents have a very narrow therapeutic index and a toxic side-effect profile. They
are generally more effective in combination because of synergism through biochemical interactions.
It is important to choose drugs with different mechanisms of action, resistance, and toxicity profiles
to get the full benefit of combination therapy.
Chemotherapy has the greatest effect on rapidly dividing cells, because most of the potent
chemotherapy drugs act by damaging DNA. These agents are more active in different phases of the
cell cycle. A therapeutic effect is seen on cancer cells, but adverse effects are also seen on human
cells that rapidly divide (e.g., hair follicles, gastrointestinal (GI) tract, and blood cells). Agents can
be phase specific or phase nonspecific. Nonspecific agents are effective in all phases.
Cell Cycle Phases
• G0 = resting phase: No cell division occurs, and cancer cells are generally not susceptible to
chemotherapy. This lack of susceptibility is problematic for slow-growing tumors that exist
primarily in this phase.
• G1 = postmitotic phase: Enzymes for DNA synthesis are manufactured, lasting 10-24 hours.
• S = DNA synthesis phase: DNA separation and replication occurs, lasting 10-20 hours.
• G2 = premitotic phase: Specialized proteins and RNA (ribonucleic acid) are made, lasting 2-10
hours.
• M = mitosis: Actual cell division occurs, lasting 30-60 minutes.
Drug Classes
There are numerous chemotherapy agents. Drugs are grouped by class. Refer to the corresponding
table for each class of drugs.
Alkylating agents
Table 19-2 provides summary information about alkylating agents.
Mechanism of action
Alkylating agents cause covalent bond formation of drugs to nucleic acids and proteins, which
results in the cross-linking of one or two DNA strands and inhibition of DNA replication. These
agents are not phase specific. The most commonly used agents include cyclophosphamide,
ifosfamide, carmustine, dacarbazine, and temozolomide.
• All drugs are carcinogenic, teratogenic, and mutagenic.
• Medications may cause sterility.

• Let your dentist know you are on chemotherapy because of an increased risk of bleeding and
infections.
• Hydration and mesna therapy are recommended for cyclophosphamide and ifosfamide.
• Let your doctor know if you have burning on urination.
Adverse drug events

The following adverse events may occur: myelosuppression, primarily leukopenia; mucosal
ulceration; pulmonary fibrosis (carmustine) and interstitial pneumonitis; pyrexia and fatigue
(bendamustine); alopecia; nausea and vomiting; amenorrhea and azoospermia; hemorrhagic cystitis
with cyclophosphamide and ifosfamide; encephalopathy with ifosfamide; and seizures (polifeprosan
and carmustine).
Drug interactions
Drugs with specific interactions of moderate to major severity include the following:
• Altretamine: Tricyclic antidepressants and monoamine oxidase inhibitors
• Bendamustine: Strong cytochrome P450 (CYP450) 1A2 inhibitors
• Busulfan: Itraconazole, phenytoin, and acetaminophen
• Carmustine: Cimetidine, ethyl alcohol, phenytoin, and amphotericin B
• Cyclophosphamide: Allopurinol, barbiturates, digoxin, phenytoin, and warfarin
• Ifosfamide: Allopurinol, phenytoin, and warfarin
• Streptozocin: Nephrotoxic agents
Monitor pulmonary function tests, renal and hepatic tests, chest x-rays; CBC with differential
(baseline and expected nadir prior to next cycle) and electrolytes, urinalysis for red blood count
detection from hemorrhagic cystitis, signs of bleeding (bruising and melena), infection (sore throat
and fever), and nausea or vomiting.
[Table 19-2. Alkylating Agents]
Antimetabolites: S-phase specific
See
Table 19-3 for general information about antimetabolites.
Mechanism of action
These agents are structural analogues of natural metabolites and act by falsely inserting themselves
in place of a pyrimidine or purine ring, causing interference in nucleic acid synthesis. Phase-specific
agents are most active in the S phase and in tumors with a high growth fraction. They are
subdivided into three groups: folate, purine, and pyrimidine antagonists.
• Avoid crowds and sick people.
• You may be asked to chew ice if receiving fluorouracil (5-FU) to reduce damage to the mucosal
lining in your mouth.
• Contact your doctor if you have uncontrollable nausea or vomiting; excessive diarrhea; or pain,
swelling, or tingling in palms of hands and soles of feet (hand-foot syndrome).
• Call your doctor if you feel dizzy or lightheaded or have trouble urinating (clofarabine).
• You should be receiving folic acid and vitamin B12 injections if you are receiving pemetrexed.
• Nelarabine may cause sleepiness and dizziness.
Adverse drug events

Adverse events include hand-foot syndrome, stomatitis (5-FU and capecitabine); severe diarrhea,
GI mucosal damage, nausea, vomiting, fatigue, myelosuppression, alopecia, neurotoxicity
(nelarabine, cytarabine, fludarabine, and methotrexate); rash, fever, and flu-like symptoms
(gemcitabine); renal toxicity and mucositis (5-FU and methotrexate); conjunctivitis
[Table 19-3. Antimetabolites]
(cytarabine, especially in high doses); hemolytic uremic syndrome (gemcitabine); opportunistic

infections (cladribine and fludarabine); and tumor lysis syndrome, systemic inflammatory response
syndrome, or capillary leak (clofarabine).
Interactions
Drugs with specific interactions include the following:
• Capecitabine: Warfarin and phenytoin
• Cytarabine: Digoxin
• Fluorouracil: Warfarin
• Mercaptopurine: Warfarin and allopurinol
• Methotrexate: Nonsteroidal anti-inflammatory drugs (NSAIDs), amiodarone, amoxicillin,

sulfasalazine, doxycycline, erythromycin, hydrochlorothiazide, mercaptopurine, omeprazole,
phenytoin, and folic acid
• Pentostatin: Cyclophosphamide and fludarabine
Note any complaints of mucositis or mouth soreness; monitor for neurotoxicity (e.g., ask the patient
to write his or her name), CBC with differential prior to each dose of drug, and hepatic and renal
function; and monitor for tingling or swelling of palms of hands and soles of feet, bruising or
bleeding, and international normalized ratio (capecitabine). Monitor weight and question patient
about diarrhea, jaundice, and hepatomegaly (mercaptopurine). Continuous intravenous (IV) fluids
and allopurinol for prevention of tumor lysis syndrome should be administered to patients taking
clofarabine, and those patients should also receive prophylactic corticosteroids for systemic
inflammatory response syndrome and capillary leak. Pemetrexed toxicities are reduced by lowering
plasma homocysteine levels with concomitant folic acid and vitamin B12. Dexamethasone should
be given to prevent cutaneous reactions caused by pemetrexed.
Antitumor antibiotics
For additional information about antitumor antibiotics, consult

Table 19-4.
Mechanism of action
Anthracyclines block DNA and RNA transcription through the intercalation (insertion) of adjoining
nucleic acid pairs in DNA, which results in DNA strand breakage. They also inhibit the
topoisomerase II enzyme. Mitomycin is an alkylating-like agent that cross-links DNA.
Dactinomycin blocks RNA synthesis. Bleomycin inhibits DNA synthesis in mitosis and G2 stages
of growth. Bleomycin is the only cell cycle-specific agent.
• Contact your doctor if you have fast, slow, or irregular heartbeats or breathing difficulties.
• Anthracyclines may cause a change of urine color or change the whites of eyes to a blue-green or
orange-red.
• Bleomycin may cause a change in skin color or nail growth.
Adverse drug events

Events include severe nausea and vomiting, alopecia, and stomatitis. Anthracyclines may cause
cardiac toxicity, acute or chronic (doxorubicin = daunorubicin > idarubicin > epirubicin >
mitoxantrone). All anthracyclines have limits on cumulative lifetime dosing, are vesicants, and are
associated with secondary acute myelogenous leukemia (AML); avoid in patients with a cardiac
history. Myelosuppression risk exists with all agents, although mitomycin demonstrates a delayed
[Table 19-4. Antitumor Antibiotics]
effect. Dactinomycin may cause renal toxicity, leukopenia, and increased pigmentation of
previously radiated skin. Bleomycin may cause pulmonary fibrosis and interstitial pneumonitis.
Mitomycin may cause hemolytic uremic syndrome.
Drug interactions
• Bleomycin: Phenytoin and digoxin
• Doxorubicin: Cisplatin, digoxin, paclitaxel, phenytoin, phenobarbital, trastuzumab, and

zidovudine
• Epirubicin: Cimetidine and trastuzumab
• Idarubicin: Probenecid and trastuzumab
Monitor hepatic and renal function, CBC with differential, and pulmonary function tests before and
after treatment with bleomycin. Provide cardiac monitoring through left ventricular ejection fraction
measurements for anthracyclines as well as monitoring of the cumulative lifetime dose, and be alert
for extravasation and necrosis with anthracyclines. Adjust anthracycline dosing on the basis of
elevated total bilirubin.
Pharmacokinetics
Anthracyclines are extensively bound in the tissue, have large volumes of distribution and long
half-lives, and are excreted in the bile. Dosing adjustments are necessary in patients with hepatic
impairment. Bleomycin is renally excreted and requires dosing adjustments in impaired patients.
Other factors
Lifetime doses of doxorubicin should not exceed 450-550 mg/m 2, taking into account other
anthracycline agents received. The lifetime maximum for epirubicin is 900 mg/m2; for idarubicin, it
is 150 mg/m2.
Hormones and antagonists
Table 19-5 provides information about hormones and antagonists.
Mechanism of action
This diverse group of compounds acts on hormone-dependent tumors by inhibiting or decreasing
the production of the disease-causing hormone.

• Avoid use in pregnant women; several agents may cause weight gain and menstrual irregularities
in women.
• Be aware of leg swelling or tenderness (e.g., signs of a deep vein thrombosis), breathing problems,
and sweating.
• Transient muscle or bone pain, problems urinating, and spinal cord compression may occur
initially in patients receiving luteinizing hormone-releasing hormone (LHRH) agonists.
• Take exemestane after meals.
Adverse drug events

Events include edema, menstrual disorders, hot flashes, transient muscle or bone pain, tumor flare,
and transient increase in serum testosterone (LHRH agonists); thromboembolic events,
gynecomastia, elevated liver enzymes, nausea and vomiting, diarrhea, erectile impotence, decreased
libido, endometrial cancers with tamoxifen, bone loss (LHRH and aromatase inhibitors); and risk of
ventricular arrhythmias and QT prolongation.
Interactions
• Aminoglutethimide: Dexamethasone, warfarin, tamoxifen, and theophylline
• Bicalutamide: Warfarin
• Degarelix: Amiodarone, procainamide, quinidine, and sotalol
• Fluoxymesterone: Cyclosporine, anticoagulants, and valerian
• Flutamide: Warfarin
• Medroxyprogesterone acetate: Aminoglutethimide and rifampin
• Megestrol: Dofetilide contraindication
• Nilutamide: Alcohol
• Tamoxifen: Anticoagulants and cyclophosphamide
• Toremifene: CYP450 3A4 inducers (carbamazepine and phenytoin)
Check white blood counts (WBCs) with differential, platelets, liver function tests, thyroid function,
and serum creatinine regularly. Note any weight changes, abnormal vaginal bleeding, body or bone
pain, galactorrhea, or decreased libido. Monitor for embolic disorders and uterine cancer (in
females). Check prostate-specific antigen (PSA) and testosterone levels in males. Monitor bone
mineral density for LHRH agonist and aromatase inhibitors.
Pharmacokinetics
The majority of agents are available orally with longer half-lives, allowing once-daily dosing.
[Table 19-5. Hormones and Antagonists]
Other factors
Agents are often contraindicated if the patient has more than one hormone-dependent tumor. With
the exception of tamoxifen, third generation aromatase inhibitors, and LHRH agonists, the majority
of agents are not indicated for first-line therapy.
Plant alkaloids
See
Table 19-6 for information about plant alkaloids.
Mechanism of action
These agents inhibit the replication of cancerous cells. Taxanes and vincas interfere with
microtubule assembly in the M phase. Camptothecins and epipodophyllotoxins inhibit
topoisomerase I and II enzymes, respectively, causing DNA strand breaks. Topoisomerase I and II
affect G2 and S phases, respectively.
• Contact doctor for uncontrollable diarrhea (irinotecan), nausea or vomiting, or signs and
symptoms of an infection.
• Patients should receive prophylaxis for emesis and pretreatment for anaphylaxis or peripheral
edema (taxanes).
• Patients should receive a prescription for loperamide for delayed diarrhea with irinotecan therapy.
Adverse drug events

Adverse events include myelosuppression, mucositis, nausea and vomiting, alopecia, edema, hand-
foot syndrome (docetaxel); hypotension or hypersensitivity on administration (paclitaxel);
neurotoxicity (vincristine); peripheral neuropathy and myalgia or arthralgia (ixabepilone and
paclitaxel); diarrhea, headache, and secondary malignancies (topoisomerase II inhibitors); and
syndrome of inappropriate antidiuretic hormone secretion (SIADH) (vinca alkaloids)
Interactions
• Docetaxel: CYP450 3A4 inducers and inhibitors

• Etoposide: Cyclosporine, St. John's wort, and warfarin
[Table 19-6. Plant Alkaloids]
• Irinotecan: St. John's wort
• Ixabepilone: CYP450 3A4 inducers and inhibitors
• Paclitaxel: CYP450 3A4 inducers and inhibitors
• Teniposide: CYP450 3A4 inducers and inhibitors
• Vinblastine: Phenytoin, erythromycin, mitomycin, and zidovudine
• Vinca alkaloids: CYP450 3A4 inhibitors; itraconazole, and voriconazole
• Vincristine: Phenytoin, l-asparaginase, carbamazepine, digoxin, filgrastim, nifedipine, and

zidovudine
Monitor WBCs with differential for all agents; peripheral neuropathy, liver and renal function,
painful mouth sores, and blood pressure (taxanes and epipodophyllotoxins); acute and late-onset
diarrhea or dyspnea on exertion (irinotecan); bilirubin elevations (taxanes and camptothecins); fluid
retention (docetaxel); and neuropathy, shortness of breath, bronchospasm, and SIADH (vincas).
Pharmacokinetics
Taxanes and epipodophyllotoxins are extensively bound to plasma and tissues.
Other factors
Drug resistance may occur through p-glycoprotein pumps for all agents. Topotecan needs dose
adjustments for patients with a creatinine clearance < 40 mL/min. Vincas are vesicants and need
close monitoring for extravasation. Vincristine should not be administered intrathecally. In adult
patients, vincristine doses are often capped at 2 mg.
Dose adjustments may be needed for patients with liver impairment.
Biologic response modifiers and monoclonal antibodies
Table 19-7 provides information about biologic response modifiers and monoclonal antibodies.
[Table 19-7. Biologic Response Modifiers and Monoclonal Antibodies]
Mechanism of action
Biologic response modifiers activate the body's immune-mediated host defense mechanisms to
malignant cells. In contrast to immunotherapy, these agents have direct biological effects on
malignancies. Monoclonal antibodies bind to specific antigens and kill malignant cells through the
activation of apoptosis, an antibody-mediated toxicity, or complement-mediated lysis.
• Let your doctor know if you have severe fatigue, trouble breathing, or irregular heart rhythms.
• Chills, fever, depression, and flu-like symptoms are common.
• Monoclonal antibodies can cause infusion-related reactions such as fever and chills.
• If you receive bevacizumab, you should have your blood pressure checked regularly and have tests
that check for protein in your urine.
• You should wear sunscreen and avoid excessive sunlight if you are receiving cetuximab.
• You should receive medication for your thyroid if you are going to receive tositumomab.
• For both men and women, do not try to conceive until 12 months after finishing therapy.
• With thalidomide and lenalidomide, do not get pregnant. Two forms of birth control must be used,
both by women and by men on the drug who have sexual contact with women of childbearing
age.
Adverse drug events

Events include hypotension and hypersensitivity on infusion; cardiac, pulmonary, and renal
impairment; and mental status changes (e.g., depression), fever, chills, nausea, and musculoskeletal
pain with all agents. Other events include tumor lysis syndrome (rituximab); bleeding, hemorrhage,
hypertension, proteinuria, and skin rash (bevacizumab); cutaneous and severe infusion reactions and
interstitial lung disease (cetuximab); and hypothyroidism (tositumomab). Avoid use in patients with
autoimmune disorders.
Additional events include neurotoxicity (thalidomide), neutropenia (thalidomide and lenalidomide),

and deep-vein thrombosis and pulmonary embolism (thalidomide and lenalidomide).
Interactions
Drugs with specific drug interactions include the following:
• Aldesleukin: Glucocorticoids, NSAIDs, and antihypertensives
• Ibritumomab: Antiplatelets and anticoagulants
• Interferon-alfa 2b: Zidovudine, theophylline, phenytoin, and phenobarbital

• Tositumomab: Antiplatelets and anticoagulants
• Trastuzumab: Anthracyclines, cyclophosphamide, and warfarin
Monitor baseline and follow-up pulmonary, cardiac, and renal function tests. Check CBCs with
differential, liver function tests, thyroid-stimulating hormone, electrolytes, and glucose regularly.
Premedicate with acetaminophen and diphenhydramine for monoclonal antibodies. Observe blood
pressure during infusion (hypotension concerns) for all agents. Perform blood pressure monitoring
(hypertensive concerns) and urine dipstick analysis (bevacizumab). Monitor for vital signs, itching,
and swelling. Check for trouble breathing (cetuximab and ibritumomab).
Other factors
Ensure that the correct form of interferon alfa is being used (four forms). Do not administer
gemtuzumab and alemtuzumab as an IV push or bolus.
Miscellaneous Agents
Miscellaneous agents are described in

Table 19-8.
Platinum compounds
These compounds are alklyating-like agents that cause the inhibition of DNA synthesis. They
include cisplatin, carboplatin, and oxaliplatin. Adverse effects include nephrotoxicity, peripheral
neurotoxicity, myelosuppression, ototoxicity, nausea, and vomiting.
Cisplatin needs hydration therapy and premedications. It interacts with doxorubicin, rituximab,
tacrolimus, topotecan, and aminoglycosides.
Carboplatin needs monitoring for thrombocytopenia. It interacts with aminoglycosides.
Oxaliplatin has unique neurotoxicities (e.g., bronchial spasms).
Sorafenib
Sorafenib inhibits multiple tyrosine kinases and is used for treatment of advanced renal cell cancer.
Take tablets on an empty stomach. Sorafenib causes diarrhea, fatigue, rash, hand-foot syndrome,
hypertension, nausea and vomiting, neutropenia, and alopecia. It can decrease doxorubicin and
irinotecan levels.
Sunitinib
Sunitinib inhibits multiple tyrosine kinases and is used for treatment of advanced renal cell cancer
and GI
[Table 19-8. Miscellaneous Agents]

stromal tumors. Take it with or without food. It causes neutropenia, rash changes in skin color,
fatigue, myalgia, headaches, hypertension, nausea and vomiting, diarrhea, and increased liver
enzymes. It is extensively metabolized by CYP3A4; CYP3A4 inhibitors may increase levels, and
CYP3A4 inducers may decrease levels. Ketoconazole increases levels, and rifampin reduces levels.
Dasatinib
Dasatinib specifically targets BCR-ABL mutations (including those resistant to imatinib), thereby
inhibiting leukemic cell growth. It is used for treatment of chronic myelogenous leukemia (CML)
and pH+ acute lymphocytic leukemia (ALL). It causes rash neutropenia, thrombocytopenia, edema,
diarrhea, nausea and vomiting, weight changes, arthralgia, myalgia, cough, shortness of breath,
infection, electrolyte changes, and arrhythmias. Significant drug interactions occur with CYP3A4
inhibitors; avoid concurrent use or reduce dose. Avoid acid reduction therapies because they will
reduce absorption. Avoid medications that prolong QT interval.
Lapatinib
Lapatinib inhibits multiple tyrosine kinases and is used in combination with capecitabine to treat
human epidermal growth factor receptor-2 (HER2) positive breast cancer. Common adverse effects
include fatigue, diarrhea, nausea, vomiting, myelosuppression, increased liver enzymes, and
palmar-plantar erythrodysesthesia. Significant drug interactions occur with strong CYP450 3A4
inhibitors and inducers; avoid concurrent use or reduce dose. These agents should be taken by
mouth, on an empty stomach, 1 hour prior to or 2 hours after a meal.
Nilotinib
Nilotinib selectively inhibits BCR-ABL kinase and is used for the treatment of pH+ CML. Adverse
effects include headache, fatigue, rash, pruritus, constipation, nausea, vomiting, and diarrhea.
Significant drug interactions occur with strong CYP450 3A4 inhibitors and inducers; avoid
concurrent use or reduce dose. Capsules should be taken by mouth, on an empty stomach, and
swallowed whole; do not crush or open.
Asparaginase
Asparaginase removes exogenous asparagines from leukemic cells that are required for their
survival. Intradermal skin testing is needed because of severe anaphylactic reactions. Adverse
effects include myelosuppression, hyperuricemia, hyperglycemia, and renal problems. Drug
interactions occur with methotrexate, prednisolone, prednisone, and vincristine.
Hydroxyurea
Hydroxyurea inhibits DNA synthesis without interfering with RNA and protein synthesis. Adverse
effects include myelosuppression (leukopenia), development of secondary leukemias, nausea,
vomiting, diarrhea, constipation, mucositis, and rare but fatal hepatotoxicity and pancreatitis. Drug
interactions occur with didanosine and stavudine.
Imatinib mesylate
Imatinib mesylate is a selective inhibitor of the Philadelphia chromosome (biomarker in CML). It
causes hepatotoxicity, fluid retention (pleural effusions and weight gain), neutropenia, GI effects,
muscle cramps, nausea, and vomiting. Drug interactions occur with CYP450 3A4 substrates
(cyclosporine, simvastatin, erythromycin, and itraconazole) and CYP450 2C9 substrates (warfarin).
Erlotinib
Erlotinib is an HER1 and epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor. For
oral therapy, take 1 hour before or 2 hours after meals. Erlotinib causes rash, diarrhea, anorexia,
stomatitis, and interstitial lung disease. Drug interactions occur with CYP450 3A4 inducers and
inhibitors. Monitor hepatic function.
Gefitinib
Gefitinib is an EGFR tyrosine kinase inhibitor and a third-line agent for non-small cell lung cancer
(NSCLC). It causes diarrhea, rash, acne, and dry skin. Drug interactions occur with CYP450 3A4
inducers and inhibitors and with warfarin.
Bortezomib
Bortezomib inhibits the 26S proteasome and stabilizes regulatory proteins causing apoptosis and
disrupting cell proliferation. It causes nausea, vomiting, thrombocytopenia, neuropathy,
hypotension, and diarrhea.
Temsirolimus
Temsirolimus inhibits the mammalian target of rapamycin (MTOR) and is used for the treatment of
renal cell carcinoma. Adverse effects include myelosuppression, anorexia, rash, mucositis, edema,
hyperglycemia, dyslipidemia, and nausea. Drug interactions occur with angiotensin-converting
enzyme inhibitors and strong CYP450 3A4 inhibitors and inducers.
Common Toxicities and Treatments
Common toxicities of chemotherapeutic agents are outlined in

Table 19-9. They can be classified as acute, subacute, chronic, cumulative, or chronic and
cumulative. Rapidly dividing cells, including mucous membranes, hair, skin, GI tract, and bone
marrow, are the most common acute toxicities. Examples of delayed or cumulative toxicities
include nephrotoxicity, neurotoxicity, cardiomyopathy, pulmonary fibrosis, and secondary
malignancies.
The prevention and treatment of chemotherapy-induced nausea and vomiting (CINV) constitute an
important area in which pharmacists may play a role in drug selection in oncology patients. The
selection of antiemetic agents should be based primarily on the emetogenic potential of the drug
regimen. Other factors that increase the risk of CINV include sex (female), young age, prior
chemotherapy exposure, lack of chronic alcohol use, combination chemotherapy, high dosage and
numerous cycles, and short infusion times. It is important that patients also receive prescriptions to
prevent delayed CINV.
Table 19-10 summarizes the pertinent antiemetic drugs used in the prophylactic setting.
[Table 19-9. Common Toxicities of Chemotherapeutic Agents]

For highly to moderately emetogenic drug regimens, dexamethasone and 5-HT3 receptor
antagonists are recommended—at a minimum—for the prevention of acute CINV. Aprepitant
should also be considered, especially for highly emetogenic regimens.
For low to minimally emetogenic drug regimens, dexamethasone and a phenothiazine are
recommended.
For prevention of delayed CINV (> 24 hours after administration of highly emetogenic and some
moderately emetogenic chemotherapy), aprepitant and dexamethasone are recommended.
All patients receiving agents with emetogenic potential should receive prophylactic therapy for
CINV, with rescue medication readily available.
Miscellaneous Commonalities across Chemotherapy Agents
• Patients should not receive live and rotavirus vaccines during chemotherapy because of immune
suppression.
• The majority of agents are teratogenic and mutagenic.
[Table 19-10. Pharmacologic Management for the Prevention of Acute Chemotherapy-Induced

Nausea and Vomiting]
• Patients should avoid becoming pregnant or breast-feeding during and immediately after
chemotherapy.
• Patients should have laboratory studies done on a regular basis to check for common toxicities,
such as myelosuppression, renal and hepatic impairment, and electrolyte disturbances.
As mentioned previously, cancer treatment is generally a combination of modalities. Chemotherapy

is an important component, because most patients present with advanced disease on diagnosis.
Surgery plays a role in resecting primary tumors or metastases. It can
[
Table 19-11. American Cancer Society Screening Recommendations]
also be used for diagnostic purposes to biopsy tumors or for other exploratory purposes. Radiation
is used to shrink primary tumors in local disease or metastases. It can be used both in neoadjuvant
therapy to downsize tumors and in adjuvant therapy to eradicate residual disease.
Screening is also an important part of cancer therapy, because it can allow the detection of disease
in very early stages, when the survival rates are much higher. Table 19-11 refers to American
Cancer Society screening recommendations for patients at average risk of developing cancer.
Tests can also be performed to screen and monitor tumor markers. They are found in the plasma,
serum, or other body fluids and may be used to identify neoplastic growth. These markers are often
not sensitive enough to diagnose cancer and may produce false positive results (i.e., falsely identify
people with a disease that they do not have). However, they are helpful in identifying the recurrence
of advanced disease in patients who had elevated levels on diagnosis.
Table 19-12 lists some commonly used tumor markers.
[Table 19-12. Common Tumor Markers and Associated Cancers]
19-4. Key Points
• Oncology includes more than 100 diverse diseases that share properties of abnormal and
detrimental cell growth.
• Diseases are classified on the basis of the tissue in which they originate (e.g., breast cancer
metastasized to the brain is classified as breast cancer).
• Signs and symptoms of cancer do not follow a specific pattern. A health care provider should
evaluate any unusual or persistent change in body appearance or function.
• Before a diagnosis of cancer can be made and systemic treatment can begin, a positive biopsy or
blood examination must confirm the presence of the disease.
• Further imaging and laboratory work-up should be done to evaluate the extent of the disease (i.e.,
determine the stage of disease).
• Cancer therapy must be individualized to each patient on the basis of the type and severity of
disease, patient characteristics, and patient and family preferences.
• Surgery, radiation, chemotherapy, and biologic therapy are all cancer treatment modalities. They
are often used in combination.
• Pharmacists can affect patients' chemotherapy and biologic therapy by counseling the patients and
educating health care providers on details of the individual drug regimens.
• Chemotherapy is often used in combinations to take advantage of different mechanisms of action,

prevent resistance, and minimize toxicities.
• Most chemotherapy is aimed at rapidly proliferating cancerous cells. However, many

chemotherapy-related side effects occur in normal highly proliferative cells of the body, such as
hair follicles, the gastrointestinal tract lining, and blood cells.
• Patients should be aware of expected toxicities of chemotherapy, which include alopecia, diarrhea,
nausea and vomiting, infertility, myelosuppression, neurotoxicity, nephrotoxicity, hepatotoxicity,
stomatitis, and pulmonary toxicity.
• The importance of laboratory studies and follow-up appointments to treatment should be stressed
to the patient.
• All prophylactic and post-treatment medications for chemotherapy-related complications should

be made available to the patient. Counsel the patient to keep a diary of events that occur prior to
and after treatments. Use this record to make interventions and monitor the patient's quality of
life.
• All pharmacists should be aware of the accepted cancer screening recommendations and should
discuss these with patients. Many diseases can be cured if they are caught early enough.
• It is the pharmacist's responsibility to ensure that the patient and family are adequately educated to
participate in making decisions about their care.
19-5. Questions
Patient Profile 1—Medication Profile: Community

Patient name: Tina Tiny
Age: 33
Sex: Female
Diagnosis: 1. Diagnosis on 12/03 of metastatic breast cancer
2. Mastectomy to right
breast on 12/15/03
3. Weight loss of 20 lbs
4. Allergies
Address: 234 Small Street
Height: 5´83
Weight: 150 lbs
Allergies: Sulfa, penicillin
Pharmacist notes:
Date Note
Patient complained of soreness after mastectomy and swelling of right
01/04
arm.
03/04 Patient did not pick up birth control last month (2/04).
Patient is receiving Zoladex 3.6 mg SC q28d at oncology clinic. Received
03/04
dose today.
Medication record:
Rx
Date no. Physician Drug and strength Quantity Sig Refills
12/03 12345 Buford Percocet 5/325 30 1-2 q4h prn 0
03/04 12347 Buford Tamoxifen 20 mg 30 1 po qd 2
03/04 12349 Buford Megace 40 mg/mL 80 mg/d — 2
03/04 12350 Charles Celebrex 10 mg 30 1 po qd 2
Which of the following agents that Ms. Tiny is taking can be used to treat breast and prostate
cancer?
I. Zoladex
II. Tamoxifen
III. Celebrex
1.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

When Ms. Tiny presents the tamoxifen prescription, you notice that the directions are missing.
You call the doctor to clarify what the instructions are for this patient. Which of the following
is a correct choice?
2. A. 10 mL po qd
B. 20 mL po qd
C. 40 mg po bid
D. 20 mg po qd
E. 5 mg po bid

Ms. Tiny presents to your pharmacy with complaints of lower leg calf pain that is tender to the
touch and red. You suspect a deep-vein thrombosis. Which of the following agents is most
likely to be associated with this condition?
I. Megace
II. Goserelin
3. III. Tamoxifen
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Ms. Tiny calls you 2 days after her 03/04 visit to your pharmacy. She has been feeling a lot of
bone pain and describes an "achy, creaky feeling all over." She is worried that her cancer has
spread to her bones. What advice can you give her?
I. She should call her oncology caretaker and be formally evaluated.

II. This could be a side effect of her Zoladex therapy, and the pain should subside.
4. III. This could be a side effect of her Celebrex therapy, and the pain should subside.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Ms. Tiny's mother (age 59) is worried that she will develop breast cancer like her daughter.
Which of the following is not an appropriate initial screening test for breast cancer?
A. Monthly breast self-examination

5.
B. Clinical breast examination
C. Mammography
D. Biopsy
E. Mammography and clinical breast examination

Which of the following classes of agents is best known for causing infusion-related reactions,
such as fever and chills?
I. Monoclonal antibodies
II. Alkylating agents
III. Vinca alkaloids
6.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Your patient has just received 5-FU and irinotecan for the treatment of colorectal cancer.
Before he leaves the clinic, you ensure that he has a prescription to prevent or treat which of
the following side effects from irinotecan?
7. A. Nausea with Aloxi

B. Diarrhea with loperamide
C. Headache with aspirin
D. Delayed allergic reaction with epinephrine
E. Change in urine color: no treatment available

Which of the following drugs is an oral prodrug of 5-FU?
A. Fluorouracil
8. B. Xeloda
C. Fludara
D. Cytoxan
E. Alkeran

An elderly male patient comes to your pharmacy and is worried that he might have prostate
cancer. He just had some laboratory studies done, and his doctor told him that some level was
abnormal, indicating potential prostate cancer. Which lab test might he be talking about?
I. PSA
II. Cortisol
9. III. ESR
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Stomatitis is the clinical term for which of the following chemotherapy-related adverse effects?
I. Nausea and projectile vomiting

II. Obstruction of the lower esophageal sphincter
III. Inflammation of the mucosal lining of the mouth
10.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Which of the following does not describe characteristics of most chemotherapy agents?
A. They have a wide therapeutic index.
11. B. They interfere with DNA synthesis and replication.
C. They are more effective in combination.
D. Acute adverse effects occur primarily in rapidly dividing normal cells.
E. They have both phase-specific and non-phase-specific actions

Patient Profile 2—Medication Profile: Institution

Patient name: Cassimer Migash
Age: 60
Sex: Male
Diagnosis: 1. Diagnosis on 02/04 of metastatic non-small cell lung cancer
2. Chronic obstructive pulmonary disease
3. Asthma
Address: 579 Hunter's Ridge
Height: 180 cm
Weight: 200 lbs
Allergies: NKDA
Lab and diagnostic tests:
Date Test
05/04 WBC: 2,500/mcL
05/04 RBC: 2.8 × 106/mm3
05/04 PLT: 100 × 103/mcL
05/04 Theophylline: 10 mcg/mL
05/04 Hgb: 9 g/dL
05/04 Hct: 30%
Medication record:
Date Route Drug Sig
04/04 IV Paclitaxel 175 mg/m2 175 mg/m2over 3 h q 3 wk
04/04 IV Carboplatin AUC 6 AUC 6 over 2 h q 3 wk
04/04 po Theophylline SR 400 mg 1 tab po bid
04/04 INH Albuterol inhaler 2 puffs prn
04/04 INH Cromolyn inhaler 1 puff qid
04/04 INH Beclomethasone inhaler 2 puffs qid
04/04 po Dexamethasone 20 mg 1 tab 12 h and 6 h prior to chemo
04/03 IV Diphenhydramine 50 mg Infuse 30 min and 60 min prior to chemo
04/03 IV Cimetidine 300 mg Infuse 30 min and 60 min prior to chemo
A nurse would like to know if she can administer the diphenhydramine and the cimetidine to
Mr. Migash in the same IV line simultaneously. Which of the following resources will provide
you with this information?
I. Wolters Kluwer Health's Facts & Comparisons

II. Trissel's Handbook on Injectable Drugs
12. III. Micromedex
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Which of the following agents being taken by Mr. Migash requires the premedication regimen
of dexamethasone, diphenhydramine, and ranitidine or cimetidine to prevent an anaphylactic
reaction?
I. Taxotere
II. Paraplatin
13. III. Taxol
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

On the basis of the patient's weight and height, you calculate Mr. Migash's body surface area to
be 2.1 m2. Paclitaxel is supplied as 6 mg/mL in 5 mL, 16.7 mL, and 50 mL vials. Your
pharmacy has all quantities available. What is the best way to correctly dose this patient?
14. A. One 50 mL vial and one 16.7 mL vial

B. One 50 mL vial and one 5 mL vial
C. Two 16.7 mL vials
D. Two 16.7 mL vials and one 5 mL vial
E. Four 16.7 mL vials

You are concerned that Mr. Migash will develop nausea and vomiting from his chemotherapy
regimen. Which of the following regimens would be suitable to prevent acute CINV?
A. Dexamethasone, granisetron, and aprepitant

15.
B. Granisetron and prochlorperazine
C. Metoclopramide, dexamethasone, and aprepitant
D. Palonosetron and granisetron
E. Lorazepam and droperidol

On the basis of the patient's laboratory values, which of the following adverse reactions appear
to have occurred as a likely result of the chemotherapy?
I. Thrombocytopenia
II. Leukopenia
III. Anemia
16.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

The goal of Mr. Migash's treatment regimen is
I. to cure his disease.

II. to palliate his disease-related symptoms.
III. to increase his quality of life.
17.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Doxorubicin is an antineoplastic agent that
A. is not related to epirubicin and daunorubicin.

18. B. interacts with the microtubules of cells during mitosis.
C. has an oral dosage form commercially available.
D. causes cumulative cardiac toxicity.
E. can also be used to treat tuberculosis.

Which of the following agents is used in cancer regimens but is not considered an
antineoplastic agent?
A. Methotrexate
19.
B. Leucovorin
C. Doxorubicin
D. Cyclophosphamide
E. Gemcitabine

Methotrexate (Rheumatrex) is not available as which of the following dosage forms?
A. An intravenous injection
20. B. An oral tablet or capsule
C. An intrathecal injection
D. An ointment
E. An intramuscular injection

19-6. Answers
A. Zoladex (goserelin) is an LHRH agonist that can be used to treat both breast and prostate
1. cancer. LHRH agonists are approved by the U.S. Food and Drug Administration (FDA) for
premenopausal women because they inhibit estrogen production from the ovaries.

D. The FDA-approved dose for breast cancer therapy is 20 mg po qd. The drug is not available
2.
in a liquid form.

E. All three agents are hormonal products and are associated with thromboembolic side effects.
3. It is important that patients on these products are aware of the signs and symptoms of deep-
vein thrombosis.

C. Although the bone pain is most likely a side effect of her Zoladex therapy, Ms. Tiny should
4. notify her oncology practitioner so he or she can document this side effect. If other factors
point to metastatic disease, she may need additional evaluation.

D. Biopsies should never be performed as initial screening tests. However, if results from the
mammography and other tests point to disease, a biopsy is needed to make a diagnosis. There
5. is some debate about the usefulness of clinical breast examinations for women who are
reluctant to perform breast self-examinations; however, clinical breast examinations should be
offered.

A. Monoclonal antibodies are commonly associated with infusion-related reactions. Patients
6.
should receive premedication, such as acetaminophen, to prevent this.

B. Diarrhea is a dose-limiting toxicity of irinotecan. Late-onset diarrhea can be life threatening.
All patients should receive a prescription for loperamide to treat delayed-onset diarrhea.
7. Patients should be instructed to take 2 mg po q2h while awake and 4 mg po q4h during the
night until the diarrhea has stopped for at least 12 hours. Acute-onset diarrhea can be treated
with atropine.

B. Xeloda (generic name capecitabine) is an oral prodrug of 5-FU. Fluorouracil is another
name for 5-FU. Fludara is the brand name for fludarabine and is used to treat chronic
8. lymphocytic leukemia and non-Hodgkin lymphoma intravenously. Cytoxan is the brand name
for cyclophosphamide and is available in IV and po dosage forms. Alkeran is the brand name
for melphalan and is also available in IV and po dosage forms.

A. PSA (prostate-specific antigen) is a lab test that is commonly done in men over age 40. It
9.
should be performed annually in men over age 50 to check for prostate cancer.

B.Stomatitis is used to describe an irritation or ulceration of the mucosal lining. This side
effect is common with fluorouracil and methotrexate. Having the patient hold ice chips in his
10.
or her mouth during treatment can prevent it. The cold is thought to cause vasoconstriction of
the lining and prevent damage.

A. Chemotherapy agents have a very narrow therapeutic index. This is one of the main reasons
11. these drugs have so many toxic effects. They can be phase specific or non-phase-specific drugs
and can cause many adverse reactions to normal cells that undergo rapid proliferation.

D. Both Trissel's Handbook on Injectable Drugs and the Micromedex IV compatibility tool can
12.
be used to assess whether diphenhydramine and cimetidine are compatible.

B. Taxol is the brand name of paclitaxel. This agent has been shown to cause hypersensitivity
reactions in patients. It is unclear if these reactions are due to the drug itself or the drug's
vehicle (Cremophor). All patients receiving paclitaxel should receive a premedication regimen
13.
of dexamethasone, diphenhydramine, and ranitidine or cimetidine. Taxotere is the brand name
of docetaxel. This agent also requires premedications with a minimum of a corticosteroid.
However, this regimen is given to prevent peripheral edema, not an anaphylactic reaction.

A. The patient requires 367.5 mg of drug. Both choice A and choice E will provide 400 mg of
14. drug; however, using one large vial and one medium vial is more economical than using four
medium vials.

A. This patient's regimen contains carboplatin and paclitaxel. Together these agents have a
high likelihood of causing acute (and delayed) CINV. The patient should receive a
corticosteroid, a 5-HT3 antagonist, and a neurokinin-1 inhibitor, which makes choice B
incorrect because it contains a 5-HT3 antagonist and a dopamine antagonist. Aprepitant is
15.
approved in combination with a corticosteroid and a 5-HT3 antagonist, which makes choice C
incorrect because it adds a corticosteroid and a dopamine antagonist to the aprepitant. Choice
D contains two 5-HT3 antagonists. Therapy should include more than one class of agent.
Choice E agents are not efficacious in moderate to severe CINV.

E. Myelosuppression is a common adverse reaction to most chemotherapy agents. Both
paclitaxel and carboplatin can cause anemia, thrombocytopenia, and leukopenia. It is very
16. important to monitor blood levels in these patients. If myelosuppression is too severe, the
length of time between chemotherapy cycles may be increased so that all or some of the blood
cells can return to normal levels.

D. Mr. Migash has metastatic disease. When a solid tumor is diagnosed as stage IV, this
finding is representative of the fact that the disease is incurable. The treatment goals for these
17.
patients include relieving any disease-related symptoms, minimizing toxicity from treatments,
and increasing the patient's quality of life through treatment or supportive care measures.

D. Doxorubicin is an antitumor antibiotic related to epirubicin and daunorubicin. These agents
act by binding tightly to DNA through intercalation and by inhibiting the topoisomerase II
18. enzyme. Doxorubicin does have a liposomal IV product, but it is not available orally. All
anthracyclines are associated with cardiac toxicity and have cumulative dosing limits to
prevent this.

B. Leucovorin is a reduced folate agent that is used in combination with 5-FU to potentiate the
19.
therapeutic effects of 5-FU and as a rescue treatment for high-dose methotrexate.

D. Methotrexate is not commercially available for topical use. It is available in all of the other
20.
dosage forms.

19-7. References
Adams VR, Yee GC. Lymphomas. In: Dipiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy:
A Pathophysiologic Approach. 5th ed. New York: McGraw-Hill; 2002:2331-56.
American Cancer Society. Cancer facts & figures 2009. Available at: www.cancer.org.
Balmer CM, Valley AW. Cancer treatment and chemotherapy. In: Dipiro JT, Talbert RL, Yee GC,
et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 5th ed. New York: McGraw-Hill;
2002: 2175-222.
Chabner BA, Amrain PC, Druker B, et al. Antineoplastic agents. In: Brunton LL, Lazo JS, Parker
KL, eds. Goodman & Gilman's: The Pharmacological Basis of Therapeutics. 11th ed. New York:
McGraw-Hill; 2006:1315-404.
DeVita VT, Hellman S, Rosenberg SA, eds. Cancer: Principles & Practices of Oncology. 8th ed.
Philadelphia: Lippincott Williams & Wilkins; 2008.
Dorr RT, Fritz WL. Cancer Chemotherapy Handbook. New York: Elsevier; 1980.
Medina PJ, Fausel C. Cancer treatment and chemotherapy. In: Dipiro JT, Talbert RL, Yee GC, et
al., eds. Pharmacotherapy: A Pathophysiologic Approach, 7th ed. New York: McGraw-Hill;
2008:2085-120.
Mueller BA, Schumock GT, Bertch KE, et al., eds. Pharmacotherapy Self-Assessment Program. 4th
ed. Book 10, Hematology/oncology. Lenexa, Kans.: American College of Clinical Pharmacy;
2002.
National Comprehensive Cancer Network. NCCN clinical practice guidelines—Antiemesis. Ver. 3.

2009. Available at: www.nccn.org.
20. Solid Organ Transplantation - Benjamin Duhart, Jr, MS, PharmD
20-1. Organ Transplantation
Principles of Transplantation
Types of allografts
• Heart: First successful transplant occurred in 1968. In 2007, 2,141 heart transplants were
performed in the United States.
• Intestines: First successful transplant occurred in 1987. In 2007, 57 intestinal transplants were
performed in the United States.
• Kidney: First successful cadaveric transplant occurred in 1954. In 2007, 16,119 kidney
transplants were performed in the United States.
• Liver: First successful cadaveric transplant occurred in 1967. In 2007, 5,890 liver transplants
were performed in the United States.
• Lung: First successful cadaveric single-lung transplant occurred in 1983. In 2007, 1,461 lung
• Pancreas: First successful solitary pancreas transplant occurred in 1968. In 2007, 1,304 pancreas
Goal
The goal is to improve patients' quality of life and survival by stabilizing and improving end-organ
failure-related complications.
Patient and Graft Outcomes
Table 20-1 shows the patient and graft survival rates for transplant recipients.
Definitions
• Acute rejection: A systemic immunologic response to donor antigens primarily mediated by T-

lymphocytes
• Adaptive immunity: Involves the stimulation of cells and soluble mediators in response to
specific antigens with a markedly enhanced response on repeat exposure
• Complement: An enzyme system that is a crucial part of the basic immune response on primary
exposure to an antigen and that also provides augmented signaling during memory immunity
• Human leukocyte antigen (HLA): Antigen-binding proteins that rescue protein fragments from
intracellular catabolism (class I or II) or select antigens from the extracellular milieu that are then
presented to lymphocytes (class II)
• Induction: Administration of short-term antibody therapy prior to and during the initial transplant
as prophylaxis for acute rejection
• Innate immunity: Involves the stimulation of cells and soluble mediators that nonspecifically
recognize antigens and have no ability to alter response with repeat exposure
• Major histocompatibility complex (MHC): A group of genes that encode for HLAs class I and
II
• Opsonization: Occurs when antigens or immune complexes become coated with a molecule that
facilitates binding with a phagocyte
• Panel reactive antibody (PRA): A test that quantifies a patient's immunologic reactivity to a
given pool of antigens
• Phagocytosis: A process by which recognized antigens are engulfed and subsequently undergo
intracellular catabolism
[Table 20-1. Kaplan-Meier Patient and Graft Survival Rates for Transplant Recipients]
Basic Immunology and Acute Rejection
Fundamental types of immunity
Innate immunity
Cellular components
• Macrophages: Phagocytic cells found throughout the body, which may function as antigen-
presenting cells
• Neutrophils: Highly motile cells whose major physiologic role is the destruction of invading
microorganisms through phagocytosis or opsonization
• Natural killer cells: A subset of non-B- and non-T-lymphocytes that survey for the normal
biosynthesis and expression of HLA class I, making them important in immunity against viral
infection and malignancy
Humoral components
• Complement: Activation leads to formation of lipophilic complexes, called membrane-attack
complexes, in the cell membrane of the target cell and results in osmotic leakage.
• Physiologic function: Humoral component provides a defense against pyogenic bacterial

infections.
• Bridges innate and adaptive immunity
• Mediates disposal of immune complexes
• Consists of acute phase proteins
Adaptive immunity
Cellular components
• Thymus-derived lymphocytes (T-cells): Mature T-cells become activated when they encounter
an antigen-presenting cell (APC). T-cells do not recognize antigens directly.
• CD4+ T-cells (helper T-cells) recognize antigen presented via HLA class II.
• CD8+ T-cells (cytotoxic T-cells) recognize antigen presented via HLA class I.
• Bone marrow-derived lymphocytes (B-cells): B-cells encounter the antigen to which their
surface immunoglobulin has specificity, through either its APC function or by interaction with an
activated CD4+ T-cell. B-cell-CD4+ T-cell interaction is required for translocation into a follicle
within secondary lymphoid tissue, where a germinal center forms and where high-affinity
memory B-cells and plasma cells are produced and selected (somatic hypermutation).
Humoral components
• Complement: See the previous section on innate immunity.
• Immunoglobulin (Ig): This complex protein of various isotypes is formed as a consequence of B-

cell activation for the purpose of binding and elimination of the activating antigen.
Acute rejection
Pathophysiology
During transplantation, the recipient is exposed to donor antigens to which he or she has no
previous exposure. Although undesirable, acute rejection is the normal physiologic response of the
immune system to these donor antigens. This response can be divided into five basic phases:
1. Recognition: Foreign antigen is recognized via self-or nonself-recognition mediated through

MHC.
2. Presentation: On recognition, APC present antigens in association with native HLA class II to
inactive CD4+ T-cells.
3. Activation and proliferation: Activation depends on antigen-HLA binding to the T-cell
receptor (TCR) complex and the subsequent binding of a second signal or "co-stimulatory
pathway." Subsequently, the active CD4+ T-cell produces and releases various lymphokines,
particularly interleukin-2 (IL-2), which is important for activation and proliferation of numerous
lymphocyte lineages.
4. Recruitment: Recruitment is mediated through several lymphokines produced as a consequence
of lymphocyte activation.
5. Antigen and tissue destruction: Tissue injury is mediated through induction of polyclonal
immune response.
Incidence
The incidence is organ specific and depends on many pre- and post-transplant factors. Several
known factors increase risk:
• Increased HLA mismatch
• Factors affecting previous sensitization (e.g., history of pregnancy, previous transplantation,

previous rejection, or panel reactive antibody > 20%)
• Ethnicity (i.e., African American recipients)
• Age (i.e., pediatric recipients)
• Donor source (i.e., cadaveric donor)
• Prolonged preservation time
• Noncompliance
Immunosuppressive Strategies
Balance of immunosuppression
Selection of an immunosuppression regimen for the prevention of acute rejection should be

individualized on the basis of known risk and potential for toxicity. Subsequent adjustment must
focus on the balance of the triad: rejection, infection, and toxicity.
Phases of preventive immunosuppression
Induction
The early phase is intended to provide highly potent, multifocal suppression of the immune system
for several days to a few weeks. Commonly used agents include the following:
• Corticosteroids
• Monoclonal antibody (muromonab, basiliximab, daclizumab)
• Polyclonal antibody (antithymocyte globulin—equine or rabbit)
Maintenance
The immunosuppression regimen is designed to provide chronic, balanced immunodeficiency.
Some commonly used regimens include the following:
• Double therapy:
• Calcineurin inhibitor + steroids
• Calcineurin inhibitor + antimetabolite
• Calcineurin inhibitor + mTOR (mammalian target of rapamycin) inhibitor
• mTOR inhibitor + steroids
• mTOR inhibitor + antimetabolite
• Antimetabolite + steroids
• Triple therapy:
• Calcineurin inhibitor + antimetabolite + steroids
• mTOR inhibitor + calcineurin inhibitor + steroids
• mTOR inhibitor + antimetabolite + steroids
Phases of immunosuppression during treatment
Treatment
Selection of the agents is organ specific and depends on the severity of acute rejection. Commonly
used agents include the following:
• Corticosteroids
• Calcineurin inhibitor
• Tacrolimus may be used as the primary treatment of acute rejection in liver recipients.
• Tacrolimus may also have a role as adjuvant therapy in refractory acute rejection in various
other solid organ recipients.
• Monoclonal antibody (muromonab)
• Polyclonal antibody (antithymocyte globulin—equine or rabbit)
Maintenance reevaluation
The decision to heighten maintenance immunosuppression depends on the cause for rejection (i.e.,
failure of regimen versus noncompliance).
Immunosuppressive Complications
Infectious
Infectious complications are an important cause of early morbidity and mortality. The incidence is
organ specific and is closely linked to the net degree of immunodeficiency. Prevention is a key
management strategy following transplantation. A list of infectious complications follows:
• Bacterial
• Tuberculosis: Mycobacterium tuberculosis
• Nocardiosis: Various species of Nocardia
• Fungal
• Aspergillosis: Various species of Aspergillus
• Blastomycosis: Blastomyces dermatitidis
• Candidiasis: Various species of Candida
• Coccidioidomycosis: Coccidioides immitis
• Cryptococcosis: Cryptococcus neoformans
• Histoplasmosis: Histoplasma capsulatum
• Mucormycosis: Various species of Mucor
• Pneumocystis pneumonia: Pneumocystis carinii (Pneumocystis jiroveci)
• Parasitic
• Toxoplasmosis: Toxoplasma gondii

• Viral
• Cytomegalovirus
• Epstein-Barr virus: including post-transplant lymphoproliferative disease
• Herpes simplex virus
• Varicella-zoster virus
• Human herpes viruses (i.e., HHV-6, HHV-8)
• Parvovirus
• Polyomavirus
Noninfectious
The noninfectious complications are specific to the agents included in the immunosuppressive
regimen.
20-2. Immunosuppressants
Introduction
Immunosuppressant drugs are described in

Table 20-2.
Calcineurin Inhibitors
Cyclosporine
Mechanism of action
Cyclosporine inhibits calcineurin-dependent translocation of the cytosolic subunit of NFAT
(nuclear factor of activated T-cells), the promoter gene for IL-2, into the nucleus, thereby inhibiting
transcription and synthesis of IL-2; thus, it inhibits IL-2-mediated monoclonal T-cell proliferation
and polyclonal T-cell activation.
Administration
• Intravenous
• Administer 5-6 mg/kg per day divided every 12 hours or as a continuous infusion. Each
milliliter of IV concentrate should be diluted in 20-100 mL of normal saline (NS) or 5%
dextrose in water (D5W) in a glass container. For bolus dosing, the dose should be infused
over 2-6 hours.
• Oral
• Capsules: Administer the daily dose as two equally divided doses every 12 hours with meals.
• Oral solution: Administer the daily dose as two equally divided doses every 12 hours with
meals. The solution may be diluted with chocolate milk or orange juice in a glass container.
Additional diluent should be used to rinse the container to ensure administration of the total
dose.
The drug is metabolized primarily via cytochrome P450 (CYP450) 3A isoenzymes. Substances
known to alter functionality of these enzymes will alter bioavailability and elimination of this drug (
Table 20-3).
Drug interactions lead to altered exposure of other drugs by cyclosporine (

Table 20-4).
• Altered biliary flow: Diversion of biliary flow can significantly reduce adsorption. This more
profoundly affects cyclosporine USP (United States Pharmacopeia) than it does cyclosporine
USP (modified).
• Diabetes mellitus: Administration worsens glycemic control in patients with preexisting diabetes.
• Vaccination: In general, immunosuppressants may affect efficacy of vaccinations. The use of live
vaccines should be avoided.
• Central nervous system (CNS): Seizure, hallucinations, insomnia, tremor, paresthesias
• Head, ears, eyes, nose, and throat (HEENT): Gingival hyperplasia
• Cardiovascular (CV): Hypertension
• Gastrointestinal (GI): Hepatotoxicity
• Renal: Nephrotoxicity
• Endocrine and metabolic: Diabetes mellitus, hyperlipidemia, hyperuricemia, hyperkalemia,

hypomagnesemia
• Dermatologic: Hirsutism, hypertrichosis, acne
[Table 20-2. Immunosuppressant Drugs]
[Table 20-3. Drug Interactions Leading to Altered Exposure of CYP450 3A Isoenzyme Substrates]
• Keep cyclosporine stored in its original container.
• Take the prescribed dose twice daily with meals.
• Keep timing of dosing consistent.
• Make sure you take or do not take your medication at the appropriate time prior to therapeutic
drug monitoring.
• Many medications interact with this medication. Do not take anything prescribed by another
physician until you verify that there are no drug interactions.
Monitoring
• C0 (trough): Goals depend on multifactorial risk assessment and assay type.
• C2 (concentration 2 hours after dose): Goals depend on multifactorial risk assessment and assay
type.
Pharmacokinetics
• Cyclosporine USP: Highly lipoprotein bound
• Bioavailability: significant intra- and interpatient variability
[Table 20-4. Drug Interactions Leading to Altered Exposure of Other Drugs by Cyclosporine]
• Mean F = 30%, range 5% to 92%
• Elimination: half-life = 19 hours; range 10-28 hours (increased with hepatic dysfunction)
• Cyclosporine USP (modified): Highly lipoprotein bound
• Bioavailability: improved and more consistent absorption (60-70% increased Cmax)
Tacrolimus
Mechanism of action
Tacrolimus inhibits translocation of the cytosolic subunit of NFAT, the promoter gene for IL-2, into
the nucleus via its binding with FKBP-12 and a calcium-calmodulin-calcineurin complex, thereby
inhibiting transcription and synthesis of IL-2. Thus, it inhibits IL-2-mediated monoclonal T-cell
proliferation and polyclonal T-cell activation.
Administration
• Intravenous: Dilute in NS or D5W to a concentration between 0.004 and 0.02 mg/mL, and
administer as a continuous infusion via a PVC (polyvinylchloride)-free container and tubing.
• Oral: Administer two equally divided doses po every 12 hours consistently, with or without food.
Because tacrolimus is metabolized primarily via CYP450 3A isoenzymes, substances known to
alter functionality of these enzymes will alter bioavailability and elimination of this drug (Table 20-
3).
• Vaccinations: In general, immunosuppressants may affect efficacy of vaccinations. The use of

live vaccines should be avoided.
• CNS: Seizure, hallucinations, insomnia, tremor, depression, psychosis, anorexia
• HEENT: Alopecia
• CV: Hypertension
• GI: Hepatotoxicity
• Renal: Nephrotoxicity
• Endocrine and metabolic: Diabetes mellitus, hyperlipidemia, hyperkalemia, hypercalcemia,

hypomagnesemia, hypophosphatemia
• Hematologic: Anemia
• Take the prescribed dose at a consistent time twice daily, with or without food, but always in the
same way to maintain consistency.
• Make sure you do not take your medication prior to therapeutic drug monitoring.
Monitoring
Monitor C0 (trough). Goals depend on multifactorial risk assessment (in general, 5-20 ng/mL).
Pharmacokinetics
• Highly protein bound
• Bioavailability: F = 14-32%
mTOR Inhibitor
Sirolimus
Mechanism of action
Sirolimus binds to FKBP-12 to form a complex that binds and inhibits activation of its target
protein, mTOR (mammalian target of rapamycin), a kinase that is critical in IL-2-mediated cell-
cycle progression.
Administration
• To limit variability, administer consistently with or without food.
• With tablets, administer daily dose po once a day.
• With oral solution, dilute the dose in 2 oz of water or orange juice, stir vigorously, and drink at
once. Then refill container with 4 oz of the chosen fluid, stir vigorously, and drink.
Because sirolimus is metabolized primarily via CYP450 3A isoenzymes, substances known to alter
functionality of these enzymes will alter bioavailability and elimination of this drug (Table 20-3).
Additionally, the pharmacokinetic profile of sirolimus is significantly altered by concomitant

cyclosporine (Table 20-4).
• Liver transplantation: Sirolimus is associated with increased incidence of mortality, graft loss,
and hepatic artery thrombosis in de novo liver transplant recipients.
• Lung transplantation: There have been cases of fatal bronchial anastomotic dehiscence in de
novo lung transplant recipients.

• CNS: Anorexia
• HEENT: Oral ulcers
• GI: Diarrhea, esophagitis, gastritis, gastroenteritis, hepatotoxicity, hepatic artery thrombosis in de

novo liver transplant recipients
• Renal: Synergistic nephrotoxicity with calcineurin inhibitors
• Endocrine and metabolic: Hyperlipidemia, hypertension, hyperkalemia
• Dermatologic: Rash, acne
• Hematologic: Leukopenia, thrombocytopenia, pancytopenia, thrombosis
• Other: Lymphocele, pneumonitis, bronchial anastomotic dehiscence in de novo lung transplant

recipients
• Take the prescribed dose at a consistent time once daily, with or without food, but in the same
way to maintain consistency.
Monitoring
Monitor C0 (trough). Goal depends on multifactorial risk assessment and assay type (in general, 5-
20 ng/mL).
Pharmacokinetics
• Bioavailability: tablet: F = 27%; oral solution: F = 15%
• Elimination: half-life = 57-63 hours (increased with hepatic dysfunction)
Antiproliferative Agents
Azathioprine
Mechanism of action
Azathioprine is a purine analogue prodrug, which is cleaved to 6-mercaptopurine; 6-mercaptopurine
is activated intracellularly to several active metabolites, which can be incorporated directly into
DNA (deoxyribonucleic acid) as thiopurine as well as interfere with the RNA (ribonucleic acid) and
DNA biosynthesis directly and via feedback inhibition.
Administration
• Intravenous: Dilute dose in NS or D5W and administer IV infusion over 5-60 minutes.
• Oral: Administer daily dose po once a day.
Xanthine oxidase is responsible for the elimination of the active metabolites of azathioprine.
Concomitant use of allopurinol with azathioprine results in significantly increased azathioprine-
induced toxicity. Reduce dose of azathioprine by 65-75%.
• Renal insufficiency: Bioavailability is significantly reduced in uremic patients.

• HEENT: Retinopathy
• GI: Nausea, vomiting, diarrhea, anorexia, pancreatitis, hepatotoxicity
• Dermatologic: Rash, skin cancer
• Hematologic: Leukopenia, thrombocytopenia, pancytopenia
• Take the prescribed dose at a consistent time once daily, with or without food, but take in the
same way to maintain consistency.
• Do not take anything prescribed by another physician until you verify that there are no drug
interactions.
Monitoring
No clinically important pharmacokinetic or pharmacodynamic monitoring exists.
Pharmacokinetics
• Bioavailability: F = 41-47%
• Bioavailability in uremic patients: F = 17%
Mycophenolate mofetil
Mechanism of action
Mycophenolate mofetil is metabolized to mycophenolic acid (MPA), which causes noncompetitive,
reversible inhibition of inosine monophosphate dehydrogenase, a critical enzyme in the de novo
pathway of purine synthesis, which is crucial during lymphocyte activation and proliferation.
Administration
• Intravenous: Dilute in D5W to a concentration of 6 mg/mL and infuse over at least 2 hours.
• Oral: Administer as equally divided doses po every 8-12 h consistently with or without food.
• Cyclosporine: See Table 20-4.
• Cholestyramine: Because of the interruption of enterohepatic recirculation, administration can

decrease MPA exposure.
• Colestipol and colesevelam: Simultaneous administration can decrease MPA exposure.
• Antacids: Simultaneous administration with magnesium- or aluminum-containing antacids

reduces absorption and decreases MPA exposure.
• Note: Efficacy of oral contraceptives may decrease with therapy. Additional birth control methods
are recommended.
• Severe renal impairment: Mycophenolate mofetil reduces protein binding of MPA.

• GI: Nausea, vomiting, diarrhea, abdominal pain
• Hematologic: Leukopenia, thrombocytopenia, anemia, pancytopenia
• Take the prescribed dose at consistent times during the day, with or without food, but in the same
way to maintain consistency.
Monitoring
Pharmacokinetics
• MPA is highly protein bound.
• Bioavailability: F = 94%
• Elimination: half-life = 16-18 hours
Mycophenolate sodium
Mechanism of action
Delayed-release tablets deliver MPA, which causes noncompetitive, reversible inhibition of inosine
monophosphate dehydrogenase, a critical enzyme in the de novo pathway of purine synthesis,
which is crucial during lymphocyte activation and proliferation.
Administration
Administer as equally divided doses po every 12 hours consistently without food.
• Cholestyramine: Administration interrupts enterohepatic recirculation and decreases MPA

exposure.
• Antacids: Simultaneous administration with magnesium- or aluminum-containing antacids
reduces absorption and decreases MPA exposure.
• Note: Efficacy of oral contraceptives may decrease with therapy. Additional birth control methods
are recommended.
• Severe renal impairment: Mycophenolate sodium reduces protein binding of MPA.

• GI: Nausea, vomiting, diarrhea, abdominal pain
• Hematologic: Leukopenia, thrombocytopenia, anemia, pancytopenia
• Take the prescribed dose at consistent times during the day, either 30 minutes before or 2 hours
after meals, but take the same way each day to maintain consistency.
Monitoring
Pharmacokinetics
• MPA is highly protein bound.
• Bioavailability: F = 72% to 92%
• Elimination: half-life = 8-16 hours
Corticosteroids
Selection of agent
Selection of the corticosteroid used is based on the ratio of glucocorticoid to mineralocorticoid

potency.
Intravenous agents are methylprednisolone and dexamethasone. Oral agents are prednisone,
prednisolone, and dexamethasone.
Mechanism of action
Corticosteroids bind to cytosolic glucocorticoid receptors, which translocate to the nucleus, where
the complexes bind to regulatory DNA sequences, glucocorticoid-responsive elements (GREs)
within the promoter section of various genes. Activation of these GREs modifies activities of
promoter genes such as NFAT, AP-1, and NF- B, which results in downregulation of expression of
HLA and numerous cell adhesion molecules, as well as decreased synthesis of numerous
lymphokines responsible for activation, proliferation, and migration (i.e., IL-1, IL-2, IL-6, IL-8,
IFN- , TNF- ).
Administration
Administration depends on the individual agent.
Because corticosteroids are metabolized primarily via CYP450 3A isoenzymes, substances known
to alter functionality of these enzymes will alter bioavailability and elimination of these drugs
(Table 20-3).
• Osteopenia and osteoporosis: Administration alters calcium and phosphate absorption and
excretion, as well as osteoblast activity, resulting in progression of bone loss that is common in
metabolic diseases such as end-stage renal disease and liver failure.

The incidence and extent of most adverse drug reactions with corticosteroids depend on the ratio of
glucocorticoid to mineralocorticoid potency. Adverse drug events include the following:
• CNS: Seizure, psychosis, delirium, hallucinations, mood swings, insomnia, pseudotumor cerebri
• HEENT: Cataracts, glaucoma
• CV: Hypertension, cardiomyopathy
• GI: Increased appetite, gastroesophageal reflux disease, peptic ulcer disease, pancreatitis
• Renal: Edema, alkalosis, hyperkalemia
• Endocrine and metabolic: Diabetes mellitus, hyperlipidemia, hypothalamic-pituitary-adrenal

axis suppression, growth suppression
• Dermatologic: Hirsutism, acne, skin atrophy, impaired wound healing
• Hematologic: Transient leukocytosis
• Musculoskeletal: Arthralgia, myopathy, osteoporosis, avascular necrosis
• When taking orally, take daily dose in the morning with food.
• Many drugs interact with these agents. Do not take anything prescribed by another physician until
you verify that there are no drug interactions.
Monitoring
Pharmacokinetics
Pharmacokinetics depend on the individual agent.
Monoclonal Antibodies
Orthoclone OKT3
Mechanism of action
Murine monoclonal IgG binds to and facilitates removal of cell lines expressing CD3. CD3, part of
the T-cell receptor complex, is an important molecule that distinguishes T-cells. CD3 is important
in antigen recognition and antigen-specific signal transduction.
Administration
• Premedication:
• Dose 1: Intravenous steroids, acetaminophen, and antihistamines taken 1 hour prior to the dose
are strongly recommended to modify first-dose reactions.
• Subsequent doses: Take acetaminophen and antihistamines 1 hour prior to the dose with
steroids as needed for infusion-related reactions.
• Dosing:
• Prior to administration, volume status must be carefully assessed.
• Patients with evidence of volume overload or uncompensated congestive heart failure on chest
x-ray should not receive this drug.
• The dose should be administered via IV bolus over less than a minute.
No clinically significant interactions occur.
• Uncompensated congestive heart failure or volume overload presents risk of fatal pulmonary
edema.
• In general, immunosuppressants may affect efficacy of vaccinations. The use of live vaccines
should be avoided.
• CNS: Dizziness, headache
• HEENT: Photophobia
• CV: Tachycardia
• Hematologic: Transient lymphopenia, pancytopenia
• Musculoskeletal: Rigor, tremor
• Other: Fever, chills, dyspnea, pulmonary edema
Report any shortness of breath, palpitations, light-headedness, tremor, fever, or itching to your
medical care provider immediately.
Monitoring
Monitor CD3 (suppression of CD3 lineage < 25 cells/mm3).
Pharmacokinetics
Elimination: half-life = 18 hours
Basiliximab
Mechanism of action
Chimeric (murine and human), monoclonal IgG specifically binds to the subunit, CD25, of the
human high-affinity IL-2 receptor, which is expressed only on activated lymphocytes. In this way,
basiliximab competitively inhibits IL-2 and facilitates preferential elimination of activated
lymphocytes.
Administration
Dilute to a concentration of 0.4 mg/mL in NS or D5W. Administer peripherally or centrally as a
bolus or continuous infusion over 20-30 minutes.
No clinically significant drug interactions occur.
In general, immunosuppressants may affect efficacy of vaccinations. The use of live vaccines
should be avoided.

Severe acute hypersensitivity reactions, including anaphylaxis, may occur within the 24 hours
following administration of the initial dose or on repeat exposure.
Report any shortness of breath, palpitations, light-headedness, or itching to your medical care
provider immediately.
Monitoring
Pharmacokinetics
• Adults (following a 20 mg IV infusion over 20 minutes):
• Mean Cmax = 7.1 ± 5.1 mg/L
• Mean half-life = 7.2 ± 3.2 days
• Children: Mean half-life = 11.5 ± 6.3 days
Pharmacodynamics
• Adults: CD25 saturation is at or above serum concentration of 0.2 mcg/mL. Mean duration of
saturation depends on concomitant immunosuppressive regimen.
• Children: CD25 saturation is similar to that seen in adults.
Daclizumab
Mechanism of action
Humanized monoclonal IgG specifically binds to the subunit, CD25, of the human high-affinity IL-
2 receptor, which is expressed only on activated lymphocytes. In this way, daclizumab
competitively inhibits IL-2 and facilitates preferential elimination of activated lymphocytes.
Administration
Dilute in 50 mL of NS and administer peripherally or centrally as a continuous infusion over 15
minutes.
In general, immunosuppressants may affect efficacy of vaccination. The use of live vaccines should
be avoided.

Severe acute hypersensitivity reactions, including anaphylaxis, have rarely occurred within the 24
hours following administration of the initial dose or on repeat exposure.
Report any shortness of breath, palpitations, light-headedness, or itching to your medical care
provider immediately.
Monitoring
Pharmacokinetics
• Adults (at recommended dosing):
• Mean Cmax: dose 1 = 21 ± 14 mg/mL; dose 5 = 32 ± 22 mg/mL
• Mean Cmin: dose 5 = 7.6 ± 4.0 mg/mL
• Half-life = 20 days
• Children (at recommended dosing):
• Mean Cmax: dose 1 = 16 ± 12 mg/mL; dose 5 = 21 ± 14 mg/mL

• Mean Cmin: dose 5 = 5.0 ± 2.7 mg/mL
• Half-life = 13 days
Pharmacodynamics
• Adults: CD25 saturation is at serum concentrations of 5-10 mg/mL. At recommended dosing,

saturation occurs for approximately 120 days.
• Children: CD25 saturation is at serum concentrations of 5-10 mg/mL. At recommended dosing,

saturation occurs for approximately 90 days.
Polyclonal Antibodies
Antithymocyte globulin (equine)
Mechanism of action
This antithymocyte globulin is purified, sterile, polyclonal IgG harvested from horses immunized
with human thymocytes. The preparation includes IgG directed against cell surface markers such as
CD2, CD3, CD4, CD8, CD11a, and CD 18. In this way, horse antithymocyte globulin targets
multiple phases of immunity, including T-cell activation, homing, and cytotoxic activities.
Administration
• Premedication:
• Dose 1: Giving intravenous steroids, acetaminophen, and antihistamines 1 hour prior to the
dose is strongly recommended to modify first-dose reactions.
• Subsequent doses: Give acetaminophen and antihistamines 1 hour prior to the dose with
steroids as needed for infusion reactions.
• Dosing:
• Dilute the dose to a concentration not to exceed 4 mg/mL in 1/2NS or D5W.
• Administer centrally over 4-6 hours.
In general, immunosuppressants may affect the efficacy of vaccinations. The use of live vaccines
should be avoided.
Most adverse drug reactions with antithymocyte globulin (equine) are infusion-related reactions
(i.e., fever, chills, and dyspnea); leukopenia; thrombocytopenia; or rash.
Monitoring
The goal for treatment of acute rejection is suppression of CD3 lineage to <50 cells/mm3.
Pharmacokinetics
Elimination: half-life = 36 hours-12 days
Antithymocyte globulin (rabbit)
Mechanism of action
This antithymocyte globulin is purified, pasteurized, polyclonal IgG harvested from pathogen-free
rabbits immunized with human thymocytes. This preparation includes IgG directed against cell
surface markers, such as TCRab, CD2, CD3, CD4, CD5, CD6, CD7, CD8, CD11a, CD18, CD28,
CD45, CD49, CD54, CD58, CD80, CD86, HLA class I, and ²2 microglobulin. In this way, rabbit
antithymocyte globulin targets multiple phases of immunity, including T-cell activation, homing,
and cytotoxic activities.
Administration
• Premedication:
• Dose 1: Giving intravenous steroids, acetaminophen, and antihistamines 1 hour prior to the
dose is strongly recommended to modify first-dose reactions.
• Subsequent doses: Give acetaminophen and antihistamines 1 hour prior to the dose with
steroids as needed for infusion reactions.
• Dose:
• Dilute dose to a concentration of 0.5 mg/mL in NS or D5W.
• Administer centrally over 4-6 hours.
In the case of immunoglobulin, administration may decrease the degree of lymphocyte depletion
achieved.
In general, immunosuppressants may affect efficacy of vaccinations. The use of live vaccines
should be avoided.

Most adverse drug reactions with antithymocyte globulin (rabbit) are infusion-related reactions (i.e.,
fever, chills, and dyspnea); leukopenia; thrombocytopenia; or rash.
Monitoring
The goal for treatment of acute rejection is suppression of CD3 lineage to < 50 cells/mm3.
Pharmacokinetics
A two-compartment model is used. For terminal elimination, half-life = 2-3 days for first dose;
range = 14-45 days with multiple doses.
20-3. Key Points
• The goal of solid organ transplantation is to improve patients' quality of life and survival by
stabilizing or improving complications related to end-organ failure.
• The immune system is a highly intricate system with mechanisms for antigen recognition in a
highly specific manner, as well as in a nonspecific manner.
• Acute rejection is a normal physiologic immune response to transplantation of donor antigens.
• The incidence of acute rejection is organ specific and depends on multiple pre- and post-transplant
factors.
• Selection of the post-transplant immunosuppression regimen for prevention of acute rejection

should be individualized on the basis of known risk and potential toxicity.
• Adjustment in the post-transplant immunosuppression regimen should focus on the balance

between acute rejection, infection, and toxicity.
• Selection of the agent to be used to treat acute rejection is organ dependent and depends on the
severity of acute rejection.
• Immunosuppressive complications, both infectious and noninfectious, are an important cause of

early morbidity and mortality and require close management following transplantation.
• Many agents commonly included in immunosuppression regimens require a clinician with

expertise in immunosuppressive therapeutic drug monitoring to optimize efficacy and reduce
toxicity.
• Many agents commonly included in immunosuppression regimens have the potential for
numerous pharmacokinetic and pharmacodynamic drug interactions.
20-4. Questions
Patient Profile 1—City Hospital

Address: 101 South First Street
Height: 5´113
Patient name: Doe, John
Weight: 240 lb
Age: 52
Allergies: Sulfa
Gender: Male
Medications prior to hospital admission:
Ethnicity: African American
Prograf 4 mg po bid
Diagnoses:
Amaryl 4 mg po bid
h/o ESRD s/p cadaveric renal transplant 3
mo ago Cellcept 750 mg po bid
DM × 20 yrs Metoprolol 100 mg po bid
HTN × 30 yrs Diflucan 200 mg po qd
Drug-induced hyperkalemia Dapsone 100 mg po qd
Current laboratory results: Valcyte 450 mg po qd
SCr = 1.2 EC ASA 81 mg po qd
K = 5.3 Prednisone 5 mg po qd
WBC 3.8 Additional medications prescribed during hospital

course:
Plt 120
Lasix 40 mg po bid
Imuran 100 mg po qd
Which medication(s) should be given with caution because of the patient's sulfonamide
allergy?
I. Lasix
II. Dapsone
III. Amaryl
1.
A. I only
B. II only
C. I and III only
D. II and III only
E. I, II, and III

Which of the following combinations of drugs represent therapeutic duplication?
A. Prograf and Imuran

2. B. Azathioprine and CellCept
C. Dapsone and Valcyte
D. Amaryl and Tacrolimus
E. Prednisone and CellCept

Which of the following combinations of drugs interact?
I. Diflucan and tacrolimus

II. Diflucan and Valcyte
III. Dapsone and Lasix
3.
A. I only
B. II only
C. I and II only
D. II and III only
E. I, II, and III

Mr. Doe was diagnosed with drug-induced hyperkalemia. Which medication on his profile
could be responsible for this?
A. CellCept
4.
B. Lasix
C. Prednisone
D. Prograf
E. EC ASA

Which medication(s) is (are) classified as a calcineurin inhibitor?
I. Rapamune
II. Cyclosporine
III. Tacrolimus
5.
A. I only
B. II only
C. III only
D. II and III
E. I and III

Which medication(s) cause myelosuppression?
I. Sirolimus
II. Mycophenolate mofetil
III. Valcyte
6.
A. I only
B. II only
C. III only
D. I, II, and III
E. II and III

Which medication(s) require bile for emulsification and absorption?
A. Imuran
7. B. Cyclosporine
C. Prograf
D. Prednisone
E. All of the above

All of the following are known adverse effects of cyclosporine except
A. hirsutism.
8. B. nephrotoxicity.
C. oral ulceration.
D. gingival hyperplasia.
E. hyperlipidemia.

All of the following are contraindications or precautions associated with Rapamune except
A. de novo lung transplant recipient.
9. B. hyperlipidemia.
C. diabetes mellitus.
D. de novo liver transplant recipient.
E. allergy to sirolimus.

What is the generic name for Imuran?
A. Mycophenolate mofetil
10. B. Azathioprine
C. Cyclosporine
D. Tacrolimus
E. Prednisone

Which of the immunosuppressive medication(s) listed may cause diabetes mellitus?
I. Prednisone
II. Azathioprine
III. Tacrolimus
11.
A. I only
B. II only
C. III only
D. I and III
E. I, II, and III

Which medication(s) require(s) therapeutic drug monitoring via trough concentrations?
A. Mycophenolate mofetil
12. B. Prograf
C. Daclizumab
D. Basiliximab
E. Mycophenolate mofetil and Prograf

Which medication(s) select(s) for destruction of activated lymphocytes by binding to the CD25
subunit of the high affinity IL-2 receptor?
I. Antithymocyte globulin (rabbit)

II. Antithymocyte globulin (equine)
III. Daclizumab
13.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

All of the following increase the risk of acute rejection except
A. pediatric recipient.
14. B. HLA mismatch.
C. living donor.
D. noncompliance.
E. history of previous transplantation.

Which of the following produces a significant pharmacokinetic interaction when administered
with azathioprine?
A. Allopurinol
15.
B. Diflucan
C. Sirolimus
D. Probenecid
E. Allopurinol and probenecid

Which of these conditions alter(s) the pharmacokinetic profile of cyclosporine?
I. Biliary obstruction
II. Malnutrition
III. Hyperglycemia
16.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

Which of the following medication(s) interact(s) with sirolimus?
I. Erythromycin
II. Prevalite
III. Diltiazem
17.
A. I only
B. II only
C. III only
D. I and III
E. II and III

Which of the following immunosuppressants should not be administered at the same time
secondary to an interaction related to timing of doses?
I. Prograf and mycophenolate mofetil

II. Rapamune and cyclosporine
III. Neoral and azathioprine
18.
A. I only
B. II only
C. III only
D. None of these interact.
E. II and III

Which type of immunity involves stimulation of cells and soluble mediators that
nonspecifically recognize alloantigens with no altered response on repeat exposure?
A. Autoimmunity
19.
B. Innate immunity
C. Adaptive immunity
D. Acute rejection
E. Hyperacute rejection

Which group of genes encodes for antigens that are responsible for self- or nonself-
recognition?
I. Class I human leukocyte antigen (HLA)

II. Class II human leukocyte antigen (HLA)
III. Major histocompatibility complex (MHC)
20.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

On binding of antigen displayed by the antigen-presenting cell to the T-cell receptor complex,
what additional step is required for T-helper-cell activation?
I. Binding of the co-stimulatory pathway (i.e., CD58/CD2)

II. Activation of the promoter gene NFAT
III. Transcription of the IL-2 gene
21.
21.
A. I only
B. II only
C. III only
D. No additional step is required.
E. I and II

Which cytokine released by activated CD4+ lymphocytes plays a major role in the subsequent
activation of numerous lymphocyte lineages?
A. Interleukin-1 (IL-1)
22.
B. Tumor necrosis factor-± (TNF-±)
C. Interleukin-2 (IL-2)
D. Interferon-³ (IFN-³)
E. Complement

Which solid organ was the first to be successfully transplanted?
A. Heart
23. B. Liver
C. Kidney
D. Lung
E. Pancreas

What is the 1-year patient survival rate for renal transplant recipients?
A. > 90%
24. B. 60-70%
C. 25-50%
D. < 25%
E. Limited data available; currently an experimental procedure

20-5. Answers
C. Lasix and Amaryl are structurally similar to sulfonamides and would be expected to elicit a
1. similar allergic response. Dapsone is a sulfone and would not be expected to elicit an allergic
response.

B. Both azathioprine and CellCept are classified as antiproliferative agents. Both agents inhibit
2.
purine biosynthesis and would not act synergistically.

A. Diflucan is an inhibitor of cytochrome P450 3A isoenzymes, which is the enzyme system
3.
that is responsible for metabolism of tacrolimus.

4. D. Hyperkalemia (incidence 20-40%) is a well-documented adverse drug reaction with Prograf.

5. D. Both cyclosporine and tacrolimus are calcineurin inhibitors.

D. All of the listed agents have myelosuppressive properties when administered individually.
6.
When they are administered concurrently, the myelosuppression is synergistic.

7. B. Cyclosporine is highly lipophilic and requires bile for emulsification and absorption.

C. Hirsutism, nephrotoxicity, gingival hyperplasia, and hyperlipidemia are known adverse
8.
effects of cyclosporine. Oral ulceration is not an adverse effect of cyclosporine.

C. The use of Rapamune (sirolimus) in de novo lung and liver transplant recipients is
contraindicated because of an increased incidence of fatal adverse drug reactions. Additionally,
9.
use of Rapamune in patients with uncontrolled hyperlipidemia is strongly discouraged because
of its profound effects on lipid biosynthesis and catabolism.

10. B. Azathioprine is the generic name for Imuran.

D. Prednisone and tacrolimus may cause diabetes mellitus. Azathioprine does not produce a
11.
diabetogenic effect.

B. Prograf requires therapeutic drug monitoring via trough concentrations to obtain desired
12.
therapeutic effects.

C. Daclizumab selects for destruction of activated lymphocytes by binding to the CD25
13.
subunit of the high-affinity IL-2 receptor.

C. Of the listed parameters, all are considered to increase the risk of acute rejection except a
14.
living donor as the donor source.

A. Xanthine oxidase is responsible for the elimination of the active metabolites of
15. azathioprine. Concomitant use of allopurinol with azathioprine results in significantly
increased azathioprine-induced toxicity. Reduce the dose of azathioprine by 65-75%.

D. Both biliary obstruction and severe malnutrition would change the pharmacokinetic profile
of cyclosporine. Cyclosporine requires bile for emulsification and absorption. If bile flow is
16. obstructed, then the bioavailability is significantly decreased. Additionally, cyclosporine is a
highly lipoprotein-bound drug. In severe malnutrition, total protein stores are depleted, thereby
increasing the total free drug.

D. Both erythromycin and diltiazem are inhibitors of P450 3A isoenzymes, which is the
17.
enzyme system that is responsible for sirolimus metabolism.

B. Simultaneous administration of Rapamune (sirolimus) and cyclosporine increases Cmax and
area under the curve of sirolimus by 120-500% and 140-230%, respectively. Administration 4
18.
hours apart increases Cmax and area under the curve of sirolimus by 30-40% and 35-80%,
respectively.

B. Innate immunity is the fundamental type of immunity in which antigens are recognized in a
19.
nonspecific manner. This type of immunity is not augmented on repeat exposure.

C. Class I and II HLA are the actual antigens important for self- and nonself-recognition. The
20.
group of genes that encode for these antigens is the major histocompatibility complex.

A. Activation is dependent on antigen-HLA binding to the T-cell receptor complex and the
21.
subsequent binding of a second signal or "co-stimulatory pathway."

C. Active CD4+ T-cells produce and release various lymphokines, particularly IL-2, which is
22.
important for activation and proliferation of numerous lymphocyte lineages.

23. C. The kidney was the first organ to be successfully transplanted, in 1954.

A. According to Table 20-1, the 1-year patient survival rates for both cadaveric and living
24.
donor renal transplant recipients are 94.8% and 98.0%, respectively.

20-6. References
Budde K, Curtis J, Knoll G, et al. Enteric-coated mycophenolate sodium can be safely administered
in maintenance renal transplant patients: Results of a 1-year study. Am J Transplant. 2003;4:237-
43.
Christians U, Jacobsen W, Benet LZ, Lampen A. Mechanisms of clinically relevant drug

interactions associated with tacrolimus. Clin Pharmacokinet. 2002;41:813-51.
Cotts WG, Johnson MR. The challenge of rejection and cardiac allograft vasculopathy. Heart Fail
Rev. 2001;6:227-40.
Delves PJ, Roitt IM. The immune system: First of two parts. N Engl J Med. 2000;343:37-49.
Delves PJ, Roitt IM. The immune system: Second of two parts. N Engl J Med. 2000;343:108-17.
Dunn CJ, Wagstaff AJ, Perry CM, et al. Cyclosporin: An updated review of the pharmacokinetic
properties, clinical efficacy, and tolerability of a microemulsion-based formulation (Neoral) in
organ transplantation. Drugs. 2001;61:1957-2016.
Galley BJ, Perez RV, Ramsamooj R. Acute renal transplant injury and interaction between
antithymocyte globulin and pooled human immunoglobulin. Clin Transplant. 2004;18:327-31.
Kelly P, Kahan BD. Review: Metabolism of immunosuppressant drugs. Curr Drug Metab. 2002;3:
275-87.
Klupp J, Holt DW, van Gelder T. How pharmacokinetic and pharmacodynamic drug monitoring
can improve outcome in solid organ transplant recipients. Transpl Immunol. 2002;9:211-14.
Neuberger J. Incidence, timing, and risk factors for acute and chronic rejection. Liver Transpl Surg.
1999;5(suppl 1):S30-36.
Salvadori M, Holzer H, de Mattos A, et al. Enteric-coated mycophenolate sodium is therapeutically

equivalent to mycophenolate mofetil in de novo renal transplant patients. Am J Transplant. 2003;
4:231-6.
21. Gastrointestinal Diseases - Christa M. George, PharmD, BCPS, CDE
21-1. Peptic Ulcer Disease
Definition and Incidence
Peptic ulcer disease (PUD) is a group of disorders of the upper gastrointestinal (GI) tract
characterized by ulcerative lesions that depend on acid and pepsin for their formation.
Approximately 1.5 million to 2 million Americans have an active ulcer at any given time. Annually
in the United States, 500,000 new cases are diagnosed.
The U.S. lifetime prevalence of PUD ranges from 11% to 20% for men and from 8% to 11% for
women. PUD has been estimated to cost $10 billion per year in the United States.
Classification
Ulcers are either duodenal or gastric in nature. Duodenal ulcers are more common.
Duodenal and gastric ulcers are classified as Helicobacter pylori related, nonsteroidal anti-
inflammatory drug (NSAID) related, non-H. pylori related, non-NSAID related, or stress related.
Epigastric pain occurring 1-3 hours after meals that is relieved by ingestion of food or antacids is
the classic presentation of PUD. Pain typically occurs in episodes lasting weeks to months and may
be followed by variable periods of spontaneous remission and recurrence.
Ten percent of patients with PUD present with complications and have no prior history of pain.
Pathophysiology
Duodenal ulcers result from the imbalance between duodenal acid load and the acid-buffering
capacity of the duodenum. Duodenal ulcers are more frequently associated with an antrum-
predominant gastritis.
H. pylori is a gram-negative microaerophilic bacterium that inhabits the area between the stomach's
mucosal layer and epithelial cells. The bacteria can be found anywhere gastric epithelium is present.
Over 50% of the world's population is colonized by H. pylori, but only 15% of colonized
individuals develop clinical symptoms of PUD. The prevalence of H. pylori is decreasing in
developed countries. It has been estimated that 30-40% of the U.S. population is infected with H.
pylori.
H. pylori causes duodenal inflammation, increases duodenal acid load, and impairs duodenal
bicarbonate secretion, which leads to duodenal ulcers. It causes inflammation of gastric epithelium,
particularly in the antrum-corpus area. The inflammation disrupts mucosal defense, which also
leads to gastric ulcers.
NSAIDs are the leading cause of PUD in patients negative for H. pylori infection. They are directly
toxic to gastric epithelium and inhibit the synthesis of prostaglandins.
Inhibition of prostaglandin synthesis leads to decreased secretion of bicarbonate and mucus,

decreased mucosal perfusion, decreased epithelial proliferation, and decreased mucosal resistance
to injury.
NSAIDs may cause gastric or duodenal ulcers (more frequently gastric). Gastric ulcers are
associated with a corpus-predominant (i.e., diffuse-predominant) gastritis. This pattern of gastritis is
associated with low acid output, gastric atrophy, and adenocarcinoma.
Diagnostic Criteria
Upper GI endoscopy is used to diagnose PUD. The procedure is usually reserved for patients with
symptoms of PUD who are over 55 years of age or who have alarm symptoms (bleeding, anemia,
early satiety, unexplained weight loss, progressive dysphagia, odynophagia, recurrent vomiting,
family history of GI cancer, previous esophagogastric cancer).
Patients with symptoms of PUD who are under 55 years of age and have no alarm symptoms may
be tested for the presence of H. pylori and treated with eradication therapy if results are positive.
Available tests for H. pylori are divided into two groups: those that require endoscopy and those
that do not.
• Histology and rapid urease testing may be performed on biopsy samples taken during endoscopy.
• Rapid urease testing may be performed in patients who have not taken a proton pump inhibitor
(PPI) within 1-2 weeks or an antibiotic or bismuth within 4 weeks of the endoscopy. Histology
should be performed on patients who have recently taken PPIs, antibiotics, or bismuth.
• Culture and polymerase chain reaction testing are not yet widely available for clinical use and
are thus not routinely recommended.
• Antibody testing, urea breath tests, and fecal antigen tests do not require endoscopy.
• Antibody testing should be avoided in populations with a low prevalence of H. pylori because
of the low positive predictive value in these populations.
• Urea breath tests and fecal antigen tests may be used to confirm eradication of H. pylori no
sooner than 4 weeks after completion of the treatment regimen.
The goals of PUD therapy include healing the ulcer and eliminating its cause. Additional
considerations include preventing complications and relieving symptoms.
Use of PPIs is associated with faster healing rates and symptom relief than treatment with histamine
2-receptor antagonists (H2RAs). (Note: H2RAs are less expensive.)
Choice of PUD therapy is based on the etiology of the case. For H. pylori-related PUD, antibacterial
therapy is used with antisecretory therapy.
• Eradication of H. pylori reduces the recurrence of PUD and is of prime importance.
• The American College of Gastroenterology treatment guidelines for H. pylori eradication in PUD
recommend initial triple therapy with a PPI, clarithromycin, and either amoxicillin or
metronidazole for 14 days or quadruple therapy with bismuth, metronidazole, tetracycline, and
either an H2RA or a PPI for 10-14 days.
• Sequential therapy starting with a PPI and amoxicillin for 5 days followed by a PPI and
clarithromycin for an additional 5 days requires further study.
• The eradication of H. pylori should be confirmed with urea breath testing or fecal antigen testing
no sooner than 4 weeks after completing eradication therapy.
• If a patient has persistent H. pylori infection after the initial eradication therapy regimen, salvage
therapy with bismuth quadruple therapy for 7-14 days should be administered.
For NSAID-related PUD, discontinuation of the offending agent is imperative.
• Antisecretory therapy with a PPI or an H2RA should be administered for 4 weeks to promote
healing and to relieve symptoms.
• If H. pylori is also present, antibacterial therapy should be initiated. Eradication of H. pylori does
not prevent NSAID-related complications or recurrence.
• PPIs, H2RAs, or misoprostol should be used to prevent PUD in patients who require chronic
NSAIDs and who are at risk of developing PUD (e.g., patients who are elderly or who have
concomitant cardiovascular disease, patients with a history of PUD, patients using high-dose
NSAID therapy, and patients who concomitantly use corticosteroids or anticoagulants).
Sucralfate may also be used to aid in ulcer healing, but it requires multiple daily dosing and is
associated with many significant drug interactions.
Non-H. pylori, non-NSAID-related PUD should be treated with antisecretory therapy.

Drug Therapy
Mechanism of action
PPIs suppress gastric acid secretion specifically by inhibiting the H+-K+-ATPase enzyme system of
the secretory surface of the gastric parietal cell.
H2RAs suppress gastric acid secretion by reversibly blocking histamine-2 receptors on the surface
of the gastric parietal cell.
Clarithromycin, amoxicillin, metronidazole, tetracycline, bismuth subsalicylate, and furazolidone

exhibit antibacterial effects against H. pylori.
When exposed to gastric acid, sucralfate forms a viscous adhesive that binds positively charged
protein molecules in the ulcer crater, thus forming a protective barrier that protects against back-
diffusion of hydrogen ions.
See
Table 21-1 for selected medications.
Patient counseling
Educate patients about the importance of completing the entire course of therapy to ensure the
eradication of H. pylori and to avoid bacterial resistance.
PPIs are best taken before eating. Lansoprazole and dexlansoprazole granules may be sprinkled
onto applesauce for patients who have trouble swallowing pills. Lansoprazole orally disintegrating
tablets should not be crushed or chewed. Omeprazole capsules should be swallowed whole.
Omeprazole over-the-counter (OTC) tablets should not be crushed or chewed. Omeprazole-sodium
bicarbonate capsules should be swallowed whole.
If antacids are being used to control breakthrough symptoms, the dose should be taken no less than
1-2 hours before or after an H2RA is taken. H2RAs may be taken without regard to meals.
Amoxicillin, clarithromycin, and metronidazole may be taken without regard to meals; however,
taking clarithromycin and metronidazole with meals often reduces the incidence of stomach upset.
Tetracycline is best taken on an empty stomach. Antacids, dairy products, or iron-containing

products should be taken 2 hours before or after tetracycline.
Sucralfate should be taken 1 hour before meals and at bedtime.

• Side effects occur in 15-20% of patients, but they are usually minor.
• PPIs and H2RAs are generally well tolerated, but headache, diarrhea, and nausea have been
reported.
[Table 21-1. Selected Medications Used in Peptic Ulcer Disease]
• Antibiotics may cause diarrhea, nausea, dysgeusia, rash, and monilial vaginitis.
• Bismuth subsalicylate may cause black, tarry stools.
• Constipation is the most common side effect of sucralfate.
Drug interactions
• Omeprazole inhibits the cytochrome P450 (CYP450) enzyme system, which decreases the
elimination of warfarin, phenytoin, diazepam, and cyclosporine. Lansoprazole has been reported
to increase theophylline clearance by approximately 10%.
• PPIs and H2RAs may alter the bioavailability of drugs that require an acidic environment for
absorption (e.g., ketoconazole, digoxin, and iron).
• Cimetidine is a potent inhibitor of the CYP450 enzyme system, which decreases the elimination
of numerous drugs (e.g., warfarin, theophylline, and phenytoin).
• Amoxicillin and tetracycline may decrease the effectiveness of oral contraceptives.
• Clarithromycin is a potent inhibitor of the CYP450 enzyme system, which decreases the
elimination of warfarin, digoxin, cyclosporine, carbamazepine, theophylline, and cisapride (no
longer on the market).
• Tetracycline may decrease the effectiveness of oral contraceptives. Antacids, iron products, and
dairy products bind to tetracycline, decreasing its effectiveness. Tetracycline can also increase the
therapeutic effect of warfarin. Tetracycline can increase or decrease lithium levels.
• Metronidazole produces a disulfiram-like reaction when ingested with alcohol and increases the
therapeutic effect of warfarin and lithium.
• Sucralfate leads to the absorption of small amounts of aluminum, which may accumulate if given
to patients with renal insufficiency (especially when combined with aluminum-containing
antacids).
• Sucralfate alters the absorption of numerous drugs, including warfarin, digoxin, phenytoin,
ketoconazole, quinidine, and quinolones.
• Disulfiram-like reactions have been reported with the concurrent ingestion of alcohol and
furazolidone.
Patients should monitor for the return of PUD symptoms and for the side effects of medications, as
discussed in the earlier sections.
Pharmacokinetics
Several medications are substrates for or have effects on the CYP450 enzyme system in the liver, as
discussed in the drug interactions section.
Nondrug Therapy and Complications
Patients should be counseled to decrease psychological stress and to discontinue smoking and
drinking alcohol, taking NSAIDs, and ingesting food or beverages that may exacerbate PUD
symptoms.
Major complications occur in approximately 25% of patients with PUD (hemorrhage, perforation,
penetration, and obstruction):
• Patients with active bleeding who are hemodynamically stable should receive intravenous PPI
therapy and undergo endoscopy to evaluate the risk of bleeding recurrence.
• Patients with active bleeding who are hemodynamically unstable should receive intravenous fluids
and blood transfusions. They should undergo emergency endoscopy for coagulation of bleeding
sites. Various modalities may be used to achieve bleeding-site coagulation.
• As soon as patients tolerate oral intake, intravenous PPI therapy should be changed to oral therapy.
• Surgery is reserved for those patients who have refractory ulcers, recurrent bleeding, or a
perforated ulcer.
21-2. Gastroesophageal Reflux Disease
Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of stomach
contents causes troublesome symptoms or complications.
The prevalence of GERD is highest in Western countries. It occurs equally in men and women,
except that its incidence is higher in pregnant women. The incidence of GERD is higher and more
frequently severe in Caucasians than in African Americans. Obesity has been strongly correlated to
the incidence of GERD. GERD may also occur in children. The risk of experiencing complications
from GERD increases with age.
Approximately 20% of the U.S. population experiences heartburn or regurgitation of gastric acid
weekly.
Approximately 30-50% of pregnant women have symptomatic esophageal reflux; 50% experience
heartburn daily.
Classification
The manifestations of GERD are divided into esophageal and extraesophageal syndromes.
Esophageal syndromes
Esophageal syndromes comprise those that are only symptomatic in nature and those that are
symptomatic with esophageal injury on endoscopy. Symptomatic syndromes include the typical
reflux syndrome and the reflux chest pain syndrome:
• The typical reflux syndrome is defined by the presence of troublesome heartburn, regurgitation, or
both. Patients may have other symptoms, such as epigastric pain or sleep disturbance.
• The reflux chest pain syndrome occurs when GERD causes chest pain that is similar to ischemic
cardiac pain. This pain can occur without concurrent heartburn or regurgitation.
Symptomatic syndromes with esophageal injury include GERD complications such as reflux
esophagitis, reflux stricture, Barrett's esophagus, and esophageal adenocarcinoma.
• Reflux esophagitis is characterized by visible breaks in the distal esophageal mucosa.
• A reflux stricture is defined as a persistent luminal narrowing of the esophagus caused by GERD.
• Barrett's esophagus occurs when esophageal squamous epithelium from the gastroesophageal
junction is replaced with metaplastic columnar epithelium. It is a risk factor for the development
of esophageal adenocarcinoma.
Extraesophageal syndromes
Extraesophageal syndromes include those syndromes that have established associations with GERD
and those with proposed associations with GERD.
Esophageal syndromes that have established associations with GERD include reflux cough
syndrome, reflux laryngitis syndrome, reflux asthma syndrome, and reflux dental erosion syndrome.
Esophageal syndromes that have proposed associations with GERD include pharyngitis, sinusitis,
idiopathic pulmonary fibrosis, and recurrent otitis media.
Heartburn and regurgitation are the common characteristic symptoms of the typical reflux
syndrome. Heartburn is defined as a burning sensation in the retrosternal area. Regurgitation is
defined as the perception of flow of refluxed gastric content into the mouth or hypopharynx.
Symptoms usually occur shortly after having a meal, when reclining after a meal, or on lying down
at bedtime. Symptoms often awaken patients from sleep.
Symptoms are exacerbated by eating a large meal (especially a high-fat meal), by bending over, and
occasionally by exercising.
Symptoms suggestive of complications from GERD include continuous pain, dysphagia,

odynophagia, bleeding, unexplained weight loss, and choking.
Symptom severity does not correlate with the degree of esophagitis present on endoscopy, but
severity usually does correlate with the duration of reflux.
Pathophysiology
The effortless movement of gastric contents into the esophagus is a physiologic process that occurs
numerous times daily throughout life and does not produce symptoms. It occurs more frequently in
patients with GERD.
The pathophysiology of GERD involves the prolonged contact of esophageal epithelium with
refluxed gastric contents containing acid and pepsin. Prolonged contact between esophageal
epithelium and gastric contents can overwhelm esophageal defense mechanisms and produce
symptoms.
Higher-potency gastric refluxate may produce symptoms during times of esophageal contact of
normal duration. The presence of refluxate in an esophagus with impaired defense mechanisms may
also produce symptoms.
Esophageal defenses consist of the antireflux barrier, luminal clearance mechanisms, and tissue
resistance.
• Components of the antireflux barrier are the lower esophageal sphincter (LES) and the diaphragm.
The LES is a thickened ring of circular smooth muscle localized to the distal 2-3 cm of the
esophagus. It is contracted at rest, thereby serving as a barrier to refluxate. The diaphragm
encircles the LES and acts as a mechanical support, especially during physical exertion.
• Luminal clearance factors include gravity, esophageal peristalsis, and salivary and esophageal
gland secretions (which contain acid-neutralizing bicarbonate).
• The three areas of tissue resistance are preepithelial, epithelial, and postepithelial defense.
Preepithelial and epithelial tissues limit the rate of diffusion of H+ between cell membranes.
Postepithelial defense is provided by the blood supply, which removes HCl and supplies oxygen,
nutrients, and bicarbonate.
Diagnostic Criteria
For patients who present with troublesome symptoms of GERD, a trial of empiric therapy is
appropriate. A diagnosis of GERD may be assumed for patients who respond to empiric treatment.
Diagnostic testing with endoscopy should be performed in patients who present with troublesome
GERD symptoms and dysphagia, weight loss, or epigastric mass on physical examination. It should
also be performed on patients who do not respond to empiric treatment.
• Endoscopy is the preferred method for evaluating the esophageal mucosa for esophagitis and for
evaluating for the presence of complications. It is a highly specific test, but it is not extremely
sensitive. Patients with symptoms may have normal esophageal mucosa.
• Esophageal manometry may be performed in patients with persistent symptoms despite an empiric
trial of twice-daily PPI therapy with normal esophageal mucosa on endoscopy. It consists of
passing a tube into the stomach and subsequently measuring pressures as the tube is pulled back
across the LES, esophagus, and pharynx. Esophageal manometry is often performed to facilitate
placement of ambulatory pH probes. It is always performed to aid in determining the best
procedure in antireflux surgery candidates.
• Ambulatory pH monitoring may be used to confirm the diagnosis of GERD in patients with
persistent GERD symptoms despite an empiric trial of PPI therapy, with normal esophageal
mucosa on endoscopy, and no abnormalities on esophageal manometry testing. It is performed by
passing a small electrode to measure pH intranasally to the level of 5 cm above the LES. This test
allows patient symptoms to be correlated with the timing of episodes of decreased pH levels in
the esophagus. It may not be available at all institutions.
Goals of therapy are to alleviate or eliminate symptoms, decrease frequency and duration of reflux,
promote healing of the injured mucosa, and prevent the development of complications.
Therapy is directed at increasing lower esophageal pressure, improving esophageal acid clearance
and gastric emptying, protecting esophageal mucosa, decreasing the acidity of refluxate, and
decreasing the amount of gastric contents being refluxed.
Acid suppression is the mainstay of therapy for patients with esophageal GERD syndromes. GERD
is considered a chronic condition, and most patients will require chronic therapy. Chronic therapy
should be titrated down to the lowest effective dose.
PPIs provide faster symptomatic relief and heal esophagitis more effectively than H2RAs. H2RAs
are more effective than placebo.
Antacids are appropriate self-treatment for patients with symptoms of GERD that are not
troublesome to the patient.
An empiric trial of once-daily PPI therapy is appropriate for patients with troublesome GERD
symptoms. If patients do not respond to once-daily therapy, twice-daily therapy may be used.
Patients with esophageal GERD syndromes and troublesome dysphagia should undergo endoscopy
to evaluate for the presence of reflux esophagitis, reflux stricture, Barrett's esophagus, or
esophageal adenocarcinoma.
An empirical trial of twice-daily PPI therapy may be used for patients with suspected reflux chest
pain syndrome after cardiac causes have been thoroughly considered.
Acute or maintenance therapy with once- or twice-daily PPIs may be used in patients with a
suspected extraesophageal GERD syndrome who also have esophageal GERD syndrome.
Antireflux surgery may be performed when a patient is responsive to, but intolerant of, acid
suppressive therapy or has persistent troublesome symptoms of GERD.
Drug Therapy
Mechanism of action
For information on H2RAs and PPIs, see the section on PUD.
Antacids neutralize gastric acid (which increases LES tone) and inhibit the conversion of
pepsinogen to pepsin, thus raising the pH of gastric contents.
Alginic acid reacts with sodium bicarbonate in saliva to form sodium alginate viscous solution,
which floats on the surface of gastric contents. The solution acts as a barrier to protect the
esophagus from the corrosive effects of gastric reflux.
See
Table 21-2 for selected medications.
[Table 21-2. Selected Antacids and Absorbents]
Patient counseling
Antacids and alginic acid are appropriate for the initial management of symptoms of GERD that are
not troublesome to the patient. Symptoms persisting longer than 2 weeks require further evaluation
and treatment with prescription medications.
Refrigeration of liquid antacids may aid in palatability. Chewable tablets may be more effective
than liquids because of increased adherence of antacid and saliva to the distal esophagus. Antacids
must be taken at least 2 hours apart from tetracyclines, iron, and digoxin. Antacids and quinolones
should be taken 4-6 hours apart.
Alginic acid is effective for the relief of GERD symptoms, but no data indicate esophageal healing
on endoscopy. Alginic acid is ineffective if the patient is in the supine position and must not be
taken at bedtime.
Magnesium-containing antacids frequently cause diarrhea. Aluminum-containing antacids

frequently cause constipation and bind to phosphate in the gut, which can lead to bone
demineralization. Antacids may also cause acid-base disturbances.
Magnesium and aluminum toxicity may occur when used chronically in patients with renal
insufficiency. Sodium bicarbonate may cause sodium overload, particularly in patients with
hypertension, congestive heart failure, and chronic renal failure. It may also lead to systemic
alkalosis. It should be used on a short-term basis, if at all.
Drug interactions
When taken with antacids, the absorption and effectiveness of tetracycline, ferrous sulfate, and
quinolones are reduced because the antacids form chelates with them. Antacids decrease the
absorption of azoles and sucralfate by increasing gastric pH. Antacids increase urine pH, which
decreases the renal clearance of quinidine. Antacids decrease the systemic absorption of digoxin
and H2RAs when taken concomitantly with them. Large doses of antacid may decrease the
absorption of phenytoin.
Digoxin and phenytoin levels should be monitored frequently when antacids are used
concomitantly. Suspected adverse effects of antacids should be reported to a health care provider.
Patients should monitor for the return of GERD symptoms and for the side effects of medications as
discussed in the previous section.
Pharmacokinetics
Several medications are substrates for or have effects on the CYP450 enzyme system in the liver.
See the discussion under drug interactions in Section 21-1.
Nondrug Therapy
• Lifestyle modifications alone are unlikely to control GERD symptoms. Lifestyle modifications
should be tailored to the circumstances of the individual patient.
• Weight loss should be recommended for overweight or obese patients with esophageal GERD
syndromes.
• Patients who experience GERD symptoms when recumbent should be advised to elevate the head
of the bed.
• Patients should be advised to avoid foods that exacerbate GERD symptoms (alcohol, coffee,
chocolate, high-fat foods, spicy foods, acidic foods, and carbonated drinks).
• Patients should be advised to adopt behaviors that reduce esophageal acid exposure, such as to
stop smoking, to avoid lying down for 2-3 hours after meals, and to eat smaller meals.
• Calcium channel blockers, -blockers, nitrates, barbiturates, anticholinergics, and theophylline

decrease LES pressure. Tetracyclines, NSAIDs, aspirin, bisphosphonates, iron, quinidine, and
potassium chloride have direct irritant effects on the esophageal mucosa.
21-3. Inflammatory Bowel Disease
Idiopathic inflammatory bowel disease (IBD) is divided into two major types:
• Ulcerative colitis (UC) is defined as a chronic mucosal inflammatory condition confined to the
rectum and colon.
• Crohn's disease (CD) is defined as a transmural inflammation of the GI tract that can affect any
part of the GI tract from mouth to anus.
The prevalence of UC is approximately 37.5-229.0 cases per 100,000 persons. The prevalence of
CD is approximately 50 cases per 100,000 persons.
Approximately 500,000 persons have CD and 500,000 persons have UC in the United States. UC is
slightly predominant in men; CD is predominant in women. The overall incidence of IBD is similar
between men and women.
North America, Scandinavia, and Great Britain have the highest incidence rates for IBD.
UC typically occurs in persons between 30 and 40 years of age. CD typically occurs between ages
20 and 30. Both may be diagnosed at any stage in life, but of all cases of IBD, 10-15% are
diagnosed before adulthood.
The incidence of IBD is low for Hispanics and Asian Americans. Its incidence in African
Americans has increased and is equal to that of Caucasians. In addition, its incidence rate is high
among the Jewish population in North America, Europe, and Israel.
Classification
The two major types of IBD are ulcerative colitis and Crohn's disease. Clinical presentation and
diagnostic tests help distinguish one form from the other.
IBD is characterized by acute exacerbations of symptoms followed by periods of remission that are
spontaneous or secondary to changes in medical therapy.
Ulcerative colitis
The hallmark clinical symptom of UC is bloody diarrhea, which is often accompanied by rectal
urgency and tenesmus.
The extent and severity of UC are characterized by clinical and endoscopic findings. Clinical
symptoms are categorized as mild, moderate, severe, and fulminant. Endoscopic findings are
categorized as distal (limited to below the splenic flexure) or extensive (extending proximal to the
splenic flexure).
• Mild UC is characterized by fewer than four stools per day with or without blood, without
systemic disturbance and with a normal erythrocyte sedimentation rate (ESR).
• Moderate UC is characterized by more than four stools per day with minimal signs of toxicity.
• Severe UC is characterized by more than six stools per day with blood; systemic disturbance (e.g.,
fever, tachycardia, anemia); and ESR greater than 30.
• Fulminant UC is characterized by more than 10 bowel movements per day, continuous bleeding,
toxicity, abdominal tenderness and distension, blood transfusion requirement, and colonic
dilation on abdominal plain films.
Crohn's disease
The presentation of CD is variable and its onset is often insidious. Typical symptoms include
chronic or nocturnal diarrhea and abdominal pain. Additional typical symptoms include weight loss,
fever, and rectal bleeding.
Clinical signs may include pallor, abdominal mass or tenderness, cachexia, perianal fissure, fistula,
or abscess.
Extraintestinal symptoms include inflammation of the skin, joints, and eyes.
Symptoms differ depending on the site and severity of inflammation:
• Mild to moderate: Patients are ambulatory and tolerate oral alimentation without dehydration;
toxicity (fever, rigors, or prostration); abdominal tenderness; painful mass or obstruction; or
weight loss > 10%.
• Moderate to severe: Patients fail to respond to treatment for mild to moderate disease or have
fever, weight loss, abdominal pain, nausea, vomiting (without obstruction), or anemia.
• Severe to fulminant: Patients have persistent symptoms despite the use of steroids or biologic
agents as outpatients, or individuals present with high fever, persistent vomiting, evidence of
obstruction, rebound tenderness, cachexia, or abscess.
Symptomatic remission occurs when a patient is asymptomatic or without any symptomatic

inflammatory sequelae.
The ileum and colon are the most commonly affected sites. Ileitis may mimic appendicitis.
Intestinal obstruction and inflammatory masses or abscesses may also develop. Patients with
colonic CD commonly have rectal bleeding, perianal lesions, and extraintestinal manifestations
(e.g., spondylarthritis, peripheral arthritis, erythema nodosum, pyoderma gangrenosum, uveitis,
fatty liver, chronic active hepatitis, cirrhosis, primary sclerosing cholangitis, gallstones, cholangio-
carcinoma, and hypercoagulability).
Oral CD is characterized by lesions ranging from a few aphthous ulcers to deep linear ulcers with
edema and induration. Gastroduodenal involvement may mimic PUD.
Pathophysiology
The etiology of UC and CD is unclear, but similar factors may contribute to both diseases. These
factors include infectious agents, genetics, environmental factors, immune deficits, and
psychological factors. Major etiologic theories involve a combination of infectious and
immunologic factors.
UC is confined to the rectum and colon and affects only the mucosa and submucosa. The primary
lesion of UC is a crypt abscess, which forms in the crypts of the mucosa. CD most commonly
affects the terminal ileum and involves extensive damage to the bowel wall.
UC and CD complications can be local or systemic. Local complications of UC include

hemorrhoids, anal fissures, and perirectal abscesses. Toxic megacolon can lead to perforation and is
a major complication that affects 1-3% of patients with UC or CD. Colonic strictures and
hemorrhage may also occur. Small bowel strictures, obstruction, and fistulae are common in CD.
Systemic complications (extraintestinal) can occur with UC and CD.
Diagnostic Criteria
UC is diagnosed on the basis of clinical symptoms, proctosigmoidoscopy or colonoscopy, tissue

biopsy, and bacteria-negative stool studies. CD is diagnosed on the basis of clinical symptoms,
contrast radiography or endoscopy, tissue biopsy, and bacteria-negative stool studies. Abdominal
ultrasonography, computed tomography, and magnetic resonance imaging aid in the identification
of masses, abscesses, and perianal complications in UC and CD.
Treatment of IBD involves medications that target inflammatory mediators and alter immuno-
inflammatory processes. These medications include anti-inflammatory, immunosuppressive, and
biologic agents.
Nutritional considerations are also important because many patients with IBD may be
malnourished.
Goals of therapy for UC and CD include induction and maintenance of remission of symptoms,
induction and maintenance of mucosal healing, improved quality of life, resolution of complications
and systemic symptoms, and prevention of future complications. For patients with CD, remission
means that patients are asymptomatic or without inflammatory sequelae, including patients who
have responded to medical intervention. Patients who require steroids to maintain their condition
are considered steroid dependent, not in remission.
In UC patients, remission is likely to last at least 1 year with medical therapy. Without medical
therapy, up to two-thirds of patients will relapse within 9 months. For mild CD, up to 40% of
patients improve in 3-4 months with observation alone. Most will remain in remission for
prolonged periods without medical therapy.
The treatment of choice for distal UC that involves only the rectum (proctitis) is topical therapy
with aminosalicylates:
• Treatment is initiated with a nightly suppository or enema. Improvement usually occurs within 2-3
weeks. Most patients will require maintenance therapy with topical aminosalicylates to remain in
remission.
• Rectally administered steroids may be used in combination with aminosalicylates when patients
do not respond to aminosalicylates alone.
• For patients who do not respond to or who cannot tolerate topical therapy, oral therapy with
steroids or aminosalicylates is necessary.
Mild to moderate distal colitis may be treated with oral aminosalicylates, topical mesalamine, or
topical steroids; however, topical aminosalicylates are more effective than topical steroids or oral
aminosalicylates.
• Combining oral and topical aminosalicylates is more effective than using them individually.
• Patients who are refractory to maximum doses of these agents may require oral steroid treatment.
• For the maintenance of remission, mesalamine enemas may be used every 1-2 days. Oral
aminosalicylates are also effective for maintaining remission. Combining oral and topical
aminosalicylates is more effective at maintaining remission than using them individually. Topical
steroids are not effective at maintaining remission.
For moderate to severe distal colitis, twice-daily enemas are required. Combining oral and topical
aminosalicylates may also be required.
For severe distal colitis, combining oral and topical aminosalicylates is required.
• Oral corticosteroids are reserved for patients who fail initial aminosalicylate therapy.
• Corticosteroids are tapered after remission is achieved, and topical and oral aminosalicylates are
continued as maintenance therapy.
Extensive UC (pancolitis) requires oral therapy; however, topical therapy is still a useful adjunct in
controlling rectal disease.
For mild to moderate extensive UC, oral aminosalicylates are first-line therapy.
• Patients who fail to respond require the addition of high-dose oral corticosteroid therapy.
• Azathioprine and 6-mercaptopurine may be used in patients who do not respond to, or cannot be
weaned from, corticosteroids. These drugs may also be used to maintain remission.
• Corticosteroid tapering should begin only when complete remission is achieved.
• Corticosteroids do not have a role in maintenance therapy; aminosalicylates are usually effective
at maintaining remission.
• For patients who fail oral therapy, hospitalization and intravenous steroid therapy is necessary.
For moderate to severe UC refractory to conventional therapy, infliximab may be used to avoid or
reduce corticosteroid use and to induce remission.
For severe or fulminant colitis, hospitalization and complete bowel rest are required.
• Intravenous (IV) steroids are the mainstays of therapy.
• Topical therapy may be added for patients with significant rectal symptoms.
• In patients who do not respond to 7 days of IV steroids, surgery or IV cyclosporine should be

considered. Patients who respond to IV cyclosporine are converted to oral cyclosporine and a
steroid taper.
• Azathioprine may be added to maintain remission.
Abdominal x-ray should be performed to exclude toxic megacolon. Surgery is often required for
patients with toxic megacolon, and preoperative antibiotics are recommended to reduce the chance
of septic complications.
For CD, clinical improvement should be evident within 2-4 weeks. Maximal clinical improvement
should occur within 12-16 weeks. Treatment for acute disease should be continued until remission
is achieved or the patient's symptoms fail to improve.
For mild to moderate CD localized to the ileum or right colon, controlled-release oral budesonide is
appropriate initial therapy.
• Controlled-release oral budesonide is more effective than oral mesalamine and placebo. It has
similar efficacy to conventional oral corticosteroids.
• Oral mesalamine has been used as first-line therapy; however, new evidence indicates that it is
only minimally more effective than placebo and less effective than corticosteroids.
• Oral sulfasalazine is more effective than placebo but less effective than corticosteroids for
ileocolonic and colonic CD.
• Rectal aminosalicylates are often used to treat distal colonic CD; however, controlled studies
showing efficacy are lacking.
• Although metronidazole and ciprofloxacin are widely used in the treatment of CD, clinical trials
have not consistently demonstrated efficacy.
• No controlled data exist regarding the treatment of mild to moderate oral CD. Lidocaine lozenges
may provide symptomatic relief. Lesions will respond to systemic steroids or azathioprine in 50%
of patients.
• For CD of the stomach, esophagus, duodenum, and jejunum, PPIs, oral corticosteroids,
mercaptopurine, azathioprine, methotrexate, infliximab, adalimumab, and certolizumab pegol
have improved symptoms in uncontrolled trials.
• When remission is achieved, maintenance therapy should be initiated. For patients who do not
respond, treatment with alternative agents for mild to moderate disease may be initiated or the
treatment may be advanced to agents used for moderate to severe disease.
For patients with moderate to severe disease, oral corticosteroids are the mainstay of therapy.
• Prednisone 40-60 mg daily should be given until symptoms resolve and weight gain resumes.
Steroids are not appropriate maintenance therapy.
• Infections or abscesses should be treated with appropriate antibiotics or surgical drainage.
• Azathioprine and 6-mercaptopurine may be added to oral corticosteroids to maintain a steroid-

induced remission. They are also effective for steroid-dependent or steroid-refractory patients.
• Parenteral methotrexate is effective for inducing remission and allowing steroid dose reduction in
patients with steroid-dependent and steroid-refractory CD.
• Infliximab, adalimumab, and certolizumab pegol may be used in patients who do not respond to
oral corticosteroids or immunosuppressive agents. They may also be used as an alternative to oral
corticosteroids when the side effects of oral corticosteroids need to be avoided.
• Natalizumab may be used when patients are intolerant or unresponsive to oral corticosteroids,
immunosuppressants, and biologic therapies.
• Enteral nutrition should be used to support the patient's overall nutrition status, not to induce
remission of CD.
• When remission is achieved, maintenance therapy should be initiated.
For severe to fulminant CD, hospitalization for intravenous steroids and hydration is required.
• Intravenous steroids equivalent to 40-60 mg/day of prednisone should be administered.
• Parenteral fluid and electrolyte therapy should be administered to restore hydration.
• Parenteral or enteral nutrition support should be administered after 5-7 days if the patient cannot
meet adequate nutritional requirements.
• Anemic patients may require blood transfusions.
• Intestinal obstructions related to adhesions should be managed with bowel rest and nasogastric
tube suctioning. Obstructions related to inflammatory strictures require antibiotic therapy and IV
steroids. Surgery should be considered if obstructive symptoms do not respond to therapy.
• Abscesses should be drained and appropriate antibiotic therapy instituted.
• High-dose metronidazole or ciprofloxacin may be used in the management of fistulas. Chronic

therapy may be required to prevent recurrent drainage.
• Azathioprine, 6-mercaptopurine, and infliximab may also be used in the management of fistulas.
• If patients do not respond to IV steroids after 5-7 days of therapy, cyclosporine or tacrolimus
therapy may be instituted.
• When symptoms respond to initial treatment, the patient should be converted to an equivalent oral
corticosteroid regimen.
• Patients who do not respond to therapy require surgical intervention.
Maintenance therapy should be initiated when remission is achieved.
• Corticosteroids should not be used as long-term maintenance therapy.
• Sulfasalazine and mesalamine have not shown consistent benefit as maintenance therapy.
• Azathioprine, 6-mercaptopurine, and methotrexate have shown benefit as maintenance therapy.
• Azathioprine may be used as maintenance therapy in steroid-naive patients who achieved

remission with infliximab.
• Infliximab, adalimumab, and certolizumab pegol are effective maintenance therapies.
• Natalizumab may be used for maintenance therapy after it has been successfully used to induce
remission.
Drug Therapy
See
Table 21-3 for selected medications used in IBD.
Mechanism of action
Sulfasalazine is cleaved to sulfapyridine (excreted in the urine) by bacteria in the gut and
mesalamine (the
[Table 21-3. Selected Medications Used in Inflammatory Bowel Disease]
active component). The sulfapyridine molecule is responsible for the many side effects associated
with sulfasalazine.
Mesalamine's mechanism of action is poorly understood. Mesalamine inhibits cyclooxygenase and
may also inhibit production of cyclooxygenase, thromboxane synthetase, platelet-activating factor
synthetase, and interleukin-1 in macrophages. It may also act as a superoxide free-radical scavenger.
Corticosteroids have immunomodulatory effects and inhibit the production of cytokines and other
inflammatory mediators.
Corticosteroids, azathioprine, 6-mercaptopurine, cyclosporine, and tacrolimus are

immunosuppressive agents. For full discussion of their mechanism of action, patient counseling,
side effects, drug interactions, and pharmacokinetics, see Chapter 20 on transplantation.
The exact mechanism of action of metronidazole and ciprofloxacin in IBD is not known. One
theory suggests that antibacterials interrupt the role of bacteria in the inflammatory process.
Methotrexate inhibits dihydrofolate reductase and purine synthesis, reduces the production of
leukotriene-B4 and interleukin-1 and -2, and may induce T-cell apoptosis.
Infliximab is a chimeric monoclonal antibody that inhibits human tumor necrosis factor, which
inhibits subsequent cytokine-triggered inflammatory processes.
Adalimumab is a recombinant monoclonal antibody that inhibits human tumor necrosis factor,
which inhibits subsequent cytokine-triggered inflammatory processes.
Certolizumab pegol is a pegylated humanized antibody Fab fragment of tumor necrosis factor
monoclonal antibody. It inhibits human tumor necrosis factor activity, which inhibits subsequent
cytokine-triggered inflammatory processes. Pegylation delays elimination and prolongs the half-life
of the drug.
Natalizumab is a monoclonal antibody against the alpha-4 subunit of integrin molecules. It blocks
the association of integrin with vascular receptors, which limits adhesion and transmigration of
leukocytes.
Patient counseling
Sulfasalazine should be taken after meals. Patients should avoid sun exposure while taking it. Folic
acid supplementation should be given during sulfasalazine treatment to avoid anemia. Sulfasalazine
may cause orange discoloration of urine and skin.
Mesalamine tablets should be swallowed whole. Suppositories should not be handled excessively
and foil wrappers should be removed before insertion. Suspension enemas should be shaken well
before use.
Antacids and ciprofloxacin should be taken 4-6 hours apart. Iron- or zinc-containing products
should be taken 4 hours before or 2 hours after taking ciprofloxacin. Patients should avoid
excessive exposure to sunlight.
Patients taking methotrexate should avoid alcohol, salicylates, and prolonged exposure to sunlight.
Female patients of childbearing age should be counseled on appropriate contraceptive measures
during methotrexate therapy.
Patients receiving therapy with infliximab should be counseled on the possibility of infusion
reactions, delayed hypersensitivity reactions, and increased risk of infections. Live vaccines should
not be administered to patients taking infliximab.
Patients taking adalimumab should be counseled on the increased risk of infections and to report
any symptoms of infection to their physician immediately. They should also be counseled on the
potential for injection site reactions and be taught proper injection technique and proper sharps
disposal. Live vaccines should not be administered to patients taking adalimumab.
Patients taking certolizumab pegol should be counseled on the increased risk of infections and to
report any symptoms of infection to their physician immediately. They should also be counseled on
the potential for injection-site reactions and be taught proper injection technique and sharps
disposal. Live vaccines should not be administered to patients taking certolizumab pegol.
Patients taking natalizumab should be counseled on the risk of acute hypersensitivity infusion
reactions. They should also be counseled on the increased risk of infections, particularly progressive
multifocal leukoencephalopathy. Patients should report symptoms of infection to their physician
immediately.
Sulfasalazine may cause nausea, vomiting, anorexia, and headaches. The sulfapyridine moiety leads
to hypersensitivity reactions (e.g., rash, fever, agranulocytosis, pancreatitis, nephritis, and hepatitis)
and altered spermatogenesis in males.
Mesalamine is better tolerated than sulfasalazine. Olsalazine may cause self-limited watery
diarrhea. Balsalazide causes abdominal pain in 10% of patients.
Ciprofloxacin may cause nausea, diarrhea, headache, and vaginal candidiasis.
Methotrexate frequently causes nausea and leukopenia. Asymptomatic elevations in liver function
tests may occur.
Infliximab may cause infusion-related reactions, upper respiratory infections, headache, rash,
cough, and stomach pain. Allergic reactions have been reported. Infliximab increases the risk of
serious infections (bacterial, viral, and fungal infections; tuberculosis) and certain types of cancer.
New onset or exacerbation of preexisting heart failure, hepatotoxicity, neuropathy, anemia, and
lupus-like syndrome have also been reported.
Adalimumab may cause injection-site reactions, upper respiratory infections, headaches, rash, and
nausea. Allergic reactions have been reported. Adalimumab increases the risk of serious infections
(bacterial, viral, and fungal infections; tuberculosis) and certain types of cancer. New onset or
exacerbation of preexisting heart failure, neuropathy, anemia, and lupus-like syndrome have also
been reported.
Certolizumab pegol may cause injection-site reactions, upper respiratory tract infections, rash, and
urinary tract infections. Allergic reactions have been reported. Certolizumab increases the risk of
serious infections (bacterial, viral, and fungal infections; tuberculosis) and certain types of cancer.
New onset or exacerbation of preexisting heart failure, neuropathy, anemia, and lupus-like
syndrome have also been reported.
Natalizumab increases the risk of developing progressive multifocal leukoencephalopathy. Serious

allergic reactions (usually within 2 hours of infusion) and hepatotoxicity have been reported.
Natalizumab increases the risk of serious infections (bacterial, viral, and fungal infections;
tuberculosis).
Drug interactions
Sulfasalazine may decrease the bioavailability of digoxin by inhibiting its absorption.
Azathioprine is converted into 6-mercaptopurine in vivo; 6-mercaptopurine then undergoes hepatic

first-pass metabolism, which is catalyzed by xanthene oxidase. By inhibiting xanthene oxidase,
allopurinol increases the bioavailability of azathioprine. The azathioprine dose should be lowered
by 25-50% when the two agents are used concurrently.
Ciprofloxacin binds with antacids, zinc, and iron products. It also increases the therapeutic effects
of warfarin, cyclosporine, and theophylline.
Corticosteroids should not be administered with natalizumab because of the increased risk of
serious infections.
The use of methotrexate and concurrent NSAIDs has caused fatal interactions. Methotrexate may
increase levels of 6-mercaptopurine.
Infliximab should not be administered with etanercept or anakinra because of the increased risk of
serious infections. Live vaccines should not be administered to patients taking infliximab. The
herbal supplement echinacea may decrease the effectiveness of infliximab.
Adalimumab should not be administered with anakinra because of the increased risk of serious
infections. Live vaccines should not be administered to patients taking adalimumab. The herbal
supplement echinacea may decrease the effectiveness of adalimumab. Methotrexate may decrease
the clearance of adalimumab; however, this effect has not been shown to be clinically significant.
Certolizumab pegol should not be administered with anakinra, abatacept, rituximab, or natalizumab
because of the increased risk of serious infections. Live vaccines should not be administered to
patients taking certolizumab. The herbal supplement echinacea may decrease the effectiveness of
certolizumab. Certolizumab may falsely elevate the activated partial thromboplastin time and the
lupus anticoagulant assays.
Natalizumab should not be administered with other immunosuppressants, such as 6-

mercaptopurine, azathioprine, cyclosporine, and methotrexate, or with tumor necrosis factor
inhibitors because of the increased risk of progressive multifocal leukoencephalopathy. The herbal
supplement echinacea may decrease the effectiveness of natalizumab.
Serum chemistries, complete blood counts, liver function tests, blood glucose concentrations, ESR,
response to therapy, and the presence of adverse effects should be monitored. Tuberculosis skin
testing should be performed before administering biologic agents.
Pharmacokinetics
• Sulfasalazine is metabolized by intestinal flora to sulfapyridine and 5-aminosalicylic acid.

Unchanged drug and metabolites are excreted in the urine.
• Mesalamine is metabolized in the liver and gut to 5-aminosalicylic acid. The metabolite is
eliminated via the urine and feces.
• Azathioprine is thought to be hepatically metabolized to 6-mercaptopurine by glutathione S-

transferase; 6-mercaptopurine is further metabolized by hypoxanthine guanine
phosphoribosyltransferase, xanthene oxidase, and thiopurine methyltransferase. Metabolites are
excreted in the urine.
• Ciprofloxacin is partially metabolized in the liver. Unchanged drug and metabolites are excreted
in the urine and feces.
• Metronidazole is metabolized in the liver and is excreted in the urine and feces.
• Prednisone is metabolized in the liver and excreted in the urine.
• Methotrexate is primarily eliminated by the kidneys.
Nondrug Therapy
Patients with UC and CD are often malnourished because of malabsorption or maldigestion caused
by chronic bowel inflammation, "short gut" syndrome from multiple bowel surgeries, or bile salt
deficiency in the gut. The catabolic effects of the disease process can also lead to malnutrition.
Individuals should eliminate foods that exacerbate symptoms. Patients with lactase deficiency
should avoid dairy products or take lactase supplements to avoid symptoms.
Enteral or parenteral supplementation may be used in patients with severe UC or CD to maintain

adequate nutritional status.
Surgery may be necessary for patients with severe UC or CD. Surgery involves removing diseased
segments of bowel, repairing fistulas, and draining abscesses.
• In UC, surgery is indicated for patients who fail maximum medical therapy to correct
complications (perforation, strictures, obstruction, hemorrhage, toxic megacolon). It is also used
as prophylaxis against the development of cancer (in patients with long-standing UC) and in
patients with premalignant changes found on bowel biopsies.
• In CD, surgery is indicated for neoplastic or preneoplastic lesions, obstructing stenoses,

suppurative complications, or CD that does not respond to pharmacotherapy. Smoking cessation
should be encouraged to reduce the risk of recurrence of CD after surgery (as well as for overall
health benefits).
21-4. Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) is defined as abdominal pain or discomfort that occurs in
association with altered bowel habits over a period of 3 months.
IBS is a prevalent and expensive condition. It significantly impairs health-related quality of life and
leads to reduced work productivity.
IBS patients visit physicians more frequently, have more diagnostic tests performed, take more
medications, miss more workdays, show lower work productivity, are hospitalized more frequently,
and consume more direct health care costs than patients without IBS.
The worldwide prevalence of IBS is 7-10%. Most cases of IBS are diagnosed before age 50. IBS is
1.5 times more common in women than in men. It is also more common in patients from lower
socioeconomic groups.
Classifications
No symptom-based diagnostic criteria have ideal accuracy for diagnosing IBS. Traditional criteria
(Kruis, Manning) are at least as accurate as the more recent Rome I criteria. Rome II and III criteria
have been proposed, but their accuracy has not been evaluated.
Because of the lack of ideal accuracy of symptom-based diagnostic criteria, the American College
of Gastroenterology proposed a new definition of IBS (see previous section).
Once the diagnosis is made, IBS may be classified according to its predominant symptom: diarrhea
predominant, constipation predominant, or mixed (symptoms may alternate). Symptoms may also
be further categorized as mild, moderate, or severe.
IBS is a heterogeneous disorder with various clinical presentations:
• Abdominal pain is generally described as crampy or achy, and the intensity and location are highly
variable. Pain may be exacerbated by meals and may last from 1 to 3 hours. Stress and emotional
turmoil can also exacerbate pain.
• Patients typically present with diarrhea, constipation, or alternating periods of both.
• Upper GI symptoms occur more frequently in patients with constipation (heartburn, dyspepsia,
early satiety, and nausea). Women experience abdominal distention, bloating, and nausea more
often than men.
• Extraintestinal symptoms are common. They include genitourinary symptoms (e.g., pelvic pain,
dysmenorrhea, dyspareunia, urinary frequency, nocturia, and sensation of incomplete bladder
evacuation); impaired sexual function (e.g., decreased libido); and musculoskeletal complaints
(e.g., lower back pain, headaches, and chronic fatigue).
• Alarm features include rectal bleeding, weight loss, iron deficiency anemia, nocturnal symptoms,
family history of colorectal cancer, IBD, or celiac sprue. These symptoms may indicate the
presence of an organic disease.
Pathophysiology
The pathogenesis is multifactorial and includes abnormal gut sensorimotor activity, central nervous
system (CNS) dysfunction, psychological disturbances, genetic predisposition, enteric infection,
and other luminal factors:
• Colonic motor abnormalities commonly occur in IBS. Patients with IBS may exhibit an
exaggerated gastrocolonic response lasting up to 3 hours.
• Small intestinal motor patterns are frequently disturbed in patients with IBS. Small intestinal
transit is delayed in constipation-predominant IBS and is accelerated in diarrhea-predominant
IBS.
• Bloating may be the result of abnormal retrograde reflux of intestinal gas, enhanced perception of
the presence of intestinal gas, or obstructive intestinal motor patterns.
• Motor dysfunction of other smooth muscles may occur in IBS. The following abnormalities may
also be found: lowered LES sphincter pressures, abnormal esophageal body peristalsis, gastric
slow-wave dysrhythmias, delayed gastric and gallbladder emptying, and dysfunction of the
sphincter of Oddi.
• It is theorized that IBS results from sensitization of visceral afferent fibers, which causes normal
physiologic events to be perceived as painful. It is unknown if sensorineural dysfunction is
generalized or localized to the gut afferent fibers.
• It is unknown whether IBS is primarily a CNS disorder with centrally directed changes in gut
sensorimotor function or primarily a gut disorder with inappropriate CNS input. Further
investigation is needed in this area.
• Eighty percent of patients with IBS exhibit psychiatric disturbances. The onset of psychiatric
disturbances usually predates or occurs concurrently with the onset of IBS. Psychological stress
triggers symptoms in many patients. IBS is also associated with a history of sexual abuse.
• Other factors that may contribute to IBS are alterations in gut flora (controversial), antecedent GI
infection, carbohydrate malabsorption, food allergies, neurohumoral disturbances, genetic
factors, and abnormal stool characteristics (low concentrations of bile or short-chain fatty acids).
Relief of pain with defecation, looser stool with pain onset, more frequent stools with pain onset,
and abdominal distention are significantly more common in IBS than in organic disease.
Diagnostic Criteria
• Physical examination is usually normal.
• Routine diagnostic testing with complete blood count, serum chemistries, thyroid function tests,
stool for ova and parasites, and abdominal imaging are not recommended in patients with typical
IBS symptoms and no alarm symptoms because of the low probability of diagnosing organic
disease.
• Serologic screening for celiac sprue should be pursued in patients with diarrhea-predominant or
mixed-symptom IBS.
• Lactose breath testing may be considered when lactose intolerance is suspected after dietary
modification.
• Colonoscopy should be performed in patients with IBS with alarm symptoms to rule out CD,
ulcerative colitis, and colorectal cancer.
• Colonoscopy should be performed in patients with IBS over the age of 50 to rule out colon cancer.
Treatment should be offered to patients seeking medical care if the patient and physician believe
that the IBS symptoms decrease the patient's quality of life. Goals of therapy include improving IBS
symptoms and improving patient quality of life.
Evidence from small clinical trials is inconsistent regarding the effectiveness of anticholinergic and
antimuscarinic agents (dicyclomine and hyoscyamine) in the management of IBS; however, they are
often used as first-line therapy in patients with mild symptoms. They may provide short-term relief
of abdominal pain and discomfort. They should be used with caution in patients with constipation.
Psyllium has been shown to be moderately effective for IBS, although the evidence is weak.
Calcium polycarbophil was shown to improve symptoms in one small study. Polyethylene glycol
was shown to improve stool frequency, but not abdominal pain, in a small study of adolescents with
constipation-predominant IBS. It may be used as adjunctive therapy in patients with constipation-
predominant IBS.
Loperamide significantly improves stool consistency and decreases stool frequency in patients with
diarrhea-predominant IBS. It has no effect on abdominal pain or global IBS symptoms.
Tegaserod improves global IBS symptoms, bloating, abdominal pain, and altered bowel habits in
patients with constipation-predominant IBS. It was withdrawn from the U.S. market in March 2007
because of an increased incidence (0.11%) of cardiovascular events in patients taking the drug. It is
available only through the U.S. Food and Drug Administration (FDA) under an emergency
investigational drug protocol.
Tricyclic antidepressants (TCAs) improve abdominal pain in patients with IBS. They also improve
global IBS symptoms in patients with diarrhea-predominant IBS but not constipation-predominant
IBS.
Selective serotonin reuptake inhibitors (SSRIs) improve abdominal pain in patients with IBS and
are also effective in the treatment of comorbid psychiatric disorders in patients with IBS. SSRIs are
recommended for patients with moderate to severe abdominal pain or those with psychiatric
comorbidities. Several types of psychological counseling and therapy are effective in some patients
with IBS.
Alosetron improves global IBS symptoms, abdominal discomfort, stool consistency, and stool
frequency in women with diarrhea-predominant IBS. Because of the incidence of colon ischemia
and complicated constipation, alosetron is available only through a prescribing program regulated
by the FDA and administered by the drug's manufacturer. It is approved only for use in women with
chronic, severe, diarrhea-predominant IBS who do not respond to other therapies.
Lubiprostone has been shown to relieve global IBS symptoms in women with constipation-
predominant IBS.
Drug Therapy
Table 21-4 shows selected medications used to treat IBS.
Mechanism of action
The antispasmodic agent dicyclomine decreases GI motility by relaxing smooth muscle in the gut.
Hyoscyamine is an anticholinergic agent that decreases GI motility by decreasing smooth muscle

tone through antimuscarinic activity in the gut.
Tricyclic antidepressants, such as amitriptyline, delay intestinal transit and may blunt perception of
visceral distention. The effect of TCAs on the cerebral processing of visceral pain is unknown.
Tegaserod maleate, a partial 5-HT4 agonist that stimulates the peristaltic reflex and intestinal
secretion, inhibits visceral sensitivity by binding to 5-HT4 receptors in the gut.
Lactulose, milk of magnesia, and polyethylene glycol solutions are osmotic laxatives that aid in the
treatment of IBS patients with constipation.
Fiber supplements (bulk laxatives) increase stool bulk and water content.
Loperamide inhibits peristalsis by directly affecting the circular and longitudinal muscles of the
intestinal wall.
Diphenoxylate is a meperidine congener that directly affects the circular smooth muscle in the gut,
which slows GI transit time.
Alosetron is a selective 5-HT3 receptor antagonist that inhibits activation of nonselective cation
channels in the gut, thereby modulating the enteric nervous system.
[Table 21-4. Selected Medications Used in Irritable Bowel Syndrome]
SSRIs inhibit the neuronal uptake of serotonin in the CNS. Citalopram has peripheral effects on
colonic tone and sensitivity. Paroxetine has potent anticholinergic effects.
Lubiprostone is the only C-2 chloride channel activator available. By activating C-2 chloride
channels in the gut, lubiprostone increases secretion of saltwater into the intestinal lumen. It is
approved only for women with constipation-dependent IBS.
Patient counseling
Antispasmodics and anticholinergic agents are best used on an as-needed basis up to three times per
day during acute attacks or before meals when postprandial symptoms are present.
Patients taking a TCA should avoid prolonged exposure to sunlight and avoid concurrent use of
CNS depressants.
Tegaserod should be taken 30 minutes before meals and should not be initiated during an acute
exacerbation of IBS. It is available only through an emergency investigational drug protocol from
the FDA.
Osmotic laxatives should be used on an as-needed basis. Lactulose may be mixed with water or
juice to increase palatability. Patients should drink plenty of water.
Patients must be enrolled in the manufacturer's prescribing program to receive alosetron. Patients
should not initiate therapy with alosetron if they are currently constipated. Alosetron should be
discontinued if no improvement in symptoms is seen after 4 weeks of therapy.
See Chapter 25 on psychiatric disease for a full discussion of SSRIs.
Lubiprostone should be taken with food and water. Softgel capsules should be swallowed whole.
Dicyclomine, hyoscyamine, and TCAs may cause anticholinergic side effects (CNS depression, dry
mouth, urinary retention, constipation, and decreased sweating).
Tegaserod may cause diarrhea, nausea, headache, and abdominal pain. It was associated with an
increased risk of cardiovascular events in clinical trials.
Osmotic laxatives may cause abdominal pain and cramping.
Alosetron may cause constipation, abdominal pain, and nausea. Intestinal obstruction, perforation,
toxic megacolon, ischemic colitis, and death have occurred.
See Chapter 25 on psychiatric disease for a full discussion of SSRIs.
Lubiprostone's most common side effects are nausea, diarrhea, and headache. Allergic reactions and
dyspnea within 1 hour of the first dose have also been reported. Though dyspnea may recur with
repeated doses, it usually resolves within 3 hours.
Drug interactions
Anticholinergics and antispasmodics may decrease the effectiveness of antipsychotic medications.

Side effects from anticholinergics are increased when they are given concurrently with a TCA.
TCA concentrations may be increased or decreased by medications that induce or inhibit the
activity of the CYP450 enzyme system in the liver. TCAs should not be given concurrently with
monoamine oxidase inhibitors or sympathomimetic agents.
No significant drug interactions with tegaserod have been reported.

Other medications should not be taken within 1 hour of the start of therapy with osmotic laxatives.
The levels of alosetron may be decreased by concurrent administration of rifamycin derivatives.
There are no known drug interactions with lubiprostone.
Patients should monitor for the presence of IBS symptoms and for the side effects of medications,
as discussed in the section on adverse drug effects.
Pharmacokinetics
Dicyclomine, hyoscyamine, amitriptyline, paroxetine, tegaserod, alosetron, loperamide, and

diphenoxylate/atropine undergo hepatic metabolism.
Lubiprostone is metabolized in the stomach and small intestine.
Nondrug Therapy
An effective physician-patient relationship is necessary for successful treatment. Education should

be provided regarding disease pathophysiology and treatment and reassurance that the symptoms
are real.
Although evidence supporting exclusion diets is lacking, patients may be counseled to avoid foods
that exacerbate IBS symptoms. Foods commonly implicated are fatty foods, beans, gas-producing
foods, alcohol, caffeine, lactose (in lactase-deficient individuals), and occasionally excess fiber.
Cognitive behavioral therapy, dynamic psychotherapy, and hypnotherapy are more effective than
usual care in relieving global symptoms of IBS. Although the quality of the evidence regarding such
therapy is low, the potential benefit outweighs the potential risks.
21-5. Key Points
Peptic Ulcer Disease
• PUD is a group of disorders of the upper GI tract characterized by ulcerative lesions that require
acid and pepsin for their formation.
• Duodenal and gastric ulcers are classified as Helicobacter pylori related, NSAID related, non-H.
pylori related, non-NSAID related, or stress related.
• Epigastric pain occurring 1-3 hours after meals that is relieved by ingestion of food or antacids is
the classic symptom of PUD.
• H. pylori is a gram-negative microaerophilic bacterium inhabiting the area between the mucous
layer and epithelial cells in the stomach. It can be found anywhere gastric epithelium is present.
• NSAIDs are the leading cause of PUD in patients who are negative for H. pylori infection.
• NSAIDs are directly toxic to gastric epithelium and inhibit the synthesis of prostaglandins.
• The goals of PUD therapy are ulcer healing and eliminating the cause. Additional considerations
are prevention of complications and relief of symptoms.
• Upper GI endoscopy is used to diagnose PUD. The procedure is usually reserved for patients with
symptoms of PUD who are over 55 years of age or who have alarm symptoms (bleeding, anemia,
early satiety, unexplained weight loss, progressive dysphagia, odynophagia, recurrent vomiting,
family history of gastrointestinal cancer, or previous esophagogastric cancer).
• Patients with symptoms of PUD who are less than 55 years of age and have no alarm symptoms
may be tested for the presence of H. pylori and treated with eradication therapy if results are
positive.
• Histology and rapid urease testing may be performed on biopsy samples obtained during
endoscopy to test for H. pylori.
• Serum antibody tests, urea breath tests, and fecal antibody testing do not require endoscopy to test
for H. pylori.
• The American College of Gastroenterology treatment guidelines for H. pylori eradication in PUD
recommend initial triple therapy with a PPI, clarithromycin, and either amoxicillin or
metronidazole for 14 days or quadruple therapy with bismuth, metronidazole, tetracycline, and
either an H2RA or a PPI for 10-14 days.
• NSAID-related PUD treatment consists of discontinuing the offending agent and issuing
antisecretory therapy for symptom relief.
• Antisecretory therapy with a PPI or an H2RA should be administered for 4 weeks to promote
healing and to relieve symptoms.
• Patients with active bleeding who are hemodynamically stable should receive intravenous PPI
therapy and undergo endoscopy to evaluate the risk of bleeding recurrence.
• Patients with active bleeding who are hemodynamically unstable should receive intravenous fluids
and blood transfusions. They should undergo emergency endoscopy for coagulation of bleeding
sites. Various modalities may be used to achieve bleeding-site coagulation.
• Surgery is reserved for patients who have refractory ulcers, recurrent bleeding, or a perforated
ulcer.
• Patients should be counseled on the importance of adherence to treatment regimens, proper

dosing, and the side effects of medications.
• Patients should be counseled to decrease psychological stress, to discontinue smoking and

drinking alcohol, to stop using NSAIDs, and to avoid food or beverages that exacerbate PUD
symptoms.
Gastroesophageal Reflux Disease
• GERD is a condition that develops when the reflux of stomach contents causes troublesome
symptoms or complications.
• Approximately 20% of the U.S. population experiences heartburn or regurgitation of gastric acid
weekly.
• The manifestations of GERD are divided into esophageal and extraesophageal syndromes.
• Esophageal syndromes consist of those that are only symptomatic in nature and those that are
symptomatic with esophageal injury on endoscopy. Symptomatic syndromes include the typical
reflux syndrome and the reflux chest pain syndrome.
• The typical reflux syndrome is defined by the presence of troublesome heartburn or regurgitation.
Patients may also have other symptoms, such as epigastric pain or sleep disturbance.
• The pathophysiology of GERD involves the prolonged contact of esophageal epithelium with
refluxed gastric contents that contain acid and pepsin.
• Esophageal defenses consist of the antireflux barrier, luminal clearance mechanisms, and tissue
resistance. Increased contact time of refluxate and esophageal mucosa or impaired defense
mechanisms can lead to the symptoms of GERD.
• For patients who present with troublesome symptoms of GERD, a trial of empiric therapy is
appropriate. A diagnosis of GERD may be assumed for patients who respond to empiric
treatment.
• Diagnostic testing with endoscopy should be performed in patients who present with troublesome
GERD symptoms and dysphagia, weight loss, or epigastric mass on physical examination. It
should also be performed on patients who do not respond to empiric treatment.
• Goals of therapy are to alleviate or eliminate symptoms, decrease frequency and duration of
reflux, promote healing of the injured mucosa, and prevent the development of complications.
• An empiric trial of once-daily PPI therapy is appropriate for patients with troublesome GERD
symptoms. If patients do not respond to once-daily therapy, twice-daily therapy may be used.
• Antireflux surgery may be performed when a patient is responsive to, but intolerant of, acid
suppressive therapy or has persistent troublesome symptoms of GERD.
• Patients should be counseled on medication dosing and administration, side effects, drug
interactions, monitoring of GERD symptoms, and lifestyle modifications.
• Lifestyle modifications alone are unlikely to control GERD symptoms. Lifestyle modifications
should be tailored to the circumstances of the individual patient.
• GERD is considered a chronic condition, and most patients will require chronic therapy with
antisecretory agents. Antisecretory therapy should be titrated to the lowest effective dose.
Inflammatory Bowel Disease
• Idiopathic IBD is divided into two major types: (1) ulcerative colitis and (2) Crohn's disease.
• UC is a mucosal inflammatory condition confined to the rectum and colon.
• CD is a transmural inflammation of the GI tract that can affect any part (mouth to anus).
• The hallmark clinical symptom of UC is bloody diarrhea, often with rectal urgency and tenesmus.
• Clinical symptoms are categorized as mild, moderate, or severe. Endoscopic findings are
categorized as distal (limited to below the splenic flexure) or extensive (extending proximal to
the splenic flexure).
• Typical symptoms of CD include chronic or nocturnal diarrhea and abdominal pain. Additional
typical symptoms include weight loss, fever, and rectal bleeding.
• Symptoms differ depending on the site of inflammation and are categorized as mild, moderate, or
severe.
• The etiology of IBD is unclear, but similar factors may contribute to both UC and CD. The
diagnosis of IBD is made on the basis of negative stool evaluation for infectious causes.
• Treatment of IBD involves medications that target inflammatory mediators and alter immuno-
inflammatory processes. These medications include anti-inflammatory agents,
immunosuppressive agents, and biologic agents.
• Goals of therapy for UC and CD include inducing and maintaining remission of symptoms,
improving quality of life, resolving complications and systemic symptoms, and preventing future
complications.
interactions, monitoring of IBD symptoms, and proper nutrition.
• Patients with IBD are often malnourished because of malabsorption or maldigestion caused by
chronic bowel inflammation, "short gut" syndrome from multiple bowel surgeries, or bile salt
deficiency in the gut.
• Surgery may be necessary for patients with severe UC or CD. Surgery (proctocolectomy) is
curative for UC but not for CD.
Irritable Bowel Syndrome
• IBS is abdominal pain or discomfort that occurs in association with altered bowel habits over a
period of 3 months.
• IBS is a prevalent and expensive condition. It significantly impairs health-related quality of life
and leads to reduced work productivity.
• IBS is a heterogeneous disorder with various clinical presentations. Common symptoms include
abdominal pain, diarrhea, and constipation.
• The pathogenesis is multifactorial, including abnormal gut sensorimotor activity, CNS

dysfunction, psychological disturbances, genetic predisposition, enteric infection, and other
luminal factors.
• No symptom-based diagnostic criteria have ideal accuracy for diagnosing IBS. Traditional criteria
(Kruis, Manning) are at least as accurate as the more recent Rome I criteria. Rome II and III
criteria have been proposed, but their accuracy has not been evaluated.
• Alarm features include rectal bleeding, weight loss, iron-deficiency anemia, nocturnal symptoms,
family history of colorectal cancer, IBD, or celiac sprue. These symptoms may indicate the
presence of an organic disease.
• Treatment should be offered to patients seeking medical care if the patient and physician believe
that the IBS symptoms decrease the patient's quality of life.
• Goals of therapy include improving IBS symptoms and patient quality of life.
• Anticholinergic and antimuscarinic agents provide short-term relief of abdominal pain and
discomfort. Psyllium has been shown to be moderately effective for IBS. Calcium polycarbophil
was shown to improve symptoms in one small study. Polyethylene glycol was shown to improve
stool frequency. Loperamide decreases stool frequency in patients with diarrhea-predominant
IBS. TCAs improve abdominal pain in IBS patients. SSRIs are recommended for patients with
moderate to severe abdominal pain or psychiatric comorbidities. Tegaserod improves global IBS
symptoms, bloating, abdominal pain, and altered bowel habits in patients with constipation-
predominant IBS. Alosetron improves global IBS symptoms, abdominal discomfort, stool
consistency, and stool frequency in women with diarrhea-predominant IBS. Lubiprostone has
been shown to relieve global IBS symptoms in women with constipation-predominant IBS.
interactions, and monitoring of IBS symptoms.
• An effective physician-patient relationship is necessary for successful treatment.
• Education regarding disease pathophysiology and treatment, and reassurance that the symptoms
are real should be provided.
• Patients should be counseled to avoid foods that exacerbate symptoms.
• Cognitive behavioral therapy, dynamic psychotherapy, and hypnotherapy are more effective than
usual care in relieving global symptoms of IBS.
21-6. Questions
H. B. is a 59-year-old black male recently diagnosed with PUD on endoscopy. Tissue biopsy is
positive for H. pylori. H. B. has no known drug allergies. Which of the following is the ideal
therapeutic regimen for H. pylori-related PUD in H. B.?
1. A. PPI, clarithromycin, amoxicillin

B. PPI, bismuth, metronidazole, tetracycline
C. Omeprazole, amoxicillin
D. Omeprazole, bismuth, clarithromycin, furazolidone
E. Omeprazole, sucralfate, clarithromycin, furazolidone

If H. B. were allergic to penicillin, which treatment recommendation would you choose?
A. PPI, clarithromycin, amoxicillin

2. B. PPI, bismuth, metronidazole, tetracycline
C. Omeprazole, metronidazole
D. Clarithromycin, metronidazole, tetracycline
E. Clarithromycin, metronidazole, furazolidone

Which one of the following is the leading cause of PUD in H. pylori-negative patients?
A. Mineralocorticoids
3. B. NSAIDs
C. DMARDs
D. Antibiotics
E. Corticosteroids

Which of the following are true of NSAIDs?
I. They inhibit production of prostaglandins.

II. They are directly toxic to gastroduodenal epithelium.
III. They require dose adjustments in renal insufficiency.
IV. They cause only gastric ulcers.
4. V. They allow healing of PUD during continued therapy.
A. I, II, and III only

B. I and III only
C. II and IV only
D. V only
E. All are correct.

Which of the following are goals of therapy for PUD?
I. Reduce episodes of diarrhea.

II. Eliminate symptoms.
III. Reduce risk of gastric cancer.
IV. Heal ulcerations.
5. V. Avoid spreading H. pylori.

B. I and III only
C. II and IV only
D. V only
E. All are correct.

Which of the following tests do not require endoscopy to test for H. pylori infection?
I. Serum antibody test

II. Fecal antigen test
III. Urea breath test
IV. Histology test
6. V. Rapid urease test

B. I and III only
C. II and IV only
D. V only
E. All are correct.

A. B. is a 45-year-old white female with a past medical history significant only for seizure
disorder. She has experienced heartburn after meals intermittently for the past 2 weeks. It
becomes worse when she is reclining at bedtime. Her medications include phenytoin 300 mg
hs. A. B. says her symptoms are not troublesome and she is going to self-treat with over-the-
counter medications. Which one of the following should not be recommended to A. B.?
7.
A. Aluminum hydroxide
B. Cimetidine
C. Famotidine
D. Ranitidine
E. Magnesium hydroxide

A. B.'s symptoms are not relieved after 2 weeks of OTC treatment with famotidine and lifestyle
modifications. A. B. states her symptoms are becoming "troublesome." Which of the following
is the best choice?
A. Add the prokinetic agent metoclopramide to famotidine.

8.
B. Endoscopy should be performed because A. B. has symptoms suggestive of complications
from GERD.
C. Add alginic acid 2 tablets qhs to famotidine.
D. Discontinue current therapy and initiate therapy with omeprazole 20 mg daily.
E. Continue famotidine for 1 more week to achieve maximum effectiveness.

Which of the following are the most common symptoms of esophageal GERD syndromes?
I. Heartburn
II. Belching
III. Regurgitation
IV. Hypersalivation
9. V. Hoarseness

B. I and III only
C. II and IV only
D. V only
E. All are correct.

Which of the following diagnoses carries an increased risk for developing esophageal
adenocarcinoma?
I. Typical reflux syndrome

II. Reflux cough syndrome
III. Reflux laryngitis
IV. Nontroublesome symptoms of GERD
10.
V. Barrett's esophagus

B. I and III only
C. II and IV only
D. V only
E. All are correct.

Which of the following may exacerbate GERD symptoms by lowering the LES pressure?
A. Quinidine
11. B. Iron
C. Potassium chloride
D. Diltiazem
E. Tetracycline

Which of the following is the best choice for the initial treatment of troublesome symptoms of
the typical reflux syndrome?
A. Nizatidine 75 mg qd
12.
B. Pantoprazole 40 mg qd
C. Metoclopramide 10 mg qid
D. A 3-month trial of lifestyle modifications
E. Pantoprazole 40 mg qd with metoclopramide 10 mg qid

A. Y. is a 32-year-old white male who presents with bloody diarrhea (less than four stools per
day) for 2 days. Complete blood counts and ESR are normal. Physical exam is normal.
Colonoscopy reveals distal colitis. Which of the following is the best choice for initial therapy
for A. Y.?
13.
A. Prednisone 40 mg po qd
B. Sulfasalazine 4-6 g po qd
C. Mesalamine 1-4 g PR qhs
D. Mesalamine 4-6 g po qd
E. Methylprednisolone 16 mg IV q8h

A. Y. continues to have bloody diarrhea (without systemic disturbances). Which one of the
following is the best choice?
A. Add prednisone 40 mg po qd and discontinue enema.

14.
B. Add mesalamine 2-4 g po qd and continue enema.
C. Add methylprednisolone 16 mg IV q8h until remission is achieved.
D. Add mesalamine 2-4 g po qd and discontinue enema.
E. Add azathioprine 1.0-2.5 mg/kg per day and discontinue enema.

Which of the following are true for UC?
I. Aminosalicylates are the drugs of choice for maintenance therapy.

II. Oral corticosteroids are the drugs of choice for maintenance therapy.
III. Azathioprine often allows reduction in corticosteroid dose.
IV. Topical aminosalicylates are the drugs of choice for severe or fulminant disease.
15. V. Ciprofloxacin is alternative first-line therapy for mild to moderate disease.

B. I and III only
C. II and IV only
D. V only
E. All are correct.

Which of the following is true for CD?
I. Infliximab is the drug of choice for mild to moderate disease.

II. Oral corticosteroids are the drugs of choice for maintenance therapy.
III. Topical aminosalicylates are the drugs of choice for mild to moderate disease.
IV. Oral cyclosporine is the drug of choice for maintenance therapy.
16. V. Budesonide should be used as initial therapy for CD of the ileum and right colon.

B. I and III only
C. II and IV only
D. V only
E. All are correct.

Which of the following is true for moderate to severe CD?
A. Azathioprine is the drug of choice for initial therapy.

17. B. Budesonide is appropriate maintenance therapy.
C. Oral corticosteroids are the drugs of choice for initial therapy.
D. Methotrexate has no role in CD therapy.
E. Topical aminosalicylates are appropriate maintenance therapy.

Which of the following is associated with the development of progressive multifocal
leukoencephalopathy?
A. Prednisone
18.
18.
B. Sulfasalazine
C. Mesalamine
D. Methotrexate
E. Natalizumab

J. J. is a 39-year-old female who presents with mild abdominal pain and diarrhea for 12 weeks.
J. J. has no significant past medical history and occasionally misses days from her full-time
job. Her symptoms are worse after meals. Which of the following is the best choice for initial
therapy?
I. Paroxetine 10 mg qd
II. Amitriptyline 10 mg hs
III. Tegaserod 6 mg bid
19.
IV. Alosetron 1 mg qd
V. Dicyclomine 10 mg qid after meals

B. I and III only
C. II and IV only
D. V only
E. All are correct.

J. J.'s symptoms are controlled for several months until she loses her job. Her abdominal pain
then returns. She has five episodes of diarrhea per day and complains of fatigue and insomnia.
Which of the following are the most appropriate for J. J.?
I. Initiate psychological counseling.

II. Prescribe amitriptyline 10-50 mg hs.
III. Add loperamide 2 mg after each loose stool (16 mg/d maximum).
20. IV. Add alosetron 1 mg qd.
V. Start tegaserod 6 mg bid.

B. I and II only
C. II and IV only
D. V only
E. All are correct.

Which of the following is indicated for constipation-predominant IBS?
A. Tegaserod 6 mg bid
21. B. Alosetron 1 mg bid
C. Loperamide 2-16 mg/d
D. Paroxetine 10-40 mg qd
E. Diphenoxylate + atropine 2 tabs qid

Which of the following is affected by medications that induce or inhibit the cytochrome P450
enzyme system?
A. Tegaserod
22.
B. Alosetron
C. Fibercon
D. Polyethylene glycol
E. Amitriptyline

Which life-threatening complication caused the restriction of alosetron?
A. Stevens-Johnson syndrome
23. B. Toxic epidermal necrolysis
C. Aplastic anemia
D. Ischemic colitis
E. Chronic diarrhea

Alosetron is indicated for which group of IBS patients?
A. Women with diarrhea-predominant IBS

24. B. Men with diarrhea-predominant IBS
C. Women with constipation-predominant IBS
D. Men with constipation-predominant IBS
E. Children with diarrhea-predominant IBS

21-7. Answers
A. Triple-drug therapy with a PPI, clarithromycin, and amoxicillin is recommended by the

American Gastroenterological Association as initial therapy for H. pylori. Quadruple therapy
1. with a bismuth-based regimen is less convenient but may be used first line in patients who are
penicillin allergic. Two-drug regimens are less effective and are not recommended.
Furazolidone is unavailable in the United States.

B. The patient is allergic to penicillin; therefore, amoxicillin cannot be used. Two-drug
2. regimens are less effective and not recommended. Antisecretory therapy is an integral part of
H. pylori regimens to promote ulcer healing. Furazolidone is unavailable in the United States.

3. B. NSAIDs are the leading cause of PUD in patients who are negative for H. pylori infection.

A. NSAIDs inhibit production of prostaglandins and are directly toxic to gastroduodenal
4. epithelium. NSAIDs require dose adjustments in renal insufficiency. NSAIDs may cause
gastric or duodenal ulcers and must be discontinued to allow for ulcer healing.

5. C. Elimination of symptoms and healing of ulcerations are goals of therapy for PUD.

6. A. The serum antibody test, fecal antigen test, and urea breath test do not require endoscopy.

B. Cimetidine is a potent inhibitor of the cytochrome P450 enzyme system and will increase
7.
serum concentrations of phenytoin in A. B.

D. Prokinetic agents are useful mainly in patients with concurrent gastric motility disorders and
are not routinely recommended. A. B. does not currently exhibit symptoms of GERD
8. complications. Alginic acid is ineffective when the patient is lying in the supine position and
should not be given at bedtime. Nonprescription medications for GERD should be
discontinued if symptoms are not relieved after a 2-week trial.

9. B. Heartburn and regurgitation are the most common symptoms of the typical reflux syndrome.

D. Patients with Barrett's esophagus have an increased risk of developing esophageal
10.
adenocarcinoma.

D. Calcium channel blockers decrease LES pressure. Quinidine, iron, potassium chloride, and
11.
tetracycline have direct irritant effects on the esophageal mucosa.

B. The correct dose of nizatidine (prescription strength) would be 150 mg bid. Metoclopramide
12. is not routinely recommended for the treatment of the typical reflux syndrome. When patients
find their symptoms "troublesome," pharmacologic therapy should be initiated.

C. Topical aminosalicylates (answer C) are more effective than oral aminosalicylates (answer
B) and topical steroids for mild distal UC (although oral aminosalicylates or topical steroids
13. may be used first line if the patient prefers). Oral and IV steroids (answers A and E) are
reserved for more severe cases of UC or cases that do not respond to oral and topical
aminosalicylates. The oral dose of mesalamine in answer D is incorrect.

B. Oral aminosalicylates should be added if no response is achieved with topical
aminosalicylates. Oral and IV steroids are reserved for moderate to severe UC or for patients
14.
with systemic disturbances. Azathioprine may be added if UC is refractory to aminosalicylates
and to allow corticosteroid dose reduction.

B. Aminosalicylates are the drugs of choice for maintenance therapy of UC, not
corticosteroids. Azathioprine often allows a reduction in dose of corticosteroids in the
15. management of active UC. Severe or fulminant UC requires oral, not topical, therapy.
Ciprofloxacin may be used as an alternative first-line therapy in the treatment of mild to
moderate CD, not UC.

D. Budesonide is the treatment of choice for mild to moderate CD of the ileum and right colon.
Infliximab is reserved for moderate to severe disease in patients who do not respond to oral
corticosteroids or immunosuppressive agents. It may also be used in patients in whom side
16. effects from oral corticosteroids must be avoided. Oral corticosteroids should not be used for
long-term maintenance therapy. Oral budesonide is the drug of choice for mild to moderate
CD, not topical corticosteroids. Oral cyclosporine has no role in CD; IV cyclosporine may be
used in severe or fulminant CD that does not respond to 5-7 days of IV corticosteroids.

C. Moderate to severe disease initially requires oral corticosteroid therapy. Corticosteroids
17. have no role in maintenance therapy. Topical aminosalicylates may be used as adjuncts in
colonic CD. Methotrexate is used as maintenance therapy for moderate to severe CD.

E. Natalizumab has been associated with the development of progressive multifocal
18.
leukoencephalopathy.

D. J. J. has mild, diarrhea-predominant IBS. Symptomatic treatment with dicyclomine is
appropriate initial therapy, especially since her symptoms are meal related. A TCA may be
added to dicyclomine if needed. Tegaserod is indicated for constipation-predominant IBS.
19.
Alosetron is reserved for patients with severe, diarrhea-predominant disease who have failed
other therapies. Paroxetine may be added if initial therapies are ineffective or if J. J. develops
severe abdominal pain or psychiatric comorbidities.

A. Alosetron is reserved for patients with severe, diarrhea-predominant disease who have
failed other therapies. Several types of psychotherapy have been shown to be more effective
20. than usual care in IBS. TCAs improve abdominal pain in IBS and may also help with
insomnia. Loperamide may be used on an as-needed basis for diarrhea. Tegaserod is indicated
for constipation-predominant IBS.

A. Alosetron is approved for restricted use in diarrhea-predominant IBS. Loperamide and
diphenoxylate + atropine are antidiarrheal medications that will exacerbate constipation.
21.
Paroxetine is an SSRI with potent anticholinergic effects, which could worsen constipation.
Another drug should be chosen if an SSRI is needed for depression.

22. E. TCA serum concentrations are affected by drugs that alter cytochrome P450 activity.

23. D. Severe constipation, ischemic colitis, and death have been reported with alosetron.

A. Alosetron is approved for women with diarrhea-predominant IBS. It was not found to be
24.
effective in men and is not approved for use in children.

21-8. References
Peptic Ulcer Disease
Berardi RR, Welage LS. Peptic ulcer disease. In: Dipiro JT, Talbert RL, Yee GC, et al., eds.
87.
Chey WD, Wong BC. American College of Gastroenterology guideline on the management of
Helicobacter pylori infection. Am J Gastroenterol. 2007; 102:1808-25.
Del Valle, J. Peptic ulcer disease and related disorders. In: Fauci AS, Braunwald E, Kasper DL, et
al., eds. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.
Malfertheiner P, Megraud F, O'Morain C, et al. Current concepts in the management of

Helicobacter pylori infection: The Maastricht III Consensus Report. Gut. 2007;56:772-81.
NIH Consensus Conference. Helicobacter pylori in peptic ulcer diseases: NIH Consensus
Development Panel on Helicobacter Pylori in Peptic Ulcer Disease. JAMA. 1994;272:65-69.
Ramakrishnan K, Salinas RC. Peptic ulcer disease. Am Fam Physician. 2007;76:1005-12.
Rokkas T, Sechopoulos P, Robotis I, et al. Cumulative H. pylori eradication rates in clinical

practice by adopting first- and second-line regimens proposed by the Maastrict III consensus and
a third-line empirical regimen. Am J Gastroenterol. 2009;104: 21-25.
Shiotani A, Graham DY. Pathogenesis and therapy of gastric and duodenal ulcer disease. Med Clin
North Am. 2002;86:1447-66.
Singh G, Triadafilopoulos G. Epidemiology of NSAID-induced GI complications. J Rheumatol.

1999; 26(suppl 26):18-24.
Vakil, N. H. pylori treatment: New wine in old bottles? Am J Gastroenterol. 2009;104:26-30.
Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal toxicity of nonsteroidal anti-inflammatory

drugs. N Engl J Med. 1999;340:1888-89.
Gastroesophageal Reflux Disease

Cappell MS. Clinical presentation, diagnosis, and management of gastroesophageal reflux disease.
Med Clin North Am. 2005;89:243-91.
DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal
reflux disease. Am J Gastroenterol. 2005;100:190-200.
Goyal RK. Diseases of the esophagus. In: Fauci AS, Braunwald E, Kasper DL, et al., eds. Harrison's
Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.
Kahrilas PJ, Shaheen NJ, Vaezi MF. American Gastroenterological Association institute technical
review on the management of gastroesophageal reflux disease. Gastroenterol. 2008;135:1392-
413.
Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association medical
position statement on the management of gastroesophageal reflux disease. Gastroenterol.
2008;135:1383-91.
Locke GR, Talley NH, Fett SL, et al. Prevalence and clinical spectrum of gastroesophageal reflux:
A population-based study in Olmstead county. Gastroenterol. 1997;112:1448-56.
Vakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and classification of
gastroesophageal reflux disease: A global, evidence-based consensus. Am J Gastroenterol.
2006;101:1900-20.
Williams DB, Schade RR. Gastroesophageal reflux disease. In: Dipiro JT, Talbert RL, Yee GC, et
2008:555-67.
Inflammatory Bowel Disease
Ardizzone S, Porro GB. Inflammatory bowel disease: New insights into pathogenesis and treatment.
J Intern Med. 2002;252:475-96.
Banerjee S, Peppercorn MA. Inflammatory bowel disease: Medical therapy for specific clinical
presentations. Gastroenterol Clin North Am. 2002; 31:185-202.
Drug therapy for ulcerative colitis. Pharmacist's/Prescriber's Letter. 2007;23:230308.
Friedman S, Blumberg RS. Inflammatory bowel disease. In: Fauci AS, Braunwald E, Kasper DL, et
al., eds. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.
Hemstreet BA, DiPiro JT. Inflammatory bowel disease. In: Dipiro JT, Talbert RL, Yee GC, et al.,
2008:589-605.
Kornbluth A, Sachar DB. Ulcerative colitis practice guidelines in adults (update): American
College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol.
2004;99:1371-85.
Lichtenstein GR, Hanauer SB, Sandborn WJ, et al. Management of Crohn's disease in adults:
American College of Gastroenterology Practice guidelines. Am J Gastroenterol. 2009;104:465-
83.
Rutgeerts P, Vermeire S, Van Assche, G. Biological therapies for inflammatory bowel diseases.
Gastroenterol. 2009;136:1182-97.
Irritable Bowel Syndrome
Brandt LJ, Chey WD, Foxx-Orenstein AE, et al. An evidence-based position statement on the
management of irritable bowel syndrome. Am J Gastroenterol. 2009;104(suppl 1): S1-7.
Brandt LJ, Chey WD, Foxx-Orenstein AE, et al. An evidence-based systematic review on the
management of irritable bowel syndrome. Am J Gastroenterol. 2009;104(suppl 1):S8-S35.
Drossman DA, Camilleri M, Mayer EA, Whitehead WE. AGA technical review on irritable bowel
syndrome. Gastroenterol. 2002;123:2108-31.
Owyang C. Irritable bowel syndrome. In: Fauci AS, Braunwald E, Kasper DL, et al., eds. Harrison's
Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.
Palsson OS, Drossman DA. Psychiatric and psychological dysfunction in irritable bowel syndrome
and the role of psychological treatments. Gastroenterol Clin North Am. 2005;34:281-303.
Spruill WJ, Wade WE. Diarrhea, constipation, and irritable bowel syndrome. In: Dipiro JT, Talbert
RL, Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York:
McGraw-Hill; 2008:617-32.
22. Rheumatoid Arthritis, Osteoarthritis, Gout, and Lupus - Kevin L. Freeman, PharmD,
BCNSP
22-1. Rheumatoid Arthritis
Introduction
Rheumatoid arthritis (RA) is a highly variable, chronic autoimmune disorder of unknown etiology
characterized by symmetric, erosive synovitis. Manifestations may extend to extra-articular sites.
Incidence
RA affects 1% of the population and is two to three times more common in women than in men. It
has a peak incidence in women between 30 and 60 years of age. Certain families, monozygotic
twins, and people with specific HLA (human leukocyte antigen) genetic markers have a greater
incidence of RA, which suggests a genetic predisposition.
The onset of RA is unpredictable and varies from rapid to insidious progression. The course of the
disease is likewise variable: 10-20% of patients have a short course with remission, 70-80% have
mild to moderate disease with cyclic exacerbations, and 10-20% develop progressively destructive
disease.
RA usually affects diarthrodial joints such as the proximal interphalangeal (PIP) joints,
metacarpophalangeal (MCP) joints, metatarsophalangeal (MTP) joints, wrists, and ankles. Also
commonly involved are the elbows, shoulders, sternoclavicular joints, temporomandibular joints,
hips, and knees.
The initial complaints may include generalized fatigue and multiple joint pain.
Morning stiffness is a hallmark of RA. Patients describe it as a gel-like sensation in the joints that
occurs after attempting to move upon awakening.
Ulnar deviation, swan-neck deformities, boutonniere deformities, hammertoe formation, and

ankylosis are common irreversible joint abnormalities that occur in RA.
The extra-articular features that occur in RA include rheumatoid nodules, vasculitis, anemia,
thrombocytopenia, Felty's syndrome, and Sjogren's syndrome.
Etiology
The cause of RA remains a mystery. Factors that may be responsible are of environmental, genetic,
endocrinologic, gastrointestinal, atmospheric, and infectious origin.
RA is widely held to have a strong genetic component. This assertion is supported by the fact that a
greater prevalence of RA is found in patients with the major histocompatibility complex antigen
HLA-DR4. This class II antigen is expressed on the surface of helper T-lymphocytes and
macrophages. In combination with environmental factors, an inappropriate immune response may
occur, resulting in chronic inflammation.
Patients with RA have been demonstrated to have increased antibody titers to Mycobacterium
tuberculosis, Proteus mirabilis, Escherichia coli, Klebsiella pneumoniae, normal human gut flora
antigen, Epstein-Barr virus, and the superantigen staphylococcal enterotoxin B.
Female patients are at greater risk of RA after breast-feeding, which supports the theory that
endocrinologic risk factors are involved.
Gastrointestinal (GI) factors may be responsible for hyperactivity of the immune system—that is,
antibodies to enteric organisms and gluten develop in the GI tract.
Atmospheric changes are associated with symptomatic changes in the disease course.
Pathophysiology
Because of causes still unknown, the body's immune system (starting with macrophages) attacks the
cells within the joint capsule, thereby causing synovitis (as indicated by the warmth, swelling,
redness, and pain associated with RA). Specifically, helper T-lymphocytes stimulate B-cells to
attack antigen (in this case, the body's own collagen). In addition, helper T-lymphocytes release
cytokines (interleukins and tumor necrosis factor, or TNF), which cause further inflammation and
injury in the joints. During the inflammatory process, the cells of the synovium grow and divide
abnormally, causing a normally thin synovium to become thick (pannus). These abnormal synovial
cells begin to invade and destroy the cartilage and bone within the joint. These effects are
responsible for the pain and deformities seen in patients with RA.
Diagnostic Criteria
Patients meeting four of the following criteria are classified as having RA:
• Morning stiffness of or near joints lasting 1 hour before maximum improvement. This condition
must be present for at least 6 weeks.
• Three or more joint areas, including the right or left PIP joint, MCP joint, wrist, elbow, MTP joint,
ankle, or knee, must have arthritis, as demonstrated by soft tissue swelling or fluid. This
condition must be present for at least 6 weeks and observed by a physician.
• Arthritis, as demonstrated by soft tissue swelling or fluid in the hand joints (MCP, PIP, or wrist),
must be present for at least 6 weeks and observed by a physician.
• Symmetric arthritis must occur in the areas noted in the second criterion. This condition must be
present for at least 6 weeks and observed by a physician.
• Subcutaneous nodules (rheumatoid nodules) over bony prominences, extensor surfaces, or in

juxtaarticular regions must be present.
• Positive rheumatoid factor (antibodies that collect in the synovium of the joint) must be present,
as demonstrated by a positive test in less than 5% of normal subjects.
• Radiologic changes of the hands or wrists (e.g., erosions or bone decalcification in or next to
involved joints) must be present.
Treatment Goals
According to the American College of Rheumatology (ACR), the goals in managing RA are to
prevent or control joint damage, prevent loss of function, and decrease pain.
Monitoring
At each visit, the patient should be evaluated for subjective evidence of active disease on the basis
of the following criteria:
• Degree of joint pain
• Duration of morning stiffness
• Duration of fatigue
• Presence of actively inflamed joints on examination
• Limitation of function
Periodically, the patient should be evaluated for disease activity or progression:
• Evidence of disease progression on physical examination (loss of motion, instability,

malalignment, deformity)
• Erythrocyte sedimentation rate or C-reactive protein elevation
• Progression of radiographic damage of involved joints
Other parameters for assessing response to treatment (outcomes):
• Physician's global assessment of disease activity

• Patient's global assessment of disease activity
• Functional status or quality-of-life assessment using standardized questionnaires
The majority of clinical studies use a benchmark of 20% improvement in the preceding criteria, also
known as ACR 20.
Drug Therapy
Aggressive use of disease-modifying antirheumatic drugs (DMARDs) is suggested (

Table 22-1).
The ACR recommendations focus on the use of biologic and nonbiologic therapies for the treatment
of RA. The use of nonmedical therapies and anti-inflammatory drugs as well as other analgesics is
still a part of the optimal treatment regimen; however, it was not evaluated as part of the 2008
recommendations (
Figures 22-1 and
22-2).
The 2008 ACR recommendations for the initiation or reinstitution of biologic and nonbiologic
therapies depend on three factors:
[Table 22-1. Disease-Modifying Antirheumatic Drugs]
• Disease duration:
• Early (< 6 months)
• Intermediate (6-24 months)
• Long or longer (> 24 months)
• Disease activity:
• Available indices:
• Disease Activity Score in 28 Joints
• Simplified Disease Activity Index
• Clinical Disease Activity Index
• Mild disease: typically fewer than six inflamed joints, no extra-articular disease, and no
radiographic evidence of erosions
• Severe disease: typically more than 20 inflamed joints, elevation in C-reactive protein, and
positive rheumatoid factor, extra-articular disease, or both
• Prognostic factors:
• Physical examination, health questionnaire, and laboratory analysis
• Poor prognosis: functional limitation, extra-articular disease, elevated rheumatoid factor or anti-
cyclic citrullinated peptide (CCP) antibodies (anti-CCP may be more specific than rheumatoid
factor)
Nonsteroidal anti-inflammatory drugs
Salicylates, nonsteroidal anti-inflammatory drugs (NSAIDs), and selective cyclooxygenase-2

(COX-2) inhibitors are agents with analgesic and anti-inflammatory properties useful in the
management of RA. These agents reduce joint pain and swelling; however, they do not inhibit joint
destruction or otherwise alter the course of the disease. For this reason, they should not be
considered as a sole treatment option. These agents act by inhibiting prostaglandin synthesis and
release. Cyclooxygenase is present in many cells, including platelets, endothelial cells, and cells of
the gastric and intestinal mucosa. The initial choice of agent is based on the efficacy, safety, cost,
and convenience for any given patient. A wide range of interpatient variability exists with regard to
clinical effect; several NSAIDs may need to be tried before achieving patient satisfaction. See
Table 22-2.
Aspirin
Mechanism of action
Aspirin prevents prostaglandin formation by inhibiting the action of the enzyme cyclooxygenase.
The
[Figure 22-1. Nonbiologic DMARD Use]
[Figure 22-2. Biological DMARD Use]
antithrombotic effect of aspirin occurs by an irreversible inhibition of platelet cyclooxygenase. This

irreversible inhibition is unique to aspirin, because the remaining NSAIDs do so in a reversible
manner.
Dosage
The usual daily dosage needed to achieve anti-inflammatory effects is 3-5 g per day.
Aspirin should be taken with food or milk to decrease gastrointestinal intolerance. Patients should
report any dark or black stools, abdominal pain, or swelling to their physician immediately.
Adverse drug events
Aspirin irreversibly inhibits platelet activity, and serious bleeding may result. Dyspepsia, GI
bleeding, tinnitus, hepatitis, and renal damage have been reported.
• Warfarin: Aspirin may enhance the hypoprothrombinemic effects of warfarin.
[Table 22-2. Drug Therapy with Nonsteroidal Anti-Inflammatory Drugs]
• Uricosuric agents: The uricosuric effects of agents such as probenecid are antagonized by
aspirin.
• Methotrexate: Aspirin may displace methotrexate from its protein binding sites, thereby
increasing serum methotrexate concentrations.
Complete blood count (CBC) as well as creatinine should be monitored at least yearly.
Other NSAIDs
Mechanism of action
The mechanism of action is the same as described for aspirin.
Patient instructions are the same as described for aspirin. Studies indicate that the optimal times for
taking an NSAID might be after the evening meal and immediately on awakening. Patients with a
hypersensitivity to aspirin should not take NSAIDs.
Adverse drug events

Compared with patients with osteoarthritis, patients with RA on NSAID therapy are at increased
risk for a serious complication.
As with aspirin, NSAIDs cause platelet dysfunction. Unlike aspirin, however, this effect is readily
reversible with discontinuation of the medication.
All NSAIDs are capable of causing GI intolerance and peptic ulceration. Risk factors for the
development of peptic ulcer disease include advanced age, history of previous ulcer, concomitant
use of corticosteroids or anticoagulants, higher dosage of NSAID, use of multiple NSAIDs, or
serious underlying disease. Options to decrease the risk of developing GI ulceration include adding
a high-dose histamine blocker such as ranitidine or a proton pump inhibitor such as lansoprazole to
the patient's regimen. Lansoprazole and esomeprazole both have U.S. Food and Drug
Administration (FDA) approval for reducing the risk of NSAID-induced gastric ulcers in those
patients who had a previous risk of ulceration and who continue to require NSAID treatment.
Misoprostol, an oral prostaglandin analogue, may be added at a dose of 100-200 mcg four times
daily to prevent ulceration. Misoprostol is available in combination with diclofenac and sold under
the trade name Arthrotec. Some evidence exists that, compared with other NSAIDs, ibuprofen,
nabumetone, and naproxen carry lower risks of ulceration and GI symptoms. Piroxicam, in contrast,
appears to carry a higher risk of serious GI consequences. A 2008 joint consensus statement by the
American College of Cardiology Foundation, the American Heart Association, and the American
College of Gastroenterology recommends that patients with a history of ulcer disease or with risk
factors for ulceration be treated with a proton pump inhibitor while on NSAID therapy.
Hepatic failure has been reported with NSAID use.
Renal blood flow can be decreased by NSAIDs, which may lead to permanent renal damage.
Prostaglandins are responsible for maintaining the patency of the afferent renal tubule. Inhibition by
NSAIDs decreases glomerular filtration pressure, resulting in decreased blood flow. Because of this
mechanism, patients with hypertension, severe vascular disease, and kidney or liver problems and
those taking diuretics must be monitored closely.
Central nervous system (CNS) side effects such as dizziness, drowsiness, and confusion may occur
with all NSAIDs.
Within the class, some drug-specific adverse reactions occur. Meclofenamate, for example, has a
high incidence (> 10%) of abdominal cramping and diarrhea. Paradoxically, indomethacin tends to
have more severe CNS adverse effects, such as headache.
Concern exists about NSAIDs and their risk of cardiovascular events. The FDA now requires that
manufacturers include a black box warning regarding the potentially serious cardiovascular and GI
adverse events associated with these drugs.
Interactions are the same as those described for aspirin. Ibuprofen may diminish the antiplatelet
mechanism of aspirin if it is taken before aspirin or taken daily on a scheduled basis. It is
recommended that aspirin be taken 2 hours before taking ibuprofen.
COX-2 inhibitors
COX-1 is the isoenzyme constitutively found in most tissues that produce the prostaglandins PGI2
and PGE2, which protect the gastric barrier, and thromboxane A2, which is responsible for platelet
function. COX-2 is the inducible isoenzyme present at sites of inflammation. COX-2 is also found
in the brain, kidneys, and reproductive organs. Celecoxib (Celebrex) has been shown to have lower
incidence of endoscopically demonstrated gastroduodenal lesions than do ibuprofen, naproxen, and
diclofenac. The lower risk for GI complications is apparently eliminated when patients take low-
dose aspirin concomitantly.
Celecoxib
Mechanism of action
Celecoxib selectively inhibits prostaglandin synthesis by specifically targeting the COX-2
isoenzyme.
Patients with a history of allergic reaction to sulfonamides should avoid the use of celecoxib.
Adverse drug events

Although the rates of GI ulceration have been demonstrated to be lower with COX-2 inhibitors than
with traditional NSAIDs, the risk is not completely eliminated. In addition, the risk of dyspepsia,
abdominal pain, and nausea is not significantly less with COX-2 inhibitors than with traditional
NSAIDs. Celecoxib now contains a black box warning regarding cardiovascular and GI risk
associated with its use (as described later).
Interactions are the same as those associated with aspirin.
CBC as well as creatinine should be monitored at least yearly.
Other aspects
The FDA recommended the voluntary removal of valdecoxib (Bextra) from the market in 2005
because of the lack of adequate data on the cardiovascular safety of its long-term use and the recent
data demonstrating increased cardiovascular risk in short-term coronary artery bypass graft (CABG)
patients. This risk is in addition to that of potentially life-threatening skin reactions. Merck removed
rofecoxib (Vioxx) from the market in September 2004 because its use was shown to be associated
with an increased cardiovascular risk in the VIGOR (Vioxx Gastrointestinal Outcomes Research),
APPROVE (Adenomatous Polyp Prevention on Vioxx), and VICTOR (Vioxx in Colorectal
Therapy, Definition of Optimal Regimen) trials. The FDA has concluded that the benefits of
celecoxib outweigh the risks in properly selected and informed patients. Celecoxib contains a black
box warning about cardiovascular and GI risk. Patients with a high risk of cardiovascular events
should not use celecoxib, including CABG patients. Low doses of celecoxib (200 mg per day) do
not seem to be associated with increased risk.
Disease-modifying antirheumatic drugs
Unlike the NSAIDs, DMARDs have the ability to reduce or prevent joint damage and preserve joint
integrity and function. The ACR recommends that patients with an established diagnosis of RA be
offered treatment with DMARDs. Biologic DMARDs are reserved for use after failure of
nonbiologic agents, unless the patient has early disease with high activity and poor prognosis risk
factors. Methotrexate is typically selected for initial therapy because of its track record to induce
long-term response. Methotrexate or leflunomide may be used as monotherapy in patients with all
disease durations and activity regardless of poor prognostic features. Unfortunately, all DMARDs
tend to lose effectiveness over time. It is rare for a patient to use one medication for longer than 2
years.
Nonbiologic DMARDs
Hydroxychloroquine
Mechanism of action
Hydroxychloroquine (Plaquenil) may inhibit interleukin-1 release by monocytes, thereby decreasing
macrophage chemotaxis and phagocytosis.
Beneficial effect may not be seen until 1-6 months of use. Patients should report any changes in
vision to their physician immediately.
Adverse drug events

The most serious potential adverse effect associated with hydroxychloroquine is retinal damage that
can lead to vision loss. This damage is caused by the deposition of the drug in the melanin layer of
the cones. A cumulative dose of 800 g and age > 70 years increase the risk. Hydroxychloroquine
may also cause rash, abdominal cramping, diarrhea, myopathy, skin pigment changes, and
peripheral neuropathy.
Ophthalmic evaluations should be performed at baseline. If the patient has no risk factors (liver
disease, retinal disease, age > 60) and the baseline exam is normal, the American College of
Ophthalmology recommends no further testing for 5 years. High-risk patients should have annual
exams.
Dose
The dose is 6.0-7.5 mg/kg of lean body weight daily or 200 mg bid (maximum dose).
Sulfasalazine
Mechanism of action
The intestinal flora breaks sulfasalazine (Azulfidine) down to 5-aminosalicylic acid and
sulfapyridine, the active moiety in RA. Sulfapyridine likely inhibits endothelial cell proliferation,
reactive oxygen species, and cytokines. In addition, it has been shown to slow radiographic
progression of RA.
Sulfasalazine may produce effects more quickly (within 1 month) than hydroxychloroquine. A
coated tablet form may help reduce adverse GI effects.
Adverse drug events

The most common adverse reactions associated with sulfasalazine include headache, GI intolerance,
dysgeusia, rash, leukopenia, and thrombocytopenia.
Sulfasalazine may inhibit the absorption of folic acid.
Patient tests should include baseline CBC, liver function tests (LFTs), and glucose-6-phosphate
dehydrogenase (G6PD) levels. Patients should then have a CBC every 2-4 weeks for the first 3
months and then once every 3 months thereafter. Patients should receive a pneumococcal
vaccination prior to initiation.
Dose
Begin with 500 mg daily, titrated up to 1-3 g per day divided tid or qid.
Methotrexate
Mechanism of action
Methotrexate (Rheumatrex) inhibits dihydrofolate reductase. It reduces dihydrofolate to
tetrahydrofolate, which can be used as a carrier of single carbon units for the synthesis of
nucleotides and thymidylate. Therefore, methotrexate interferes with DNA synthesis, repair, and
cellular replication.
Patients should be instructed not to change the amount of methotrexate taken without first
consulting their physician.
Adverse drug events
• Liver: Methotrexate may cause liver damage. People with diabetes, liver problems, obesity, and
psoriasis and those who are elderly or alcoholic are at higher risk. If LFTs are more than three
times the upper limit of normal, methotrexate should be discontinued.
• Bone marrow: Leukopenia, thrombocytopenia, and pancytopenia are rare but serious adverse
events associated with methotrexate therapy.
• Lung: Pulmonary toxicity occurs in up to 5% of people who take methotrexate. Risk factors for
the development of pulmonary toxicity include age, diabetes, rheumatoid involvement of the
lungs, protein in the urine, and previous use of sulfasalazine, oral gold, or penicillamine.
• GI: Nausea, vomiting, and stomatitis occur with an incidence of 5-30%.
Aspirin and other NSAIDs may increase methotrexate concentrations by as much as 30-35%.
Trimethoprim-sulfamethoxazole may cause additive hematologic abnormalities because of its
similar affinity for dihydrofolate reductase.
CBC, LFTs, albumin, and creatinine should be monitored every 2-4 weeks for the first 3 months
and every 8-12 weeks thereafter. Patients at risk for hepatitis B and C should be screened prior to
initiation.
Other aspects
Taking folate supplements may help minimize adverse effects such as liver toxicity. Folic acid in
doses up to 3 mg per day has proven effective and does not diminish methotrexate activity. Patients
should receive a pneumococcal vaccination prior to initiation.
Dose
The dose is 7.5-25.0 mg once weekly.
Leflunomide
Mechanism of action
Leflunomide (Arava) inhibits dihydroorotate dehydrogenase (an enzyme involved in de novo
pyrimidine synthesis) and has antiproliferative activity. Several in vivo and in vitro experimental
models have demonstrated its anti-inflammatory effect.
Leflunomide is under pregnancy category X. Women taking leflunomide who wish to become
pregnant should follow the drug elimination procedure outlined under "Other aspects."
Adverse drug events

Diarrhea, elevated LFTs, alopecia, hypertension, and rash have been reported with leflunomide
therapy.
An increased risk of liver toxicity exists when leflunomide is used in conjunction with
methotrexate. Rifampin causes a 40% increase in levels of leflunomide's active metabolite, M1.
CBC, LFTs, albumin, and creatinine should be monitored every 2-4 weeks for the first 3 months
and every 8-12 weeks thereafter. If alanine aminotransferase exceeds two times the upper limit of
normal, reduce the dose of leflunomide to 10 mg per day. Patients at risk for hepatitis B and C
should be screened prior to initiation.
Kinetics
After absorption, 80% of the parent compound is converted to the active metabolite, M1, which is
responsible for all of leflunomide's activity. Because the half-life is 2 weeks, a loading dose is
necessary. In addition, M1 undergoes extensive enterohepatic recirculation.
Other aspects
Begin the following drug elimination procedure if a patient decides to become pregnant: 8 g of
cholestyramine three times daily for 11 days; plasma levels of M1 < 0.02 mg/L must be verified on
two separate occasions at least 14 days apart.
Many randomized controlled trials have established leflunomide as an alternative to methotrexate as

monotherapy.
Patients should receive a pneumococcal vaccination prior to initiation.

Dose
100 mg daily for 3 days (loading dose), then 20 mg daily
D-penicillamine
Mechanism of action
How penicillamine (Cuprimine) induces therapeutic effects in RA is currently unknown. It is
known, however, that penicillamine significantly reduces immunoglobulin M rheumatoid factor and
appears to suppress disease activity.
Penicillamine should be taken on an empty stomach and at least 2 hours from any dose of antacids
or iron supplements.
Adverse drug events
• Bone marrow: Penicillamine may cause thrombocytopenia and leukopenia approximately 6

months into therapy. Rarely, aplastic anemia develops and is associated with its use.
• Renal: Proteinuria may occur in up to 32% of patients on penicillamine therapy.
• Dermatologic: Skin rash may occur 6-9 months after therapy commences.
• Other: Penicillamine causes stomatitis, dysgeusia, and polymyositis.
Absorption decreases approximately 70% with concomitant administration of antacids, iron, and
zinc. Penicillamine may increase digoxin levels. In addition, penicillamine's chelating effects in
combination with oral gold compounds may cause gold from deep tissue compartments to mobilize,
which can increase toxicity.
Patients should have CBC, platelet count, creatinine, and urine dipstick for protein lab testing done
before initiating therapy. Afterward, the patient should have a CBC and urine dipstick for protein
every 2 weeks until the dosage is stable and then every 1-3 months.
Other aspects
Penicillamine may take up to 1 year to be effective. Note that more than half the patients who take
it withdraw because of side effects.
Dose
Begin with 125-250 mg/d, and increase by 125-250 mg/d every 8-10 weeks, not to exceed a
maximum dose of 750 mg/d.
Gold compounds
The intramuscular (IM) gold compounds are gold sodium thiomalate (Myochrysine) and
aurothioglucose (Solganal). Auranofin (Ridaura) is given orally.
Mechanism of action
The mechanism of action of gold compounds is currently unknown; they appear to suppress the
synovitis seen in RA. Current research indicates that they may stimulate specific protective factors,
such as interleukin-6 and interleukin-10.
Patients receiving gold therapy should avoid prolonged sun exposure, which may increase the risk
of serious rash.
Adverse drug events

IM gold
Patients may experience an immediate "nitroid reaction" (i.e., flushing, weakness, dizziness,
sweating, syncope, and hypotension). Rash is the single-largest adverse effect associated with gold
therapy. The rash may range from simple erythema to exfoliative dermatitis. Gold therapy may also
cause proteinuria or microscopic hematuria. Rarely, immunologic glomerulonephritis may occur, in
which case gold therapy should be permanently discontinued. Leukopenia and thrombocytopenia
occur with a 1-3% incidence.
Oral gold
Adverse reactions are similar to those associated with the IM formulation. However, GI complaints
of nausea, diarrhea, emesis, and dysgeusia are higher.
Patients receiving concomitant penicillamine therapy may be subject to an increased risk of toxicity
associated with gold therapy. The risk of rash is higher when gold therapy is used with
hydroxychloroquine.
At baseline, all patients should have a CBC, platelet count, creatinine, and urine dipstick for
protein. For patients receiving IM therapy, a CBC, platelet count, and urine dipstick are
recommended every 1-2 weeks for the first 20 weeks and then again at the time of each (or every
other) injection. Those on oral therapy should have a CBC, platelet count, and urine dipstick for
protein every 4-12 weeks.
Other aspects
Aurothioglucose may have a lower rate of injection reactions; its sesame seed formulation slows
absorption.
Dosing
IM gold
A 10 mg test dose IM is followed by a 25 mg test dose on week 2 and then weekly 50 mg doses
until a cumulative dose of 1 g is achieved. The maintenance regimen is 50 mg every 2 weeks for 3
months or until 1.5 g is given; then every 3 weeks; and then monthly.
Oral gold
The dose is 3 mg bid up to 3 mg tid.
Biologic DMARDs
Antitumor necrosis factor therapy

The drugs used in antitumor necrosis factor (anti-TNF) therapy are infliximab (Remicade),
etanercept (Enbrel), and adalimumab (Humira).
Mechanism of action
Composed of human constant and murine variable regions, infliximab binds specifically to human
tumor necrosis factor (TNF).
Similarly, by binding specifically to TNF, etanercept binds and blocks its interaction with the cell
surface's TNF receptors. It is produced by recombinant technology in Chinese hamster ovaries.
Adalimumab is a recombinant human immunoglobulin G1 monoclonal antibody that binds to TNF

with high affinity.
Patients should not receive live vaccines during treatment. Therapy should be temporarily
discontinued in the event of an acute infection.
Adverse drug events

Therapy has been associated with serious mycobacterial, fungal, and opportunistic infectious
complications such as sepsis and tuberculosis, leading to requirement of an FDA black box warning
to that effect in 2008. Other adverse reactions include rash, headache, nausea, and cough. Although
rare, both etanercept and infliximab have been associated with nerve damage that resembles the
disease process in multiple sclerosis. Lymphoma has been reported with all three TNF antagonists.
Live vaccines may interact with these drugs.
Be clinically alert for tuberculosis, histoplasmosis, and other opportunistic infections.
Other aspects
Patients should be tested for tuberculosis (skin testing, chest radiograph, or both) and hepatitis B (if
risk factors are present) before initiating therapy with any biologic agent. Currently, infliximab is
approved for therapy only in combination with methotrexate. Increased mortality in heart failure
patients taking infliximab has been shown. The ACR recommends against the use of anti-TNF
agents in patients with class III-IV heart failure.
Dose
The dosage for infliximab is 3 mg/kg intravenous (IV) initially, at weeks 2 and 6, and then every 8
weeks in combination with methotrexate.
The dosage for etanercept is 25 mg subcutaneous (SC) twice weekly or 50 mg SC once weekly.
The dosage for adalimumab is 40 mg SC every second week.
Anakinra
Mechanism of action
Anakinra (Kineret) blocks the biologic activity of interleukin-1 by competitively inhibiting
interleukin-1 binding to the interleukin-1 type I receptor.
Kineret is supplied in a single-use, prefilled syringe that should be stored in the refrigerator. Any
syringe left unrefrigerated for more than 24 hours should be discarded.
Adverse drug events

Like the anti-TNF agents, anakinra increases the risk of serious infections. Injection-site reactions
are extremely common. Headache, nausea, diarrhea, sinusitis, flu-like symptoms, and abdominal
pain have also been reported.
Live vaccines can interact with anakinra.
Patients should have a CBC checked at baseline, then monthly for 3 months, and then once every 3
months for the first year of therapy.
Dose
The dose is 100 mg daily SC.
Abatacept
Mechanism of action
Abatacept (Orencia) selectively modulates T-cell activation causing downregulation and an anti-
inflammatory effect.
Adverse drug events

Like the other biologic DMARDs, abatacept increases the risk of infections, especially upper
respiratory infections. Nausea and headache are also frequently reported. In addition, patients with
chronic obstructive pulmonary disease developed adverse effects more frequently than with
placebo. More cases of lung cancer were observed in patients treated with abatacept than with
placebo. The lymphoma rate was higher as well.
Use of abatacept is contraindicated with other biologic DMARDs because of increased risk of
infection. Live vaccines are contraindicated as well.
Other aspects
Abatacept contains maltose and may falsely elevate blood glucose readings. Monitors that do not
react to maltose, such as those based on glucose dehydrogenase nicotine adenine dinucleotide,
glucose oxidase, or glucose hexokinase test methods, are recommended.
Dose
Dose is based on weight (< 60 kg = 500 mg; 60-100 kg = 750 mg; > 100 kg = 1,000 mg). Infusions
are given over 30 minutes. After the initial dose, give at 2 and 4 weeks, followed by every 4 weeks.
Rituximab
Mechanism of action
Rituximab (Rituxan) causes a transient depletion of B-lymphocytes by binding to the CD20 surface
antigens.
Other aspects
Rituximab should be used only in patients with moderate to severe RA who have had an inadequate
response or a contraindication to anti-TNF products.
Dose
Give 1,000 mg every 2 weeks for two doses; patients may be premedicated with a glucocorticoid to
decrease infusion-related reactions.
Other agents
Azathioprine
Azathioprine (Imuran) is a purine analogue immunosuppressive agent that is generally reserved for
refractory RA. It is associated with dose-related bone marrow suppression, stomatitis, diarrhea,
rash, and liver failure. Patients must have a baseline CBC, creatinine, and liver profile. Patients
should then have a CBC and platelet count every 1-2 weeks after any change in dosage and every 1-
3 months thereafter. Azathioprine should not be administered with allopurinol because xanthine
oxidase metabolizes 6-mercaptopurine.
Cyclosporine A
By blocking T-cell activation, cyclosporine A (Sandimmune) produces powerful
immunosuppressive effects and is beneficial as monotherapy in the treatment of RA. Serious
adverse effects such as hypertension, nephrotoxicity, glucose intolerance, and hepatotoxicity have
limited its use.
Corticosteroids
Low-dose oral corticosteroids (< 10 mg per day of prednisone or the equivalent) and local injections
of glucocorticoids are highly effective. Studies indicate that corticosteroids decrease the progression
of RA. They may be useful for acute flare-ups and in patients with significant systemic
manifestations of RA. RA is associated with an increased risk of osteoporosis (independent of
steroid therapy), and the addition of steroidal anti-inflammatory agents increases the risk. Patients
on glucocorticoids should receive 1,500 mg of elemental calcium per day and 400-800 international
units (IU) of vitamin D per day.
Nondrug Therapy
Surgery
Prosorba column
A device called the Prosorba column removes inflammatory antibodies from the patient's blood.
Joint surgery
Patients may have arthroscopy performed to clean out the bone and cartilage fragments that cause
pain within the joint capsule. Patients may eventually require complete joint replacement surgery.
Lifestyle modifications
A mild exercise regimen can be an effective therapy.
Some evidence suggests a moderate increase in daily protein intake may be beneficial in RA.
Patients with RA benefit from a formal support group.
22-2. Osteoarthritis
Introduction
Osteoarthritis (OA), a disease that affects the weight-bearing joints of the peripheral and axial
skeleton, is the most common form of arthritis in the United States. OA is also known as
degenerative joint disease.
Incidence
According to radiologic evidence, approximately 60-80% of people over the age of 65 have OA.
Before the age of 50, men have a higher incidence; however, after the age of 50, women have a
higher incidence.
Pain is a common initial finding in patients with OA. This pain typically worsens with weight-
bearing activity and improves with rest of the affected joint. Changes in weather and barometric
pressure tend to influence the severity of pain.
Joint stiffness, including morning stiffness, is another common complaint. This stiffness differs
from that of RA. It is relatively short in duration, is related to periods of inactivity, and resolves
with movement.
Crepitus is common, especially when the knee joint is involved.
Joint deformities also occur in OA. Heberden's nodes, Bouchard's nodes, and osteophytes on the
distal interphalangeal and proximal interphalangeal joints are commonly seen.
Pathophysiology
Although the causes of OA are not completely understood, biomechanical stresses affecting the
articular cartilage and subchondral bone are thought to be the primary factors in the development of
OA. In addition, inflammatory, biochemical, and immunologic components play a role. The
function of the normal cartilage—that is, to dissipate the force and stress caused by normal weight-
bearing activity—is impaired in OA.
• Collagen fibers are destroyed and subsequently release proteoglycans. The hydration of the
cartilage increases, and the cartilage becomes thick.
• Metalloproteinases, which degrade the proteoglycans, are released to initiate the reparation
process. This degradation causes an increase in chondrocyte activity.
• The resulting cartilage is thin because the chondrocyte activity cannot match the rate at which
proteoglycan degradation occurs.
• With this ever-thinning layer of cartilage now exposing bone, the grinding motion stimulates
osteoclast and osteoblast activity, thereby causing bone resorption and vascular changes.
Ultimately, these changes lead to the formation of osteophytes.
Diagnostic Criteria
Osteoarthritis of the hip
According to the ACR classification criteria, osteoarthritis of the hip exists if the patient has hip
pain and at least two of the following:
• Erythrocyte sedimentation rate < 20 mm/h
• Radiographic femoral or acetabular osteophytes
• Radiographic joint space narrowing
Other criteria include one of the following:

• Hip pain and radiographic femoral or acetabular osteophytes
• Hip pain and radiographic joint space narrowing and erythrocyte sedimentation rate < 20 mm/h
Osteoarthritis of the knee
According to ACR classification criteria, osteoarthritis of the knee exists if the patient has knee
pain, radiographic osteophytes, and at least one of the following:
• Age > 50 years
• Morning stiffness 30 minutes in duration
• Crepitus on motion
Other criteria include one of the following:
• Knee pain and radiographic osteophytes
• Knee pain and age 40 years, morning stiffness 30 minutes in duration, and crepitus on motion
Treatment of patients with OA focuses on symptom control. Currently, no therapeutic options are
known to change the course of the disease.
Drug Therapy
Pain relief is the primary treatment goal for patients with OA. The recommended initial drug of
choice is acetaminophen. For those patients who do not respond fully, the addition of an NSAID
(see discussion of this class in Section 22-1) is made. Box 22-1 outlines pharmacologic therapy for
patients with osteoarthritis.
Acetaminophen
Mechanism of action
Acetaminophen centrally inhibits prostaglandin synthesis.
Patients with hepatic disease or viral hepatitis are at risk of toxicity from chronic acetaminophen
use.
Adverse drug events

Hepatotoxicity is the most severe side effect associated with acetaminophen therapy. For this
reason, patients should not ingest more than 4 g of acetaminophen per day. Long-term therapy has
also been linked to renal failure.
Box 22-1. Pharmacologic Therapy for Patients with Osteoarthritis
Oral
• Acetaminophen 4 g/d
• COX-2-specific inhibitor
• Nonselective NSAID plus misoprostol or a proton pump inhibitor
• Nonacetylated salicylate
• Other pure analgesics
Tramadol (Ultram) 50 mg/dose (up to 400 mg/d)
Ultracet 37.5 mg/dose (up to 300 mg/d)
• Alternative therapy: glucosamine 1,500 mg/d (alone or in combination with chondroitin)
Intra-articular
• Glucocorticoids
• Hyaluronan
Topical
• Capsaicin
• Methyl salicylate
Other aspects
Acetaminophen is generally considered the initial drug of choice; however, there have been no
clinical trials comparing its side effects, potential toxicity, or pain-relieving properties with those of
NSAIDs.
Tramadol
Tramadol is a central opioid agonist that binds to mu receptors and weakly inhibits norepinephrine
and serotonin reuptake.
Adverse drug events
Nausea, vomiting, constipation, and seizures are associated with tramadol use. Withdrawal
symptoms may occur with abrupt discontinuation.
Drug interactions
Tramadol is contraindicated in patients taking monoamine oxidase inhibitors because of the risk of
serotonin syndrome.
Other aspects
Tramadol is available as an immediate-release product (Ultram), as an extended-release product
(Ultram ER), and in combination with acetaminophen 325 mg (Ultracet).
Topical agents (capsaicin)
Mechanism of action
Derived from the pepper plant, capsaicin works by exciting the nociceptive C-afferent neurons,
which, in turn, causes the release of substance P, which is responsible for transmitting pain from the
peripheral to the central nervous system.
Patients should avoid contact with eyes. It is important to wash hands thoroughly after use.
Adverse drug events

Patients will experience mild burning and stinging at the site of application.
Other aspects
Patients usually derive benefit after several weeks of application. Capsaicin is often used in
conjunction with oral agents.
Glucosamine sulfate and chondroitin
Mechanism of action
Glucosamine is found naturally in articular cartilage and acts as a substrate in the synthesis of
proteoglycans. Chondroitin, another constituent in the cartilage, attracts and retains water, which
provides shock absorption. In addition, chondroitin prevents the breakdown of cartilage and
stimulates RNA (ribonucleic acid) synthesis of chondrocytes.
Patients taking anticoagulants concomitantly may be at increased risk of bleeding.
Adverse drug events

Adverse events tend to be mild but include dyspepsia and euphoria.
Other aspects
This combination is available over the counter and has some clinical literature to support its use.
The Arthritis Foundation, however, does not currently recognize it as a treatment for OA.
Other agents
The FDA has approved hyaluronic acid derivatives for the treatment of pain associated with OA of
the knee. These agents may be an option after all conventional therapies for OA have been
exhausted. The injection of this product into the synovium appears to replenish the viscosity to the
space, thus enabling normal tissue to regenerate.
Nondrug Therapy
Nondrug therapy for OA consists of the following:
• Patient education
• Self-management programs (e.g., Arthritis Foundation Self-Management Program)
• Personalized social support through telephone contact
• Weight loss (if overweight)
• Aerobic exercise programs
• Physical therapy (i.e., range-of-motion exercises)
• Muscle-strengthening exercises
• Assistive devices for ambulation
• Patellar taping
• Appropriate footwear
• Lateral-wedged insoles (for genu varum)
• Bracing
• Occupational therapy
• Joint protection and energy conservation
• Assistive devices for activities of daily living
22-3. Gout
Introduction
Gout, a systemic disease caused by the buildup of uric acid in the joints, causes inflammation,
swelling, and pain. Hyperuricemia is defined as a urate level > 8 mg/dL in men and 7 mg/dL in
women.
Incidence
Gout has been known as "the disease of kings and the king of diseases" and can be traced to the
time of Hippocrates. Gout occurs in approximately 1% of the population. The vast majority of gout
patients are men.
Pain in one joint of the lower extremity is the most common first symptom of gout. The initial
period of pain, usually monarticular and self-limiting, is followed by a period in which the patient is
completely asymptomatic.
Termed intercritical periods, the time between acute gouty arthritis attacks may be 3 months to 2
years. The length of time shortens as the disease progresses.
The first attack is typically at night or in the early morning.
Gout commonly affects the ankle, heel, knee, wrist, finger, elbow, and instep. The most common
site of the initial attack is the first MTP joint and is known as podagra.
The patient may experience fever, chills, and malaise during an acute gouty arthritis attack. Left
untreated, the attack may last 1-2 weeks.
The skin over the affected joint becomes red, hot, swollen, and tender. As the patient recovers from
the attack, local desquamation may occur.
Pathophysiology
Uric acid is the end product of purine metabolism (

Figure 22-3). Xanthine oxidase is the rate-limiting step in the formation of uric acid. Uric acid,
which serves no known biological function, has a body content of 1.0-1.2 g.
Approximately 70% of uric acid is excreted via the kidneys. At physiologic pH, uric acid primarily
exists as monosodium urate (MSU) salt.
Approximately 95% of serum uric acid is filtered across the glomerulus. Of this filtered amount,
almost 100% is reabsorbed in the early part of the proximal tubule, only to be secreted back into the
lumen in the more distal part of the tubule.
Primary gout is a result of an innate defect in purine metabolism or uric acid excretion. In this case,
[Figure 22-3. Ribose-Uric Acid Pathway]
hyperuricemia may result from uric acid overproduction (in "overproducers"), impaired renal
clearance of uric acid (in "underexcreters"), or a combination of both. In rare instances, enzyme
defects of either hypoxanthine guanine phosphoribosyltransferase or 5-phosphoribosyl-1-
pyrophosphate may cause primary gout (Figure 22-3).
Secondary gout is associated with increased nucleic acid turnover, decreased renal function,
increased purine production, or drug-induced decreased elimination of uric acid. Hematologic
disorders that are lymphoproliferative and myeloproliferative in nature are known causes of
secondary hyperuricemia. Salicylates such as aspirin may inhibit tubular secretion of uric acid at
low doses. All diuretics, with the exception of spironolactone, may cause hyperuricemia.
Ethambutol, pyrazinamide, nicotinic acid, ethanol, niacin, and cyclosporine are known to cause an
increase in serum uric acid.
Acute gout attacks are caused by the deposition of monosodium urate (MSU) in the synovium of
the joint. This deposition results in the stimulation of the body's inflammatory cascade. The MSU
crystals undergo phagocytosis by polymorphonuclear leukocytes. These leukocytes, damaged by the
sharp crystals, burst and release their contents (interleukin-1, lysosomes, and prostaglandins) into
the synovium, resulting in the inflammatory reaction—that is, pain, swelling, and erythema.
If left untreated, deposits of MSU crystals, also known as tophi, lead to joint deformity and
disability. Ultimately, patients may develop one of two types of renal disease: urate nephropathy or
uric acid nephropathy. Urate nephropathy results from the deposition of MSU crystals in the renal
interstitium. Uric acid nephropathy results from the deposition of uric acid in the collecting tubules.
Diagnostic Criteria
The American Rheumatism Association lists the following criteria for the diagnosis of gout:
• Definite: Sodium urate crystals in the affected joint appear negatively birefringent when viewed
through a polarized light source.
• Suggestive: A minimum of six of the following criteria should be met.
• More than one attack of arthritis
• Development of maximum inflammation within 1 day
• Oligoarthritis attack
• Redness over joint

• Painful or swollen first MTP joint
• Unilateral attack on first MTP joint
• Unilateral attack on tarsal joint
• Tophus
• Hyperuricemia
• Asymptomatic swelling within a joint
Ruling out pseudogout is also important. In pseudogout, crystals deposited into the joint synovium
cause intense pain and inflammation, but the culprit is calcium pyrophosphate dihydrate, not
monosodium urate.
Treatment Goals
• Relieve pain and inflammation.
• Reduce serum uric acid concentration.
• Prevent recurrent gout attacks.
Drug Therapy
Drugs for the treatment of gout are outlined in

Table 22-3.
Acute gouty arthritis attack
Three treatments are available: colchicine, NSAIDs (indomethacin in particular), and

corticosteroids. Avoiding treatments that affect serum uric acid concentrations is best during an
acute attack.
Colchicine
Mechanism of action
Colchicine inhibits the phagocytosis of urate crystals by leukocytes. Colchicine also inhibits the
release of chemotactic factor, thus reducing the adhesion of polymorphonuclear leukocytes. The net
result makes colchicine an anti-inflammatory agent without analgesic activity.
Patients should immediately stop taking colchicine if abdominal cramping or diarrhea occurs.
Patients should never exceed a total of 8 mg during an acute gouty arthritis attack.
Adverse drug events
Nausea, bloating, emesis, and diarrhea occur in up to 80% of patients taking colchicine. Rarely, it
may cause bone marrow suppression. This effect occurs with a higher incidence in those patients
with underlying renal or hepatic dysfunction. When colchicine is given intravenously, possible
extravasation may cause local skin necrosis. In addition, the intravenous route has been associated
with bone marrow suppression,
[Table 22-3. Drugs for the Treatment of Gout]
disseminated intravascular coagulation, seizures, and death.

Patients with active peptic ulcer disease should not take colchicine.
With long-term therapy, patients should have a serum creatinine test, liver function test, and
complete white blood cell count check periodically.
Dose
For the treatment of an acute gouty arthritis attack, patients should take 1.2 mg orally followed by
0.6 mg in 1 hour. Maximum dose is 1.8 mg.
Other aspects
Colchicine is most effective when initiated within 12-36 hours of the attack.
Indomethacin
Indomethacin is the most extensively studied NSAID in the treatment of an acute gouty arthritis
attack. Unlike colchicine, indomethacin is effective at any point during the acute attack. For more
information, see the review of NSAIDs in Section 22-1.
Corticosteroids
For the treatment of acute gout pain, corticosteroids are effective when given intra-articularly,
intravenously, or orally. Their use is limited to treatment failures of colchicine and NSAIDs.
Intramuscular corticotropin (adrenocorticotropic hormone) is also effective when given (40 units) to
treat an acute gouty arthritis attack.
Gout prophylaxis (intercritical period)
Patients with asymptomatic hyperuricemia should not be routinely treated with pharmacologic
agents. These patients should undergo a workup to determine the cause of hyperuricemia. The use
of low-dose (0.6-1.2 mg/d) colchicine can prevent subsequent attacks of gout. Patients in the
intercritical period (after an acute gouty arthritis attack) are candidates for long-term prophylactic
therapy directed at affecting serum uric acid levels. Choice of therapy is based on the patient's
pathophysiologic cause of hyperuricemia. Patients are generally classified as overproducers or
underexcreters. Placing the patient on a purine-restricted diet and performing a 24-hour urine
collection to measure uric acid concentration may identify overproducers of uric acid. Those
patients who excrete more than 600 mg of uric acid are considered overproducers. Once this
diagnosis is made, patients are treated with one of two classes of agents: xanthine oxidase inhibitors
or uricosurics.
Probenecid
Mechanism of action
Probenecid (Benemid) is a uricosuric agent that promotes the excretion of uric acid by blocking its
reuptake at the proximal convoluted tubule.
Patients should drink at least 2 liters of water per day to decrease the risk of uric acid stone
formation. Patients should take probenecid with food if GI intolerance occurs.
Adverse drug events

Probenecid is generally well tolerated and is associated with very few adverse side effects. Up to
10% of patients receiving probenecid therapy develop uric acid stones. Probenecid may cause
abdominal discomfort, but patients can often avoid it by taking probenecid with food.
Because probenecid prevents the tubular secretion of many weak organic acids, it has potential drug
interactions—for example, with the penicillins, cephalosporins, nitrofurantoin, and rifampin.
Although the interaction between probenecid, penicillins, and cephalosporins has been used
therapeutically, the interaction with nitrofurantoin reduces nitrofurantoin's effectiveness. Using
probenecid and aspirin together, even in low doses, is not advisable because aspirin blocks uric acid
excretion. A crossover study in patients with gouty arthritis concluded that low-dose aspirin did not
significantly interfere with the uricosuric effects of probenecid. Avoiding the combination would be
reasonable, however. Additionally, the diuretic effects of furosemide and hydrochlorothiazide are
magnified when probenecid is taken concomitantly. Finally, patients receiving sulfonylureas should
be monitored closely for hypoglycemia when started on probenecid.
Other aspects
Patients should never begin uricosuric therapy during an acute gouty arthritis attack because of the
risk of exacerbating the attack. Probenecid should not be used in patients with a creatinine clearance
less than 50 mL/min.
Sulfinpyrazone
Mechanism of action
Sulfinpyrazone (Anturane) is a uricosuric agent that promotes the excretion of uric acid by blocking
its reuptake at the proximal convoluted tubule.
Patients should drink at least 2 liters of water per day to decrease the risk of uric acid stone
formation. Patients should take sulfinpyrazone with food if GI intolerance occurs. Patients who are
sensitive to aspirin should not take this agent because of the risk of bronchoconstriction.
Adverse drug events
Like probenecid, sulfinpyrazone is generally well tolerated. The most common reported adverse
effects are GI discomfort and uric acid stone formation. In addition, rarely, sulfinpyrazone has been
associated with bone marrow suppression and immunoallergic interstitial nephritis.
Sulfinpyrazone decreases the effectiveness of nitrofurantoin. When sulfinpyrazone is taken with
aspirin, the effect of sulfinpyrazone is lessened.
Patients should have complete blood work periodically because of the rare risk of bone marrow
suppression associated with sulfinpyrazone therapy.
Other aspects
Patients should never start uricosuric therapy during an acute gouty arthritis attack; uricosuric
therapy may exacerbate the attack. When increasing the dose of sulfinpyrazone, titrate upward
slowly to minimize the risk of uric acid stone formation. Because uricosuric therapy may precipitate
an acute gouty arthritis attack, patients should take an NSAID or colchicine for the first 6-12
months of therapy. Patients with a creatinine clearance of less than 50 mL/min should not use
sulfinpyrazone.
Allopurinol
Mechanism of action
Allopurinol (Zyloprim) and its metabolite, oxypurinol, inhibit xanthine oxidase formation (the rate-
limiting step in uric acid synthesis), thereby facilitating the clearance of the more water-soluble
precursors of uric acid, oxypurines.
Patients should immediately report any signs of rash to their health care providers. Allopurinol
should be taken with food to minimize GI discomfort.
Adverse drug events

Allopurinol is generally well tolerated; the overall occurrence of adverse effects is less than 1%.
Patients should be advised that rash, the most common adverse effect, might occur at any time
during therapy. The rash may be as simple as a maculopapular eruption or as serious as the life-
threatening Stevens-Johnson syndrome (which is exfoliative and erythematous). Rarely, allopurinol
may cause alopecia, neutropenia, and hepatitis.
The chemotherapeutic agents azathioprine and 6-mercaptopurine are metabolized via the xanthine
oxidase pathway; therefore, allopurinol and its metabolite oxypurinol may increase serum levels of
these agents. The concomitant administration of ampicillin or amoxicillin with allopurinol increases
the risk of rash to approximately 20%.
Patients should be encouraged to report the first signs of rash to their physicians immediately.
Patients should have serum creatinine as well as liver function tests drawn periodically.
Kinetics
With a half-life of 30 hours, allopurinol is rapidly converted to its active metabolite (oxypurinol).
This speed allows for once-daily dosing.
Other aspects
To reduce the risk of precipitating an acute gouty arthritis attack, allopurinol should be initiated at a
dose of 100 mg per day and increased at 100 mg intervals weekly to an average dose of 300 mg per
day. Patients with renal insufficiency require a dose adjustment. Assuming the target dose is 300
mg per day, patients with a creatinine clearance of 10-20 mL/min should receive 200 mg per day.
Those with a clearance of less than 10 mL/min should receive 100 mg per day.
Febuxostat (Uloric) was approved in February 2009 for the chronic management of hyperuricemia
in patients with gout. It is also a xanthine oxidase inhibitor; however, unlike allopurinol, it is not a
purine-based analogue.
Secondary hyperuricemia
As discussed earlier, hyperuricemia may be caused by lymphoproliferative and myeloproliferative

disorders, as well as their chemotherapeutic treatments (e.g., tumor lysis syndrome). Allopurinol is
commonly added to the prescribed chemotherapeutic regimen to prevent complications of
hyperuricemia, for example, an acute gouty arthritis attack. Rasburicase (Elitek) is an approved
therapeutic agent that is used to prevent hyperuricemia in children with leukemia, lymphoma, and
solid-tumor malignancies. Rasburicase is a recombinant urate oxidase enzyme that converts uric
acid to allantoin, thereby allowing it to be eliminated. Patients with G6PD deficiency should not use
rasburicase.
22-4. Systemic Lupus Erythematosus
Introduction
Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disorder that can affect
any system in the body, including the skin, joints, and internal organs.
Classification
The workup of SLE must include the consideration of an alternative diagnosis. Because other
autoimmune diseases have similar characteristics and because the features of SLE, RA, and
scleroderma overlap, a thorough assessment is warranted. Drug-induced lupus must be ruled out as
well.
Signs and symptoms consistent with SLE include the following:
• Malar rash (a butterfly-shaped rash over the cheeks and across the bridge of the nose)
• Discoid rash (scaly, disk-shaped sores on the face, neck, or chest)
• Photosensitivity
• Oral ulcers
• Arthritis
• Serositis (inflammation of the lining around the heart, lungs, or abdomen that causes pain and
shortness of breath)
• Proteinuria
• Central nervous system problems
• Antinuclear antibodies (autoantibodies that react against the body's own cells)
• Anemia
• Fatigue
• Fever
• Skin rash
• Muscle aches
• Nausea
• Vomiting and diarrhea
• Anorexia
• Raynaud's phenomenon
• Weight loss
Patients typically present with chronic fatigue and depression. Dermatitis and arthritis (in multiple
joints) are the most common clinical manifestations. The arthritic pain patients describe is generally
out of proportion to the amount of synovitis present. Although it is rare, serious renal abnormalities
can occur in patients with SLE. CNS involvement, also rare, can be serious. Lupus-related
encephalopathy may occur from scarring of arterioles in the subcortical white matter. In addition,
patients with SLE are at risk of stroke because of the thromboembolic nature of the
antiphospholipid antibody.
Pathophysiology
The exact pathophysiology of SLE remains unknown. It is an autoimmune disease (type III
hypersensitivity) in which patients have an overactivity of B cells. The result is
hypergammaglobulinemia that ultimately precipitates immune complexes on the vascular
membranes, thereby causing activation of complement. Drugs, procainamide being the most
predominant, may also cause SLE. Other such medications include phenytoin, chlorpromazine,
hydralazine, quinidine, methyldopa, and isoniazid.
Diagnostic Criteria
Criteria for diagnosing SLE are as follows:
• Characteristic rash across the cheeks
• Discoid lesion rash
• Oral ulcers
• Arthritis
• Inflammation of membranes in lungs, heart, or abdomen
• Evidence of kidney disease
• Evidence of severe neurologic disease
• Blood disorders, including low red blood cell, white blood cell, and platelet counts
• Immunologic abnormalities
• Positive antinuclear antibody
A patient must experience four of the criteria before a classification of SLE can be made. These
criteria, proposed by the ACR, should not be the sole characteristics for diagnosis, however.
Therapy
Therapy for each case of SLE is based on the particular symptoms of any given patient. Arthritis is
commonly treated with NSAIDs or glucocorticoids. Dermatologic complications can be treated
with hydroxychloroquine (see Section 22-1). Hydroxychloroquine may also be used for
musculoskeletal manifestations that do not respond to NSAIDs. Thrombocytopenia generally
responds to glucocorticoid therapy. Immunosuppressive agents are used in patients with lupus
nephritis. Most commonly, cyclophosphamide is used, sometimes in combination with
glucocorticoids.
22-5. Key Points
Rheumatoid Arthritis
• RA, a highly variable autoimmune disease characterized by symmetric, erosive synovitis, often
affects extra-articular sites.
• RA usually affects diarthrodial joints (e.g., PIP joints, MCP joints, MTP joints, wrists, and
ankles). Also commonly involved are the elbows, shoulders, sternoclavicular joints,
temporomandibular joints, hips, and knees.
• Morning stiffness is the hallmark of RA.
• According to the ACR, the goals in managing RA are to prevent or control joint damage, prevent
loss of function, and decrease pain.
• The ACR recommends the aggressive use of DMARDs.
• Unlike the NSAIDs, DMARDs can reduce or prevent joint damage and preserve joint integrity
and function. DMARDs carry the risk of various toxicities, and they must be monitored on a
regular basis.
Osteoarthritis
• OA is the most common form of arthritis in the United States.
• Joint stiffness, a common complaint in osteoarthritis, differs from that in RA because it is

relatively short in duration and resolves with movement.
• Unlike RA, pain relief is the primary treatment goal in OA. The initial drug of choice is
acetaminophen.
Gout
• Gout, a systemic disease caused by the buildup of uric acid in the joints, causes inflammation,
swelling, and pain.
• Primary gout is a result of an innate defect in purine metabolism or uric acid excretion.
• Patients with gout are classified as overproducers or underexcreters on the basis of 24-hour uric
acid concentration levels.
• Treatment of an acute gouty arthritis attack involves the use of colchicine, NSAIDs, or
glucocorticoids.
• Uricosuric agents, xanthine oxidase inhibitors, or both are used to prevent further gout attacks.
These agents should not be used during an acute gouty arthritis attack.
Systemic Lupus Erythematosus
• SLE is a chronic autoimmune inflammatory disorder that can affect any system in the body.
• Therapy for SLE is primarily driven by the clinical manifestations of the disease.
22-6. Questions
A 45-year-old man presents to his local physician with a complaint of extreme stiffness in the
morning that lasts until noon on most days for the past 2 months. He also states that he feels
"drained" all the time and that both of his knees are swollen and painful. On examining the
patient, the physician documents the presence of rheumatoid nodules. The patient's laboratory
workup is significant for thrombocytopenia and a positive rheumatoid factor. He states that he
has been taking over-the-counter ibuprofen at a dose of 200 mg two or three times daily
1. without relief. Which of the following represents the best drug therapy option for this patient?
A. Increase the dose of ibuprofen to 800 mg three times daily.

B. Increase the dose of ibuprofen and add methotrexate 25 mg twice daily.
C. Increase the dose of ibuprofen and add celecoxib 100 mg twice daily.
D. Increase the dose of ibuprofen and add leflunomide at a dose of 100 mg daily for 3 days,
followed by 20 mg daily.

Which of the following represents the best way to decrease potential liver toxicity with
methotrexate while achieving optimal therapeutic benefit?
2. A. Add 1-3 mg of folic acid per day to the patient's regimen.

B. Decrease the dose of methotrexate to 25 mg once monthly.
C. Add monthly injections of leucovorin to the patient's regimen.
D. Add leflunomide to the patient's regimen.

Because combination DMARD therapy may be more efficacious in the refractory RA
population, which of the following represents the best choice for combination therapy?
3. A. Arava 20 mg once daily + Rheumatrex 25 mg once weekly
B. Remicade 3 mg/kg IM + Rheumatrex 25 mg once weekly
C. Myochrysine IM + Plaquenil 200 mg twice daily
D. Remicade 3 mg/kg IV + Rheumatrex 25 mg once weekly

A physician inquires about the recommended monitoring parameters for patients started on
Ridaura. Which of the following represents the most appropriate response?
A. Baseline ophthalmologic exam, CBC, and serum creatinine, followed by a yearly CBC,
4. serum creatinine, and ophthalmologic exam
B. Baseline liver function tests, CBC, and albumin, followed by monthly liver function tests
C. Baseline CBC, serum creatinine, and urine dipstick for protein, followed by a CBC and
urine dipstick for protein every 1-2 months
D. No recommended monitoring parameters at this time

All of the following represent methods used to decrease the GI toxicity associated with
NSAIDs except
A. changing patients from a nonselective cyclooxygenase inhibitor to a type II-specific

5.
inhibitor such as Celebrex.
B. adding a proton pump inhibitor such as Prevacid to the patient's NSAID.
C. adding Cytotec to the patient's NSAID.
D. instructing the patient to take his or her NSAID at night, when acid secretion is limited.

Which of the following is (are) true concerning diclofenac?
I. It is available as an extended-release product, Voltaren XR.

II. It is available as an injectable product, Voltaren IM.
III. It is available in combination with misoprostol, Arthrotec.
6.
A. I only
B. I and II only
C. I, II, and III
D. I and III only

Which of the following would be a contraindication for the use of Enbrel?
A. Renal insufficiency
7.
B. Active infection
C. Patient over the age of 65
D. Patient with class I or II congestive heart failure

Regarding the biologic DMARDs, the following statements are correct except
A. Kineret is packaged as a single-use prefilled syringe that should be kept in the refrigerator.
8.
B. patients should have a tuberculin skin test completed before initiation.
C. it is acceptable to use FluMist for influenza prevention.
D. patients receiving therapy are at increased risk for opportunistic infections.

The use of glucocorticoids is associated with numerous adverse effects and long-term
consequences. All of the following are initiatives to treat, prevent, or minimize these adverse
effects except
A. instructing patients to take the glucocorticoid once daily instead of dividing the total daily
9.
dose into two to four doses.
B. instructing patients on long-term therapy to add 1,500 mg of elemental calcium and 400-800
IU of ergocalciferol to their regimen.
C. suggesting adding a bisphosphonate to their therapy.
D. informing patients that stopping glucocorticoid abruptly is contraindicated.

A young lady enters your pharmacy and informs you that she plans on becoming pregnant and
would like you to review her medication profile to see if any would be potentially harmful. On
reviewing her profile, you notice that she is taking Arava for RA. Which is the most
appropriate response?
A. Arava is a category C drug and could potentially harm the fetus. She should discuss the
10.
risks and benefits of becoming pregnant with her physician first.
B. Arava is a category X drug, and she should undergo the drug elimination procedure with
cholestyramine before trying to become pregnant.
C. Arava is a category X drug with no active metabolites and a short half-life; therefore, she
should discontinue the drug and wait 1-2 weeks before trying to become pregnant.
D. Arava is a category B drug, and the risk of toxicity to the fetus is extremely low.

R. Y. is a 67-year-old man with chief complaints of a swollen big left toe and extreme pain.
The area is erythematous and tender. Laboratory analysis reveals a uric acid level of 10 mg/dL.
Review of R. Y.'s past medical history reveals hypertension and congestive heart failure. A
diagnosis of gout is made. Which is the best choice for the treatment of R. Y.'s acute gouty
arthritis attack?
11.
A. Probenecid 500 mg now, followed by 500 mg twice daily
B. Indomethacin 50 mg now, followed by 50 mg three to four times daily
C. Allopurinol 100 mg once daily
D. Colchicine 1.2 mg followed by 0.6 mg in 1 hour if symptoms persist

The following symptoms are consistent with the diagnosis of gout except
A. the presence of negatively birefringent crystals in the affected synovial joint fluid.
12.
B. the presence of calcium pyrophosphate in the affected synovial joint fluid.
C. the presence of tophi.
D. the presence of hyperuricemia.

Which of the following best describes Benemid?
A. Like allopurinol, it decreases the body's production of uric acid.

13. B. Like Anturane, it is a uricosuric agent that aids in the tubular reabsorption of uric acid.
C. It blocks the excretion of uric acid in the urine.
D. Like Anturane, it is a uricosuric agent that blocks reuptake of uric acid at the proximal
convoluted tubule.

Which of the following represents a therapeutically ineffective combination that should be
avoided?
14. A. Benemid + penicillin G

B. Benemid + cephalexin
C. Anturane + Macrobid
D. Benemid + colchicine

All of the following statements are true regarding Zyloprim except
A. it works to decrease the formation of uric acid by inhibiting xanthine oxidase.

15.
B. it does not require dosage adjustment in patients with renal insufficiency.
C. skin reactions, including Stevens-Johnson syndrome, have been reported with its use.
D. it should not be used for the treatment of an acute gouty arthritis attack.

Which of the following represent potentially dangerous drug interactions with Zyloprim?
I. Amoxicillin
II. Imuran
III. Essidrex
16.
A. I only
B. I and II only
C. I, II, and III
D. III only

All of the following are consistent with the diagnosis of osteoarthritis except
A. the presence of morning stiffness that is not associated with immobility and may last for
several hours.
17.
B. a common initial finding of pain that typically worsens with weight-bearing activity and
subsides with rest.
C. it commonly occurs in the knees or the hips.
D. crepitus is common.

Which of the following medication combinations is (are) contraindicated?
I. Tylenol + Ultram
II. Glucosamine sulfate and chondroitin
III. Ultram + Parnate
18.
A. All of the above
B. II only
C. III only
D. I and II only

Concerning treatment of osteoarthritis, which of the following statements is incorrect?
A. Tylenol is generally considered the initial drug of choice.

B. Tylenol is considered safe and effective, and it has minimal adverse effects, especially in
19.
doses greater than 4 g per day.
C. Muscle-strengthening exercises may be helpful.
D. Hyaluronic acid derivatives have been approved by the FDA for the treatment of pain
associated with osteoarthritis.

The following medications are considered to be DMARDs except
A. Plaquenil.
20.
B. Cuprimine.
C. Myochrysine.
D. Nalfon.

22-7. Answers
D. Although the patient currently has room to increase his dose of the NSAID, he would
benefit from the addition of a DMARD. This patient has a disease duration of less than 6
1. months with moderate disease and poor prognostic factors. Methotrexate represents a viable
option; however, the dose of 25 mg twice daily is excessive (it should be dosed once weekly).
The addition of leflunomide is the best choice.

A. The addition of folic acid to the methotrexate regimen has been demonstrated to reduce the
risk of liver toxicity. Lowering the dose of methotrexate is likely to decrease risk but is also
2.
likely to decrease its effectiveness. Leucovorin, an injectable formulation of folate, is used only
to reverse methotrexate toxicity.

D. Arava plus methotrexate (Rheumatrex) may be a very efficacious combination, but it
increases the risk of liver toxicity significantly. Gold therapy in combination with Plaquenil
3.
increases the risk of rash. Remicade, approved only for use in combination with Rheumatrex,
is given IV and not IM; this combination represents the best choice.

C. Gold therapy is associated with glomerulonephritis, thrombocytopenia, and leukopenia;
4. therefore, a baseline renal evaluation and periodic testing should occur during the entire course
of therapy.

D. Adding a proton pump inhibitor, adding Cytotec, or changing to a selective COX-II
5. inhibitor has been demonstrated to lower the risk of significant GI adverse effects. Timing of
the dose of an NSAID has never been demonstrated to affect the risk of GI toxicity.

D. Diclofenac is available as an immediate-release product, an extended-release product, and
6.
in combination with misoprostol. It is not available in an injectable formulation.

B. Because of its effects on tumor necrosis factor, Enbrel may decrease a patient's ability to
7. fight infection. Enbrel is contraindicated in patients with an active infection. Its use should be
temporarily discontinued until the acute process has resolved.

C. FluMist is a live weakened flu vaccine. Live vaccines are contraindicated in patients
8.
receiving biologic DMARDs.

A. Patients taking glucocorticoids are at risk of developing osteoporosis. Efforts to minimize
this adverse effect include the addition of calcium and vitamin D to the patient's regimen as
9. well as adding a bisphosphonate (e.g., Fosamax) to suppress bone resorption. Because of
adrenal suppression that occurs with long-term glucocorticoid therapy, patients should taper off
the agent.

B. Because Arava is a teratogenic agent with an active metabolite with a long half-life, a drug
10.
elimination procedure should be performed before becoming pregnant.

D. Both probenecid and allopurinol may exacerbate an acute gouty arthritis attack and should
be reserved for the prevention of further attacks only. Indomethacin is an option for the
11. treatment of an acute gouty arthritis attack; however, because of NSAIDs' tendency to cause
fluid retention in the renal tubules, it would not be the ideal agent in a patient with congestive
heart failure. Colchicine represents the best option from this list.

B. The presence of calcium pyrophosphate is consistent with the diagnosis of pseudogout, not
12.
gout.

D. Benemid is a uricosuric agent that blocks reuptake of uric acid at the proximal convoluted
13. tubule. It does not affect the body's ability to produce uric acid. Answer B is incorrect because
Benemid does not promote the reabsorption of uric acid.

C. Benemid does prevent the tubular secretion of penicillin and cephalexin. However, these
interactions are used therapeutically to increase the duration of action of a single dose. The
combination of Benemid and colchicine (marketed under the trade name Colbenemid) has been
14.
used therapeutically to prevent the manifestation of an acute gouty arthritis attack. Finally, a
combination of Anturane and Macrobid will inhibit Macrobid from reaching its site of action,
thus diminishing its therapeutic efficacy.

B. Zyloprim must be adjusted in patients with renal insufficiency. Its use has been associated
15. with serious skin reactions that may occur at any point during therapy. Zyloprim should never
be used in the treatment of an acute gouty arthritis attack.

B. The coadministration of amoxicillin and allopurinol increases the risk of rash up to 20%.
Imuran is metabolized via xanthine oxidase, whose activity is inhibited by allopurinol, thus
16.
increasing the risk of toxicity associated with Imuran. Although Essidrex may increase uric
acid levels, there is no direct drug-drug interaction associated with allopurinol.

A. The morning stiffness associated with osteoarthritis is usually of short duration, is
17.
associated with periods of inactivity, and resolves with movement.

C. Tylenol + Ultram is marketed therapeutically as Ultracet. Glucosamine sulfate with or
without chondroitin is recommended as an alternative therapy in the treatment of osteoarthritis.
18.
The combination of Ultram and Parnate, a monoamine oxidase inhibitor, is contraindicated
because of the risk of serotonin syndrome.

B. Tylenol is generally considered to be safe and effective; however, its use is associated with
19. hepatic failure and the rare incidence of renal failure. Patients should be advised to take less
than 4 g per day to limit the risk of hepatic failure.

20. D. Nalfon, also known as fenoprofen, is an NSAID, not a DMARD.

22-8. References
Rheumatoid Arthritis
American College of Rheumatology. Recommendations for the use of nonbiologic and biologic
disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum. 2008;59:762-84.
Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/AHA 2008 expert consensus document on
reducing the gastrointestinal risks of antiplatelet therapy and NSAID use. Am J Gastroenterol.
2008; 103:2890-907.
Boyce EG. Rheumatoid arthritis. In: Helms RA, Quan DJ, Herfindal ET, et al., eds. Textbook of
Therapeutics: Drugs and Disease Management. 8th ed. Baltimore: Lippincott Williams &
Wilkins; 2006:1705-36.
Goekoop YP, Allaart CF, Breedveld FC, et al. Combination therapy in rheumatoid arthritis. Curr
Opin Rheumatol. 2001;30:249-54.
Kremer JM. Rational use of new and existing disease-modifying agents in rheumatoid arthritis. Ann
Intern Med. 2001;134:695-706.
Kwoh CK, Anderson LG, Greene JM, et al. Guidelines for the management of rheumatoid arthritis.
Arthritis Rheum. 2002;46:328-46.
Olsen NJ, Stein CM. New drugs for rheumatoid arthritis. N Engl J Med. 2004;21:2167-79.
Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations
for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid
arthritis. Arthritis Rheum. 2008;59:762-84.
Sims RW, Kwoh CK, Anderson LG, et al. Guidelines for monitoring drug therapy in rheumatoid
arthritis. Arthritis Rheum. 1996;39:723-31.
Wolfe F, Rehman W, Lane NE, et al. Starting a disease-modifying antirheumatic drug or a biologic
agent in rheumatoid arthritis: Standards of practice for RA treatment. J Rheumatol.
2001;28:1704-11.
Osteoarthritis
Altman RD, Hochberg MC, Moskowitz RW, et al. Recommendations for the medical management
of osteoarthritis of the hip and knee. Arthritis Rheum. 2000;43:1905-15.
Boh LE. Osteoarthritis. In: Dipiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A
Roberts LJ, Morrow JD. Analgesic-antipyretic and anti-inflammatory agents and drugs employed in
the treatment of gout. In: Hardman JG, Limbird LE, Gilman AG, eds. Goodman and Gilman's
The Pharmacological Basis of Therapeutics. 10th ed. New York: McGraw-Hill; 2001:687-732.
Small RE. Osteoarthritis. In: Helms RA, Quan DJ, Herfindal ET, et al., eds. Textbook of
Therapeutics: Drugs and Disease Management. 8th ed. Baltimore: Lippincott Williams &
Wilkins; 2006:1737-52.
Gout
American College of Rheumatology. 2008. Gout.

www.rheumatology.org/public/factsheets/diseases_and_conditions/gout.asp.
Becker MA, Schumacher HR, Wortmann RL, et al. Febuxostat compared with allopurinol in
patients with hyperuricemia and gout. N Engl J Med. 2005; 353:2450-61.
Emmerson BT. The management of gout. N Engl J Med. 1996;334:445-51.
Harris M, Bryant LR, Danaher, et al. Effect of low-dose aspirin on serum urate levels and urinary
excretion in patients receiving probenecid for gouty arthritis. J Rheumatol. 2000;27:2873-6.
Hawkins DW, Rahn DW. Gout and hyperuricemia. In: Dipiro JT, Talbert RL, Yee GC, et al., eds.
5.
McCloskey WW, Kostka-Rokosz MD. Gout and hyperuricemia. In: Helms RA, Quan DJ, Herfindal
ET, et al., eds. Textbook of Therapeutics: Drugs and Disease Management. 8th ed. Baltimore:
Lippincott Williams & Wilkins; 2006:1753-66.
Terkeltaub RA, Edwards NL, Pratt PW, et al. Gout. In: Klippel JH, Weyand CM, Wortmann RL,
eds. Primer on the Rheumatic Diseases. 11th ed. Atlanta: Arthritis Foundation; 1998:230-43.
Systemic Lupus Erythematosus
Burlingame MB, Delafuente JC. Systemic lupus erythematosus. In: Dipiro JT, Talbert RL, Yee GC,
et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 4th ed. New York: McGraw-Hill;
1997:1378-92.
Krikoria S. Systemic lupus erythematosus. In: Helms RA, Quan DJ, Herfindal ET, et al., eds.
Textbook of Therapeutics: Drugs and Disease Management. 8th ed. Baltimore: Lippincott
Lupus Foundation of America. Lupus. www.lupus.org/.

23. Pain Management and Migraines - Elizabeth S. Miller, PharmD
23-1. Pain
Introduction
Pain is any unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or defined in terms of such damage, or both. Chronic pain is a largely unrecognized
problem in American society.
Currently, about 75 million individuals suffer from some form of chronic benign pain. Between
one-third and one-half of chronic pain sufferers have pain severe enough to require daily
medication.
Types and Clinical Presentation
Pain can be classified as acute, chronic benign, or malignant.
Acute pain is caused by an injury, illness, or surgery. It responds to medications and usually
resolves when the underlying cause has been treated or healed. It is often associated with
physiologic symptoms such as tachycardia, hypertension, diaphoresis, and mydriasis.
Chronic benign pain exists beyond an expected time for healing, typically 3-6 months or more. It is
often associated with psychological effects, including social isolation, depression, and anxiety.
Chronic pain syndromes are often not responsive to traditional analgesics and require the use of
adjuvant medications.
Malignant pain may be acute, chronic, or intermittent and is often related to cancer progression or
chemotherapy.
Pain is also defined by source. Such a classification divides pain into somatic, visceral, and
neuropathic pain.
Somatic pain originates from the skin, muscles, tendons, ligaments, and bones. It is localized and
described as sharp, stabbing, throbbing, or aching in nature. Although somatic pain can be severe, it
tends to respond well to treatment with opioids.
The body's internal organs such as the liver, intestines, or stomach generate visceral pain. Visceral
pain tends to be poorly localized and more likely to generate referred pain felt some distance away
from the actual problem. Opioids are not as effective for visceral pain as they are for somatic pain.
Neuropathic pain results when the nerves themselves are damaged. It is typically burning in nature,
although it may also be numb, be aching, or cause a sensation like an electric shock. Opioid
medications are often ineffective for treating neuropathic pain, and adjuvant analgesics play a
significant role in treatment.
Pathophysiology
Nociception, the pain sensation, begins when a sensory nerve ending is stimulated and sends
repetitive signals to the spinal cord along ascending nerve fibers. An individual nerve does not
transmit directly to the brain but instead connects to secondary nerves in the dorsal horn of the
spinal cord. The secondary nerves eventually connect to nerve cells in the brain stem.
A descending antinociceptive pathway also exists. Neurotransmitters from the descending fibers
inhibit the transmission of the pain signal. Opioids chemically resemble these neurotransmitters.
Chronic pain is not a prolonged version of acute pain. As pain signals are repeatedly generated,
neural pathways undergo changes that make them hypersensitive to pain signals and resistant to
antinociceptive input.
Diagnostic Criteria
The individual's self-report of pain is the primary source of information in acute pain.
Chronic pain assessment should include a detailed history of the pain's intensity and characteristics,
a physical examination emphasizing the neurological exam, and a psychosocial assessment (
Figure 23-1).
The purpose of diagnostic tests, such as x-rays, computed tomography, or magnetic resonance
imaging scans, or laboratory tests differs depending on the type of pain. In cancer patients, the
major purpose of diagnostic testing is to visualize the disease progression. In chronic benign pain,
the major purpose of diagnostic testing is to rule out the presence of any diseases for which there is
a curative treatment.
[Figure 23-1. Algorithm for Comprehensive Evaluation and Management of Chronic Pain]
Goals of Pain Management
Acute pain
The goal in acute pain management is to provide patients with pain relief that allows them to rest
comfortably and allows rehabilitation postsurgery or postinjury. This goal can be accomplished
with short-acting medications administered as needed.
Malignant pain
A major goal of cancer pain management is to relieve the patient's pain without inducing disabling
side effects.
The World Health Organization (WHO) has developed a three-step hierarchy for analgesic pain
management in cancer pain patients (
Figure 23-2). In general, this program includes using nonopioid analgesics as a baseline,
supplementing with opioid analgesics
[Figure 23-2. The WHO's Three-Step Hierarchy for Analgesic Pain Management in Cancer
Patients]
as needed, and adding adjunctive medications when appropriate.
Cancer patients may suffer from constant pain that continues for months or years. For this reason,
treatment with long-acting agents is more appropriate than treatment with short-acting medications.
However, short-acting agents, referred to as "breakthrough" or "rescue" doses, are often available in
addition to the long-acting medications.
Chronic benign pain
The goal of chronic benign pain treatment is to restore the patient to the highest degree of function
possible.
Multimodal therapy, the use of several different types of treatment, is usually required. Multimodal
therapies include nerve blocks, rehabilitation, physical therapy, pharmacotherapy, acupuncture, and
psychotherapy. Basic pharmacotherapy follows the WHO guidelines for treating cancer pain (Figure
23-2).
Analgesics are categorized into nonopioid analgesics, opioid analgesics, and adjuvant analgesics.
Nonopioid analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)
relieve all types of mild to moderate pain. Unless contraindicated, all pain patients should first be
given a trial of nonopioid analgesics. Nonopioids and opioids relieve pain via different
mechanisms. Thus, combination therapy offers the potential for improved relief with fewer side
effects. Nonopioids do not produce tolerance, physical dependence, or addiction.
Adjuvant analgesics are drugs with a primary indication other than pain. Commonly used analgesic
adjuvants include antiepileptic drugs, tricyclic antidepressants, and local anesthetics.
Principles of opioid use
Opioids have no ceiling effect of analgesia.
Oral medications should be used whenever possible. Intramuscular injections are painful and should
be avoided.
When patients have constant or near-constant pain, analgesics should be given around the clock.
Long-acting opioid analgesics are often used for this purpose.
The use of short-acting opioids as rescue medication is controversial in chronic benign pain. If
allowed, doses of rescue medications should range from 10% to 15% of the total daily long-acting
opioid dose.
Mixed agonist-antagonist opioids are not used in chronic pain. They may induce a withdrawal
syndrome in patients tolerant to opioids.
Drug Therapy
Mechanism of action
Morphine and other opioid agonists are thought to produce analgesia by mimicking the action of
endogenous opioid peptides that bind at opioid receptors in the antinociceptive pathway.
Opioid receptors are located in the central nervous system (CNS), pituitary gland, and
gastrointestinal (GI) tract. They are abundant in the periaqueductal gray matter of the brain and the
dorsal horn of the spinal cord, two areas that are very active in pain reduction.
When a drug binds to one of these receptors as an agonist, it produces analgesia. When a drug binds
to one of these receptors as an antagonist, analgesia and other effects are blocked.
The three major types of opioid receptor sites involved in analgesia are mu (¼), delta (´), and kappa
( ):
• Binding to the receptor produces analgesia, sedation, euphoria, respiratory depression, physical
dependence, constipation, and other effects.
• Activation of the receptor produces analgesia and respiratory depression. In addition,

psychotomimetic effects such as anxiety, strange thoughts, nightmares, and hallucinations are
more common.
• Activation of receptors produces analgesia without many adverse events. However, there is no
available -receptor agonist.
Opioid analgesics
Opioids are classified by activity at the receptor site; that is, they are classified as pure opioid
agonists, agonist-antagonists, or pure opioid antagonists.
Pure opioid agonists primarily activate receptors, although they may produce some -receptor
activation (
Table 23-1). Pure opioid agonists are the most clinically useful opioid analgesics.
Morphine is the prototypical pure opioid agonist. Methadone is an opioid agonist with additional
antagonist activity at the NMDA (N-methyl-D-aspartate) receptor. The NMDA receptor is believed
to be active primarily in chronic pain.
Mixed agonist-antagonists bind as agonists at the ‫ ؛‬receptor, producing weak analgesia. They bind
as weak antagonists at the ¼ receptor (
Table 23-2). The result is more dysphoria and psychotomimetic effects with a lower risk of
respiratory depression.
Pentazocine is the prototypical agonist-antagonist opioid. Buprenorphine is actually a partial

agonist at
[Table 23-1. Starting Doses for Strong Opioids for Severe Pain in Adults: Mu Agonists]
and receptors. This opioid has limited efficacy in pain management and is primarily used in
detoxification programs.
Opioid antagonists block the ¼ and ‫ ؛‬receptors (

Table 23-3). These drugs do not produce analgesia. They are used to reverse respiratory and CNS
depression caused by overdose with opioid agonists. Naloxone and naltrexone are opioid
antagonists.
Opioid analgesic adverse effects
Central nervous system

Opioids produce a number of CNS effects, including sedation, euphoria, dysphoria, changes in
mood, and mental clouding. Confusion, disorientation, and cognitive impairment are also possible.
Chronic sedation can be treated with CNS stimulants such as methylphenidate or

dextroamphetamine. Modafinil also promotes daytime wakefulness.
Mild to moderate muscle jerks are common in patients on high doses of opioids. Myoclonus can be
treated by changing the opioid dose, changing the opioid, or giving low doses of a benzodiazepine.
Neuroendocrine
Morphine acts in the hypothalamus to inhibit the release of gonadotropin-releasing hormone and
corticotropin-releasing factor, thus decreasing levels of luteinizing hormone, follicle-stimulating
hormone, adrenocorticotropic hormone, and ²-endorphins.
Changes in hormone levels may cause decreased levels of testosterone and cortisol, disturbances in
menstruation, and sexual dysfunction.
High doses of morphine and related opioids produce convulsions. Most convulsions occur at doses
far in excess of those required to produce analgesia.
[Table 23-2. Opioid Dosing for Mild to Moderate Pain in Adults]

[Table 23-3. Opioid Antagonists]
Respiratory
Respiratory depression is the most serious opioid-induced adverse effect. Opioids depress
respiration by a direct effect on the brain-stem respiratory centers, making the brain stem less
responsive to carbon dioxide.
The receptor is the primary receptor involved in respiratory depression, although activation of the
receptor also contributes.
At equianalgesic doses, all of the pure opioid agonists depress respiration to the same degree. The
agonist-antagonists have a ceiling effect (i.e., a dose beyond which no further respiratory depression
or analgesia is produced), but this level is usually above recommended doses.
Opioids depress cough by inducing a direct effect on the cough reflex in the medulla.
Cardiovascular
Therapeutic doses of many opioids produce peripheral vasodilation, reduced peripheral resistance,
and inhibition of the baroreceptor reflexes.
Peripheral vasodilation results primarily from opioid-induced release of histamine. Orthostatic

hypotension and fainting can result. The naturally occurring and semisynthetic products are potent
histamine releasers. Fentanyl has little propensity to release histamine.
Methadone has been associated with torsades de pointes, an atypical rapid ventricular tachycardia,
at an average daily dose of 400 mg. Methadone should be used cautiously in patients on other QTc-
prolonging medications.
Gastrointestinal
All clinically significant agonists produce some degree of nausea and vomiting by direct
stimulation of the chemoreceptor trigger zone in the medulla, sensitization of the vestibular system,
and slowing of GI motility.
Nausea and vomiting commonly occur in ambulatory patients (15-40% of patients with nausea and
vomiting are ambulatory). Both can be pretreated with an antiemetic such as promethazine or
prochlorperazine.
Opioids promote constipation by delaying gastric emptying, slowing bowel motility, and decreasing
peristalsis. Opioids may also reduce secretions from the colonic mucosa. At its worst,
gastrointestinal dysfunction results in ileus, fecal impaction, and obstruction.
Because transdermal delivery bypasses absorption from the GI tract, constipation has been reported
to be less frequent with this delivery method than with other methods.
Patients on opiates do not develop tolerance to constipation. All patients taking around-the-clock
opioid analgesics should be placed on prophylactic bowel regimens. Bowel regimens include
increased fluid and fiber intake, daily stool softeners, and mild laxatives.
Severe constipation is managed with osmotic laxatives such as magnesium citrate and milk of
magnesia.
Genitourinary
Opioids increase smooth muscle tone in the bladder and ureters and may cause bladder spasm and
urgency.
An opioid-induced increase in sphincter tone can make urination difficult. Urinary retention is most
common in elderly men.
Biliary
Opioids increase smooth muscle tone in the biliary tract, especially in the sphincter of Oddi, which
regulates the flow of bile and pancreatic fluids. This effect can result in a decrease in biliary and
pancreatic secretions and a rise in the bile duct pressure. Patients may experience epigastric distress
and occasionally biliary spasm.
All opioids are capable of causing constriction of the sphincter of Oddi and the biliary tract.
Although morphine may cause more biliary constriction in animals than do other opioids, this
finding has never been shown to be clinically useful in humans.
Skin and eye

Therapeutic doses of morphine dilate cutaneous blood vessels, which causes flushing on the face,
neck, and upper thorax. Sweating and pruritus may also occur. These changes may be caused in part
by release of histamine. Histamine release may induce or worsen asthmatic attacks in predisposed
patients and can lead to wheezing, bronchoconstriction, and status asthmaticus.
Skin rash around the transdermal fentanyl patch is a common side effect caused by the patch
adhesive.
Following a toxic dose of agonists, miosis is marked and pinpoint pupils are pathognomonic;
however, mydriasis occurs when asphyxia intervenes.
Overdose
Acute overdose with opioids is manifested by respiratory depression; somnolence progressing to

stupor or coma; skeletal muscle flaccidity; cold, clammy skin; constricted pupils; and sometimes
pulmonary edema, bradycardia, hypotension, and death.
An opioid antagonist may be given to block opioid receptors and reverse the effects of overdose.
Antagonist administration may cause a complete reversal of opioid effects and precipitate an acute
withdrawal syndrome in persons physically dependent on opioids.
Antagonists are dosed to patient response every few minutes. If no response is observed after 10
mg, the diagnosis of opioid-induced toxicity should be questioned.
Infusion may be useful in cases of overdose with long-acting drugs such as methadone. The
infusion rate for adults is approximately 100 mL/h (0.4 mg/h).
Tolerance and physical dependence
The use of opioids is often limited by concerns regarding tolerance, physical dependence, and
addiction.
Tolerance can be defined as a state in which a larger dose is required to produce the same response
that could formerly be elicited by a smaller dose. Tolerance to analgesia is demonstrated by the
need for an increased dosage of a drug to produce the same level of analgesia. Tolerance to
analgesia develops more slowly than tolerance to other opioid effects.
Tolerance to adverse effects of opioids occurs after 2-3 weeks of continuous administration.
Tolerance to the constipating and neuroendocrine effects of opioids does not occur.
Physical dependence is the occurrence of a withdrawal syndrome after an opioid is stopped or

quickly decreased without titration. Warn patients to avoid abrupt discontinuation of such drugs.
Addiction is the psychological dependence on the use of a substance. It is characterized by impaired

control over drug use, compulsive use, craving, and continued use despite harm.
Pharmacokinetics of Selected Opioids
Morphine
Compared with other opioids, morphine is relatively insoluble in lipids (i.e., in adults, only small
amounts of the drug cross the blood-brain barrier).
Morphine does not accumulate in tissues when given in normal dose and therefore does not cause
increasing toxicity with frequent dosing.
Morphine is primarily metabolized by glucuronidation during the first pass through the liver.
Approximately 50% of morphine is converted by the liver to morphine-3-glucuronide and 15% to
morphine-6-glucuronide (M6G). The pharmacologic effects of morphine (both analgesia and side
effects) are in part caused by M6G.
Much of an oral dose is inactivated during this first pass through the liver; consequently, oral doses
need to be much larger than parenteral doses to produce the same analgesic effects.
Fentanyl
Fentanyl is highly soluble in lipids. It accumulates in skeletal muscle and fat and is released slowly
into the blood. Plasma half-life is 3-4 hours after parenteral administration.
Fentanyl is rapidly metabolized, primarily by dealkylation, to inactive metabolites in the liver. This
process is mediated through the cytochrome P450 (CYP450) 3A4 hepatic enzyme system. The
presence of inactive metabolites makes fentanyl a preferred drug in patients with liver dysfunction.
Fentanyl is not used orally because of low oral bioavailability.
Transdermal fentanyl
The uptake of fentanyl through the skin is relatively slow and constant. The skin does not
metabolize the drug, and 92% of the dose is delivered into the bloodstream as intact fentanyl.
Because of temperature-dependent increases in fentanyl release from the patch system as well as
increased skin permeability, an increase in body temperature to 40°C (104°F) theoretically may
increase serum fentanyl concentrations by approximately one-third.
Fentanyl is absorbed into the upper layers of the skin, forming a depot. Fentanyl then becomes
available to systemic circulation. Serum fentanyl concentrations are measurable within 2 hours after
application of the first patch, and analgesic effects can be observed 8-16 hours after application.
Steady state is reached after several sequential patch applications.
Transmucosal fentanyl citrate lozenge

The absorption pharmacokinetics of fentanyl from the oral transmucosal dosage form is a
combination of initial rapid absorption from buccal mucosa and delayed absorption of fentanyl from
the GI tract. Normally 25% of the total dose is available by buccal absorption, and 25% is available
from the GI tract, making the total bioavailability 50%.
Analgesia begins in 10-15 minutes, peaks in 20 minutes, and persists for 1-2 hours.
Transmucosal fentanyl is indicated only for those already receiving and who are tolerant to around-
the-clock opioid therapy.
Fentanyl citrate buccal tablet

Following buccal administration, fentanyl is readily absorbed with an absolute bioavailability of
65%. Approximately 50% of the total dose administered is absorbed transmucosally and becomes
systemically available. The remaining half of the total dose is swallowed and undergoes more
prolonged absorption from the GI tract.
Buccal tablets are indicated only for those already receiving around-the-clock opioid therapy.
Methadone
After therapeutic doses, about 90% of methadone is bound to plasma protein and is widely
distributed in tissues. Methadone is found in low concentrations in the blood and the brain, with
higher concentrations in the kidney, spleen, liver, and lung. Terminal half-life is extremely variable
(15-55 hours); therefore, accumulation is possible, and dosing intervals need to be carefully
monitored.
Methadone is extensively metabolized in the liver, mainly by N-demethylation. This process

appears to be mediated primarily by CYP450 3A4 and to a lesser extent by CYP450 2D6. The
major metabolites are excreted in the bile and urine.
Analgesic efficacy does not correspond to the half-life of the drug. Methadone may be dosed every
3 hours for pain control.
Oxycodone
Oxycodone is metabolized to noroxycodone, oxymorphone, and their glucuronides via the CYP450
enzyme system. The major circulating metabolite is noroxycodone. Noroxycodone is reported to be
a weaker analgesic than oxycodone. Oxymorphone, although possessing good analgesic activity, is
present in the plasma only in low concentrations. Its metabolism is mediated by CYP450 2D6.
Hydromorphone
Hydromorphone is metabolized to three major metabolites: hydromorphone 3-glucuronide,

hydromorphone 3-glucoside, and dihydroisomorphine 6-glucoside. Whether hydromorphone is
metabolized by the CYP450 system is not known. Hydromorphone is a poor inhibitor of CYP450
isoenzymes and is not expected to inhibit the metabolism of other drugs.
Meperidine
Normeperidine, a metabolite of meperidine, produces anxiety, tremors, myoclonus, and generalized

seizures when it accumulates with repetitive dosing. Patients with compromised renal function are
particularly at risk. Naloxone does not reverse this hyperexcitability. For these reasons, meperidine
should not be used for more than 48 hours in patients with renal or CNS disease or at doses greater
than 600 mg every 24 hours.
Propoxyphene
Propoxyphene is appropriate for short-term mild to intermittent pain. It produces a toxic metabolite,
norpropoxyphene, with effects similar to normeperidine.
Drug Interactions and Drug-Disease Interactions
Drug interactions
All drugs with CNS depressant actions (barbiturates, benzodiazepines, alcohol) can intensify
sedation and respiratory depression caused by morphine and other opioids.
Antihistamines, tricyclic antidepressants, and atropine-like drugs can exacerbate morphine-induced
constipation and urinary retention.
Antihypertensive drugs and others that lower blood pressure can exacerbate opioid-induced
hypotension.
The combination of meperidine and a monoamine oxidase (MAO) inhibitor has produced a
syndrome characterized by excitation, delirium, hyperpyrexia, convulsions, and severe respiratory
depression. Death has also occurred. Although this syndrome has not been reported with other
opioids, combinations containing opioids and MAO inhibitors should be avoided.
Agonist-antagonists can precipitate a withdrawal syndrome if administered to an individual who is

physically dependent on a pure opioid agonist.
CYP450 enzymes metabolize codeine, hydrocodone, fentanyl, methadone, and oxycodone.

Although not well documented, drug interactions through this system may exist. In particular,
transdermal fentanyl should be used with caution in a patient on a CYP450 3A4 inhibitor. The
patient should be monitored over an extended period and dose adjustments made as appropriate.
Codeine, hydrocodone, and oxycodone require metabolism through CYP450 2D6 to active drug (
Table 23-4). Approximately 7% of Caucasians, 3% of African Americans, and 1% of Asians are
poor metabolizers of CYP450 2D6; they produce no CYP450 2D6 or produce undetectable levels of
it. Poor metabolizers may experience little or no analgesia from drugs requiring 2D6 for conversion
to active metabolites.
About 5% of the patients have multiple copies of the CYP450 2D6 gene, making them ultrafast
metabolizers. The clearance of some opioids may be increased, making more frequent dosing of the
medications necessary.
[Table 23-4. CYP450 2D6 Enzyme Activity]
In view of the extensive hepatic metabolism of opioids, their effects may be increased in patients
with liver disease, particularly those with severe liver failure. Most opioids require dose reduction
in severe liver disease.
Fentanyl, morphine, and methadone require dosing adjustment in renal impairment. Doses of
fentanyl and morphine should be reduced 25% when creatinine clearance (CrCl) is 10-50 mL/min
and by 50% when CrCl is < 10 mL/min. The dosing interval of methadone should be increased to at
least every 6 hours when CrCl is 10-50 mL/min and to every 8 hours when CrCl is < 10 mL/min.
Renal impairment slows the clearance of morphine conjugates, resulting in accumulation of the
active metabolite M6G. For this reason, dosage reduction may be advisable in the presence of
clinically significant renal impairment.
Methadone appears to be firmly bound to protein in various tissues, including the brain. After
repeated administrations, methadone gradually accumulates in tissues. The risk of accumulation is
greater in patients with impaired renal or hepatic function because both organs are involved in the
metabolism of methadone.
Patient Counseling
Respiratory depression is increased by concurrent use of other drugs with CNS-depressant activity
(e.g., alcohol, barbiturates, and benzodiazepines). Outpatients should be warned against the use of
alcohol with all other CNS depressants.
Inform patients about symptoms of hypotension (lightheadedness, dizziness). Patients should

minimize hypotension by moving slowly when changing from a supine to an upright position.
Fentanyl transdermal patch
The fentanyl transdermal patch must be applied to a clean, nonhairy site on the upper torso. Only
water should be used to clean the area. Soap or alcohol can increase the effects of the medication
and should not be used. The patch should not be applied to oily, broken, burned, cut, or irritated
skin. It must be held in place for a minimum of 30 seconds to ensure adhesion.
Each new patch should be applied to a different area of skin to avoid irritation. If a patch comes off
or causes irritation, it should be removed and a new patch applied to a different site.
To dispose of the patch, fold it in half and flush down the toilet.
Do not cut or damage the patch.
Temperature-dependent increases in fentanyl release from the patch could result in an overdose.
Advise patients to avoid exposing the patch to direct external heat sources such as heating pads,
electric blankets, heat lamps, saunas, hot tubs, and heated waterbeds. In addition, patients who
develop a high fever while wearing the patch should contact their physician immediately.
Long-acting opioid formulations
The long-acting formulations should be swallowed whole (i.e., not broken, chewed, or crushed).
Avinza, a long-acting morphine capsule formulation, contains fumaric acid. Doses above 1,600 mg
per day contain a quantity of fumaric acid that has not been demonstrated to be safe and may result
in serious renal toxicity.
Kadian and Avinza (long-acting morphine sulfate) may be opened and the beads ingested with a
small amount of applesauce (sprinkle administration). In addition, Kadian is approved for sprinkle
administration through a gastrostomy tube.
Patients must not consume alcoholic beverages or any medications containing alcohol while on
Opana ER therapy. The co-ingestion of alcohol with Opana ER may result in increased plasma
levels and a potentially fatal overdose of oxymorphone. In addition, food increases the Opana ER
maximum concentration by approximately 50%. Opana ER should be ingested 1 hour before and 2
hours after a meal.
Transmucosal fentanyl citrate lozenge
The lozenge is used by placing it in the mouth between the cheek and the gum. Consumption of the
lozenge should take 15 minutes. Another lozenge may be used 30 minutes after the start of the first
one. Tell the patient not to bite or chew the lozenge.
To dispose of a finished lozenge, discard the handle in a place that is out of reach of children and
pets. If medicine remains on the handle, place the handle under hot running tap water until the
medicine is dissolved. Never leave unused or partly used lozenges where children or pets can get to
them.
Fentanyl citrate buccal tablet
Once removed from the blister pack, the lozenge must be used right away. It is placed in the mouth
above the back molars and between the upper cheek and gum. It is left in place until it dissolves,
which may take between 14 and 25 minutes. After 30 minutes, any remaining tablet is swallowed
with a glass of water.
Evaluate for pain control 1 hour after opioid administration. If analgesia is insufficient, consider a
dosage increase. Patients taking opioids chronically should be evaluated regularly for adequate
doses.
Monitor the patient for respiratory depression. Higher risk for respiratory depression exists in
patients who are not tolerant to opioid analgesics. Consider treatment when the respiratory rate is
less than 8-12 respirations per minute for 30 minutes or longer despite stimulation or if oxygen
saturation is less than 90%.
If a patient is easily arousable, he or she is unlikely to have respiratory depression.
Tramadol
Tramadol is an analogue of codeine, whose mechanism of action is not completely understood.

Analgesia is apparently mediated by binding of the parent molecule and the O-desmethyltramadol
(M1) active metabolite to opioid receptors, as well as by weak inhibition of neuronal uptake of
norepinephrine and serotonin. Tramadol is not a federally controlled substance.
The liver extensively metabolizes tramadol. The formation of the M1 active metabolite is
dependent on CYP450 2D6. M1 appears to be up to 6 times more potent than tramadol in producing
analgesia and 200 times more potent in binding to ¼ opioid receptors. CYP450 3A4 and CYP450
2B6 also play a role in tramadol metabolism. Caution should be exercised when administering
tramadol to patients on CYP450 2D6 and CYP450 3A4 inhibitors.
The most common adverse effects are sedation, dizziness, headache, dry mouth, and constipation.
Respiratory depression is minimal. Seizures have been reported; avoid use of tramadol in patients
with seizure disorders or recognized risk for seizure (such as head trauma, metabolic disorders,
alcohol and drug withdrawal, and CNS infections).
23-2. Nonpharmacologic Treatment of Pain
General Principles of Nonpharmacologic Treatment
Nonpharmacologic strategies used in combination with appropriate drug regimens may improve
pain relief by enhancing the therapeutic effects of medications and permitting use of lower doses.
Nonpharmacologic interventions should not be a substitute for analgesic use.
Physical Interventions
Physical therapy
Physical therapy is most commonly used to help restore physical strength and functioning after
injury or surgery.
Physical therapy can provide pain relief for patients with musculoskeletal pain, some types of
neuropathic pain, and sympathetically mediated pain.
Acupuncture
The National Institutes of Health recognize the benefit of acupuncture as an adjunct treatment of
painful conditions.
Transcutaneous electrical nerve stimulation
In transcutaneous electrical nerve stimulation (TENS), a controlled, low-voltage electrical current is

applied through electrodes placed on the skin. Theoretically, the current will interfere with the
ability of nerves to transmit pain signals to the spinal cord and brain. After several decades of
research, it still is not clear if TENS provides any better pain relief than placebo.
Neurostimulation
Neurostimulation involves implanting a computerized generator and electrodes near the spinal cord,
near the peripheral nerves, or within the brain. Stimulators are most effective for patients with
neuropathic pain and are not very beneficial in other types of pain.
Behavioral Techniques
Biofeedback
In biofeedback, electrodes connected to amplifiers are placed on the body or scalp. During
biofeedback sessions, a therapist helps the patient learn to mentally control and change the signals
from the electrodes, which helps the patient gain conscious control over normally unconscious
functions. Biofeedback is most commonly used to relax muscles and reduce stress. Its advantages
are that it is noninvasive, inexpensive, and safe; however, usually between 5 and 15 sessions are
required before effective control is achieved.
Distraction and relaxation
Distraction and relaxation assist the patient in refocusing attention on nonpainful stimuli. Both are
believed to improve mental health, which translates into improved pain control.
23-3. Migraine
Introduction
Migraine is a chronic neurovascular disorder characterized by recurrent attacks of severe headache

and autonomic nervous system dysfunction. Some patients also experience aura with neurologic
symptoms. An estimated 18% of women and 6% of men experience migraine.
Clinical Presentation and Diagnostic Criteria
Migraine classification is based on whether an aura of visual or sensory symptoms is present.

Migraine with aura is less common than migraine without aura.
Migraine headache manifests as moderate or severe throbbing pain that is localized in the temple or
around the eye. It is accompanied by nausea in 90% of patients and vomiting in about half of
patients.
Photophobia (increased sensitivity to light) and phonophobia (increased sensitivity to sound) also
are frequent complaints. A prodrome of mood changes, stiff neck, fatigue, or other symptoms may
occur hours or days before the onset of the headache.
Criteria for diagnosing migraine without aura
• The patient has at least five headaches lasting 4-72 hours each.
• The headaches have at least two of the following four characteristics:
• Unilateral location
• Pulsating quality
• Moderate or severe intensity (inhibits or prohibits daily activities)
• Aggravation with walking stairs or similar routine physical activity
• During the headache, at least one of the following symptoms occurs:
• Nausea or vomiting
• Photophobia
• Phonophobia
• Symptoms cannot be consistent with other headache types.
Criteria for diagnosis of migraine with aura
• The patient has at least two attacks with three of the following four criteria:
• One or more completely reversible aura symptoms occur, indicating focal cerebral cortical or
brain stem dysfunction (or both).
• At least one aura symptom develops gradually (> 4 minutes) or two or more symptoms occur in
succession.
• No aura symptom lasts > 60 minutes.
• Headache follows aura in < 1 hour.
• There is no evidence of related organic disease.
Pathophysiology
Migraine and the brain
The pathogenesis of migraine is unclear and is thought to be multifactorial. The current thinking is
that a primary neuronal dysfunction originates in the CNS, leading to a sequence of changes that
account for the different stages of migraine.
The Cortical Spreading Depression theory explains that a wave of depolarization spreads across the
cerebral cortex from occipital to frontal regions, resulting in brain ion dysfunction and secondary
vasoconstrictor vascular events. These changes account for the progression and variety of symptoms
that occur in patients with prodromal or aura phase.
The headache phase is probably related to trigeminovascular activation with the release of
inflammatory neuropeptides, such as substance P, neurokinin A, and calcitonin gene-related
peptide, in the trigeminal vascular system. This process, in turn, causes vasodilation.
It is suggested that the pain of headache is due to vasodilation as well as direct stimulation via the
thalamus of the cortical pain areas situated in higher centers of the CNS. Not all migraine patients
experience aura, so both direct effects and the secondary vasoactive responses account for the
headache in patients who have migraine attacks without the aura.
The pathophysiology of the postdrome is unknown, but it may be caused by a gradual recovery from
the extreme neurologic disruption that occurs during migraine.
Individuals prone to migraine may have a genetic migraine threshold that renders them susceptible
to a migraine attack on exposure to some or any of a range of patient-specific triggers. Hormonal
influences, environmental and physiologic stressors, low blood sugar, and fatigue are all thought to
affect this threshold. Once the threshold is exceeded, trigeminovascular activation is thought to be
responsible for inducing a migraine.
Abortive therapy
The U.S. Headache Consortium identifies the following goals for successful treatment of acute
attacks of migraine:
• Treat attacks rapidly and consistently and prevent recurrence.
• Restore the patient's ability to function.
• Minimize the use of rescue medication.
• Optimize self-care and reduce subsequent use of resources.
• Promote cost-effective therapies with minimal adverse effects.
Successful treatment of migraine depends on early intervention in relation to onset of headache and
adequate dosing.
Preventive therapy
Preventive therapy should be considered in the following situations:

• Attacks unresponsive to abortive medication
• Attacks causing substantial disability
• Attacks occurring twice or more monthly
• Patient at risk for rebound headache
• Trend in increasing frequency of attacks
Two-thirds of patients taking preventive medication will have a 50% decrease in the frequency of
attacks.
The minimum duration of trial for a daily preventive medication is 2-3 months. No consensus exists
on the duration of the prophylaxis trial period; however, prophylaxis efficacy may continue to
improve when a medication is taken continuously for months to years.
The goals of migraine preventive therapy are as follows:
• Reduce attack frequency, severity, and duration.
• Improve responsiveness to treatment of acute attacks.
• Improve function and reduce disability.
Rebound headaches
Persons who take abortive medications daily can develop drug rebound headaches, or headaches
that begin upon discontinuation of a medication. Essentially all of the medications, with the
possible exception of the triptans, cause rebound headache.
Drug Therapy
Abortive therapy: Nonprescription medications
Aspirin, acetaminophen, ibuprofen, and other aspirinlike analgesics provide adequate relief of mild
to moderate migraines. Advil Migraine (ibuprofen 200 mg liquid-filled caps) and Motrin Migraine
Relief (ibuprofen 200 mg) are examples of nonprescription medications indicated for migraine
relief.
Combination products containing aspirin, acetaminophen, or both with caffeine are also available
without a prescription. Caffeine has analgesic and possibly anti-inflammatory properties. It may
also increase gastric acidity and perfusion, enhancing the absorption of aspirin. Excedrin Migraine
(acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg) is an example of an available
combination nonprescription product.
Abortive therapy: Nonspecific prescription medications
Combination products containing an analgesic, caffeine, and butalbital or codeine are available. The
butalbital may be useful for its sedative properties. Excessive use of these products can cause
physical dependence and rebound headaches.
A combination of the vasoconstrictor isometheptene, the sedative dichloralphenazone, and

acetaminophen (Midrin) may be useful for mild to moderate migraines. Isometheptene is also
available in combination with acetaminophen and caffeine (Migraten). Both combinations are
generally well tolerated.
Opioids are well recognized as good analgesics, but strong evidence exists only for the efficacy of
butorphanol nasal spray for migraine. Although opioids are commonly used, surprisingly few
studies of opioid use in headache pain document whether overuse and the development of
dependence are as frequent as clinically perceived.
Given intravenously, the antiemetic metoclopramide may be appropriate as monotherapy for acute
attacks, particularly in patients with significant nausea. Chlorpromazine and prochlorperazine may
also be considered. Serotonin-receptor antagonists (5-HT3) have not been shown to be useful
migraine treatments.
Abortive therapy: Ergotamine
Mechanism of action
In cranial arteries, ergotamine acts directly to promote constriction and reduce the amplitude of
pulsations. In addition, the drug can affect blood flow by depressing the vasomotor center.
Antimigraine effects are possibly due to agonist activity at serotonin receptor subtypes 5-HT1B and
5-HT1D.
Because of the risk of dependence, ergotamine should not be taken daily on a long-term basis.
Caffeine may be added to ergotamine to enhance vasoconstriction and ergotamine absorption (

Table 23-5).
Pharmacokinetics
Oral ergotamine has poor bioavailability because of extensive first-pass metabolism. Sublingual
administration may not provide therapeutic blood levels.
Although the half-life of ergotamine is only 2 hours, pharmacologic effects can be seen for 24 hours
after administration.
The drug is eliminated primarily by hepatic metabolism. Metabolites are excreted in the bile.
Adverse effects
Ergotamine is well tolerated at usual therapeutic doses.
The drug can stimulate the chemoreceptor trigger zone to cause nausea and vomiting in about 10%
of patients. Concurrent treatment with metoclopramide or a phenothiazine antiemetic can help
suppress this response.
Other common side effects include weakness in the legs, myalgia, numbness and tingling in the
periphery, angina-like pain, tachycardia, and bradycardia.
Overdose
Acute or chronic overdose can cause serious toxicity (ergotism). Symptoms include ischemia,
myalgias, and paresthesias. Ischemia can progress to gangrene.
The risk of ergotism is highest in patients with sepsis, peripheral vascular disease, and renal or
hepatic impairment.

Ergotamine should not be combined with selective serotonin-receptor agonists because of the risk
of a prolonged vasospastic reaction.
[Table 23-5. Agents Used in Migraine Treatment]
Separate doses of ergotamine and serotonin agonists by at least 24 hours.
Ergotamine is contraindicated for patients with hepatic or renal impairment, sepsis, coronary artery
disease (CAD), and peripheral vascular disease.
Patient counseling
Monitor patients to avoid overuse of the medication.
Ergotamine and its derivatives are U.S. Food and Drug Administration (FDA) pregnancy category
X. They should not be taken during pregnancy because of their ability to promote uterine
contractions and cause fetal harm or abortion.
Teach patients to recognize signs of ergotism. Muscle pain, paresthesias, and cold or pale
extremities should be reported immediately.
Abortive therapy: Dihydroergotamine
Mechanism of action
The action of dihydroergotamine (DHE) is similar to that of ergotamine. Like ergotamine, DHE
alters transmission at serotonergic, dopaminergic, and ±-adrenergic junctions.
In contrast to ergotamine, DHE causes minimal peripheral vasoconstriction, little nausea and
vomiting, and no physical dependence. However, diarrhea is prominent.
Contraindications are the same as for ergotamine: CAD, peripheral vascular disease, sepsis,
pregnancy, and hepatic or renal impairment.
As with ergotamine, do not administer DHE within 24 hours of a serotonin agonist.
Pharmacokinetics
DHE is not active orally because of extensive first-pass metabolism.
An active metabolite, 8´-hydroxydihydroergotamine, contributes to its therapeutic effects. The half-

life of DHE plus its active metabolite is about 21 hours.
Concomitant administration of DHE with potent CYP450 3A4 inhibitors, including protease
inhibitors and macrolide antibiotics, is contraindicated. Because CYP450 3A4 inhibition elevates
the serum levels of DHE, the risk for vasospasm leading to cerebral ischemia or ischemia of the
extremities is increased.
Abortive therapy: Selective serotonin-receptor agonists
The selective serotonin-receptor agonists, also known as triptans, are first-line drugs for terminating
a migraine attack (
Table 23-6). The triptans all activate 5-HT1B/5-HT1D and to a lesser extent 5-HT1A or 5-HT1F
receptors. Triptans have no known affinity for 5-HT2 or 5-HT3 and other 5-HT receptor subclasses,
[Table 23-6. Selective Serotonin Receptor Agonists (Triptans)]
nor do they bind to adrenergic, dopaminergic, muscarinergic, or histaminergic receptors.
Pharmacokinetics
The pharmacokinetics of the different triptans vary somewhat. However, all are generally well
tolerated and efficacious at appropriate doses.
Subcutaneous sumatriptan injection has the fastest onset of action when compared with other
triptans. Sumatriptan nasal spray has a slightly slower onset than the injection.
The onset of the majority of oral triptans, including the dissolving wafers, is similar among the
available agents. Rizatriptan may have a slightly faster onset of action at 1.0-1.5 hours.
Migraine recurrence rates may be lower with long-half-life triptans such as naratriptan and
frovatriptan. However, triptans with longer half-lives tend to have a slower onset of action.
Adverse effects
Triptans are generally well tolerated. Most side effects are mild and transient.
The triptans differ slightly from one another in terms of tolerability but not in terms of safety.
The most frequent side effects are (1) tingling and paresthesias and (2) sensations of warmth in the
head, neck, chest, and limbs. Less frequent effects are dizziness, flushing, and neck pain or
stiffness.
Chest symptoms
About 50% of patients on sumatriptan experience unpleasant chest symptoms usually described as
"heavy arms" or "chest pressure" rather than pain. These symptoms are transient and not related to
ischemic heart disease. Possible causes are pulmonary vasoconstriction, esophageal spasm,
intercostal muscle spasm, and bronchoconstriction.
Coronary vasospasm
Rarely, sumatriptan causes angina secondary to coronary vasospasm. Electrocardiographic changes
have been observed in patients with CAD or Prinzmetal's (vasospastic) angina.
To reduce the risk of angina, do not give sumatriptan to patients who have risk factors for CAD.
These patients include postmenopausal women, men over 40, smokers, and patients with
hypertension, hypercholesterolemia, obesity, diabetes, or a family history of CAD.
Other adverse effects

Mild reactions include vertigo, malaise, fatigue, and tingling sensations.
Transient pain and redness may occur at sites of subcutaneous injection.
Intranasal administration may cause irritation in the nose and throat as well as an offensive or
unusual taste.

All triptans and ergot alkaloids cause vasoconstriction. Accordingly, if one triptan is combined with
another or with an ergot alkaloid, excessive and prolonged vasospasm could result.
Do not use triptans within 24 hours of an ergot derivative or another triptan.
MAO inhibitors can suppress degradation of triptans, which causes plasma levels to rise and results
in toxicity. Furthermore, triptans should not be administered within 2 weeks of stopping an MAO
inhibitor.
Triptans are contraindicated for patients with a history of ischemic heart disease, myocardial
infarction, uncontrolled hypertension, or other heart disease. Do not use triptans during pregnancy.
Patient counseling
Patients should be counseled to contact a physician if pain or tightness in the chest occurs.
Patients should not exceed daily maximum doses. If migraines occur more than three times a
month, prophylactic treatment should be considered.
Pain at the sumatriptan injection site should last less than 1 hour.
Migraine Prophylactic Therapy
Table 23-7 summarizes selected migraine preventive treatments.
-adrenergic blocking agents
Propranolol is one of the drugs of choice for migraine prophylaxis. This agent can reduce the
number and intensity of attacks in about 70% of patients.
Not all -blockers are active against migraines. Recommended first-line agents include propranolol
and timolol. Additional agents with demonstrated efficacy include atenolol and metoprolol.
Because not all -blockers are effective, a mechanism other than -blockade is apparently
responsible for the beneficial effects.
Anticonvulsants
Good evidence supports the efficacy of divalproex sodium and sodium valproate. Adverse events
with these therapies include weight gain, hair loss, tremor,
[Table 23-7. Selected Migraine Preventive Treatments]
and teratogenic potential, such as neural tube defects. Both are considered first line for prevention.
Topiramate has good scientific evidence for clinical efficacy. It is FDA approved for migraine
prevention. Side effects associated with use include paresthesia, fatigue, nausea, dizziness, and
difficulty concentrating. Anorexia and weight loss may also occur.
Limited evidence indicates moderate efficacy of gabapentin. Gabapentin has no documented drug
interactions and is excreted unchanged in the urine. Drowsiness and dizziness are common adverse
events.
Antidepressants
Amitriptyline has been more frequently studied than the other antidepressants and is the only one
with consistent support for efficacy in migraine prevention. It is considered a first-line treatment.
There is limited evidence for the use of other tricyclic antidepressants (TCAs) such as nortriptyline,
protriptyline, doxepin, clomipramine, or imipramine.
Drowsiness, weight gain, and anticholinergic symptoms are frequently reported with the TCAs.
Limited evidence exists that supports using fluoxetine at dosages ranging from 20 mg every other
day to 40 mg per day. Although benefit may be seen in clinical practice, controlled trials offer no
evidence for the use of fluvoxamine, paroxetine, sertraline, bupropion, mirtazapine, trazodone, or
venlafaxine in this manner.
Several calcium channel blockers are moderately effective at reducing migraine attacks. They
include verapamil and diltiazem. Beneficial effects develop slowly, reaching a maximum in 1-2
months.
Calcium channel blockers cause side effects in 20-60% of patients. Constipation and orthostatic
hypotension are most common. Peripheral edema may occur as well.
Cardiovascular effects, including bradycardia, arrhythmias, QT prolongation, may necessitate

appropriate monitoring.
Methysergide
Methysergide is an ergot alkaloid used in migraine prophylaxis. It is not effective for aborting an
ongoing attack.
It is more efficacious than propranolol but has significantly more side effects.
The drug seems to activate serotonin receptors in the CNS. Suppression of pain pathways by this
mechanism may explain its usefulness.
Methysergide causes a number of adverse effects. With long-term therapy, methysergide can cause
retroperitoneal, pleuropulmonary, and cardiac fibrosis. Fibrotic changes, although rare, are most
serious.
Other adverse effects include vascular insufficiency, insomnia, altered mood, depersonalization,
hallucinations, nightmares, and GI disturbances such as nausea, vomiting, and diarrhea.
Ergot alkaloids, serotonin-receptor agonists, -adrenergic blockers, dopamine, and drugs that inhibit
the CYP450 3A4 subclass of hepatic metabolizing enzymes increase the risk of arterial spasm.
23-4. Nonpharmacologic Treatment of Migraines
General Principles of Nonpharmacologic Therapies
Nonpharmacologic approaches may be well suited to patients who have exhibited a poor tolerance
or poor response to drug therapy; who have a contraindication to drug therapy; or who have a
history of long-term, frequent, or excessive use of analgesics or other acute medications.
Nonpharmacologic interventions may also be useful in patients who are pregnant, are planning to
become pregnant, or are nursing.
Treatment Recommendations
Patients with migraine pain may experience relief by resting or sleeping in a cool, quiet, dark
environment.
Half of migraine patients experience considerable relief by applying a cold compress to the head.
Relaxation training, thermal biofeedback combined with relaxation training, electromyographic

biofeedback, and cognitive-behavioral therapies are somewhat effective in preventing migraine.
Evidence pertaining to the treatment of migraine with acupuncture is limited, and the results are
mixed. Similarly, limited evaluation has been conducted with hypnosis, TENS, cervical
manipulation, and hyperbaric oxygen.
Trigger Management
Trigger management is important in preventing migraine attacks. Triggering factors can cause
migraine and if, recognized and avoided, may impede an impending attack.
Triggers vary from person to person. Examples of triggers include changes in weather or air
pressure; bright sunlight, glare, or fluorescent lights; chemical fumes; menstrual cycles; and certain
foods such as processed meats, red wine, beer, dried fish, broad beans, fermented cheeses,
aspartame, and monosodium glutamate.
23-5. Key Points
Pain Management
• Opioids relieve pain by mimicking the actions of endogenous opioid peptides at , , and
receptors.
• Opioids fall into three categories: pure agonists, agonist-antagonists, and pure antagonists. Pure
agonists are the most pharmacologically useful.
• Addiction is a behavior pattern involving the continued use of a substance for nonmedical reasons
despite harm. Physical dependence refers to the occurrence of an abstinence syndrome if the
opioid is abruptly discontinued.
• With prolonged use, tolerance develops to analgesia, euphoria, sedation, respiratory depression,
and other adverse effects—but not to constipation.
• Opioid overdose induces coma, respiratory depression, and pinpoint pupils. Naloxone and other
pure opioid antagonists are used in cases of overdose to reverse most effects of opioids.
• Alcohol and other CNS depressants can intensify opioid-induced sedation and respiratory
depression. TCAs and antihistamines may worsen opioid-induced constipation and urinary
retention.
• Hydrocodone, codeine, fentanyl, methadone, and oxycodone are metabolized by the CYP450
system. Thus, drug interactions through the CYP450 enzymes may exist.
• The liver extensively metabolizes opioids; dose adjustments may be required in liver dysfunction.
Fentanyl, morphine, and methadone require dosing adjustments in renal dysfunction.
Migraine
• The pathogenesis of migraine is unclear and is thought to be multifactorial. The current thinking is
that a primary neuronal dysfunction originates in the CNS, leading to a sequence of changes that
account for the different stages of migraine.
• The goal of abortive therapy is to eliminate headache pain and associated nausea and vomiting.
The goal of preventive therapy is to reduce the incidence of migraine attacks.
• Nonopioid analgesics are effective for abortive therapy of mild to moderate pain.
• Opioid analgesics are reserved for severe migraine that has not responded to other drugs.
• Ergotamine is used for abortive therapy but should not be used daily. Overdose with ergotamine
can cause ergotism, a serious condition in which generalized constriction of peripheral arteries
and arterioles causes severe tissue ischemia.
• Triptans are drugs of choice for abortive therapy of migraines. They activate 5-HT1B/5-HT1D
receptors, thereby causing constriction of cranial blood vessels and suppression of inflammatory
neuropeptides.
• Triptans can cause coronary vasospasm and are contraindicated in patients with ischemic heart
disease, prior myocardial infarction, and uncontrolled hypertension. If a triptan is combined with
another triptan or with an ergot alkaloid, excessive prolonged vasospasms could result. Because
of increased triptan toxicity, triptans should not be administered concurrently with MAO
inhibitors and should not be given within 2 weeks of stopping an MAO inhibitor.
• The most recently published clinical practice guidelines consider propranolol, amitriptyline,
divalproex sodium, and timolol first line for prevention of migraines. Since the publication of the
guidelines, topiramate has gained an FDA indication for migraine prevention.
23-6. Questions
Approximately how many people in the United States experience severe chronic pain?
A. 10 million
1. B. 23 million
C. 40 million
D. 50 million
E. 75 million

Addiction is currently understood to be
I. characterized by compulsive use of drugs.

II. synonymous with physical dependence on a medication.
III. the use of a substance for psychic effects.
2.
A. I only
B. III only
C. I and III only
D. II and III only
E. I, II, and III

The World Health Organization analgesic hierarchy emphasizes
A. concurrent use of nonopioids, opioids, and adjuvant medications.

3. B. avoiding opioid use.
C. reserving opioid use only for severe pain.
D. using single agents rather than a combination of medications.
E. using nonopioids only for treatment of mild pain.

All of the following adverse effects are manifestations of ¼ opioid agonists except
A. constipation.
4. B. respiratory depression.
C. atrial flutter.
D. nausea.
E. miosis.

The preferred route of opioid administration is
A. oral.
5. B. intravenous.
C. subcutaneous.
D. rectal.
E. intramuscular.

Which of the following opioids has the longest duration of analgesic effect?
A. Methadone
6. B. Controlled-release morphine
C. Hydromorphone
D. Transdermal fentanyl
E. Controlled-release oxycodone

All of the following opioids are metabolized through the cytochrome P450 hepatic enzyme
system except
A. hydrocodone.
7.
B. oxycodone.
C. morphine.
D. methadone.
E. fentanyl.

The clearance of which opioid may be increased in patients with multiple copies of the
CYP450 2D6 gene?
A. Methadone
8.
B. Oxycodone
C. Fentanyl
D. Morphine
E. Hydromorphone

Which of the following statements regarding methadone pharmacokinetics is true?
A. The half-life corresponds to analgesic efficacy.

B. It is highly plasma protein bound and widely distributed in tissue.
9.
C. The clearance of methadone is rapid, resulting in frequent dosing.
D. Methadone has low bioavailability from the GI tract and therefore is not useful when given
orally.
E. Methadone is metabolized by hepatic glucuronidation.

Which agent can be used to reverse respiratory effects caused by opioid overdose?
A. Naloxone
10. B. Pentazocine
C. Buprenorphine
D. Naltrexone
E. Tramadol

Which of the following opioids is not appropriate for use as an around-the-clock medication in
chronic pain?
A. Morphine
11.
B. Oxycodone
C. Fentanyl
D. Hydromorphone
E. Methadone

Which of the following opioids has a toxic metabolite that can accumulate in renal
dysfunction?
A. Oxycodone
12.
B. Fentanyl
C. Meperidine
D. Hydromorphone
E. Methadone

Use Case Study 1 to answer questions 13 and 14.
Case Study 1

Patient name: Mary Martin
Age: 65
Address: 815 Elm Street
Sex: Female
Allergies: NKDA
Diagnosis:
Chronic low back pain
Hypertension
Chronic constipation
Date Medication
3/3 Paxil 20 mg qd
3/3 Zocor 40 mg qd
3/3 Lotensin 20 mg qd
3/3 Premarin 0.625 mg
3/3 Morphine sulfate extended-release 60 mg bid
3/3 Senokot S
3/28 Elavil 50 mg qhs
4/1 Milk of magnesia
Which of Mrs. Martin's medications is most likely to worsen opioid-induced constipation?
A. Paxil
13. B. Zocor
C. Lotensin
D. Premarin
E. Elavil

The physician recommends changing Mrs. Martin's opioid to one that is less constipating.
Which of the following medications is least likely to cause constipation?
A. Morphine extended release

14.
B. Methadone
C. Oxycodone extended release
D. Transdermal fentanyl patch
E. Hydromorphone

The rationale of adding caffeine to a simple analgesic for migraine treatment is to
I. decrease the required dose of acetaminophen and aspirin.

II. cause cerebral arterial vasoconstriction.
III. increase gastric acidity and perfusion, enhancing aspirin absorption.
15.
A. I only
B. III only
C. I and III only
D. II and III only
E. I, II, and III

Which of the following agents is a selective serotonin agonist?
A. Sumatriptan
16. B. Ketorolac
C. Dihydroergotamine
D. Metoclopramide
E. Caffeine

Which is true regarding the adverse effects of ergotamine?
A. Ergotamine inhibits the chemoreceptor trigger zone to minimize nausea and vomiting.
17. B. Ergotamine has minimal risk of dependence.
C. Muscle weakness is an uncommon side effect of ergotamine.
D. Angina-like pain reported with the triptans is not seen with ergotamine use.
E. Overuse of ergotamine can result in ischemia.

Which statement about triptans is correct?
A. Few contraindications exist to the use of triptans.

18. B. Triptans are contraindicated in ischemic cardiovascular disease.
C. Triptans are preferred for migraine treatment during pregnancy.
D. Patients taking ergot alkaloids can use triptans concomitantly.
E. Triptans are strictly contraindicated in patients with hypertension.

Which of the following statements is true regarding the use of opioids for migraines?
A. Opioid use is not associated with rebound headaches.

19. B. Butorphanol nasal spray is efficacious in migraine abortive therapy.
C. Opioids in combination with butalbital and caffeine do not produce physical dependence.
D. Opioids scheduled around the clock are useful for migraine prophylaxis.
E. Opioids are not commonly prescribed for migraine treatment.

Which of the following agents is most likely to cause pulmonary fibrosis?
A. Methysergide
20. B. Amitriptyline
C. Carbamazepine
D. Propranolol
E. Valproic acid

Which statement about Midrin is correct?
I. Midrin can be used concomitantly with over-the-counter products containing acetaminophen.

II. Midrin dose is limited to 5 capsules per 12 hours.
III. Midrin may cause sedation.
21.
A. I only
B. III only
C. I and III only
D. II and III only
E. I, II, and III

Dihydroergotamine differs from ergotamine in which of the following ways?
A. DHE has higher incidence of nausea and vomiting.

22. B. DHE has higher incidence of physical dependence.
C. DHE has no contraindications for ischemic cardiovascular disease.
D. DHE has a higher incidence of diarrhea.
E. DHE can be administered concomitantly with a triptan.

Use Case Study 2 to answer questions 23 and 24.
Case Study 2

Patient name: James Hunt
Age: 45
Allergies: NKDA
Address: 817 Elm Street
Sex: Male
Diagnosis: Migraine with aura, controlled hypertension
Medications:
Date Drug Sig Quantity
1/1 Sumatriptan 100 mg tablet Oral, use as directed #9 tabs
1/1 Lisinopril 10 mg tablet Oral, qd #30 tabs
Which of the following statements is true regarding initiation of prophylactic migraine therapy
in Mr. Hunt?
A. Mr. Hunt is at high risk for rebound headaches caused by excessive sumatriptan use.
B. Mr. Hunt is limiting his sumatriptan use to 3 days per week and is not a candidate for
23. prophylactic treatment.
C. Mr. Hunt is a candidate for prophylactic therapy because of the increasing frequency of
attacks.
D. Mr. Hunt requires prophylactic therapy because his hypertension is a contraindication to
using abortive therapies.
E. Prophylactic treatment is contraindicated in migraines with aura.

Which medication is appropriate to give Mr. Hunt for migraine prophylaxis?
A. Butorphanol
24. B. Propranolol
C. Dihydroergotamine
D. Acetaminophen
E. Hydrocodone

23-7. Answers
1. E. Currently, about 75 million individuals suffer from some form of chronic benign pain.

C. Physical dependence is the occurrence of a withdrawal syndrome after an opioid is stopped
2. or quickly decreased without titration. Addiction is the psychological dependence on the use of
substances for psychic effects and is characterized by compulsive use.

A. The WHO analgesic hierarchy involves choosing among three stepped levels of treatment.
Mild pain may respond to nonopioid drugs alone. Combining a low-dose opioid with a
3. nonopioid can relieve pain of moderate severity. More severe pain requires the addition of a
higher-dose opioid preparation to the nonopioid. At any step, analgesic adjuvants may be
useful.

C. Atrial flutter is not a documented adverse effect of opioids. However, therapeutic doses of
many opioids produce peripheral vasodilation, reduced peripheral resistance, and inhibition of
4.
the baroreceptor reflexes. Recently, methadone has been associated with torsades de pointes,
an atypical rapid ventricular tachycardia.

A. Oral medications should be used whenever possible because of convenience, flexibility, and
5.
steady serum levels.

D. Transdermal fentanyl provides analgesia for up to 72 hours. The analgesic effects of
6.
methadone do not correlate with its long half-life.

7. C. Morphine is metabolized by hepatic glucuronidation.

B. Oxycodone is metabolized through CYP450 2D6 to active metabolites. Fast
8. metabolizers—those with multiple copies of the CYP450 2D6 gene—would clear oxycodone
and its metabolites quickly.

B. About 90% of methadone is bound to plasma protein and is widely distributed in tissues.
9. Methadone has a long terminal half-life, resulting in slow clearance. This half-life does not
correspond to analgesic dosing. It is metabolized via the CYP450 enzyme system.

A. Naloxone is a antagonist useful in opioid overdose. Naltrexone is also a antagonist, but
10.
it is reserved for use in alcoholism and opioid addiction.

D. Hydromorphone is an opioid with a short half-life with no available long-acting
11.
formulation. Thus, it is not useful as an around-the-clock medication.

C. Normeperidine, a metabolite of meperidine, can accumulate with chronic use, with renal
12.
impairment, and when the dose exceeds 600 mg every 24 hours.

E. The anticholinergic effects of tricyclic antidepressants such as Elavil can exacerbate opioid-
13.
induced constipation and urinary retention.

D. Because transdermal delivery bypasses absorption from the GI tract, constipation has been
14.
reported to be less frequent than with other opioids.

C. Caffeine has analgesic and possibly anti-inflammatory properties. Therefore, reduced doses
15. of acetaminophen and aspirin may be required. Caffeine may also increase gastric acidity and
perfusion, enhancing the absorption of aspirin.

16. A. Sumatriptan is a selective serotonin agonist.

E. Adverse effects of ergotamine include nausea and vomiting, physical dependence, muscle
17. weakness, and angina-like pain. Overuse of ergotamine can result in ischemia that may
progress to gangrene.

B. Triptans are contraindicated in pregnancy and ischemic cardiovascular disease. They cannot
18.
be used within 24 hours of another triptan or ergot alkaloid.

B. Good evidence exists for the efficacy of butorphanol nasal spray in migraine abortive
19. therapy. Although opioids are commonly used for abortive therapy, they may be associated
with rebound headaches and physical dependence.

A. With long-term therapy, methysergide can cause retroperitoneal, pleuropulmonary, and
20.
cardiac fibrosis. Fibrotic changes, although rare, are serious.

D. Midrin may be useful for mild to moderate migraines. It is generally well tolerated but may
21. cause sedation. Because of Midrin's acetaminophen content, use of other acetaminophen
products should be limited.

D. In contrast to ergotamine, DHE causes minimal peripheral vasoconstriction, little nausea
22.
and vomiting, and no physical dependence. However, diarrhea is prominent.

C. Prophylactic therapy should be considered because his migraines occur more than twice
23.
monthly and there is a trend toward increasing frequency of attacks.

B. Propranolol has been shown to be effective for migraine prophylaxis. This agent can reduce
24. the number and intensity of attacks in about 70% of patients. Butorphanol, acetaminophen,
dihydroergotamine, and hydrocodone are not approved for migraine prophylaxis.

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24. Seizure Disorders - Stephanie J. Phelps, PharmD, BCPS
24-1. Epilepsy
Introduction
Epilepsy occurs when neurons become depolarized and repetitively fire action potentials. It is
involuntary and episodic. The term is applied after two unprovoked seizures. A seizure does not
mean a person has epilepsy; however, epilepsy means a person has seizures. Anticonvulsants do not
cure epilepsy.
Terminology
• Aura: A subjective sensation or motor phenomenon that marks a seizure onset and is generally
associated with sensations that are localized in a particular region of the brain
• Automatisms: Purposeless movements seen with partial seizures
• Postictal: Symptoms and signs seen after a seizure
Types of Epilepsy
There are two main types of epilepsy: partial seizures and generalized seizures.
Partial seizures
Partial seizures begin in one hemisphere of the brain. They are unilateral, asymmetric movements,
generally associated with an aura. Complex partial seizures are accompanied by altered
consciousness.
Drugs for new-onset seizures
• Monotherapy: Carbamazepine (drug of choice), oxcarbazepine (> 4 years), phenobarbital,

phenytoin, topiramate, valproic acid
• Adjunctive therapy: Gabapentin (> 12 years), lacosamide, lamotrigine (> 2 years), levetiracetam
(> 4 years), oxcarbazepine (> 2 years), phenobarbital, phenytoin, tiagabine (> 4 years), topiramate
(> 10 years), valproic acid, vigabatrin, zonisamide
Drugs for refractory seizures
• Monotherapy: Carbamazepine, felbamate, lamotrigine (conversion > 2 years), phenytoin,

phenobarbital, topiramate, valproic acid
• Adjunctive therapy: Gabapentin, lamotrigine, lacosamide, levetiracetam, oxcarbazepine,
phenobarbital, phenytoin, zonisamide
Generalized seizures
Generalized seizures begin simultaneously in both brain hemispheres. They are characterized by
bilateral movements and have no aura.
Absence seizures
This type of generalized seizure has a sudden onset. It is brief (seconds) and characterized by a
blank stare, upward rotation of the eyes, and lip smacking (confused with daydreaming). It has a
three per second spike and wave on electroencephalography (EEG) and can be precipitated by
hyperventilation.
Drugs
Historically, ethosuximide has been the drug of choice. If a patient has both absence and
generalized tonic-clonic seizures and is older than 2 years of age, many consider valproic acid to be
the drug of choice. Although not labeled, lamotrigine and topiramate have been used.
Primary generalized tonic-clonic seizure
This type of seizure has two phases:
• Tonic phase: Rigid, violent, sudden muscular contractions (stiff or rigid); crying or moaning;
deviation of the eyes and head to one side; rotation of the whole body and distortion of features;
suppression of respiration; falling to the ground; loss of consciousness; tongue biting; involuntary
urination
• Clonic phase: Repetitive jerks; cyanosis continues; foaming at the mouth; small grunting
respirations between seizures, but deep respirations as all muscles relax at the end of the seizure
Drugs of choice
• Monotherapy: Carbamazepine, phenobarbital, phenytoin, topiramate (> 10 years)
• Adjunctive therapy: Lamotrigine (> 2 years), levetiracetam (> 6 years), topiramate (> 2 years),
valproic acid
Juvenile myoclonic epilepsy
Myoclonic seizures precede generalized tonic-clonic seizures; they generally occur on awakening.
Sleep deprivation and alcohol commonly precipitate them.
Lifelong treatment is required with valproic acid, lamotrigine, levetiracetam, topiramate, or some
combination.
Other less common seizure types
Catamenial epilepsy
Catamenial epilepsy is associated with hormonal changes during menstruation. It may be treated
with acetazolamide.
Infantile spasms
Infantile spasms begin in the first 6 months of life. They occur in clusters, several times a day.
Parents describe symptoms that sound like colic. Infantile spasms have high mortality and
morbidity.
Treat this condition with adrenocorticotropic hormone (ACTH) or oral steroids, vigabatrin, or
valproic acid (> 2 years). Although not labeled for this purpose, topiramate and zonisamide have
been used.
Lennox-Gastaut Syndrome
This difficult-to-treat epilepsy most often appears between 2 and 6 years of age and is often
accompanied by mental retardation and behavior problems. It is characterized by frequent and
different types of seizures.
Treat this condition with combination anticonvulsants that include felbamate (> 2 years),
lamotrigine (> 2 years), rufinamide, and topiramate (> 2 years). Although not labeled by the Food
and Drug Administration (FDA) for this purpose, zonisamide has been used.
Post-traumatic epilepsy
These seizures occur after head trauma. Patients may be started on phenytoin or fosphenytoin for a
period of 7 days. If no seizures occur, phenytoin should be discontinued.
Etiologies for Epilepsy
• Mechanical: Birth injuries, head trauma, tumors, vascular abnormalities (stroke)
• Metabolic: Electrolyte disturbances (low sodium, elevated calcium); glucose abnormalities (low);
inborn errors of metabolism
• Genetic: Benign familial neonatal seizures (chromosome 20), juvenile myoclonic epilepsy
(chromosome 6), Baltic myoclonic (chromosome 21)
• Other: Fever; infection
• Drugs: These include the following:
• Recreational drugs such as alcohol, cocaine and crack, ephedra, narcotics, methylphenidate
• Carbapenems (imipenem), lindane, local anesthetics (lidocaine), metoclopramide, theophylline,
tricyclic antidepressants
• Meperidine (the metabolite normeperidine can cause seizures in patients with renal failure who
receive normal doses)
• Anticonvulsants that are used for treatment of a nonindicated seizure type (

Table 24-1)
Criteria for Treating Epilepsy
Almost no child should be treated after one seizure.
Treat adults who have structural brain damage, a first seizure that was severe, or an occupation that
places them at risk of injury should a second seizure occur.
Principles in the treatment of epilepsy
• Monotherapy (one agent): This form of treatment is always preferred.
• Polytherapy (two agents): Add an anticonvulsant with a different mechanism of action, provided
serum concentrations (where appropriate)
[Table 24-1. Seizures Caused by Anticonvulsants]
and doses of the first anticonvulsant have been maximized. Begin to reduce the dose of the first
drug slowly. This step is important if the patient has developed side effects or if the patient has
not responded to the first anticonvulsant.
• Polytherapy (three or more agents): Although rarely needed, add a third anticonvulsant if (1) a
combination of anticonvulsants is tolerated and significantly reduces seizure frequency or
severity, but greater control might be achieved, or (2) the two anticonvulsants have been
maximized. Reassess response, and discontinue unnecessary anticonvulsants as soon as possible.
Reasons for Treatment Failure
• Incorrect diagnosis
• Wrong anticonvulsant
• Inappropriate dose, route, or formulation
• Altered pharmacokinetics that require a dosage alteration

• Poor patient adherence
• Seizures that are refractory to therapy
Patient Counseling Information Applicable to All Anticonvulsants
• It is important that you keep a diary of your seizures and keep regular appointments with your
doctor, so that he or she can determine whether your medication is working properly and whether
you are experiencing unwanted side effects.
• The full effects of this medication may not be seen for several weeks. Continue to take the
medication unless directed otherwise by your physician.
• Take with food or milk if upset stomach occurs.
• Do not drink alcohol or take central nervous system (CNS) depressants or illegal drugs with this
medication.
• If this medication causes blurred vision or drowsiness, do not drive or operate heavy machinery
while taking this medication until you have become accustomed to its effects
• Consult with your physician if you anticipate pregnancy, become pregnant, or plan to breast-feed
while taking this medication.
• Some medications decrease the effectiveness of birth control pills. You should discuss this with
your physician or pharmacist, who may recommend that you use a backup birth control method
to prevent pregnancy.
• If you are a woman capable of having children, you should take 1 mg of folic acid a day.
• Do not stop taking this medication unless your doctor advises you to do so; some medicines have
to be stopped slowly. Let your doctor or pharmacist know if you stop taking this medication.
• Check with your pharmacist or doctor before taking or starting any new medication (prescription,
over-the-counter, or herbal product).
• If you miss a dose, take it as soon as you remember unless it is almost time for the next dose. If it
is almost time for the next dose, skip the missed dose and resume your regular schedule. Do not
take extra or double doses. If you miss two or more doses, contact your physician for further
instructions.
• Contact your physician immediately if skin rash occurs.
Mechanisms of Action of Anticonvulsants

Anticonvulsants work through a variety of mechanisms including the following:
• Enhancing sodium channel inactivation
• Reducing current through T-type calcium channels
• Enhancing -aminobutyric acid (GABA) activity
• Enhancing antiglutamate activity
24-2. Medications Used to Treat Epilepsy
Carbamazepine
Carbamazepine is the most widely used anticonvulsant in adults and children. It is the drug of
choice for complex partial seizures. It is effective in most generalized seizures but ineffective in
absence seizures and febrile seizures.
Pharmacokinetics
• Bioavailability: Good (75-85%). Dispense in moisture-proof containers because studies show

decreased bioavailability with high humidity (as may occur in medicine cabinets).
• Protein binding: 75-90% bound to alpha-1-acid glycoprotein; the 10,11-epoxide metabolite is

50% protein bound.
• Metabolism: Extensively hepatically metabolized to 10,11-epoxide, which is effective as an

anticonvulsant and is capable of causing toxicity.
• Renal elimination: Low (1-3%).
• Half-life: About a day if used as monotherapy and about 12 hours if given with more than one
anticonvulsant.
• Reference range: 4-12 mg/L (monotherapy, 8-12 mg/L; polytherapy, 4-8 mg/L).
Other aspects
Carbamazepine is one of a few drugs that can induce its own metabolism (i.e., autoinduction).
Mean time to onset is 21 days (range: 17-31 days).
Side effects
Upon initiation, side effects are nausea, vomiting, drowsiness, dizziness, and neutropenia. A dose-
related, transient, and reversible rash that rarely causes the drug to be discontinued may also occur.
With chronic therapy, the following side effects may occur:
• Syndrome of inappropriate antidiuretic hormone (SIADH) causing hyponatremia and water

retention
• Osteomalacia (treat with vitamin D if alkaline phosphatase increase and 25-

hydroxycholecalciferol decreases)
• Folate deficiency causing megaloblastic anemia
Some severe or life-threatening side effects are possible:
• FDA black box warning: Potentially fatal, severe dermatologic reactions (including Stevens-
Johnson syndrome and toxic epidermal necrolysis) may occur. Over 90% of patients who
experience these reactions do so within the first few months of treatment. Patients of Asian
descent are at higher risk for toxic dermatologic reactions and should be screened for the variant
HLA-B*1502 allele (genetic marker) prior to initiating therapy.
• FDA black box warning: Aplastic anemia may occur. In such cases, discontinuation of
carbamazepine is recommended if white blood count < 2,000-3,000 or neutrophils < 1,000-1,500.
• FDA warning: Direct hepatotoxicity and multiorgan hypersensitivity reactions may occur. These
side effects generally present within 1 month. Fever, rash, or fatalities may occur even if
carbamazepine is discontinued. Stop carbamazepine if liver function tests increase more than
three times above normal.
• FDA warning: Increased risk of suicidal behavior or ideation is possible. The FDA has analyzed
suicidality reports from placebo-controlled studies involving 11 anticonvulsants (including
carbamazepine) and found that patients receiving anticonvulsants had approximately twice the
risk of suicidal behavior or ideation (0.43%) of patients receiving placebo (0.22%).
• Teratogenic concerns: Fetal carbamazepine syndrome is possible. Features include epicanthal

folds, short nose, long philtrum, hypoplastic nails, microcephaly, and developmental delay.
Carbamazepine is a pregnancy category D drug.
• Carbamazepine is a CYP3A4, CYP2C9, and CYP2C19 inducer.
• Erythromycin, cimetidine, lithium, and propoxyphene increase the serum concentration or effect
of carbamazepine.
• Phenobarbital, primidone, and phenytoin decrease the anticonvulsant effect of carbamazepine.

• Carbamazepine may increase the serum concentration or effect of felbamate; felbamate will
increase concentrations of the 10,11-epoxide metabolite carbamazepine and cause toxicity.
Commercially available formulations
Table 24-2 shows the commercially available formulations.
[Table 24-2. Dosage Forms, Normal Maintenance Doses, and Dosing Interval for Older
Anticonvulsants]
Patient counseling
See general counseling information. In addition, counsel the patient as follows:
• Shake suspension well.
• Do not store in areas of high humidity (e.g., medicine cabinets).
• Do not use with monoamine oxidase inhibitors.
Ethosuximide
Indications are absence and myoclonic seizures.
Pharmacokinetics
• Bioavailability: Good
• Protein binding: Very low (< 10%)
• Metabolism: 80% hepatically metabolized to three inactive metabolites
• Renal elimination: 50% as metabolites; 10% to 20% as unchanged drug
• Half-life: 30-60 hours
• Reference range: 40-100 mg/L
Side effects
Upon initiation, side effects are nausea, vomiting, dizziness, drowsiness, lethargy, headache, rashes
(including Stevens-Johnson syndrome), and urticaria.
With chronic therapy, anorexia and weight loss, as well as gum hypertrophy, could occur.
ethosuximide) and found that patients receiving anticonvulsants had approximately twice the risk
of suicidal behavior or ideation (0.43%) of patients receiving placebo (0.22%).
• CYP3A3/4 substrate
• Phenytoin, carbamazepine, primidone, and phenobarbital may increase the clearance of

ethosuximide.
• Isoniazid may inhibit metabolism and increase ethosuximide serum concentrations.
See Table 24-2 for commercially available formulations.
Felbamate
Felbamate should be used as adjunctive therapy only in severe refractory partial seizures, with or
without secondary generalization, in patients older than 14 years of age and in partial or generalized
seizures associated with Lennox-Gastaut syndrome.
Pharmacokinetics
• Bioavailability: Complete (> 90%)
• Protein binding: Low (20-25%)
• Metabolism: Hepatic via hydroxylation and conjugation
• Renal elimination: 40-50% excreted unchanged; 40% as inactive metabolites in urine
• Half-life: 20-30 hours; shorter (i.e., 14 hours) with concomitant enzyme-inducing drugs;
prolonged (by 9-15 hours) in renal dysfunction
• Reference range: Not necessary to routinely monitor serum drug concentrations, but dose should
be titrated to clinical response; therapeutic range not fully determined, but some have proposed
30-100 mg/L
Side effects
Upon initiation, nausea and vomiting, anorexia, headache, insomnia, and dizziness may occur.
With chronic therapy, weight loss significant enough to warrant discontinuing the medication is
possible.
Severe or life-threatening side effects are possible:
• FDA black box warning: Direct hepatotoxicity may occur at any time; however, the earliest
onset of severe liver dysfunction occurred 3 weeks after starting felbamate. It is not known if
dose, duration, or use of concomitant medications affects the risk. Most cases require liver
transplantation. Liver enzyme tests and bilirubin should be obtained before initiation and
periodically, and felbamate should be immediately withdrawn if liver function tests become
elevated.
• FDA black box warning: Aplastic anemia can develop at any point without warning. Risk may
be 100-fold greater than the general population. Complete blood count with differential and
platelet count should be taken before, during, and for a significant time after discontinuing
felbamate therapy. Felbamate should be immediately withdrawn if bone marrow suppression
occurs.
• FDA warning: Increased risk of suicidal behavior or ideation may occur. The FDA has analyzed
felbamate) and found that patients receiving anticonvulsants had approximately twice the risk of
suicidal behavior or ideation (0.43%) of patients receiving placebo (0.22%).
• Felbamate induces CYP3A4.
• Felbamate inhibits CYP2C19, epoxide hydroxylase, and -oxidation.
• Carbamazepine, phenobarbital, and phenytoin decrease the anticonvulsant effect of felbamate.
• Phenobarbital, phenytoin, and valproic acid increase the anticonvulsant effect of felbamate.
• Felbamate decreases carbamazepine concentrations but increases the concentration of

carbamazepine epoxide (active metabolite), which may result in carbamazepine toxicity.
• Felbamate increases the serum concentrations of phenobarbital, phenytoin, and valproic acid.
When felbamate is begun, a 20% reduction in phenytoin dose resulted in phenytoin
concentrations comparable to those prior to initiation of felbamate.
See
Table 24-3 for commercially available formulations.
Patient counseling
See general counseling information. In addition, the patient or legal guardian should sign a consent
form before taking this medication. A patient information consent form is included as part of the
package insert and is available from the local representative or by calling 800-526-3840.
Fosphenytoin
Indications are for short-term parenteral administration for generalized convulsive status
epilepticus.
Pharmacokinetics
• Bioavailability: Time for complete conversion to phenytoin is 15 minutes and 30 minutes after
intravenous (IV) and intramuscular (IM) administration, respectively.
• Protein binding: Protein binding is high (95-99% primarily to albumin).
• Metabolism: Each millimole of fosphenytoin is metabolized to 1 millimole of phenytoin,

phosphate, and formaldehyde. Formaldehyde is then converted to formate, which is metabolized
by a folate-dependent mechanism. Conversion increases the dose and infusion rate, most likely
because of a decrease in fosphenytoin protein binding.
• Renal elimination: None.
• Half-life: See the later discussion of phenytoin for the half-life of the active drug.
• Reference range: 10-20 mg/L (phenytoin).
Side effects
Upon initiation, side effects include hypotension (with rapid IV administration), vasodilation,
tachycardia, and bradycardia; burning, pruritus, tingling, and paresthesia (predominately in the
groin area); and rash and exfoliative dermatitis.
Chronic therapy does not result in additional side effects.
fosphenytoin) and found that patients receiving anticonvulsants had approximately twice the risk
• FDA warning: The FDA is investigating the possibility of an increased risk of serious skin
reactions (e.g., Stevens-Johnson syndrome and toxic epidermal necrolysis) in patients given
phenytoin who have the human leukocyte antigen allele HLA-B*1502. This allele occurs almost
exclusively in individuals with ancestry across broad areas of Asia, including Han Chinese,
Filipinos, Malaysians, South Asian Indians, and Thais. Until the FDA evaluation is finalized,
fosphenytoin should be avoided as an alternative for carbamazepine in patients who test positive
for HLA-B*1502.
See the later discussion of phenytoin for drug-drug interactions.
[Table 24-3. Dosage Forms, Normal Maintenance Doses, and Dosing Intervals for the Newer
Anticonvulsants]
Gabapentin
Indications are for adjunctive therapy for partial seizures.
Pharmacokinetics
• Bioavailability: Poor (60% with decreasing absorption as age decreases)
• Metabolism: None
• Renal elimination: 100%
• Half-life: Short (< 12 hours); increases with decreased renal function (anuric patients: 132 hours;
decreased during hemodialysis to about 4 hours)
• Reference range: Routine monitoring of serum concentrations not required; minimum effective
concentration thought to be 2 mg/L
Side effects
Upon initiation, somnolence, dizziness, ataxia, fatigue, and nervousness may occur.
With chronic therapy, weight gain may occur. Neuropsychiatric events (i.e., emotional lability,
hostility, hyperkinesias) are possible in children, especially those with mental retardation and
attention deficit disorders. This problem generally resolves following a reduction in the dose.
gabapentin) and found that patients receiving anticonvulsants had approximately twice the risk of
• No interactions affect metabolism; aluminum-and magnesium-containing antacids may decrease

absorption.
• High protein intake can increase absorption.
• Although it is not a true drug interaction, combination with carbamazepine may cause dizziness.
Reduce the dose of carbamazepine.
Patient counseling
See general counseling information. In addition, the patient should be counseled as follows:
• Food may decrease the extent of absorption.
• If you take antacids, wait at least 2 hours before taking gabapentin.
• Refrigerate oral solution.
Lacosamide
Indications are for adjunctive therapy for partial seizures (> 17 years).
Pharmacokinetics
• Bioavailability: Complete
• Metabolism: None
• Renal: 95% (40% as unchanged drug, 30% as inactive metabolite, 20% as uncharacterized
metabolite)
• Half-life: About 13 hours

Side effects
Upon initiation, nausea and vomiting may occur, as well as dizziness, lack of coordination, and
diplopia.
Severe or life-threatening include increased risk of suicidal behavior or ideation. An FDA warning
has been issued: The FDA has analyzed suicidality reports from placebo-controlled studies
involving 11 anticonvulsants (including lacosamide) and found that patients receiving
anticonvulsants had approximately twice the risk of suicidal behavior or ideation (0.43%) of
patients receiving placebo (0.22%).
Carbamazepine, phenobarbital, and phenytoin may decrease the serum concentration of lacosamide.
Lamotrigine
Lamotrigine is indicated as adjunctive therapy for partial seizures (> 2 years), primary and
secondary generalized tonic-clonic seizures (> 2 years), and seizures associated with Lennox-
Gastaut syndrome. It is also approved for conversion to monotherapy. Although it is used for
absence, atypical absence, atonic, and myoclonic seizures, it is not labeled for these indications.
Pharmacokinetics
• Protein binding: Low (55% to albumin)
• Metabolism: > 75% hepatically metabolized via glucuronidation; autoinduction possible
• Renal: 75-90% excreted as glucuronide metabolites and 10% as unchanged drug
• Half-life: Dependent on patient age and concomitant drug therapy
• Reference range: Proposed serum concentration of 1-5 mg/L, but clinical value of monitoring
concentrations has not been established.
Side effects
Upon initiation, nausea and vomiting, dizziness, sedation, somnolence, and diplopia may occur.
No additional side effects are associated with chronic therapy.
• FDA black box warning: Although rare, toxic epidermal necrolysis has been reported, and
deaths have occurred. The risk of rash may be increased in those receiving valproic acid, large
initial doses, or a rapid increase in dosage. The rash usually appears within 2-8 weeks of therapy
initiation but has been reported after prolonged treatment (e.g., 6 months). Refer the patient to a
physician if signs or symptoms of a rash develop. The physician may suggest holding a single
dose until the rash is evaluated.
lamotrigine) and found that patients receiving anticonvulsants had approximately twice the risk
• Lamotrigine is a weak uridine diphosphate glucuronosyltransferase inducer.
• Valproic acid may increase the serum concentration or effect of lamotrigine.
• Carbamazepine, phenobarbital, phenytoin, and primidone decrease the serum concentration and
effect of lamotrigine.
• Estrogen-containing oral contraceptives may decrease the serum concentration of lamotrigine.
• Lamotrigine may decrease the serum concentration or effect of valproic acid.
• Although not a true drug-drug interaction, the combination with carbamazepine may cause
dizziness. Reduce the dose of carbamazepine.
Patient counseling
See general counseling information. In addition, patients should be counseled to notify their
physician immediately if a skin rash occurs.
Levetiracetam
Levetiracetam is indicated for adjunct for partial, primary generalized, and myoclonic seizures.
Pharmacokinetics
• Metabolism: Not extensive; metabolites not active and renally eliminated
• Renal: Undergoes glomerular filtration and subsequent partial tubular reabsorption; 66% excreted
unchanged and 27% as inactive metabolites
• Half-life: Short (4-8 hours)
• Reference range: Not established; clinical value of monitoring concentrations not established
Side effects
Upon initiation, dizziness, fatigue, and sedation may occur.
No additional side effects occur with chronic therapy.
Severe or life-threatening side effects include increased risk of suicidal behavior or ideation. The
medication carries an FDA warning: The FDA has analyzed suicidality reports from placebo-
controlled studies involving 11 anticonvulsants (including levetiracetam) and found that patients
receiving anticonvulsants had approximately twice the risk of suicidal behavior or ideation (0.43%)
of patients receiving placebo (0.22%).
No significant interactions have been identified.
Oxcarbazepine
Oxcarbazepine is indicated for monotherapy (> 4 years) and adjunct therapy (> 2 years) for partial
seizures.
Pharmacokinetics
• Protein binding: 67% (parent compound); 40%, monohydroxy metabolite (MHD) (primarily to
albumin)
• Metabolism: Extensive to 10-MHD metabolite, which is active
• Renal: > 95%
• Half-life: 2 hours (oxcarbazepine); 9 hours (MHD)
Side effects
Upon initiation, nausea, vomiting, drowsiness, dizziness, and neutropenia (transient) may occur. On
rare instances, a dose-related, transient, and reversible rash causes the drug to be discontinued. The
frequency is less than that with carbamazepine, but cross-hypersensitivity reactions with
carbamazepine may occur in 25% of patients.
With chronic therapy, the following side effects are possible:
• SIADH: This syndrome, causing hyponatremia and water retention, is more common than with
carbamazepine.
• Antiepileptic drug hypersensitivity syndrome: A multiorgan involvement reaction occurs with

rash, lymphadenopathy, fever, abnormal liver function tests, hepatitis, nephritis, oliguria,
hepatorenal syndrome, hematological abnormalities, pruritus, asthenia, or arthralgia.
oxcarbazepine) and found that patients receiving anticonvulsants had approximately twice the
risk of suicidal behavior or ideation (0.43%) of patients receiving placebo (0.22%).
• Oxcarbazepine is an inhibitor of CYP2C19.
• Oxcarbazepine is an inducer of CYP3A4 and CYP3A5.
• Oxcarbazepine increases serum concentrations of phenobarbital and phenytoin.
• Oxcarbazepine may decrease serum concentrations of felodipine, lamotrigine, and oral

contraceptives (i.e., ethinyl estradiol, levonorgestrel).
• Carbamazepine, phenobarbital, phenytoin, and valproic acid may decrease MHD concentrations.

Patient counseling
This medication decreases the effectiveness of birth control pills. Use a supplemental birth control
method to prevent pregnancy while taking oxcarbazepine or contact your physician about a high-
estrogen oral contraceptive.
Phenobarbital
Phenobarbital is indicated for neonatal seizures and generalized seizures (except absence). Other
anticonvulsants are more effective in complex partial seizures.
Pharmacokinetics
• Bioavailability: Good (70-90%)
• Protein binding: Low (30-50%)
• Metabolism: Hepatic via hydroxylation and glucuronide conjugation
• Renal elimination: 20-50% unchanged in urine; increases with alkalinization of the urine
• Half-life: Long (20-400 hours); increasing half-life with decreasing age
Side effects
Upon initiation, drowsiness, dizziness, light-headedness, lack of coordination, headaches, or

nervousness may occur.
• Hyperactivity occurs, primarily in children; however, it rarely necessitates discontinuation of

therapy.
• Lower memory and concentration abilities occur. The medication slightly lowers IQ.
• Folate deficiency may cause megaloblastic anemia.
• Vitamin K-deficient hemorrhagic disease is possible. Administer vitamin K to the mother before
delivery and to the newborn.

• Hepatic failure: Discontinue phenobarbital if liver function tests increase to more than three
times above normal.
• Stevens-Johnson syndrome: Refer the patient to a physician if a rash develops. The physician
may suggest holding a single dose until the rash is evaluated.
• FDA warning: Increased risk of suicidal behavior or ideation are possible. The FDA has analyzed
phenobarbital) and found that patients receiving anticonvulsants had approximately twice the risk
• Teratogenic effects (phenobarbital syndrome): Effects include developmental delay, short

nose, low nasal bridge, low-set ears, wide mouth, protruding lips, and distal digital hypoplasia.
The medication is pregnancy category D.
• Phenobarbital is an inducer of CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP3A4, and

uridine diphosphate glucuronosyltransferase.
• Chloramphenicol, felbamate, ketoconazole, methylphenidate, and valproic acid increase the serum
concentration or effect of phenobarbital.
• Phenytoin decreases the anticonvulsant effect of phenobarbital.
• Phenobarbital may increase the serum concentration or effect of alcohol, caffeine, and monoamine
oxidase inhibitors.
• Phenobarbital may decrease the serum concentration or effect of rifampin, birth control pills,
corticosteroids, cyclophosphamide, cyclosporine, delavirdine, griseofulvin, haloperidol,
lamotrigine, metronidazole, propranolol, quinidine, ritonavir, saquinavir, theophylline, and
warfarin.
Other aspects
Phenobarbital is subject to control under the Federal Controlled Substances Act of 1970 as a
schedule V (C-V) drug.
Patient counseling
See general counseling information. In addition, this medication decreases the effectiveness of birth
control pills. Counsel the patient to use a supplemental birth control method to prevent pregnancy
while taking phenobarbital or contact a physician about a high-estrogen oral contraceptive.
Phenytoin
Phenytoin is indicated for all seizure types except absence and febrile seizures. It is also indicated
for prevention of seizures following neurosurgery. It is frequently used to prevent post-traumatic
epilepsy following head trauma, but is not approved for this indication.
Pharmacokinetics
• Bioavailability: Slow, variable, and formulation dependent; decreased in children
• Protein binding: Very high (90-95%); increased free fraction in neonates
• Metabolism: Hepatic
• Renal elimination: Low (< 5%)
• Half-life: Exhibits capacity-limited or saturable pharmacokinetics (i.e., Michaelis-Menten) and

does not technically have a half-life
Side effects
Upon initiation, nausea, vomiting, drowsiness, and dizziness may occur.
• Peripheral neuropathy may occur.
• Hydantoin facies (thickening of subcutaneous tissues, enlargement of nose and lips) is possible.
• Acne, hirsutism, and gingival hyperplasia may occur. Suggest good oral hygiene.
• Osteomalacia may occur. Treat with vitamin D if alkaline phosphatase increases and 25-
hydroxycholecalciferol decreases.
• Vitamin K-deficient hemorrhagic disease is possible. Administer vitamin K to the mother before
delivery and to the newborn.
• Folate deficiency may cause megaloblastic anemia.
Severe or life-threatening side effects are as follows:

• Hepatic failure: Discontinue if liver function tests increase more than three times above normal.
• Stevens-Johnson syndrome: Refer the patient to a physician if signs or symptoms of a rash

develop. The physician may suggest holding a single dose until the rash is evaluated.
• FDA warning: The FDA is investigating the possibility of an increased risk of serious skin
reactions (e.g., Stevens-Johnson syndrome and toxic epidermal necrolysis) in patients given
phenytoin who have the human leukocyte antigen allele HLA-B*1502. This allele occurs almost
exclusively in individuals with ancestry across broad areas of Asia, including Han Chinese,
Filipinos, Malaysians, South Asian Indians, and Thais. Until the FDA evaluation is finalized,
phenytoin should be avoided as an alternative for carbamazepine in patients who test positive for
HLA-B*1502.
phenytoin) and found that patients receiving anticonvulsants had approximately twice the risk of
• Teratogenic effects (fetal hydantoin syndrome): Features include craniofacial anomalies, broad
nasal bridges, short upturned noses, low-set and prominent ears, distal digital hypoplasia, and
intrauterine growth restriction. The medication is pregnancy category D.
• Phenytoin induces CYP2C19, UTG.
• Phenytoin inhibits CYP2C9.
• Phenytoin displaces some drugs from albumin binding sites.
• Acute alcohol use; amiodarone; chloramphenicol; chlordiazepoxide; diazepam; disulfiram;

estrogens; felbamate; histamine antagonists (e.g., cimetidine); halothane; isoniazid;
methylphenidate; phenothiazines; phenylbutazone; salicylates; succinimides; sulfonamides
(sulfadiazine, sulfamethoxazole, and sulfisoxazole); tolbutamide; trazodone; warfarin; and
zidovudine increase the serum concentration or effect of phenytoin.
• Antacids, bleomycin, cisplatin, nevirapine, rifampin, ritonavir, vinblastine, zidovudine, and some
herbals (i.e., shankhapushpi, kava kava, and valerian) decrease the effect of phenytoin.
• Phenytoin may increase the serum concentration or effect of valproic acid.
• Phenytoin may decrease the serum concentration or effect of phenobarbital.
Drug-nutrient interactions
Patients receiving tube feedings and oral phenytoin at the same time may have a significant
decrease in absorption of phenytoin. If possible, discontinue feeding 2 hours before and after a dose
of phenytoin.
Patient counseling
• Do not break, crush, or chew capsule before swallowing; swallow whole.
• Shake suspension well.
• This medication may alter your gums. Brush and floss daily, and have regular visits with your
dentist.
Pregabalin
Pregabalin is indicated for adjunctive therapy in partial seizures.
Side effects
Upon initiation, nausea, vomiting, dizziness, drowsiness, and lethargy may occur.
With chronic therapy, increased appetite and weight gain are possible.
Severe or life-threatening side effects may occur:
• Angioedema: There is some risk of angioedema (e.g., swelling of the face, tongue, lips, gums,
and throat or larynx), with or without life-threatening respiratory compromise.
pregabalin) and found that patients receiving anticonvulsants had approximately twice the risk of
No known interactions.
Other aspects
Pregabalin is subject to control under the Federal Controlled Substances Act of 1970 as a schedule
V (C-V) drug.
Primidone
Primidone is indicated for generalized tonic-clonic, complex partial, and simple partial seizures.
Pharmacokinetics
• Bioavailability: 60-80%
• Protein binding: High (99%)
• Metabolism: Hepatically metabolized to phenobarbital (active) and phenylethylmalonamide

(PEMA)
• Renal elimination: Urinary excretion of active metabolites and 15-25% unchanged primidone
• Half-life: Primidone,10-12 hours for primidone; PEMA, 16 hours; phenobarbital, age dependent
(20-400 hours)
• Reference range: 5-12 mg/L for primidone; 15-45 mg/L for phenobarbital
Side effects
Upon initiation, nausea, vomiting, dizziness, drowsiness, and lethargy may occur.
With chronic therapy, malignant lymphoma-like syndrome, megaloblastic anemia, and systemic
lupus-like syndrome are possible.
primidone and phenobarbital) and found that patients receiving anticonvulsants had
approximately twice the risk of suicidal behavior or ideation (0.43%) of patients receiving
placebo (0.22%).
• Primidone is an inducer of CYP1A2, CYP2B6, CYP2C, CYP2C8, CYP3A3/4, and CYP3A5-7.

• Primidone may decrease serum concentrations of ethosuximide, valproic acid, and griseofulvin.
• Methylphenidate may increase primidone serum concentrations.
• Phenytoin may decrease primidone serum concentrations.
Tiagabine
Tiagabine is indicated for adjunctive therapy in the treatment of partial seizures.
Pharmacokinetics
• Bioavailability: Complete (> 95%)
• Protein binding: High (96%, mainly to albumin and alpha1-acid glycoprotein)
• Metabolism: Hepatic via oxidation and glucuronidation; undergoes enterohepatic recirculation
• Renal: Low (about 2% excreted unchanged in urine)
• Reference range: Not established
Side effects
Upon initiation, nausea and vomiting, somnolence, impaired concentration, confusion, ataxia, and
speech and language problems may occur.
No additional side effects have been associated with chronic therapy to date.
tiagabine) and found that patients receiving anticonvulsants had approximately twice the risk of
• Tiagabine is a CYP3A substrate and may also be metabolized by CYP1A2, 2D6, or 2C19.
• Valproic acid may increase the serum concentration or effect of tiagabine.

• Carbamazepine, phenobarbital, primidone, and phenytoin may decrease the anticonvulsant effect
of tiagabine.
• Tiagabine may decrease the serum concentration or effect of valproic acid.
Topiramate
Topiramate is indicated for initial monotherapy (> 10 years of age) for partial onset seizures or
primary generalized tonic-clonic seizures and for adjunctive therapy for patients (2-16 years) with
partial onset seizures or primary generalized tonic-clonic seizures. It is also indicated for seizures
associated with Lennox-Gastaut syndrome (> 2 years).
Pharmacokinetics
• Bioavailability: 80%
• Protein binding: 15-41%
• Metabolism: Minor hepatic (via hydroxylation, hydrolysis, and glucuronidation)
• Elimination: 70% excreted unchanged in urine; may undergo renal tubular reabsorption
• Half-life: About 20 hours
• Reference range: Not established; clinical value of monitoring concentrations not established
Side effects
Upon initiation, drowsiness, dizziness, difficulty with concentration, loss of appetite, mood
changes, and paresthesias may occur.
• Hyperchloremic metabolic acidosis
• Acute myopia and secondary angle closure glaucoma
• Kidney stones (caution patient that adequate hydration may reduce stone formation)
• Paresthesia
• Word finding difficulties and decreased cognition (dose related)
• Significant weight loss
Severe or life-threatening side effects are as follows:
• Oligohidrosis: Children taking topiramate may not adequately sweat when overheated and could
develop hyperthermia and heat stroke. Caution the parent to assess the child's ability to sweat, to
be cautious about the child getting overheated, and to have the child drink plenty of water.
topiramate) and found that patients receiving anticonvulsants had approximately twice the risk of
• Topiramate induces -oxidation.
• Topiramate inhibits CYP2C19.
• CNS depressants (alcohol, morphine, codeine) and carbonic anhydrase inhibitors (acetazolamide)
may increase the serum concentration or effect of topiramate.
• Phenobarbital, phenytoin, and valproic acid may decrease the anticonvulsant effect of topiramate.
• Topiramate may increase the serum concentration or effect of metformin.
• Topiramate may decrease the serum concentration or effect of oral contraceptives and valproic
acid.
Patient counseling
• If using the Topamax sprinkle capsule, sprinkle the contents on a small amount of cool, soft food
(e.g., applesauce or yogurt) and swallow immediately without chewing.
• Drink plenty of fluids to avoid kidney stones.

• Confirm that children in hot climates can sweat.
Valproic Acid
Valproic acid is used for all types of generalized and partial seizures; along with ethosuximide, it is
the drug of choice for absence seizures. It is rarely used in children < 2 years of age.
Pharmacokinetics
• Protein binding: High (80-90%; dose dependent)
• Metabolism: Extensive via hepatic glucuronide conjugation and oxidation
• Renal: Low (2-3% unchanged in urine)
• Reference range: 50-150 mg/L (curvilinear relationship between serum concentration and protein
binding)
Side effects
Upon initiation, nausea and vomiting may occur.
• Weight gain: This side effect is at times significant enough to warrant discontinuing the
medication.
• Alopecia: Effects may be partial or total. To prevent or treat alopecia, supplement with zinc and
selenium.
• Tremor: This effect is dose dependent. Treat it by decreasing the dose, discontinuing the drug, or
adding propranolol.
• Thrombocytopenia: A dose-dependent decrease in platelets may occur.
• Elevation in liver enzymes: This side effect may be transient and responds to discontinuation of
valproic acid.
• FDA black box warning: Fatal hepatotoxicity is possible. It is most common in children < 2
years of age who have severe epilepsy and are receiving multiple anticonvulsants.
• FDA black box warning: Fatal hemorrhagic pancreatitis may occur.
• FDA black box warning: Fetal valproate syndrome may occur. Features include craniofacial
anomalies, small inverted noses, shallow philtrum, flat nasal bridge, long upper lip, congenital
liver disease, and spina bifida. This medication is pregnancy category D.
valproic acid) and found that patients receiving anticonvulsants had approximately twice the risk
• Valproic acid inhibits CYP2C9, CYP 2C19, uridine diphosphate glucuronosyltransferase, epoxide
hydroxylase, and ²-oxidation.
• It displaces some drugs from albumin binding sites.
• Felbamate, phenytoin, and salicylates increase the serum concentration or effect of valproic acid.
• Carbamazepine, felbamate, lamotrigine, phenytoin, phenobarbital, and primidone decrease the

anticonvulsant effect of valproic acid.
• Valproic acid may increase the serum concentration or effect of amitriptyline, carbamazepine,
ethosuximide, felbamate, lamotrigine, phenobarbital, primidone, and zidovudine.
• Valproic acid may decrease the serum concentration or effect of phenytoin.
Patient counseling
See general counseling information. Patients should also be counseled as follows:
• You may take this medication with food or milk to reduce stomach irritation. Do not take with
carbonated drinks.
• Swallow valproic acid capsules whole with water only; do not break, chew, or crush.
• Swallow divalproex sodium delayed-released capsules whole or sprinkle the contents on a small
amount of cool, soft food (e.g., applesauce or pudding) and swallow without chewing
immediately after preparation.
• Swallow divalproex sodium delayed-release tablets whole; do not break, chew, or crush.
• You may mix valproic acid syrup with any liquid or add it to a small amount of food.
• Report any sore throat, fever, fatigue, bleeding, or bruising that is severe or persists to your
physician.
• Your doctor may monitor your liver function with blood tests every 1-2 weeks initially and
periodically thereafter.
Vigabatrin
Vigabatrin is indicated for infantile spasms; it is adjunctive therapy for complex partial seizures.
Pharmacokinetics
• Protein binding: Low
• Metabolism: Minimal
• Renal: 80% (unchanged)
Side effects
Upon initiation, fatigue, headache, drowsiness, dizziness, tremor, or agitation. Hyperactivity (e.g.,
hyperkinesia, agitation, excitation, or restlessness) has been reported in children.
With chronic therapy, permanent decrease in peripheral vision may occur. However, there is no
effect on central vision or color.
vigabitrin) and found that patients receiving anticonvulsants had approximately twice the risk of
• FDA black box warning: Medication may cause permanent vision loss in infants, children, and
adults. Due to the risk of vision loss and because vigabatrin provides an observable symptomatic
benefit when it is effective, the patient who fails to show substantial benefit within a short period
of time after initiation of treatment (2-4 weeks for infantile spasms; < 3 months in adults) should
be withdrawn from therapy. If in the clinical judgment of the prescriber evidence of treatment
failure becomes obvious earlier in treatment, vigabatrin should be discontinued at that time.
Patient counseling
See general counseling information. In addition, counsel patients to notify their physician of any
change in vision.
Zonisamide
Zonisamide is indicated for partial seizures.
Pharmacokinetics
• Protein binding: Low (40%)
• Metabolism: Undergoes acetylation and subsequent conjugation with glucuronide in the liver
• Renal elimination: 62% (35% as unchanged)
• Reference range: proposed therapeutic range, 10-20 mg/L; concentrations > 30 mg/L associated
with adverse effects
Side effects
With chronic therapy, side effects are very similar to those of topiramate:
• Kidney stones (contraindicated in patients with a history of kidney stones; should be adequately
hydrated)
• Weight loss
• Reversible or irreversible psychosis (rare)
Severe or life-threatening side effects may occur:
• Oligohidrosis: The medication carries an FDA warning. Children taking zonisamide may not
sweat as needed and could develop hyperthermia. Warn parents of the need to be aware of
children getting overheated and to have them drink plenty of water.
• FDA warning: Zonisamide may cause a dose-dependent metabolic acidosis, which has
occurred at doses as small as 25 mg/d. Metabolic acidosis is usually asymptomatic; however,
chronic untreated metabolic acidosis may result in decreased growth rates in children, as well
as decreased fetal growth and fetal death following exposure during pregnancy. The FDA is
now recommending a serum bicarbonate level prior to initiation and periodically during
therapy. If metabolic acidosis develops, consider decreasing the dose or discontinuing use with
appropriate dose tapering.
• FDA warning: Increased risk of suicidal behavior or ideation may occur. The FDA has
analyzed suicidality reports from placebo-controlled studies involving 11 anticonvulsants
(including zonisamide) and found that patients receiving anticonvulsants had approximately
twice the risk of suicidal behavior or ideation (0.43%) of patients receiving placebo (0.22%).
• Other: Zonisamide is a sulfonamide. Life-threatening sulfonamide reactions may occur (e.g.,

Stevens-Johnson syndrome, toxic epidermal necrolysis, aplastic anemia, agranulocytosis, and
fulminant hepatic necrosis).
• Zonisamide is a CYP3A4 substrate.
• Carbamazepine, phenobarbital, phenytoin, and valproic acid decrease the effect of zonisamide.
• Lamotrigine may inhibit the clearance of zonisamide and increase zonisamide serum
concentrations.
Patient counseling
• Notify your pharmacist or physician if you are allergic to sulfa medications.
• Drink plenty of fluids to help prevent kidney stones.
• Contact your doctor if your child is not sweating as usual.
24-3. Other Issues
Nondrug Treatment of Epilepsy

Nondrug treatments are as follows:
• Ketogenic diet
• Vagal nerve stimulator
• Surgical correction
Withdrawal of Anticonvulsants
Over half of patients who remain seizure free for 2 years can have their anticonvulsant successfully
withdrawn. Most who are seizure free for 4 years can be successfully withdrawn from
anticonvulsants.
Unless the patient is experiencing a severe or life-threatening adverse effect, never abruptly
discontinue an anticonvulsant; taper slowly over 2-6 months.
Status Epilepticus
Status epilepticus is defined as a seizure that lasts longer than 5 minutes or two or more discrete
seizures between which there is incomplete recovery of consciousness. It is a medical emergency.
See
Table 24-4 for suggested order of therapies.
Benzodiazepines
Benzodiazepines are first-line agents. Diazepam or lorazepam are preferred.
Hydantoin (phenytoin or fosphenytoin)
Phenytoin (intravenous)
Phenytoin can only be mixed with normal saline.
If an individual is not already receiving phenytoin, give a loading dose of 15-20 mg/kg. Because
phenytoin contains propylene glycol and is in itself cardiotoxic, do not infuse faster than 50
mg/minute.
If the maintenance dose is to be given every 12 hours, give the first dose 12 hours after the end of
the loading dose. If the maintenance dose is to be given every 24 hours, give the first dose 24 hours
after the end of the loading dose.
The alkaline pH of phenytoin precludes IM administration.
Fosphenytoin
Fosphenytoin is a phenytoin prodrug that is converted to phenytoin within minutes after infusion. It
can be admixed with any IV solution.
Fosphenytoin must be dosed in PE (phenytoin equivalents): 1 mg of phenytoin = 1.5 mg of

fosphenytoin. It can be given at a rate of 150 mg/min (three times faster than phenytoin).
Phenobarbital
Phenobarbital may cause respiratory depression or arrest. The likelihood of such an effect may be
increased if benzodiazepines have been given.
Phenobarbital-induced sedation may eliminate the ability to perform an accurate neurologic

assessment.
[Table 24-4. Treatment of Status Epilepticus]
Because phenobarbital contains propylene glycol and is cardiotoxic, do not infuse faster than 60
mg/min in adults and 30 mg/min in children.
Midazolam
Because of midazolam's very short half-life, the loading dose should be followed by continuous
infusion.
Medically induced coma
Medically induced coma is used for severe refractory status epilepticus. It is usually achieved with
pentobarbital.
Give a loading dose (20-40 mg/kg) over 1-2 hours, followed by continuous infusion (1-4 mg/kg/hr).
If hypotension occurs, begin dopamine or slow the rate of infusion.
Titrate to burst suppression (isoelectric) on EEG.
Other therapies used for refractory status epilepticus
• Propofol
• Newer anticonvulsants (IV: levetiracetam; oral: topiramate)
• Magnesium
• Lidocaine
• IV immune globulin
Febrile Seizures
A febrile seizure is a benign seizure that occurs in the absence of CNS infection in a child with
fever. It is the most common seizure disorder in childhood. The age of onset is 4 months to 5 years
(peaks at 14-18 months).
A child is at risk if he or she has two of the following risk factors:
• A first- or second-degree relative with a history of a febrile seizure
• Developmental delay
• Delayed discharge (> 28 days) from a newborn center
• Day care attendance
Overall, the development of epilepsy in children who have experienced such seizures is rare (1-
2%). However, about 15% of children who have complex febrile seizures (as defined below) will
go on to develop epilepsy.
There are two types of febrile seizures:
• Simple febrile seizure:
• Benign
• A primary generalized seizure
• Less than 15 minutes in duration
• Does not recur within 24 hours
• Complex febrile seizure:
• Focal (involves an arm, leg, or face on one side only or eye deviation toward one side)
• Prolonged (> 15 minutes) or recurring within 24 hours of the initial seizure
Acute treatment of a simple or complex febrile seizure
Drugs of choice for prolonged febrile seizure are rectally administered benzodiazepines (rectal
diazepam or lorazepam). Diastat is a commercially available gel of diazepam to be given rectally.
Prophylaxis for a simple or complex febrile seizure

If temperature is > 38C°, give the patient a nonaspirin antipyretic.
Daily anticonvulsants are not indicated for the prevention of recurrent febrile seizures.
Maintenance therapy
Maintenance therapy is not generally used. However, an anticonvulsant (i.e., phenobarbital) may be
considered after a complex febrile seizure if epilepsy is suspected.
Carbamazepine and phenytoin are not effective in the prevention of recurrent febrile seizures.
24-4. Key Points
• Phenytoin can be mixed only with normal saline and should not be given faster than 50 mg/min.
• Gabapentin and levetiracetam are not associated with any significant drug interactions.
• As of September 2009, the following anticonvulsants carry a U.S. black box warning:
carbamazepine (aplastic anemia, dermatologic reactions); valproic acid (liver failure,
teratogenicity, pancreatitis); felbamate (aplastic anemia, hepatic failure); and lamotrigine (serious
rash). FDA warnings have been given for Zonisamide and topiramate, which have been reported
to cause oligohidrosis and hyperthermia. The FDA has found that 11 of the anticonvulsants are
associated with an increased risk of suicidal behavior or ideation.
• Although absence seizures are frequently treated with ethosuximide or valproic acid (if 2 years
of age), lamotrigine and topiramate are also used.
• Carbapenems (e.g., imipenem) and normeperidine (a metabolite of meperidine that accumulates in

renal failure) may cause seizures.
• Carbamazepine undergoes autoinduction (i.e., it induces its own metabolism), and phenytoin has
capacity-limited or saturable (i.e., Michaelis-Menten) pharmacokinetics.
• Because of the potential for severe life-threatening liver toxicity, valproic acid is generally not
used in a patient < 2 years of age.
• There may be an association between folic acid deficiency and spina bifida; hence, all women
with epilepsy who are of childbearing age should be on daily folic acid (1 mg).
• Unless a patient is experiencing a life-threatening adverse effect, an anticonvulsant should not be

abruptly discontinued.
• Topiramate may cause significant weight loss, and valproic acid may cause significant weight
gain.
• Topiramate and zonisamide may cause kidney stones.
• Patients with an allergy to sulfa medications should not be given zonisamide.
24-5. Questions
Which of the following is true regarding phenytoin?
A. The maximum rate of intravenous administration is 50 mg/min.

B. If intravenous access cannot be established, phenytoin can be given IM.
1.
C. Because phenytoin contains propylene glycol, it is soluble as any IV fluid.
D. It is an inhibitor of the cytochrome P450 system.
E. A major limitation to the use of the product in pediatric patients is the lack of a
commercially available liquid formulation.

A 50 kg patient with no history of epilepsy presents in status epilepticus. The patient is given
an adequate dose of lorazepam and is about to be given a loading dose of intravenous
phenytoin. Assuming a phenytoin Vd of 0.6 L/kg, what dose of phenytoin should be given to
achieve a serum phenytoin concentration of ~ 16-18 mg/L?
2.
A. 18 mg/kg
B. 500 mg
C. 30 mg/kg
D. 50 mg
E. 5 g

Which of the following is true regarding a patient with refractory status epilepticus who is
placed in a medically induced coma with a barbiturate?
A. If the patient is mechanically ventilated, the barbiturates will induce respiratory arrest.
3. B. The goal of a coma that is medically induced with a barbiturate is to induce burst
suppression (isoelectric) on EEG.
C. If hypotension develops, the patient should be given nitroprusside.
D. The barbiturates are not associated with drug interactions.
E. A major problem with this type of therapy is kidney failure.

Which of the following is associated with autoinduction?
A. Phenobarbital
4. B. Phenytoin
C. Carbamazepine
D. Gabapentin
E. Levetiracetam

Which of these agents reduces the likelihood of congenital malformations in epileptic women
receiving valproate?
A. Folic acid
5.
B. Vitamin B12
C. Ginkgo biloba
D. Iron
E. Selenium

A 33-year-old woman is being started on an anticonvulsant. She is already slightly overweight
and is very concerned about the effects of the various medications on her weight. Which of the
following is (are) true regarding anticonvulsants and their effect on weight?
I. Valproic acid increases weight.

II. Topiramate decreases weight.
6. III. Phenytoin increases weight.
A. I
B. I and II
C. II
D. III
E. I, II, and III

A 24-year-old woman has complex partial seizures that are currently controlled with valproic
acid, gabapentin, and topiramate. She calls your pharmacy to ask if any of her medications can
cause nosebleeds since she has had one or two in the past week. You refer her to her local
medical doctor, where her platelet count is reported to be 95,132/mm3. Which of the following
is true?
7.
A. None of her anticonvulsants cause thrombocytopenia.
B. Valproate can cause a dose-related thrombocytopenia.
C. Gabapentin has inhibited the metabolism of topiramate, and the elevated concentration of
topiramate is responsible for the thrombocytopenia.
D. Gabapentin can cause idiosyncratic thrombocytopenia.
E. Topiramate can cause thrombocytopenia.

A patient has hypertension, diabetes mellitus, and chronic renal failure (serum Cr = 6.8), and
has developed seizures. Which of the following anticonvulsants would require dosage
adjustment in this patient?
8. A. Gabapentin, topiramate
B. Lamotrigine, felbamate
C. Phenobarbital, gabapentin
D. Phenytoin, valproic acid
E. Phenobarbital, levetiracetam

Which of the following anticonvulsants is metabolized to phenobarbital?
A. Ethosuximide
9. B. Primidone
C. Zonisamide
D. Levetiracetam
E. Carbamazepine

A 7-year-old boy on valproic acid for partial complex seizures with secondary generalization
that are refractory to phenobarbital, phenytoin, carbamazepine, and gabapentin continued to
have seizures and was started on lamotrigine 2 weeks ago. Today he presents with a diffuse
maculopapular erythematous rash with lesions on the lips. Which of the following is correct?
A. A rash associated with lamotrigine generally occurs within the first few days; hence, the
10. rash is not associated with an anticonvulsant.
B. The patient should be given diphenhydramine, and lamotrigine should be continued.
C. Lamotrigine should be discontinued.
D. The rash is secondary to a drug interaction between gabapentin and carbamazepine.
E. All of the anticonvulsants are associated with life-threatening rash. To prevent status
epilepticus associated with abrupt discontinuation of the anticonvulsants, the medications
should be slowly discontinued.

A new anticonvulsant has just been approved by the FDA. Its bioavailability is > 95%, and it is
highly protein bound to ±1-acid glycoprotein. It undergoes extensive hepatic metabolism by
CYP450 2C9. Less than 5% is excreted unchanged in the urine. It is known to inhibit CYP450
3A4. A patient on this anticonvulsant has developed significant depression and is being started
on an antidepressant that is 93% bound to albumin and is a potent inhibitor of CYP450 2C19.
The antidepressant is metabolized by CYP450 3A4 to an active metabolite that is hepatically
cleared by CYP450 2C9. The neurologist wants to know if any drug interactions may occur
that would necessitate a reduction in drug dosage.
11.
A. No drug interactions should occur in this patient.
B. The dose of the anticonvulsant should be reduced because of a potential protein binding
interaction that would increase the serum concentration of the anticonvulsant.
C. The dose of the anticonvulsant should be increased.
D. The dose of the antidepressant should be reduced.
E. Because of an interaction in the gut that decreases bioavailability, the dose should be
increased.

Which of the following is (are) not associated with any drug-drug interactions?
I. Gabapentin
II. Carbamazepine
III. Levetiracetam
12.
A. I
B. II
C. I and III
D. II and III
E. I and II
F. III

A 42-year-old woman has been successfully treated with valproic acid for years, but she has
experienced some undesirable side effects. She is slowly titrated onto a new anticonvulsant,
and the valproic acid is slowly discontinued. She presents to the emergency department with
severe flank pain and is diagnosed with a kidney stone. Which of the following may have
precipitated her current situation?
13.
A. Gabapentin
B. Lamotrigine
C. Levetiracetam
D. Topiramate
E. Phenytoin

Which of the following drugs carries (carry) a black box warning?
I. Carbamazepine
II. Felbamate
III. Levetiracetam
14.
A. II
B. III
C. I
D. I and II
E. II and III

Which of the following carries a black box warning for pancreatitis?
A. Carbamazepine
15. B. Felbamate
C. Zonisamide
D. Valproic acid
E. Phenytoin

What is the drug of choice for absence seizures in a child < 2 years of age?
A. Phenytoin
16. B. Phenobarbital
C. Ethosuximide
D. Valproic acid
E. Primidone

Diastat is given by which of the following routes?
A. Rectally
17. B. Intramuscularly
C. Intravenously
D. Intranasally
E. Subcutaneously

Which of the following is true?
A. Febrile seizures must be accompanied by a CNS infection.

18. B. Complex febrile seizures last > 15 minutes.
C. Most children who have a febrile seizure go on to develop epilepsy.
D. The drug of choice for a simple febrile seizure is carbamazepine.
E. Simple febrile seizures should never be treated.

Which of the following anticonvulsants is (are) available in a liquid, chewable tablet, and
intravenous formulation?
I. Carbamazepine
II. Phenytoin
III. Valproic acid
19.
A. II
B. III
C. I
D. I and II
E. I, II, and III

Patients should be told to drink plenty of fluid when taking which of the following?
A. Carbamazepine
20. B. Topiramate
C. Levetiracetam
D. Gabapentin
E. Phenytoin

Which of the following medications may cause seizures in an adult patient with renal failure?
A. Meperidine
21. B. Phenobarbital
C. Carbamazepine
D. Lamotrigine
E. Theophylline

Which of the following is associated with Michaelis-Menten pharmacokinetics?
A. Carbamazepine
22. B. Valproic acid
C. Topiramate
D. Phenytoin
E. Phenobarbital

A patient on which of the following medications should be made aware of the importance of
good oral hygiene?
A. Felbamate
23.
B. Phenytoin
C. Zonisamide
D. Phenobarbital
E. Levetiracetam

24-6. Answers
A. Because phenytoin contains propylene glycol and is itself cardiotoxic, the IV formulation
should not be infused faster than 50 mg/min. Phenytoin is extremely alkaline (pH ~ 13). Not
1. only is IM administration associated with tissue damage, it is erratically absorbed. Phenytoin
can be admixed only with normal saline, is an inducer, and is also available as a suspension
and a chewable tablet.

B. The equation for calculation of a loading dose is as follows: Dose = Cp (serum
2. concentration) desired × Vd (volume of distribution). So Cp desired is ~ 17 × (0.6 L/kg × 50
kg) 510 mg.

B. The goal is to produce a "flat" EEG. If the patient is mechanically ventilated, the effect of a
medication on respiration is not a factor in its administration. Although pentobarbital may
3. cause hypotension if given too rapidly, nitroprusside is a vasodilator used to treat hypertension.
The barbiturates are known inducers. Coma that is medically induced with a barbiturate does
not cause kidney failure.

C. Carbamazepine induces its own metabolism, with peak effects seen about 21 days after
4. beginning the medication or following an increase in dosage. Phenobarbital and phenytoin are
inducers. Gabapentin and levetiracetam are not cleared hepatically.

A. Many of the anticonvulsants can cause folic acid deficiency. An association exists between
5. folic acid deficiency and spina bifida; hence, all women with epilepsy who are of childbearing
age should receive supplemental folic acid every day (1 mg).

B. Topiramate can cause significant weight loss, and valproate can cause significant weight
6.
gain. Phenytoin does not significantly affect weight.

B. Valproic acid can cause clinically significant thrombocytopenia. Gabapentin is not
7. associated with any drug interaction that affects metabolism, and it does not cause a decrease
in platelets. Topiramate does not cause thrombocytopenia.

A. Gabapentin and topiramate would require dosage adjustment because they are renally
8.
eliminated.

B. Primidone (Mysoline) is an active anticonvulsant, but it is also metabolized to
9.
phenobarbital.

C. Lamotrigine has a black box warning for severe rash. Because this patient has a diffuse rash
and lesions on the lips, lamotrigine should be discontinued. Because the incidence of severe
rash may be higher in children than in adults, current practice would be to discontinue
lamotrigine and not "treat through" the rash with diphenhydramine. Gabapentin does not
10.
interact with lamotrigine. However, the combination of valproic acid and lamotrigine is
associated with a higher incidence of rash. Although abrupt discontinuation of an
anticonvulsant may induce status epilepticus, an anticonvulsant may be abruptly discontinued
in the face of a life-threatening event.

D is correct because the new anticonvulsant inhibits CYP450 3A4 and the antidepressant is
11.
metabolized by this enzyme.

C. At this time, neither gabapentin nor levetiracetam is associated with significant drug-drug
interactions. The absorption of gabapentin may be reduced by concurrent administration of
12. aluminum- or magnesium-containing antacids; hence, antacids should be given 2 hours before
or after a dose of gabapentin. Carbamazepine is an inducer that is associated with numerous
drug-drug interactions.

D. Both topiramate and zonisamide may cause kidney stones. Although neither agent is
contraindicated in an individual with a history of kidney stones, these drugs should be used
13.
cautiously in such patients. Patients should be counseled to remain adequately hydrated
because doing so may decrease the risk of stone formation.

D. Both carbamazepine and felbamate are associated with aplastic anemia and hepatic failure.
14.
Levetiracetam has no black box warning.

15. D. Valproic acid may cause fatal hemorrhagic pancreatitis.

C. Although valproic acid is extremely effective and is frequently used as monotherapy for
16.
absence seizures, it should not be given to a patient < 2 years of age.

17. A. Diastat is a commercially available gel form of diazepam that is given rectally.

B. Unlike simple febrile seizures, which last a brief period, complex febrile seizures are
prolonged (> 15 minutes) or recur within 24 hours of the initial seizure. Febrile seizures must
18.
occur in the absence of CNS infection in a child with fever. Most febrile seizures are benign,
and children do not go on to develop epilepsy. Carbamazepine is ineffective in febrile seizures.

A. Only phenytoin is available as a liquid (125 mg/5 mL), as a chewable tablet (50 mg), and in
19. an intravenous dosage form. Carbamazepine is not available in an IV dosage form, and
valproic acid is not available as a chewable tablet.

B. Because topiramate may cause kidney stones, patients should be encouraged to drink plenty
20.
of fluids. This would also be true for zonisamide.

A. Normeperidine, a metabolite of meperidine, can accumulate in patients with renal failure
21. who receive normal doses and cause seizures. The other agents listed are not eliminated renally
in adults.

22. D. Phenytoin has capacity-limited or saturable (i.e., Michaelis-Menten) pharmacokinetics.

B. Phenytoin may cause gingival hyperplasia (i.e., overgrowth of the gums). Hence, patients
23.
should be instructed to brush and floss daily and to have regular visits with the dentist.
24-7. References

24-7. References
American Academy of Neurology, Quality Standards Subcommittee. Practice parameter: A

guideline for discontinuing antiepileptic drugs in seizure-free patients—summary statement.
Neurology. 1996;47:600-2.
Anderson GD. A mechanistic approach to antiepileptic drug interactions. Ann Pharmacother.

1998;32: 554-63.
Baumann RJ, Duffner PK. Treatment of children with simple febrile seizures: The AAP practice
parameter. Pediatr Neurol. 2000;23:11-17.
Brunbech L, Sabers A. Effect of antiepileptic drugs on cognitive function in individuals with

epilepsy: A comparative review of newer versus older agents. Drugs. 2002;62:593-604.
Carroll MC, Yueng-Yue KA, Esterly NB, et al. Drug-induced hypersensitivity syndrome in
pediatric patients. Pediatrics. 2001;108:485-92.
Commission on Antiepileptic Drugs, International League against Epilepsy. Guidelines for

therapeutic monitoring on antiepileptic drugs. Epilepsia. 1993;34:585-87.
Deckers CL, Knoester PD, de Haan GJ, et al. Selection criteria for the clinical use of the newer
antiepileptic drugs. CNS Drugs. 2003;17:405-21.
Johannessen SI, Battino D, Berry DJ, et al. Therapeutic drug monitoring of the newer antiepileptic
drugs. Ther Drug Monit. 2003;25:347-463.
Perucca E. The clinical pharmacokinetics of the new antiepileptic drugs. Epilepsia. 1999;40(suppl
9): S7-13.
Working Group on Status Epilepticus. Treatment of convulsive status epilepticus:

Recommendations of the Epilepsy Foundation of America's Working Group on Status
Epilepticus. JAMA. 1993;270: 854-59.
25. Psychiatric Disease - Jason Carter, PharmD
25-1. Axis Diagnosis
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the
American Psychiatric Association organizes psychiatric diagnoses into five axes:
I. Clinical disorders
II. Personality disorders and mental retardation
III. General medical conditions
IV. Psychosocial and environmental problems
V. Global assessment of functioning
25-2. Schizophrenia
Introduction
Schizophrenia is a psychiatric disorder characterized by a profound disruption in perception,

cognition, and emotion.
Epidemiology
Approximately 1% of the U.S. adult population has schizophrenia. There are 200,000 new cases
reported yearly.
No gender or racial differences exist. Onset is earlier in males (average age, 18-24 years) than in
females (average age, late 20s to early 40s).
Paranoid
Paranoid schizophrenia is characterized by prominent preoccupation with hallucinations (usually

auditory) and one or more delusions.
Disorganized
Disorganized schizophrenia is characterized by disorganized speech and behavior, as well as

blunted, flat, or inappropriate affect.
Catatonic
With catatonic schizophrenia, psychomotor disturbances are present that may involve catalepsy or
stupor, excessive motor activity, rigid posture, mutism, peculiar or repetitive movements, and
echolalia or echopraxia.
Undifferentiated
With undifferentiated schizophrenia, hallucinations or delusions are present but without prominent
paranoid, disorganized, or catatonic symptoms.
Residual
With residual schizophrenia, hallucinations and delusions are not prominent, but there is continued
evidence of an ongoing disturbance (flat affect, poverty of speech, or avolition).
The onset of schizophrenia is typically characterized by deterioration in occupational and social

situations over a period of 6 months or more.
Symptoms
Symptoms include the following:
• Hallucinations (auditory, visual, tactile, olfactory, or gustatory)
• Delusions (usually persecutory or grandiose)
• Disorganized thoughts or speech
• Impaired cognition, attention, concentration, judgment, and motivation
Symptoms are commonly referred to as positive (hallucinations or delusions); negative (flat affect,
avolition, anhedonia, and poverty of thought); or disorganized (disorganized speech or behavior).
Most patients fluctuate between acute episodes and remission, but complete remission without any
symptoms is uncommon.
Associated features
Morbidity
There are many comorbid disease states (mental and medical); for example, substance abuse is
found in 60-70% of persons with schizophrenia.
Mortality
Shortened life expectancy is a feature of schizophrenia. Patients with schizophrenia are at increased
risk of suicide (10% commit suicide). Risk factors for suicide are as follows:
• Male
• Socially isolated
• Comorbid psychiatric disorders
• Unemployed
• < 30 years of age
Etiology
The etiology is most likely multifactorial:
• Genetic
• Neurobiologic
• Developmental (season of birth, viral illness, traumatic injury)
DSM-IV Diagnostic Criteria
Two or more of the following symptoms prevail for at least 1 month:
• Hallucinations
• Delusions
• Disorganized speech
• Grossly disorganized or catatonic behavior
• Negative symptoms
• Anhedonia
• Flat affect
• Avolition
Significant social dysfunction exists:
• Signs of the disturbance are continuous and persist for 6 months.
• Schizoaffective disorders and mood disorders, mental retardation, substance abuse, and other
causative medical disorders have been ruled out.
• All antipsychotics are equally effective if used properly.
• Clozapine is the only agent proven effective in treating refractory schizophrenia.
• The basis for choosing an antipsychotic medication is the following:
• Past history of response (patient's response or a family member's response to a medication)
• Side-effect profile of the antipsychotic
• Administer therapy with a trial of antipsychotics (at least 4-6 weeks at recommended doses).
• Do everything possible to simplify the drug regimen.
• Consider long-acting injectable preparations in situations of poor compliance.
Drug Therapy
Tables 25-1 and

25-2 provide an overview of drug therapy alternatives.
Mechanism of action
These drugs block postsynaptic dopamine-2 receptors. They share anticholinergic, antihistaminic,
and -blocking properties.
Other conventional agents
Though not commonly used, perphenazine (Trilafon), thiothixene (Navane), trifluoperazine

(Stelazine), and loxapine (Loxitane) are conventional agents used to treat schizophrenia.
Management of adverse effects
Sedation
The level of sedation depends on the drug used. Low-potency drugs in this class are more sedating
than high-potency drugs.
Sedation effects are worse initially, but become more tolerable over time.
[Table 25-1. Typical (Conventional or Older) Antipsychotics]

[Table 25-2. Adverse Effects of Typical Antipsychotic Medications]
Orthostasis
Severity depends on the drug used. Low-potency formulations promote more orthostasis than do
high potency formulations.
This condition is especially problematic in elderly patients.
Weight gain
Weight gain is very prominent in patients taking these medications. Low doses should be used.
Appropriate diet and exercise should be encouraged to offset weight gain.
Anticholinergic effect
Severity depends on the drug used. Low-potency drugs of this type are more sedating than high-
potency ones.
Dry mouth, blurred vision, constipation, and urinary hesitancy may occur. Use high-potency agents
in patients bothered by anticholinergic side effects.
Extrapyramidal symptoms
Extrapyramidal symptoms (EPSs) are most likely attributed to an imbalance in dopamine and
acetylcholine. Antipsychotics cause a hypodopaminergic state.
Dystonic reactions
Reactions usually occur within 24-96 hours of initiating or changing dose. They present as painful,
involuntary muscle spasms in skeletal muscles (most commonly in the facial or neck muscles, but
sometimes in the back, arm, and leg muscles).
Treatment is benztropine (Cogentin) 1-2 mg intramuscular (IM) or diphenhydramine (Benadryl) 25-

50 mg IM every 30 minutes until the reaction is relieved. Prophylaxis with oral therapy is usually
initiated.
Akathisia
Akathisia usually occurs within a few weeks of initiating antipsychotic therapy. It is described as a
subjective feeling of discomfort, usually seen as motor restlessness of the legs (inability to stand
still or sit still).
Akathisia is treated with lipophilic -blockers (e.g., propranolol), benzodiazepines, clonidine, and
anticholinergics.
Pseudoparkinsonism
Pseudoparkinsonism usually occurs after months or years of therapy. This condition resembles
Parkinson's symptoms (e.g., cogwheel rigidity, bradykinesia, tremor, shuffling gait).
It is treated with amantadine (Symmetrel) 100 mg bid or anticholinergics.

Other adverse effects
Tardive dyskinesia
Tardive dyskinesia (TD) is an irreversible drug-induced movement disorder that occurs after years
of antipsychotic therapy. It is caused by long-term suppression of dopamine.
A triad of symptoms characterize TD:
• Choreoathetosis (splayed, writhing fingers)
• Oral or buccal movements (grimacing, bruxism, lip-smacking)
• Protrusion of the tongue
The only treatment is prevention (i.e., use the lowest effective dose of antipsychotic). However,
various therapies (vitamin E, lecithin, vitamin B6) may help alleviate symptoms.
Monitor for TD by administering the Abnormal Involuntary Movement Scale (AIMS) to all patients
taking antipsychotics.
Neuroleptic malignant syndrome

Neuroleptic malignant syndrome (NMS) has a low incidence and high mortality. It is thought to be
due to dopamine blockade. Clinical presentation of NMS is as follows:
• Rapid progression (<24 hours)
• Body temperature > 104°F
• Lead-pipe rigidity
• Hypertension
• Diaphoresis
• Increased heart rate
• Incontinence
• Increased liver function test (LFT), creatinine phosphokinase (CPK), and white blood count
(WBC)
Treatment is as follows:
• Transport patient to an emergency room immediately (STAT).

• Discontinue antipsychotic medication.
• Administer supportive therapy (cooling blankets, hydration); the dopamine agonist bromocriptine
(Parlodel); and the smooth muscle relaxant dantrolene (Dantrium).
Endocrine and metabolic effects

Such effects include amenorrhea, galactorrhea, and gynecomastia caused by hyperprolactinemia.
Dopamine regulates prolactin release. When dopamine is blocked, prolactin is elevated.
Other effects include weight gain and decreased glucose tolerance.
Dermatologic effects (especially in long-term therapy)

Allergy to medication, photosensitivity, and pigmentation problems may occur.
Hypothalamic effects
Temperature dysregulation (i.e., sensitivity to extreme temperatures) is possible.
Cardiac effects
QT prolongation is possible. Effects are more common with thioridazine (black box warning).
The recommendation is to obtain an electrocardiogram (ECG) for all patients on antipsychotics.
Ophthalmologic effects
Pigmentary retinopathy is associated with daily thioridazine doses > 800 mg. Melanin deposits
occur on the cornea and may lead to blindness.
Atypical (newer) antipsychotics

See
Table 25-3 for an overview of these drugs.
No universally accepted definition of atypical exists, but these drugs generally have the following
features.
• Side effects are less severe (little or no EPS, minimal to no prolactin increase, less risk of TD).
• More weight gain, more lipid abnormalities, and a greater risk of diabetes are seen with these
drugs.
• A dose-dependent increased risk of ventricular arrhythmias and sudden cardiac death is seen,
possibly because of prolongation of the QT interval similar to typical antipsychotics.
[Table 25-3. Atypical Antipsychotics]

• Decreased affinity for the dopamine receptor is present.
• Results from the CATIE (Clinical Antipsychotic Trials in Intervention Effectiveness) showed very
high discontinuation rates for all antipsychotics secondary to inefficacy or intolerable side effects.
No difference was seen between perphenazine and atypicals (except olanzapine).
• There is a black box warning for increase in mortality with atypical antipsychotics in elderly
patients with dementia, and atypical antipsychotics are not approved for the treatment of patients
with dementia-related psychosis.
Mechanism of action
These drugs are weak dopamine and dopamine-2 receptor blockers that block serotonin and ±-
adrenergic, histaminic, and muscarinic receptors in the central nervous system.
Treatment Strategies
Acute schizophrenia
• Decrease danger to self and others.
• Haloperidol or fluphenazine (immediate release) 5-10 mg IM and lorazepam 2 mg IM q4h prn

may be used for psychosis or agitation. An anticholinergic may also be needed (e.g., benztropine
or diphenhydramine for EPSs).
• Olanzapine 10 mg IM may be used and can be repeated in 2 hours and again 4 hours later, for a
maximum of 30 mg/d for psychosis or agitation.
• Patients may use ziprasidone 10 mg IM administered every 2 hours or 20 mg IM administered

every 4 hours, for a maximum of 40 mg/d for psychosis or agitation.
Maintenance
• Start an atypical antipsychotic at a recommended dose or continue a conventional agent (if it was
effective for patient before hospital admission).
• Positive symptoms will respond first.
• Monitor for side effects and emphasize compliance.
• Lifelong therapy is usually needed.
• Use lowest effective dose to decrease risk of side effects (e.g., TD).
Recommended monitoring for patients on atypical antipsychotics

• Fasting glucose and lipids and blood pressure at baseline and at 12 weeks
• Weight (body mass index) at baseline, 4 weeks, 8 weeks, and 12 weeks, and then quarterly
• Waist circumference at baseline and then annually
Noncompliance and alternative dosing
Haloperidol decanoate (Haldol-D)

The dosage conversion from po to IM is as follows: po daily dose × 10 = IM dose every 4 weeks.
For example, 20 mg daily dose × 10 = 200 mg every 4 weeks.
Steady state is reached in 8-12 weeks.
Fluphenazine decanoate (Prolixin-D)

The dosage conversion from po to IM is as follows: 1 mg po = 1.25 mg IM. For example, 20 mg
daily dose × 1.25 mg = 25 mg IM every 2 weeks.
Steady state is reached in approximately 6 weeks.
Depot administration technique

Both medications are suspended in sesame seed oil. They are very viscous. Ensure that the patient
has no allergy to sesame seed oil.
Administer in gluteal or deltoid muscle with a 16-or 18-gauge needle.
Risperidone long-acting injection (Risperdal Consta)

Overlap with po medication for 3 weeks.
The recommended dose is 25 mg every 2 weeks. The maximum dose is 50 mg every 2 weeks.
Alternate IM administration between two buttocks.
Steady state is reached in approximately 8 weeks.
Use the diluent and needle supplied in the pack to reconstitute and administer injection.
25-3. Bipolar Disorder
Introduction
Bipolar disorder (manic-depressive illness) is a recurrent mood disorder with a lifetime prevalence
of 0.8%-1.6%. This disorder is associated with significant morbidity and mortality.
Incidence is equal in females and males. Onset is usually between ages 8 and 44. The first episode
for females is usually marked by a depressive episode. For males, it is usually marked by a manic
episode.
• Bipolar I: This type is characterized by the occurrence of manic episodes and major depressive
episodes.
• Bipolar II: This type is characterized by the occurrence of hypomanic episodes and major
depressive episodes.
• Cyclothymia: This type is defined as numerous episodes of hypomania and depressive episodes
that cannot be classified as major depressive episodes. Diagnosis requires that cyclothymia occur
for at least a 2-year period.
See DSM-IV for complete diagnostic criteria.
Mania
Mania is characterized by heightened mood (euphoria), flight of ideas, rapid or pressured speech,
grandiosity, increased energy, decreased need for sleep, irritability, and impulsivity. Judgment is
significantly impaired (e.g., increased risk-taking behavior). Marked impairment also exists in
social or occupational functioning.
Psychotic features are usually present. Hospitalization is needed.
Changes in sleeping patterns (especially insomnia) commonly initiate manic episodes.
Drug-induced causes include antidepressants (tricyclic antidepressants, selective serotonin reuptake

inhibitors, monoamine oxidase inhibitors); bronchodilators (albuterol, salmeterol); stimulants;
xanthines (caffeine, theophylline); dopamine agonists (bromocriptine, amantadine); and
sympathomimetics.
Note: The STEP-BD (Systematic Treatment Enhancement Program for Bipolar Disorder) trial
showed that antidepressants used in combination with mood stabilizers did not increase the risk of
inducing mania in bipolar depression. However, this combination was not associated with increased
efficacy.
Hypomania
Hypomania is a less severe form of mania. This disorder usually does not cause marked impairment
in social or occupational functioning.
Many patients find this state highly desirable because they experience a great sense of well-being
and feel productive, creative, and confident.
Dysphoric (mixed) mania
Dysphoric mania is characterized by manic and depressive features, mood variability, and mood
lability. Symptoms usually include agitation, insomnia, suicidal ideation, psychosis, and appetite
disturbances.
Major depression
See Section 25-4.
Rapid cycling
In rapid cycling, the patient experiences > 4 mood episodes in a year. Mood episodes may occur in
any combination.
Rapid cycling primarily occurs in women (70-90%). The prognosis is usually poor.
Etiology
The etiology is unknown; however, the leading hypothesis supports genetic etiology. Other theories
include neurotransmitter involvement, circadian rhythm, and kindling hypothesis.
Clinical Course
The mean age of onset is 21 years. The first episode for females is usually depression. For males, it
is mania.
Untreated episodes may last from weeks to months. A high mortality rate exists because of suicide.
Comorbid substance abuse is very common (60-70%).
Acute
In acute cases, the goal is to control the current episode (i.e., slow down the patient and reduce
harm to self and others).
Maintenance
Maintenance goals are as follows:
• Prevent or minimize future episodes.

• Maintain drug therapy, and reduce adverse effects.
• Prevent drug interactions.
• Educate the patient and family about the disorder.
• Provide adequate follow-up services (including substance abuse treatment).
• Maximize the patient's functional status and quality of life.
Drug Therapy
Table 25-4 provides information about mood stabilizers.
Lithium
Indications
Lithium is indicated for acute treatment and prophylaxis of manic episodes associated with bipolar
disorders. It is effective for both the manic and depressive components.
Mechanism of action
The mechanism of action is unknown. Various theories suggest that lithium facilitates ³-
aminobutyric acid (GABA) function, alters cation transport across cell membranes in nerve and
muscle cells, or influences reuptake of 5-hydroxytryptamine (5-HT) or norepinephrine (NE).
[Table 25-4. Mood Stabilizers]
Contraindications
Contraindications include renal disease, severe cardiovascular disease, history of leukemia, first
trimester of pregnancy, and hypersensitivity to lithium.
Precautions
Use with caution in patients who have thyroid disease, patients who have sodium depletion, patients
who are receiving diuretics, or dehydrated patients.
Monitoring (baseline and follow-up)
• Thyroid panel: Lithium may cause hypothyroidism. Test baseline and thyroid-stimulating
hormone (TSH) every 6-12 months or as clinically indicated.
• Serum creatinine (SCr) and blood urea nitrogen (BUN): Lithium is 100% renally eliminated.
Test baseline and every 3 months for patients with renal dysfunction and every 12 months
otherwise or as clinically indicated.
• Complete blood count (CBC) with differential: Lithium may cause leukocytosis and may
reactivate leukemia. Test baseline and every month for 3 months; then test as clinically indicated.
• Electrolytes: In the event of hyponatremia, lithium toxicity may occur.
• ECG: Lithium causes flattened or inverted T waves. This condition is reversible. Test baseline
and every 6-12 months or as clinically indicated.
• Urinalysis: Lithium may decrease specific gravity.
• Pregnancy test: Lithium may cause cardiovascular defects (e.g., Ebstein's anomaly).
• Lithium level: Lithium reaches steady-state levels in 4-5 days (half-life = ~24 h). Obtain the level
2-8 hours after the dose (acute: 0.6-1.2 mEq/L; maintenance: 0.8-1.0 mEq/L). Draw the level
weekly for 4 weeks and then monthly for 3 months or as clinically indicated.
Drug interactions
Table 25-5 summarizes the drug interactions associated with lithium.
[Table 25-5. Drug Interactions with Lithium]
In addition, several toxicity concerns are associated with the drug:
• Mild toxicity (serum levels 1.5-2.0 mEq/L): Gastrointestinal (GI) upset (nausea, vomiting,
diarrhea); muscle weakness; fatigue; fine hand tremor; difficulty with concentration and memory
• Moderate toxicity (serum levels 2.0-2.5 mEq/L): Ataxia, lethargy, nystagmus, worsening
confusion, severe GI upset, coarse tremors, increased deep tendon reflexes
• Severe toxicity (serum levels > 3.0 mEq/L): Severely impaired consciousness, coma, seizures,
respiratory complications, death
Toxicity is treated as follows:
• Discontinue lithium and initiate gastric lavage.
• Correct electrolyte and fluid imbalances.
• Monitor neurologic changes.
• Give supportive care.
• Give dialysis if indicated.
Patient information
• Monitoring serum lithium levels routinely is important.
• Maintain a steady salt and fluid intake.
• Do not crush or chew extended- or slow-release dosage forms.
Divalproex sodium
Divalproex sodium is indicated for bipolar disorder. It is considered first-line treatment for acute
manic episodes. It has unlabeled use for prophylaxis of manic episodes, is effective for rapid cyclers
and patients with dysphoric mood, and is helpful in the management of agitation and aggression.
Mechanism of action
Its mechanism of action is unknown, but divalproex sodium is thought to increase GABA or mimic
its action at the postsynaptic receptor site.
Contraindications
Contraindications include
• Hepatic dysfunction
• Hypersensitivity to divalproex sodium
• Patients < 2 years old
• Pregnancy
With respect to pregnancy, valproic acid (VPA) may cause neural tube defects. If the benefit
outweighs the risk, supplement with 4-5 mg/d of folic acid to decrease risk of fetal damage.
Monitoring
VPA
• VPA level reaches steady state in 3-5 days (half-life = 9-16 h); 50-125 mcg/mL is optimal.
• Draw level weekly for 2-3 weeks, then every 3 months or as clinically indicated.
LFTs
• Test baseline and every month for 6 months, and then every 6 months or as clinically indicated.
• Divalproex sodium is hepatically eliminated; it carries a black box warning for hepatotoxicity.
CBC with differential

• Test baseline and every month for 6 months, and then every 6 months or as clinically indicated.
• VPA may cause thrombocytopenia.
Drug interactions
• Divalproex sodium is a cytochrome P450 (CYP450) 2C19 enzyme substrate, a CYP450 2C9 and
2D6 inhibitor, and a weak CYP450 3A3/4 inhibitor.
• Interactions occur with carbamazepine, lamotrigine, and phenytoin. Increased sedative effects
occur with phenobarbital and benzodiazepines.
Patient information
• Take with food to avoid GI upset.
• Take a multivitamin with selenium and zinc if alopecia (hair loss) occurs.
• It is important to monitor VPA levels routinely.
Carbamazepine
Carbamazepine (CBZ) is considered second-line therapy for acute and prophylactic treatment of
bipolar disorder.
Mechanism of action
The mechanism of action is unknown.
Monitoring
Monitor CBC with differential, electrolytes, LFTs, SCr or BUN, and ECG (if the patient is > 40
years old or has a preexisting heart disease).
CBZ is an autoinducer. Monitor levels routinely, especially during first few months of therapy. The
optimal level is 4-12 mcg/mL.
Contraindications
Contraindications include history of previous bone marrow depression and hypersensitivity to CBZ.
Drug interactions
• CBZ is a CYP450 2C8 and 3A3/4 enzyme substrate.
• It is a CYP450 1A2, 2C, and 3A3/4 inducer.
• CBZ may induce the metabolism of benzodiazepines, clozapine, corticosteroids, oral

contraceptives, VPA, warfarin, phenytoin, and tricyclic antidepressants (plus others).
• Cimetidine, clarithromycin, diltiazem, propoxyphene, verapamil, metronidazole, and lamotrigine

(plus others) inhibit CBZ.
Lamotrigine (Lamictal)
Lamotrigine is approved for maintenance treatment of Bipolar I disorder. Titration of the dose is
required to monitor for signs and symptoms of severe and potentially life-threatening skin rashes (
Table 25-6). Coadministration with VPA increases the risk.
Drug interactions and effects
• CBZ, phenytoin, oral contraceptives, rifampin, and phenobarbital decrease lamotrigine

concentrations.
• VPA increases lamotrigine concentrations.
• Adverse effects include nausea, headache, tremor or anxiety, and sedation.
Other therapies
Atypical antipsychotics
These agents are approved for treatment of bipolar disorder. Olanzapine or fluoxetine (Symbyax) is
indicated for the treatment of depressive episodes associated with bipolar disorder.
Gabapentin (Neurontin)
This agent may be useful as adjunctive therapy for bipolar disorder. No significant drug interactions
exist. No drug serum level monitoring is required.
Gabapentin is renally eliminated. It has mild sedative effects (sedation, ataxia, and fatigue).
Oxcarbazepine (Trileptal)
This agent is structurally similar to CBZ (ketoanalogue of CBZ). It is sometimes used as a mood
stabilizer in patients with bipolar disorder, but further studies are needed.
No autoinduction problems exist, and there are no drug serum levels to monitor. It appears to have
fewer drug-drug interactions than CBZ.
[Table 25-6. Lamotrigine Dose Titration]
Topiramate (Topamax)
This agent may be useful for treatment of bipolar disorder, but further studies are needed. Doses are
usually lower than those indicated for treating seizure disorders.
Topiramate may cause weight loss.

These agents are usually reserved as last-line therapy. Data in the literature are inconsistent about
using verapamil for mania (other calcium channel blockers may be effective).
Although these agents are not routinely used, they could possibly be used in pregnancy.
25-4. Major Depression
Introduction
Major depression is a prevalent and serious illness in the United States. It affects 10 million to 14
million people of all ages.
The condition is treatable but grossly undertreated. Most cases go unrecognized, which may be due
to the social stigma surrounding depression. Several myths contribute to the problem of
undertreatment (e.g., major depression is due to personal weakness or an inability to handle life's
problems).
Epidemiology
The lifetime prevalence rate is 17%. One out of four females (10-24%) is affected. One out of 8
males (5%-12%) is affected.
Major depression is most common between the ages of 25 and 44.
Risk factors include the following:
• Family history
• Female
• Previous depressive episode
• Previous suicide attempt
• Comorbid medical or substance abuse disorder
Etiology
The etiology is unknown; however, there are many hypotheses, including the following:
• Dysregulation of neurotransmitters
• Decreased concentration of certain neurotransmitters

• Genetic basis for the disorder
Physical findings
• Fatigue
• Pain (i.e., headaches, back pain, GI upset)
• Sleep disturbances (usually insomnia)
• Appetite disturbances (usually decreased appetite)
• Psychomotor retardation or agitation
Emotional symptoms
• Anhedonia
• Depressed mood for most of the day
• Hopelessness or helplessness
• Inappropriate feelings of guilt and worthlessness
• Anxiety or worry
• Suicidal ideation
Cognitive symptoms
• Decreased ability to concentrate
• Indecisiveness
Laboratory studies
There are no diagnostic laboratory tests for depression, but the following lab work should be
conducted to rule out other medical illnesses that may manifest as depressive symptoms:
• CBC with differential
• Thyroid function tests

• Rapid plasma reagin (test for syphilis)
• Urine drug screen
Medical conditions that may contribute to the development or worsening of depression include the
following:
• Myocardial infarction (MI)
• Cerebrovascular accident
• Parkinson's disease
• Multiple sclerosis
• Systemic lupus erythematosus
• Human immunodeficiency virus
• Thyroid abnormalities
• Cancer
• Vitamin deficiency
Possible drug-induced causes of depression should also be ruled out, including corticosteroids, oral
contraceptives, propranolol, clonidine, and methyldopa.
Prognosis
Seventy percent of patients are responsive to antidepressant therapy. Following the first episode,
50-60% of patients will have another episode; following the second episode, 70-80% will have a
third; and following the third, 90% will have another.
If untreated, an episode may resolve spontaneously within 6 to 24 months.
Approximately 15% of patients will commit suicide. Risk factors for suicide include being male,
>50 years old, or unemployed; having recently lost a job or spouse; being socially isolated; having
access to a weapon; and experiencing comorbid substance abuse.
Males are more likely to commit suicide, but females are more likely to attempt suicide. Males
commonly use more violent means of suicide (e.g., firearms and hanging) than do females (e.g.,
slashing of wrists and drug overdoses).
DSM-IV Diagnostic Criteria
At least five symptoms (see previous discussion of clinical presentation) must be present mostly
every day for a 2-week period and represent a change from previous functioning. At least one of the
symptoms must be depressed mood or anhedonia.
Goals are as follows:
• Improve patient's ability to function and quality of life.
• Reduce or eliminate target symptoms with an antidepressant.
• Optimally, incorporate psychotherapy.
• Prevent relapse.
All antidepressants are equally effective in a given population:
Response varies from person to person.
• Each differs in side-effect and drug-interaction profiles.
• None are "speed" or "uppers."
Note: The U.S. Food and Drug Administration now requires all antidepressant drugs to include
boxed warnings about increased risk of suicidal ideation and behavior in children and adolescents
and in young adults (up to age 24), and a medication guide highlighting these risks is to be
distributed with each new or refilled prescription for antidepressants in this population.
Basis for choosing an agent
• Past history of a patient's response or a family member's response to certain agents
• Side-effect profile and how it relates to any given patient's situation
In the first week, the following should be noted:

• Decreased anxiety
• Trend toward normalization of appetite and sleep pattern
In the second to third week, the following should be noted:
• Increased energy
• Improved concentration and memory
• Improved somatic symptoms
Note: There is an increased risk for suicide at this time because the patient has the energy to carry
out any ideations.
At 4-6 weeks, the following should be evident:
• Improved mood
• Decreased suicidal ideation
• Increased libido
Duration of therapy
Acute phase
The acute phase is usually 6-12 weeks or the length of time needed to stabilize depressive
symptoms.
Maintenance phase
During this phase, maintain therapeutic doses of antidepressant. The duration is usually 1 year; you
may taper antidepressant for a period of time and monitor for signs of relapse. The goal is to
prevent relapse.
Prophylaxis
Chronic antidepressant therapy may be necessary for certain patients experiencing the following:
• A first-degree relative with bipolar disorder or recurrent depression
• Onset of depression before age 20 or after age 60
• Recurrence of depression within 1 year after medication discontinuation
• Severe, sudden, or life-threatening depression

Drug Therapy
Tricyclic antidepressants
Tricyclic antidepressants (TCAs) are described in

Table 25-7.
Mechanism of action
TCAs increase the synaptic concentration of 5-HT or NE in the central nervous system (i.e., TCAs
inhibit the presynaptic neuronal membrane's reuptake of 5-HT or NE).
Other information about TCAs
• Doses may be titrated to full dose range over 1-3 weeks.
• Many patients are dosed half-strength because of sedative effects; however, for patients with
insomnia, the sedating effects may be helpful.
• These agents are deadly in overdose (blocks sinoatrial node in the heart).
• Drug serum levels are not commonly used in guiding therapy, but monitoring may be useful in
patients taking amitriptyline, desipramine, imipramine, or nortriptyline.
Adverse effects
Effects include orthostatic hypotension, tachycardia, sedation, anticholinergic effects, arrhythmias
(prolonged QT interval), weight gain, and sexual dysfunction.
Tertiary amines (e.g., amitriptyline, imipramine, doxepin, clomipramine) have more intense adverse
effects compared to secondary amines (e.g., nortriptyline, desipramine).
Contraindications
Concomitant use of a monoamine oxidase inhibitor (MAOI) within the past 14 days, during
pregnancy or lactation, and with narrow-angle glaucoma is contraindicated.
[Table 25-7. Tricyclic Antidepressants]
Precautions
Use with caution in patients with cardiac conduction disturbances, seizure disorders,
hyperthyroidism, and renal or hepatic impairment. Avoid abrupt withdrawal in patients with
prolonged use.
Drug interactions
• Increase in TCA level increases the levels of selective serotonin reuptake inhibitors (SSRIs),
cimetidine, diltiazem, verapamil, labetalol, propoxyphene, quinidine, haloperidol, and
methylphenidate.
• Decrease in TCA level affects CBZ, phenytoin, and barbiturate metabolism.
• Administration with MAOIs may cause serotonin syndrome.
• Monitoring blood pressure, pulse, ECG changes, and mental status changes is prudent; drug serum
monitoring may be useful for amitriptyline, desipramine, imipramine, and nortriptyline.
Monoamine oxidase inhibitors
Table 25-8 summarizes information about MAOIs.
Mechanism of action
MAOIs increase the synaptic concentration of NE, 5-HT, and dopamine (DA) by inhibiting the
breakdown enzyme—monoamine oxidase.
Note: MAOIs may be useful for patients who do not respond to other antidepressants or for
treatment of atypical depression; however, they are rarely used because of the need for dietary
restrictions, their side effect profile, and their potentially dangerous interactions with other
medications.
Adverse effects
Effects include orthostatic hypotension, weight gain, sexual dysfunction, anticholinergic effects,
and hypertensive crisis.
Contraindications
Be alert for renal or hepatic dysfunction, cardiovascular disease, and concomitant sympathomimetic
therapy (e.g., pseudoephedrine, ephedra).
When a patient is switched from MAOIs to SSRIs, the MAOI must be discontinued 2 weeks prior
to initiation of SSRI to prevent serotonin syndrome. When a patient is switched from SSRIs to
MAOIs, the SSRI must be discontinued 2 weeks prior to initiation of MAOI, with the exception of
fluoxetine, which requires 5 weeks because of its long half-life.
Precautions
Be aware of drug-food interaction with tyramine-containing foods (e.g., red wine, aged cheeses, and
marmite).
Drug interactions
• TCAs
• SSRIs
• Meperidine
Selective serotonin reuptake inhibitors
See
Table 25-9 for information about SSRIs.
Mechanism of action
These agents selectively inhibit the reuptake of 5-HT.
All SSRIs should be tapered upon discontinuation of treatment (over 2-4 weeks), except fluoxetine.
Side effects with abrupt withdrawal include flu-like symptoms, dizziness, nausea, tremor, anxiety,
and palpitations.
Adverse effects
Effects include GI complaints, nervousness, insomnia, headache, fatigue, and sexual dysfunction,
but SSRIs are safer in overdose than TCAs.
[Table 25-8. Monoamine Oxidase Inhibitors]
[Table 25-9. Selective Serotonin Reuptake Inhibitors]
Drug interactions
Drug interactions exist with TCAs, MAOIs, and SSRIs. Interactions are variable depending on the
SSRI. Reportedly there are fewer drug interactions with escitalopram and citalopram.
Serotonin-norepinephrine reuptake inhibitors
See
Table 25-10 for information about serotonin-norepinephrine reuptake inhibitors (SNRIs).
Venlafaxine (Effexor, Effexor XR)

Mechanism of action
This agent inhibits the reuptake of 5-HT and NE (and also DA at higher doses). It is frequently
referred to as an SNRI. Anticholinergic and antihistaminic effects are negligible. As the dose
increases, NE and DA reuptake are more pronounced.
Adverse effects
Effects include GI upset, anxiety, insomnia, and headache. Elevation in blood pressure is possible;
use with
[Table 25-10. Serotonin-Norepinephrine Reuptake Inhibitors]

caution in patients with uncontrolled hypertension. An extended release formulation is available to
minimize GI upset. Other side effects are similar to those of SSRIs. Withdrawal symptoms may
occur if the medication is abruptly discontinued.
Drug interactions
Cimetidine inhibits venlafaxine metabolism. Cyproheptadine induces venlafaxine metabolism.
Serotonin syndrome is seen in combination with sibutramine, sumatriptan, tramadol, and trazodone.
PT/INR (prothrombin time per international ratio) elevations have been seen when venlafaxine is
added to patients taking warfarin.
Other aspects
Venlafaxine is indicated for both generalized anxiety disorder and major depression. It is not
recommended in patients with uncontrolled hypertension or recent MI or cerebrovascular disorders.
Desvenlafaxine (Pristiq)
Mechanism of action
The mechanism of action of desvenlafaxine is similar to that of venlafaxine.
Adverse effects
Common effects include GI upset, increased serum cholesterol and triglycerides, xerostomia, sleep
disturbances, and erectile dysfunction. Serious effects include hypertension, hyponatremia, and
abnormal bleeding.
Withdrawal symptoms may occur if the drug is abruptly discontinued.
Drug interactions
The primary metabolic pathway is conjugation; therefore, desvenlafaxine has fewer drug
interactions than venlafaxine.
Serotonin syndrome is seen in combination with MAOIs, SSRIs, sibutramine, tramadol, triptans,
and linezolid.
Use in combination with unfractionated heparin, glycoprotein IIb or IIIa receptor inhibitors,
warfarin, and nonsteroidal anti-inflammatory drugs may increase the risk of bleeding.
Duloxetine (Cymbalta)
Mechanism of action
The mechanism of action of duloxetine is similar to that of venlafaxine. It is a potent inhibitor of 5-
HT and NE, and it has no significant affinity for dopaminergic, adrenergic, cholinergic, or
histaminergic receptors.
Adverse effects
Effects include GI upset, dry mouth, dizziness, decreased appetite, elevation in blood pressure, and
other side effects similar to those of SSRIs. Urinary hesitation may occur. The patient may have
withdrawal symptoms with abrupt discontinuation.
Drug interactions
CYP1A2 inhibitors (e.g., cimetidine, quinolone antibiotics) and CYP2D6 inhibitors (e.g.,
fluoxetine, quinidine) increase duloxetine levels. The combination of duloxetine with triptans and
serotonergic drugs may cause serotonin syndrome.
Other aspects
Duloxetine is indicated for both major depression (20 or 30 mg bid or 60 mg qd) and diabetic
peripheral neuropathic pain (60 mg qd). It is metabolized by CYP450 1A2 and 2D6; these inhibitors
may increase plasma levels of duloxetine, causing increased side effects. Duloxetine is
contraindicated in uncontrolled narrow-angle glaucoma.
Other classes of antidepressant medication
Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban)

Mechanism of action
Bupropion, an inhibitor of NE and DA reuptake (effects on 5-HT reuptake are minimal), is referred
to as a norepinephrine-dopamine reuptake inhibitor (NDRI).
Adverse effects
Effects include GI upset, insomnia, anxiety, headache, and psychosis (rare). Buproprion is less
associated with sexual dysfunction than are SSRIs and other classes. It also decreases the seizure
threshold.
Drug interactions
Cimetidine and ritonavir inhibit bupropion metabolism, and CBZ induces bupropion metabolism.
Other aspects
There is an increased risk of seizure with bupropion, especially in patients with a seizure disorder,
eating disorder, or electrolyte imbalance. The maximum daily dose is 450 mg (400 mg SR). Titrate
the dose slowly to minimize seizure risk. Bupropion is marketed as Zyban for smoking cessation.
Trazodone (Desyrel)
Mechanism of action
This agent inhibits 5-HT reuptake and blocks 5-HT2A receptors.
Adverse effects
Effects include extreme sedation, orthostatic hypotension, and priapism. There are no
anticholinergic or cardiotoxic effects.
Drug interactions
Fluoxetine and ritonavir inhibit trazodone metabolism.
Other aspects
Because it causes excessive sedation, trazodone is not clinically used as an antidepressant; rather, it
is commonly used to treat insomnia (usually dosed 25-150 mg qhs).
Nefazodone (Serzone)
Mechanism of action
This agent inhibits 5-HT and NE uptake and blocks 5-HT2A receptors.
Adverse effects
Effects include GI upset, sedation, dry mouth, constipation, and lightheadedness. Nefazodone is
associated with minimal sexual dysfunction and orthostatic hypotension.
Drug interactions
Nefazodone is a potent inhibitor of CYP3A4 isoenzyme; use with caution with drugs metabolized
through this enzyme (e.g., buspirone, 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase
inhibitors, alprazolam, triazolam, digoxin). Ritonavir inhibits nefazodone metabolism.
Other aspects
Nefazodone is usually dosed bid because of its short half-life. There is a black box warning for
hepatotoxicity.
Mirtazapine (Remeron and Remeron Soltab)

Mirtazapine is available in 7.5, 15.0, 30.0, and 45.0 mg tablets.
Mechanism of action
This agent antagonizes presynaptic ±2 autoreceptors and heteroreceptors that prevent the release of
5-HT and NE (resulting in increased 5-HT and NE in the synapses). It antagonizes 5-HT2A and 5-
HT3 receptors, thereby resulting in less GI upset and less anxiety.
Adverse effects
Effects include sedation, increased appetite, weight gain, and constipation. Elevation in LFTs and
increase in triglycerides may occur. There is also a small risk of agranulocytosis or neutropenia.
Other aspects
Mirtazapine may be useful in geriatric patients because it causes increased appetite, is sedating, and
has no significant drug interactions.
Aripiprazole (Abilify)
Aripiprazole is approved for adjunct treatment of major depressive disorders. It is available in 2, 5,
10, 15, 20, and 30 mg tabs and in a 1 mg/mL concentrate. The maximum dose is 15 mg/d.
Mechanism of action
This agent's action is not fully understood; it partially antagonizes D2 and 5-HT1A receptors and
antagonizes 5-HT2A receptors.
Adverse effects
See Section 25-2 on schizophrenia.
Selegiline (Emsam)
Selegiline is available in 6, 9, and 12 mg/24 hour patches.
Mechanism of action
This agent's mechanism of action is not fully understood; however, it is believed to be linked to
selegiline's irreversible inhibition of monoamine oxidase.
Adverse effects
Effects include headache, insomnia, application-site reaction, diarrhea, and dry mouth.
Other aspects
There are no dietary restrictions for the 6 mg dose.
Psychostimulants
Methylphenidate has been used to treat depression (especially in the geriatric population) and has
been shown to increase activity level as well as improve mood symptoms. It may cause GI upset,
insomnia, and cardiovascular effects. It should be used with caution in anxious or psychotic
patients. It inhibits TCA metabolism.
Nonpharmacologic Treatments
Psychotherapy
Psychotherapy is especially useful combined with drug therapy.
Electroconvulsive therapy
Electroconvulsive therapy (ECT) is very safe and effective for treating depression. It is believed to
physically "reset" receptors in the brain. ECT is usually reserved for refractory or psychotic patients.
Procedure
The patient is anesthetized and paralyzed in an outpatient setting. The patient is monitored through
an electroencephalogram (EEG) during the procedure, and a seizure is induced for 30-90 seconds.
Acute and maintenance treatment

The procedure is administered every other day for 6-9 treatments. Maintenance treatment is variable
for each patient, but ECT is usually administered monthly after acute treatment.
Adverse effects
Effects include short-term memory loss and confusion on the day of treatment.
Relative contraindications
ECT increases intracranial pressure and, therefore, is not recommended in patients with recent MI,
intracerebral hemorrhage, or cerebral lesions.
25-5. Anxiety Disorders
Introduction
Anxiety disorders are serious, debilitating mental illnesses that include a group of conditions that
share extreme anxiety as the primary mood disturbance.
Epidemiology
Anxiety disorders affect approximately 19 million adults in the United States. There are no racial or
cultural differences, and gender differences depend on the specific anxiety disorder.
There is significant comorbidity with other psychiatric illnesses (e.g., substance abuse).
Generalized anxiety disorder
Generalized anxiety disorder (GAD) is characterized by unprovoked excessive worry and tension.
Anxiety usually consumes the patient's day, thereby affecting social and occupational functioning.
Physical complaints (e.g., GI upset, headache, muscle tension, tremors, insomnia, fatigue) are
common. Incidence of GAD is higher in females than in males.
Panic disorder
Panic disorder (PD), with or without agoraphobia, is characterized by feelings of terror that
suddenly strike without warning and usually last for approximately 10-15 minutes.
Physical symptoms include increased heart rate, sweating, tremors, shortness of breath, chest pain,
and dizziness. The patient feels as if death is imminent.
Agoraphobia (fear of open or public places) usually develops later in the illness, especially if PD is
not treated. Agoraphobic patients associate panic attacks with certain places and occasions, so they
avoid going out and remain at home. Agoraphobia is more prevalent in females than in males.
Obsessive-compulsive disorder
Obsessive-compulsive disorder (OCD) is characterized by intrusive, recurrent, and repetitive

thoughts that severely interfere with the patient's social and occupational functioning (e.g.,
preoccupation with contamination, order, counting, cleanliness, safety).
Compulsions (e.g., repetitive washing of hands and checking and rechecking) are acts that must be
performed in an attempt to decrease the anxiety felt about the obsessions. Prevalence of OCD is
equal in males and females.
Social anxiety disorder
Social anxiety disorder (SAD) is characterized by feelings of anxiety in social situations (e.g.,
speaking in front of others and attending social gatherings). Patients feel as though everyone is
staring and judging them. People affected by SAD usually do not seek treatment and will, instead,
self-medicate with alcohol. There is equal male and female prevalence.
Simple or specific phobias
Simple phobias are defined as specific fears (e.g., heights, dogs, mice, spiders, needles) that cause
an extreme anxiety response. Affected persons usually do not seek treatment and will, instead,
avoid situations that involve the phobia.
Exposure therapy to the perceived threat is common therapy. Incidence in females is greater than in
males.
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is characterized by severe anxiety that is caused by an event
outside of normal human experience (e.g., war, rape, natural disasters). Symptoms include vividly
reliving the event to the extent that anxiety symptoms (i.e., flashbacks, nightmares or night terrors,
extreme mood changes, feelings of fright) commonly occur. PTSD is often associated with strong
guilt feelings, impaired relationships, social withdrawal, and personality changes. There is a greater
prevalence in females than in males.
Anxiety due to a medical disorder
Anxiety is likely to be related to evidence of a medical condition (e.g., congestive heart failure,
hyperthyroidism, chronic obstructive pulmonary disease [COPD]).
Substance-induced anxiety disorder
Anxiety symptoms are likely to be a direct result of use of an agent (e.g., amphetamines, toxin,
medication). Symptoms may also occur with intoxication or withdrawal.
Associated features
High comorbidity exists with other psychiatric illnesses, especially depression. High comorbidity
also exists with alcohol or substance abuse.
This disorder is associated with chronic medical illnesses (e.g., chronic pain syndromes, long-term
illnesses, GI distress, headaches).
Etiology
This disorder's etiology is presently unknown. Most current evidence suggests the cause is primarily
biologic (imbalance of GABA, 5-HT, and NE) with genetic predisposition.
Drug Therapy
Benzodiazepines
Benzodiazepines (BZDs), the most commonly used anxiolytics, are described in

Table 25-11.
Mechanism of action
BZDs potentiate the actions of GABA by increasing the influx of chloride ions into neurons. It is
hypothesized that, through their effects on neurons mediated by receptor complexes, BZDs reduce
neuronal firing and, thus, the symptoms of anxiety.
Note: The rate of absorption varies with BZDs. The more lipophilic compounds (i.e., alprazolam,
diazepam, clorazepate, flurazepam) are rapidly absorbed and result in quicker onset of action. The
less lipophilic BZDs are chlordiazepoxide, clonazepam, and lorazepam.
Adverse effects
Effects include sedation, dizziness, confusion, blurred vision, diplopia, syncope, residual daytime
sedation, and reduced psychomotor and cognitive dysfunction.
Metabolism
Lorazepam, oxazepam, and temazepam (LOT) are conjugated and are preferred in patients with
hepatic dysfunction and elderly patients.
[Table 25-11. Benzodiazepines]
Drug interactions
BZDs metabolized by CYP3A4 (e.g., alprazolam, diazepam, and triazolam) have decreased
clearance if taken concomitantly with CYP3A4 inhibitors (e.g., ketoconazole, erythromycin,
nefazodone). BZDs are deadly in overdose if taken concomitantly with alcohol.
Clinical pearls
• BZDs may cause a paradoxical reaction in children, cognitively impaired elderly patients,
mentally retarded patients, and post-head injury patients.
• Never abruptly discontinue BZDs because doing so may precipitate status epilepticus. Always
taper the dose to avoid seizure risk and withdrawal symptoms.
• In elderly patients, the BZDs of choice are those that are conjugated (LOT). There is an increased
risk of falls in this population.
• It is best to avoid use of BZDs in pregnancy (especially first trimester) because of risk of cleft
palate. BZDs are also present in breast milk and should be avoided in nursing females.
• The abuse potential is great; BZDs are not recommended for patients with substance abuse issues.
• Tolerance is common, and increasing doses are needed to control anxiety levels.
• Alprazolam extended-release (Xanax XR) is dosed once daily; do not crush, chew, or break doses.
It is also available as an orally disintegrating tablet (Niravam).
Buspirone (BuSpar)
Mechanism of action
The mechanism of action is poorly understood; 5-HT1A is a partial agonist, and buspirone
reportedly stimulates presynaptic 5-HT1A receptors. In addition, the agent has a moderate affinity
for D2 receptors.
Buspirone does not interact with the BZD-GABA receptor complex.
Onset of anxiolytic effect is longer for buspirone than for BZD (2-3 weeks).
Adverse effects
Effects include GI upset, headache, and nervousness.
Benefits
Possible benefits over BZDs include the following:
• Usually less sedating than BZDs
• Little to no psychomotor or cognitive impairment
• No association with withdrawal symptoms, abuse, or physical dependence
• Not cross-tolerant with BZDs or alcohol
Antidepressants as treatment for anxiety disorders
TCAs are usually a third-line treatment because of side effects and the danger of overdose.
Clomipramine is effective for OCD.
MAOIs are usually a third-line treatment because of side effects and drug-food interactions.
SSRIs and SNRIs are a first-line treatment for many anxiety disorders, especially in patients with
comorbid depression and substance abuse problems.
Titrate doses of antidepressants slowly to decrease risk of initial anxiety symptoms. Ultimately,
higher doses are commonly used for anxiety disorders.
Other classes of drugs used to treat anxiety disorders
-blockers (e.g., propranolol and atenolol) ease peripheral symptoms of anxiety and may be useful
for panic disorders and SAD.
Hydroxyzine reduces anxiety and is often used in patients with substance abuse issues.
Nonpharmacologic Treatment
• Supportive psychotherapy (individual, group, family)
• Cognitive behavioral therapy
• Focus on coping with the fear of the symptoms of anxiety
• Relaxation techniques
• Exercise and lifestyle modifications (reduce caffeine and simple sugars)
25-6. Eating Disorders
Anorexia Nervosa
Characteristics
Patients suffering from anorexia nervosa refuse to maintain body weight at or above a minimal,
normal weight for their age and height (85% or less of expected body weight). They experience
intense fear of gaining weight or becoming fat, although they are underweight. There is a
disturbance in self-perception of body weight, size, proportion, and attractiveness.
A female patient experiences amenorrhea for at least three consecutive cycles.
Types
• Restricting
• Binge eating and purging
Bulimia Nervosa
Characteristics
Recurrent episodes of binge eating occur (often followed by intense feelings of guilt). The patient
may consume as much as 5,000-20,000 calories over 2-8 hours. Recurrent and inappropriate
compensatory behavior occurs in order to prevent weight gain.
A person averages 2 binges per week for 3 months. Self-evaluation is primarily influenced by body
shape and weight.
Types
• Purging (vomiting, abuse of laxatives or diuretics)
• Nonpurging (excessive exercise, fasting)
Binge Eating Disorder
Characteristics
Recurrent episodes of binge eating occur (patients are usually obese). The patient eats when not
physically hungry, eats more rapidly than normal, and feels disgusted with himself or herself.
Marked distress is present regarding binge eating.
Binge eating episodes occur, on average, at least 2 days per week for 6 months.
Etiology and Prevalence
The etiology of eating disorders is essentially unknown, but various theories have been proposed
(genetic predisposition, environmental and societal issues, chemical imbalance in the brain). There
is usually a defined event or situation that begins the disorder (e.g., a significant stressor such as
starting college, divorce, or death of a loved one).
Eating disorders are most commonly seen in Caucasian, middle- to upper-class females.
The age of onset for anorexia nervosa is 13-20 years old. The male-to-female ratio is 1:10-20. For
bulimia nervosa, the age of onset is 16-18 years old, and the male-to-female ratio is 1:10.
Medical Complications and Signs of Disease
• Eating disorders produce states of semistarvation and noticeable malnutrition, especially in

anorexia.
• In bulimia, patients are more difficult to identify because they are commonly of normal body
weight.
• Dehydration occurs.
• There is a high incidence of comorbid anxiety, depression, OCD, and substance abuse.
• Dental caries and enamel erosion occur because of stomach acid exposure.
• Calluses on the dorsum of the hand or fingers develop because of induction of vomiting.
• Mortality rate is about 10% from starvation (primarily because of electrolyte imbalances),
arrhythmia, or suicide.
• Long-term complications include endocrine or metabolic, cardiovascular, renal, gastroenterologic,

hematologic, pulmonary, musculoskeletal, immunologic, and dermatologic issues.
Treatment
Psychotherapy is the mainstay of treatment. Therapy can be individual, group, family, supportive,
cognitive behavioral, or insight oriented. Primary objectives are to define and examine extent of
problem. The patient learns to accept the condition, and treatment results in a reconstruction of self-
identity and self-confidence.
Dietary intake is slowly normalized with the goal of restoring normal body weight. Nutritional
counseling is used. Distorted ideas about caloric intake and body shape are corrected.
Relapse prevention focuses on developing and using coping mechanisms and avoiding high-risk
situations.
Drug Therapy
SSRIs are primarily used and may be more effective for patients with bulimia. Antidepressants do
not appear to be beneficial in helping severely malnourished anorexia nervosa patients gain weight,
but they may help patients maintain weight after it has been gained.
Fluoxetine (Prozac) is indicated for the treatment of bulimia nervosa. Higher doses are used; titrate
to 60 mg/d every morning.
Topiramate (Topamax) and zonisamide (Zonegran) may be beneficial in binge-eating disorder and
bulimia nervosa.
Ideally, treatment of eating disorders includes both psychotherapy and pharmacotherapy.
25-7. Key Points
Schizophrenia
• Patients with schizophrenia have positive (hallucinations and delusions), negative (flat affect,
avolition, anhedonia, poverty of thought), and disorganized speech and behavior symptoms.
Positive symptoms usually respond to drug therapy first.
• Antipsychotics (conventional or atypical) are essential treatment for schizophrenia; atypical

medications (risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, and paliperidone)
have been considered first-line medical treatment because they lower risk of EPSs and TD more
than conventional medications and they appear to be more beneficial for negative symptoms.
• Recent evidence has shown that schizophrenic patients discontinue medications frequently
regardless of whether they are taking second-generation or first-generation antipsychotics. Such
research questions whether the atypical antipsychotics are more effective at treating negative
symptoms than are the typical medications.
• Atypical antipsychotics (especially olanzapine) are associated with weight gain and with lipid and
glucose abnormalities (ziprasidone and aripiprazole do not appear to have the weight gain and
metabolic abnormalities).
• Low-potency conventional agents (chlorpromazine, thioridazine) are used more often than high-
potency agents (haloperidol, fluphenazine).
• Low-potency agents have more sedation, orthostatic hypotension, and anticholinergic side effects
and fewer EPS than high-potency agents. High-potency agents have more EPS and less sedation,
orthostatic hypotension, and anticholinergic effects.
• EPS consist of dystonic reactions (to be remedied by diphenhydramine 25-50 mg IM or

benztropine 1-2 mg IM every 30 minutes until resolution); akathisia (to be treated with
lorazepam, clonidine, or propranolol); and pseudoparkinsonism (ameliorated by amantadine or
benztropine).
• Clozapine is the only agent proven effective for refractory schizophrenia.
• Consider long-acting injectable preparations in situations of poor compliance.
Bipolar Disorder
• The acute treatment for bipolar disorder focuses on slowing down the patient and reducing harm
to himself or herself and others
• Maintenance treatment focuses on preventing or reducing the number of future episodes.
• A mood stabilizer is an essential component in the treatment of bipolar disorder. First-line mood
stabilizers include lithium and divalproex sodium (or valproic acid).
• The risk of lithium side effects and toxicity can be prevented by monitoring the patient for signs
and symptoms of problems and by obtaining regular blood-level readings.
• Other drug therapies that may be used to treat the patient with bipolar disorder include atypical
antipsychotics, gabapentin, carbamazepine, oxcarbazepine, topiramate, and lamotrigine
(especially if the patient is depressed).
Major Depression
• All antidepressants are equally effective in a given population.
• Response varies from person to person. Antidepressants differ in side-effect and drug-interaction
profiles, and none are "speed" or "uppers."
• Choice of agent depends on the history of response of other family members to certain
antidepressants (if available) and the particular side-effect profile (as it relates to any given
patient).
• First-line agents include SSRIs, bupropion, venlafaxine, and duloxetine; second-line agents may
include mirtazapine and nefazodone; third-line agents may include TCAs and MAOIs.
• The goal is to reduce or eliminate target symptoms with an antidepressant; incorporating

psychotherapy is optimal.
• The goal of treatment of depression is to improve the patient's ability to function and his or her
quality of life.
Anxiety Disorders
• Anxiety disorders are serious, debilitating mental illnesses that have extreme anxiety as the
primary mood disturbance.
• Various drug therapies include benzodiazepines, buspirone, antidepressants (especially SSRIs and
venlafaxine), -blockers, and hydroxyzine.
• Nonpharmacologic therapy of anxiety disorders is an important aspect of care (e.g., supportive

therapy, cognitive behavioral therapy, relaxation techniques, and exercise and lifestyle
modifications).
Eating disorders
• Anorexia nervosa is characterized by a refusal to maintain body weight (at or above a minimal
normal weight for age and height), an intense fear of gaining weight, a disturbance in self-
perception of body weight, and amenorrhea for at least three consecutive cycles.
• Bulimia nervosa is characterized by recurrent episodes of binge eating, recurrent and inappropriate
compensatory behavior to prevent weight gain, an average of two binges per week for 3 months,
and self-evaluation that is primarily influenced by body shape and weight.
• Eating disorders most commonly occur in young, Caucasian, middle- to upper-class females.
• Medical complications and comorbid psychiatric disorders (e.g., anxiety, depression, and
substance abuse) are extremely common in this population.
• Medications such as antidepressants may be helpful in treating eating disorders (especially

bulimia); optimal therapy should include psychotherapy in combination with drug therapy.
25-8. Questions
Select the single best response for questions 1-4.
S. J. is a 30-year-old white female with a 10-year history of schizophrenia. Her current therapy
includes haloperidol 10 mg po bid. The psychiatrist wants to convert her to haloperidol
decanoate. What would be the appropriate equivalent monthly dose of haloperidol decanoate?
1. A. 100 mg
B. 10 mg
C. 500 mg
D. 200 mg
E. 12.5 mg

B. T. reports to the nursing station with his head pulled sharply to the side and rear. He
complains of severe pain in his neck and back area. The most appropriate diagnosis and
treatment would be which of the following?
2. A. Akathisia; propranolol 20 mg IM until resolution

B. Dystonic reaction; diphenhydramine 50 mg IM every 30 minutes until resolution
C. Tardive dyskinesia; physical therapy
D. Dystonic reaction; lorazepam 2 mg IM every 30 minutes until resolution

Negative symptoms in schizophrenia could include all of the following except
A. flat affect.
3. B. anhedonia.
C. avolition.
D. persecutory delusions.
E. poverty of thought.

A 48-year-old black male arrives at the emergency department seeking his "nerve pill." He has a
27-year history of paranoid schizophrenia with multiple hospitalizations. In recent years, he has
been effectively maintained on fluphenazine 10 mg po bid. He now states that he feels "really
bad today." His arms and jaws are stiff, his temperature is 104°F, his blood pressure is 176/110,
and his WBC is 19,000. LFTs and CPK are ordered STAT. While you await the test results, you
should do which of the following?
4.
A. Discontinue oral fluphenazine and begin quetiapine.
B. Discontinue oral fluphenazine.
C. Continue oral fluphenazine and add bromocriptine.
D. Discontinue oral fluphenazine and give fluphenazine decanoate 25 mg IM STAT.
E. Do nothing; labs need to be evaluated first.

For questions 5-8, one or more of the answers given may be correct. Answer each question as
follows:
A. I only
B. II only
C. I and III only
D. II and III only
E. I, II, and III
A 25-year-old white male has been increasingly disruptive at home. He has been claiming that he is
the president of the United States and has been staying awake all night planning bills for Congress.
He has been argumentative and threatening with his friends and family. Though he appears
extremely tired physically, he is constantly active.
The psychiatrist has decided to initiate Eskalith CR 450 mg bid in this patient. Which of the
following lab tests will need to be performed for this patient before starting this drug therapy
regimen?
5.
I. Pregnancy test
II. Thyroid function tests
III. SCr

As the pharmacist on the treatment team, you alert the patient's family to the common side
effects of lithium, which include
6.
I. polyuria.
II. alopecia.
III. elevated hepatic enzymes.

Which of the following statements are correct regarding the treatment of bipolar disorder?
I. Lithium and divalproex sodium are considered first-line therapy options for mood
stabilization.
7.
II. When treating a patient with lithium, one must monitor the WBC and ANC because of
lithium's propensity to cause agranulocytosis.
III. Patients diagnosed with bipolar I disorder exhibit intermittent cycles of mania and major
depression.

Which of the following therapies have been used for the treatment of bipolar disorder?
8. I. Olanzapine
II. Topiramate
III. Calcium channel blockers

Select the single best response for questions 9-11.
Insomnia, GI upset, and headache are common side effects of which of the following
antidepressants?
A. Phenelzine
9.
B. Amitriptyline
C. Fluoxetine
D. Trazodone
E. Both B and C

A 29-year-old depressed black female has shown little improvement with fluoxetine treatment,
so the psychiatrist decides to change her medication to tranylcypromine. What is your
recommendation for the switch?
A. Gradually decrease fluoxetine dosage over a 4-week period, and then start tranylcypromine.
10. B. Wait 2 weeks after stopping fluoxetine, and then begin tranylcypromine.
C. Over 6 weeks, gradually decrease fluoxetine dosage as you gradually increase the
tranylcypromine dosage.
D. Wait 5 weeks after stopping fluoxetine before initiating tranylcypromine.
E. Maintain fluoxetine dosage, and start tranylcypromine; stop the fluoxetine when the
tranylcypromine has achieved a therapeutic level.

Which of the following has been shown to induce or worsen depression?
A. Oral contraceptives
11. B. Amoxicillin
C. Thiamine
D. Methylphenidate
E. Phenelzine

The following case should be used to answer questions 12 and 13.
K. Y. is a 36-year-old female admitted to your mental health facility for the fifth time in the past 3
years for major depressive disorder. She presents with lack of appetite, avolition, anhedonia, and
suicidal ideations with a plan. Vitals include BP 127/76, P 82, R 18, T 98.6°F. Labs include TSH 4,
FBG 135, (-) UDS, BAL 0. Her current medications are fluoxetine 40 mg daily, metformin 1,000
mg bid, and hydroxyzine 25 mg tid. K. Y. states compliance and denies side effects. Past
medications include citalopram and venlafaxine.
What axis diagnosis is major depressive disorder?
A. I
12. B. II
C. III
D. IV
E. V

The psychiatrist asks for your recommendation for this patient with refractory depression.
What is the best option?
A. Discontinue fluoxetine, and initiate Pristiq.

13.
B. Discontinue fluoxetine, wait 2 weeks, and start Selegiline.
C. Add Abilify to current regimen.
D. Discontinue fluoxetine, and start Lexapro.
E. Add Serax to current regimen.

Which of the following is correct regarding electroconvulsive therapy (ECT)?
A. For maximum effectiveness, seizures should last 5-10 minutes.

14. B. ECT is contraindicated in patients with COPD.
C. ECT is effective treatment for pregnant females with major depression.
D. Memory loss lasting 1-2 weeks is common.
E. ECT may cause amenorrhea in female patients.

A 33-year-old waitress is experiencing symptoms of anxiety, including night terrors and mood
lability. She reports no past psychiatric history but admits that these symptoms started about 2
weeks after armed and masked gunmen robbed her restaurant. She is most likely experiencing
which of the following?
15.
A. LSD
B. PTSD
C. GAD
D. OCD

A new patient presents to your clinic. He reports that it took him 3 hours to get ready for this
appointment and that he returned home several times to check to see if the door was locked.
During the interview, he straightens up your desk, making sure all square items are at right
angles to each other. He would most likely be diagnosed with which of the following?
16.
A. PTSD
B. PCP
C. OCD
D. GAD

Which of the following statements regarding the use of SSRIs in anxiety disorders is most
accurate?
17. A. SSRIs are not usually effective in the treatment of anxiety.

B. SSRI doses for anxiety should be started lower than initial doses for depression.
C. SSRIs should be used only after a failed treatment trial with benzodiazepines.
D. SSRIs may be used on a prn basis when anxiety symptoms emerge.

Which of the following characteristics is not correct regarding benzodiazepines?
A. They potentiate the effect of ³-aminobutyric acid.

18. B. They are highly lipophilic.
C. They are cross-tolerant with alcohol.
D. Their pharmacologic action is similar to that of buspirone.
E. There is risk of seizure if they are abruptly discontinued.

For questions 19-22, one or more of the following answers given are correct. Answer each question
as follows:
A. I only
B. II only
C. I and III only
D. II and III only
E. I, II, and III
Which of the following is true regarding anorexia nervosa (AN)?
I. AN is characterized by recurrent and inappropriate compensatory behavior to prevent weight

19. gain.
II. Patients with AN generally appear to be of normal weight for age and height.
III. AN patients have an intense fear of gaining weight or becoming fat, although they are
underweight.

What DSM-IV criteria for AN are diagnostic for this type of eating disorder?
20. I. Absence of at least three consecutive menstrual cycles

II. Sunken eyes with dark circles underneath
III. A binge eating-purging episode that occurs at least once in the past 6 months

Which of the following is true regarding bulimia nervosa?
I. The individual may consume 5,000-20,000 calories in a single binge episode that may last as
21.
long as 2-8 hours.
II. The two specific types of bulimic patients are purging type and nonpurging type.
III. There is an average of two binges per week for 3 consecutive months.

Patients with AN may demonstrate which of the following characteristics?
22. I. Kleptomania
II. Laxative or diuretic abuse
III. Amenorrhea

Which of the following is the most appropriate treatment for bulimia nervosa?
A. Insight-oriented therapy
23. B. Fluoxetine 20 mg qd
C. Fluoxetine 60 mg qam + cognitive behavioral therapy
D. Olanzapine 10 mg qhs
E. Olanzapine 20 mg qhs + family therapy

25-9. Answers
D. The patient is on haloperidol 10 mg bid. Therefore, to convert to the decanoate injection,

1. the total oral daily dose is multiplied by 10. The dose would be Haldol-D 200 mg IM every 4
weeks.

B. The patient is experiencing a dystonic reaction, which can be treated with either benztropine
1-2 mg IM or diphenhydramine 25-50 mg IM every 30 minutes until resolved. The dystonic
2.
reaction is thought to occur because of an imbalance in dopamine and acetylcholine in the
nigrostriatal region of the brain.

D. Delusions are false beliefs or wrong judgments held with conviction despite
3. incontrovertible evidence to the contrary. Such symptoms are referred to as positive for
patients with schizophrenia.

B. The symptoms that the patient is displaying appear to be the result of neuroleptic malignant
syndrome. All neuroleptics have the propensity to cause this rare but deadly adverse effect. The
4.
first steps in treating NMS are to discontinue the offending agent, offer supportive therapy, and
prescribe a dopamine agonist and (commonly) a skeletal muscle relaxant.

D. Initiation of lithium requires several baseline lab tests: pregnancy test (if patient is female
and of childbearing age), ECG and BP to assess cardiovascular status, thyroid function tests to
rule out euthyroid goiter or hypothyroidism, SCr/BUN (lithium is 100% renally eliminated),
5.
and CBC with differential to evaluate for leukocytosis. Electrolytes should also be evaluated
(decreased sodium can increase lithium levels). Hence, only the pregnancy test should not be
performed, because the patient is male.

A. Common side effects that occur with the initiation of lithium include polyuria, polydipsia,
tremor, and GI upset. Common side effects that may occur later in therapy include weight gain
6.
and mental dulling. Elevated hepatic enzymes and alopecia are side effects that may occur with
divalproex sodium.

C. Agranulocytosis is a side effect that is monitored weekly with clozapine therapy for 6
7.
months. After 6 months, monitoring can be done every 2 weeks for the duration of therapy.

8. E. All of the therapies listed have been used for mood stabilization in bipolar disorder.

C. SSRIs commonly cause insomnia, GI upset, anxiety, headache, and sexual dysfunction.
9.
Phenelzine, amitriptyline, and trazodone cause sedative effects.

D. Because of fluoxetine's long half-life, 5 weeks should pass before initiating MAOI therapy.
10. If fluoxetine is not cleared from the body by the time the MAOI is started, there is a risk of
developing serotonin syndrome.

A. Many medications can cause or worsen depression, such as antihypertensives (reserpine,
methyldopa, propranolol, clonidine); antiparkinsonian agents (levodopa, carbidopa,
11.
amantadine); hormonal agents (estrogens, progesterone); corticosteroids; cycloserine; and the
anticancer agents vinblastine and vincristine.

12. A. Axis I is for clinical disorders.

C. Abilify (aripiprazole) is approved as adjunct treatment for refractory depression. The patient
has already failed a trial with venlafaxine; therefore, initiating therapy with its isomer Pristiq
(desvenlafaxine) may not be the best option. MAOIs are a viable fourth-line treatment option.
13.
However, you would wait 5 weeks after discontinuing fluoxetine before initiating an MAOI.
Lexapro (escitalopram) is an isomer of citalopram, which the patient had already failed.
Benzodiazepines are not recommended for treatment of depression.

C. ECT is a safe and effective therapy for pregnant females and patients with COPD. Relative
contraindications include increased intracranial pressure, recent MI, recent intracerebral
hemorrhage, and cerebral lesions. Memory loss is a common side effect, but it usually occurs
14.
only on the day of treatment and perhaps the following day. The induced seizure lasts 30-90
seconds and is monitored by an EEG. Additionally, ECT does not cause amenorrhea in female
patients.

B. The patient experienced a violent and frightening episode 2 weeks before her symptoms
15. appeared. The symptoms of reexperiencing of the event, night terrors, and mood lability are
common in patients with PTSD.

C. The patient is displaying signs and symptoms of OCD (e.g., a long time is spent getting
ready, and there is repeated checking behavior and preoccupation with rearranging items to 90-
16.
degree angles). These activities are time consuming and limit his social and occupational
functioning.

B. Because SSRIs can be activating and may initially cause symptoms of anxiety, it is
17.
important to "start low and go slow" with these agents when used for anxiety disorders.

D. Buspirone's mechanism of action is agonism of 5-HT1A receptors. Buspirone also possesses
moderate affinity for D2 receptors. It does not interact with the BZD-GABA receptor complex
18.
like the BZDs do. The BZDs cross the blood-brain barrier and are cross-tolerant with alcohol.
If BZDs are abruptly discontinued, seizures can result.

C. Patients with AN refuse to maintain body weight at or above a minimal, normal weight for
age and height (less than 15% of expected body weight). Patients with AN may respond to
19.
antidepressants, but psychotherapy is usually more effective. AN is most commonly seen in
Caucasian, middle- to upper-class females.

A. DSM-IV criteria list the refusal to maintain body weight at or above a minimal, normal
weight for age and height (85% or less of expected body weight and an intense fear of gaining
20.
weight or becoming fat although underweight); disturbance in self-perception of body weight
(i.e., size, proportion, attractiveness); and amenorrhea for at least three consecutive cycles.

21. E. All of the answers are correct regarding bulimia nervosa.

D. Patients with AN commonly reduce weight by reducing food intake. Many patients use
other methods to lose weight such as excessive exercise, laxative or diuretic use, substance
22.
abuse, and self-induced vomiting. Amenorrhea ensues as a result of estrogen deficiency; it may
occur before weight loss.

C. Fluoxetine is approved for treating bulimia nervosa; 60 mg is the most common dose. A
23.
combination of psychotherapy and pharmacotherapy is preferred.

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U.S. Food and Drug Administration. FDA proposes new warnings about suicidal thinking, behavior
in young adults who take antidepressant medications. Available at:
www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2007/ucm108905.htm.
U.S. Food and Drug Administration. FDA public health advisory: Deaths with antipsychotics in
elderly patients with behavioral disturbances. Available at
www.fda.gov/Drugs/DrugSafety/PublicHealthAdvisories/ucm053171.htm.
26. Common Dermatologic Disorders - Shaunta' M. Ray, PharmD, BCPS
26-1. Acne (Acne Vulgaris)
Introduction
Acne is an inflammatory disorder of the pilosebaceous glands that occurs most commonly during
the teenage years, at or soon after puberty. It may reappear later or begin in adults who had clear
skin in their teens, more commonly in women than in men.
Classification and Clinical Presentation
• Type I (comedonal): A mild form, with primarily noninflammatory lesions (open and closed
comedones), relatively few superficial inflammatory lesions, and no scarring
• Type II (papular): A moderate form, with multiple papules on the face and trunk and minimal
scarring
• Type III (pustular): An advanced form that can lead to moderate scarring
• Type IV (nodulocystic): The most severe and destructive form, with multiple deep inflammatory
lesions or nodules (often called cysts) that lead to extensive scarring
Pathophysiology
• Increased sebum production by androgenic hormones at the onset of puberty
• Obstruction of hair follicle opening because of increasing adherence to and production of

epithelial cells, producing closed comedones (whiteheads) that progress ultimately to open
comedones (blackheads)
• Increased growth of a primary microorganism on the skin and in the sebaceous ducts,
Propionibacterium acnes (P acnes), a gram-positive anaerobic rod that produces enzymes
(including lipases)
• Inflammation caused by the enzymatic breakdown of triglycerides into free fatty acids, which
causes the influx of polymorphonuclear leukocytes, ultimately resulting in pustule formation
• Type I (comedonal): Topical nonprescription medications such as benzoyl peroxide, which is

usually the first line of therapy
• Type II (papular): Topical antibiotics, topical retinoids, or both

• Type III (pustular): Oral antibiotics in addition to topical medications
• Type IV (nodulocystic): Isotretinoin
Topical Therapy
Nonprescription agents
Benzoyl peroxide is the most effective over-the-counter (OTC) agent. Benzoyl peroxide products
2.5, 5, and 10% are as follows:
• Clean and Clear Gel
• Clearasil maximum strength vanishing cream
• Clearplex
• Exact Acne Medication
• Fostex
• Neutrogena On the Spot Acne Treatment
• Noxzema antiacne lotion
• Oxy-10 Balance Spot Treatment and Face Wash
• Panoxyl Bar
• Stridex Power Pads
• Zapzyt gel
Mechanism of action
These agents destroy the anaerobic P acnes through the release of oxygen. An exfoliant effect
occurs, causing peeling of the outer layers of the skin.
P acnes does not become resistant to benzoyl peroxide; therefore, it can be used concurrently with
topical antibiotics to prevent resistance (e.g., using benzoyl peroxide for one course of therapy,
alternating with a course of topical antibiotic therapy).
Patient counseling
• Use with caution with sensitive skin.

• Do not allow contact with eyes, lips, or mouth.
• Avoid unnecessary sun exposure and use sunscreen.
Adverse effects
• These agents may cause redness, dryness, burning, itching, peeling, and swelling.
• They may bleach hair or dyed fabrics.
Other products
• Sulfur (1-10%): Products include Bye Bye Blemish—sulfur 10% (keratolytic and antibacterial
action)
• Salicylic acid (0.5-2.0%): Products include Clearasil Clearstick, Neutrogena Rapid Defense,
Noxzema, and Stridex—irritant effect, keratolytic action, and increase in rate of turnover of
epithelial cells
• Resorcinol: Keratolytic action (usually combined with sulfur)
• Combinations such as sulfur and resorcinol: Clearasil and Acnomel
• Medicated soaps and cleansers: Alcohol, acetone, and other degreasing lotions
Topical antimicrobial therapy
Topical antimicrobials are outlined in

Table 26-1.
[Table 26-1. Topical Antimicrobials]
Clindamycin
Mechanism of action
Clindamycin suppresses growth of P acnes. It may directly reduce free fatty acid concentrations on
the skin.
Patient counseling
• Contact physician if no improvement is seen within 6 weeks.
• Discontinue medication and contact physician if severe diarrhea or abdominal cramps or pain
develop.
Adverse effects
• Contact dermatitis or hypersensitivity
• Dry or scaly skin or peeling
• Rarely, pseudomembranous colitis (severe abdominal cramps, pain, bloating, and severe diarrhea)
Erythromycin
Mechanism of action
Erythromycin suppresses growth of P acnes.
Patient counseling
• Wait at least 1 hour before applying any other topical acne medication.
• Avoid contact with eyes, mouth, nose, and other mucous membranes.
• Although improvement is generally expected within 4 weeks, some patients do not respond for 8-
12 weeks.
Adverse effects
• More common: Dry or scaly skin, irritation, and itching
• Less common: Stinging sensation, peeling, and redness
Retinoids
See
Table 26-2 for information about retinoids.
Mechanism of action
• Retinoids are chemically related to vitamin A.
• Retinoids normalize follicular keratinization, heal comedones, decrease sebum production, and
decrease inflammatory lesions.
Patient counseling
• Do not use astringents, drying agents, abrasive scrubs, or harsh soaps concurrently, and use mild
soap only once or twice daily.
[Table 26-2. Retinoids]

• Apply every other night to adjust to drying effect for the first 2 weeks.
• Apply nightly after 2 weeks.
• Expect that it may take up to 2-3 months for skin to improve.
• Use sunblock on face before sun exposure because of increased sensitivity.
• These agents may irritate skin and cause redness, dryness, and scaling.
• Tazarotene is the most irritating retinoid.
• Adapalene appears to be least irritating and is preferred for sensitive skin.
Azelaic acid 20%
Trade names are Azelex and Finacea.
Mechanism of action
Axelaic acid 20% suppresses growth of P acnes. It improves inflammatory and noninflammatory
lesions. It normalizes keratinization, leading to an anticomedonal effect.
Patient counseling
• If sensitivity develops, discontinue use.
• Keep away from mouth, eyes, and mucous membranes.
• Other topical medications must be used at different times during the day.
• Temporary dryness and skin irritation (pruritus and burning) may occur on initiation of therapy.
• Hypopigmentation may occur (caution in dark-skinned individuals).
Systemic Therapy
Antimicrobials
Antimicrobials are useful for type II (papular) acne and type III (pustular) acne.
Dosing
See
Table 26-3 for information about dosage. After 6-8 weeks, dosage may be increased if necessary. If
the first antibiotic was ineffective after increasing the dosage, a second antibiotic is prescribed.
After 6 months to 1 year of therapy, the antibiotic dose may be tapered if continued at all.
Mechanism of action
Antimicrobials suppress growth of P acnes in sebaceous ducts. These agents possibly have a direct
anticomedonal effect.
Patient counseling, adverse drug effects, and drug interactions

See chapter on anti-infective agents.
Isotretinoin
Isotretinoin is available in 10, 20, and 40 mg capsules. Trade names are Accutane, Amnesteem,
Claravis, and Sotret.
Isotretinoin is for patients with severe, nodulocystic, draining acne who have not responded to
systemic antibiotic therapy or who have required more than 3 years of systemic antibiotic therapy.
This agent is over 90% effective in producing an acne-free state for years following a 4- to 5-month
course of therapy. Originally held in reserve for severe cases of nodulocystic acne, it may also be
indicated as first-line treatment for severe acne that results in scarring.
[Table 26-3. Oral Antimicrobials]
iPLEDGE program
The U.S. Food and Drug Administration (FDA) has approved an enhanced risk management
program designed to minimize fetal exposure to isotretinoin known as iPLEDGE, which replaced
the S.M.A.R.T. (System to Manage Accutane Related Teratogenicity) Program on December 30,
2005. iPLEDGE requires mandatory registration of prescribers, patients, wholesalers, and
pharmacies to further the public health goal of eliminating fetal exposure to isotretinoin.
Pharmacies are not able to dispense isotretinoin to people with severe acne who do not enroll in the
iPLEDGE program through a physician who is also enrolled. After a pharmacy registers for
iPLEDGE at www.ipledgeprogram.com, the "Responsible Site Pharmacist" is sent a follow-up
mailing, which contains instructions on how to activate the pharmacy.
The iPLEDGE program requires that all patients meet qualification criteria and monthly program
requirements. Before the patient receives his or her isotretinoin prescription each month, the
prescriber must counsel the patient and document in the iPLEDGE system that the patient has been
counseled about the risks of isotretinoin.
Mechanism of action
Isotretinoin reduces sebum production (up to 90% inhibition). It decreases production of
microcomedones, possibly by decreasing cohesiveness of follicular epithelial cells. It can have an
anti-inflammatory effect.
Patient counseling
• Isotretinoin should be taken with food and is best absorbed with a fatty meal.
• Patients can take the dose divided twice daily or the entire dose with the evening meal.
• Effects are gradual, and acne may worsen during the first month of therapy; however,
improvement usually begins by the sixth week of therapy.
• Use lip balm to treat cheilitis and moisturizers to treat dry skin.

Isotretinoin is teratogenic. It is absolutely contraindicated in pregnancy because it causes significant
birth defects. Females of childbearing potential must take measures to avoid pregnancy during the
course of isotretinoin therapy.
Females should be tested for pregnancy before initiation of therapy and told to use two methods of
contraception for at least 1 month prior to initiation of therapy and for 1 month after discontinuation
of therapy.
Side effects and toxicity
• Most common (90-100%):
• Cheilitis (chapped lips)
• Dry mouth
• Dry skin
• Pruritus
• Common (30-40%):
• Dry nose, leading to nasal crusting and epistaxis
• Dry eyes, leading to conjunctivitis and problems with contact lenses
• Muscular soreness or stiffness

• Less common (10-25%):
• Headaches
• Hyperlipidemia (primarily elevation of triglycerides, which may lead to attack of pancreatitis)
• Rare (less than 5%):
• Decreased night vision
• Thinning of hair
• Easily injured skin
• Peeling of palms and soles
• Skin rash and skin infections
• Very rare (< 1%):
• Acute depression (very rare, but reversible if detected early)
• Pseudotumor cerebri (benign intracranial hypertension with visual disturbances)
• Treatment of most common side effects:
• Cheilitis: Frequent use of lip balm
• Dry skin: Skin lubrication with moisturizers
• Nosebleeds: Lubrication of the nostrils with petrolatum
• Muscular soreness or stiffness: Use of mild OTC analgesic and anti-inflammatory agents
• Lipid panel
• Liver function tests (elevations common during initiation of therapy; usually return to normal
during treatment).
• Complete blood counts
• Pregnancy testing for women prior to use of drug

Dosing
The dosage is 1 mg/kg once or twice daily with food; however, the patient may start out with 0.5
mg/kg/d for the first month before increasing. The drug is best absorbed with a fatty meal.
The goal is a total dose of 120-150 mg/kg over 4-5 months. Longer courses of 6-8 months may be
required.
Other aspects
Approximately 20% of patients relapse within 1 year, and up to 40% relapse within 3 years after
discontinuation of therapy. Repeat therapy for 4-6 months is acceptable and effective.
Oral corticosteroids
Oral corticosteroids are commonly known as prom pills. These agents can temporarily suppress
acne with a 7- to 10-day course of prednisone 20 mg daily. They are rapidly effective when a brief
course is necessary to cause prompt improvement (e.g., important social event such as wedding,
prom, and so forth).
Systemic corticosteroids used continuously may actually cause or worsen acne. Topical
corticosteroids have no value in the treatment of acne, and the high-potency topical corticosteroids
will aggravate acne and should never be used on the faces of acne patients.
26-2. Fungal Skin Infections
Introduction
Tinea are skin infections known as dermatomycoses caused by the fungi Trichophyton,
Microsporum, and Epidermophyton.
Classification
• Tinea pedis (athlete's foot)
• Tinea capitis (ringworm of the scalp)
• Tinea cruris (jock itch)
• Tinea corporis (ringworm of the skin)
• Tinea unguium (onychomycosis; fungal infection of toenails and fingernails)
Pathophysiology
The fungi invade dead cells of the stratum corneum of skin, hair, and nails, digesting keratin.
Unlike Candida, they cannot exist on unkeratinized mucous membranes.
This condition is more common in immuno-suppressed patients.
• Tinea pedis: Self-treat topically initially; if ineffective, add orals.
• Tinea capitis: Use oral systemic therapy.
• Tinea cruris: Self-treat topically initially; if ineffective, add orals.
• Tinea corporis: Self-treat topically initially; if ineffective, add orals.
• Tinea unguium: Use oral systemic therapy.
Drug Therapy
OTC treatment
• Terbinafine 1% (Lamisil AT) cream, gel, and spray (most effective OTC antifungal agent)
• Miconazole 2% (Micatin, Cruex Spraypowder)
• Clotrimazole 1% (Lotrimin AF lotion, solution, and cream; Desenex AF)
• Tolnaftate 1% (Tinactin, Blis-To-Sol, Ting)
• Undecylenic acid 10-25% (Desenex)
Prescription treatment
See
Table 26-4 for a description of prescription drugs.
Topicals
Newer antifungals are initially applied only once daily, and recurrences can be prevented by once-
or twice-weekly applications.
Systemic therapy
Occasionally, topical therapy is not effective for tinea pedis, tinea cruris, and tinea corporis, and
systemic antifungal therapy is required. Systemic therapy is also required for tinea capitis
(ringworm of the scalp) and tinea unguium (fungal infection of the toenails and fingernails).
Medications are as follows:
• Griseofulvin
• Ketoconazole
• Fluconazole
• Itraconazole
• Terbinafine
See chapter on anti-infective agents for discussion of systemic antifungals.
[Table 26-4. Prescription Topical Antifungals]
26-3. Hair Loss (Alopecia)
Introduction
Male pattern baldness (androgenic alopecia) is the gradual and progressive loss of hair in males as
they age.
• Onset and progression vary greatly.
• A distinct pattern of progressive hair loss develops in the frontotemporal areas and crown with
sparing of the occiput.
• Hair loss is limited to the scalp.
• Miniaturization of hair is seen, where normal thick terminal hairs are converted to very fine vellus
hairs.
Pathophysiology
Alopecia is primarily due to two factors:
• Heredity (genetic)
• Testosterone
Testoterone, which promotes growth of hair in the beard, axillae, pubis, and other parts of the body,
does not promote the growth of scalp hair. It actually contributes to premature loss because it is
converted by the enzyme 5- -reductase to dihydrotestosterone, which binds preferentially to
receptors in the hair follicles on the scalp and causes them to produce progressively thinner hair
until the follicles eventually cease activity altogether.
Although there is no cure for androgenic alopecia, two drugs are available for its treatment:
• Minoxidil (Rogaine, available OTC)
• Finasteride (Propecia, by prescription only)
In alopecia's early stages, topical minoxidil or oral finasteride may reverse the gradually decreasing
diameter of the hair shaft.
Any hair growth stimulation is temporary and lasts only as long as therapy continues. If therapy is
discontinued, new hair growth is lost within 1 year.
Early hair loss occurring recently in younger men is more likely to respond than later hair loss at an
older age or when hair loss is not recent.
Alopecia of the crown in males responds better than does hair loss in the frontotemporal area.
Drug Therapy
Minoxidil
OTC trade names are Rogaine 2% and Rogaine Extra Strength 5%.
Mechanism of action
Minoxidil probably increases cutaneous blood flow directly to hair follicles due to vasodilation. It
possibly stimulates resting hair follicles (telogen phase) into active growth (anagen phase). It
possibly stimulates hair follicle cells.
Patient counseling
• Apply 1 mL twice daily (approximately one 60 mL bottle each month).
• Minoxidil may be applied without shampooing hair.
• Use at least 4 hours before bedtime to avoid oil on pillows and bed linens.
• The drug is absorbed over a 4-hour period, so do not swim, shampoo, or walk in rain for 4 hours.
• Wash hands immediately after application to prevent unwanted absorption.
• Do not inhale mist because systemic absorption is possible.

• Do not use on infected, irritated, inflamed, or sunburned skin.
• Discontinue use immediately and contact physician if chest pain, increased heart rate, faintness or
dizziness, or swollen hands or feet occur.
• Women should avoid 5% strength (which has no better results than 2%); they have greater
incidence of increased growth of facial hair with the 5% solution.
• Generally, treatment takes 4-6 months before any benefit occurs.
• No effects within 8 months for females and 12 months for males indicate therapeutic failure, and
treatment should be discontinued.
• Patients must continue using minoxidil to maintain new hair growth.
• Scalp dermatitis is common, producing dryness, pruritus, and flaking or scaling.
• Hypertrichosis (excessive hair growth) can occur on areas other than scalp (chest, forearms, ear
rim, back, face, arms, and so forth).
• Some women report unwanted facial hair growth when minoxidil is applied to scalp, primarily
with the 5% solution.
• Use may rarely produce systemic side effects (chest pain, increased heart rate, and faintness or
dizziness).
• Use is contraindicated in patients less than age 18.
• Use is contraindicated in women who are pregnant or breastfeeding.
Finasteride
The trade name of finasteride is Propecia 1 mg. It was originally approved in 1992 for the treatment
of enlarged prostate glands (benign prostatic hypertrophy) in a 5 mg dose (Proscar). A 1 mg daily
dose is approved for males only as prescription treatment for androgenic alopecia.
Over a 2-year period, it may halt the progressive hair loss of androgenic alopecia.
Mechanism of action
Finasteride inhibits the enzyme 5- -reductase, which is responsible for the conversion of
testosterone to the more powerful dihydrotestosterone—the main androgen responsible for
androgenic hair loss.
Patient counseling
• Take with or without food.
• Take for at least 3 months to see if the drug is effective.
• Improvement lasts only as long as treatment continues (new hair will be lost within 1 year of
stopping treatment).
• Gynecomastia (breast enlargement and tenderness) has been reported from 2 weeks to 2 years
following initial therapy, but it is usually reversible when therapy is discontinued.
• Hypersensitivity (skin rash, swelling of lips)
• Decreased libido, erectile dysfunction, and ejaculatory dysfunction occur, which are reversible
when the drug is discontinued.
• Use is contraindicated in females of childbearing age, because of abnormalities of the external

genitalia in male fetuses; it is also not effective in postmenopausal females.
26-4. Dry Skin
Introduction
This condition refers to lack of moisture or sebum in the stratum corneum. It most commonly
occurs in the winter (also known as winter rash). It is more commonly present in older adults.
• Flaking and scaling
• Xerosis and roughness
• Pruritus
• Loss of skin elasticity
Pathophysiology
Dry skin is due to inadequate moisture retention in the stratum corneum, which is caused by the
following factors:
• Decreased sebum production and decreasing moisture-binding capacity of skin in elderly patients
• Low humidity, which causes the skin to lose water and become dry and hardened
• Overexposure to sunlight
• Excessive cleansing and bathing, which removes lipids and other skin components
• Chronic skin diseases that impair moisture retention of skin (psoriasis, scleroderma, ichthyosis,
contact dermatitis)
The goal of treatment is to increase the moisture level of the stratum corneum by increasing cell
hydration and binding capacity, which improves skin permeability and restores elasticity.
Drug Therapy
Emollients and moisturizing agents
Emollients and moisturizing agents include petrolatum and mineral oil (Lubriderm Bath and
Shower Oil). They increase the relative moisture content of the stratum corneum and produce a
general soothing effect by reducing frictional heat and perspiration.
Humectants
Humectants include glycerin (Corn Husker's Lotion), propylene glycol, and phospholipids. They are
hygroscopic agents that increase hydration of the stratum corneum.
Keratin-softening agents
Keratin softening agents include the following:
• Urea (10-30%) (Aquacare and Carmol)
• Improves the skin's moisture-binding capacity
• Provides keratolytic effect at higher concentrations
• May cause irritation and burning
• Lactic acid (2-5%) (LactiCare)
• Increases skin hydration by controlling the rate of keratinization
• Is markedly hygroscopic
• Allantoin (Alphosyl, Psorex, Tegrin)
• Relieves dry skin by disrupting keratin structure (less effective than urea)
• Desensitizes many skin-sensitizing drugs as a protectant
Antipruritic agents
Antipruritic agents include the following:
• Camphor and menthol, which provide a cooling sensation
• Local anesthetics (e.g., benzocaine, pramoxine)
• Systemic antihistamines (H1-receptor antagonists), which have limited effectiveness
• Colloidal oatmeal (Aveeno)
Caution: Colloidal oatmeal can cause an extremely slippery bathtub.
Hydrocortisone
Hydrocortisone reduces the inflammatory response that accompanies dry skin conditions. Although
it does not directly increase skin hydration, it does prevent itching associated with dry skin and
inhibits dehydration.
Ointment is better than cream for dry skin. Patients should be counseled as follows.
• Use sparingly.
• Do not use more than 5-7 days for dry skin pruritus.
Astringents
Astringents include aluminum acetate 0.1-0.5% (Burow's solution) and hamamelis water (witch
hazel).
Protectants
Zinc oxide is a protectant.
Nondrug Recommendations and Therapy
• Bathe less frequently.

• Reduce use of soap to a minimum and use only where necessary.
• Lubricate skin immediately after bathing (i.e., apply bath oil after bathing and before drying).
• Use extrafatted soaps such as Basis.
Combination products to treat dry skin
• Alpha Keri Moisture Rich Cleansing Bar: Mineral oil, lanolin oil, and glycerin
• Aveeno Bath Treatment Moisturizing Formula: Colloidal oatmeal and mineral oil
• Jergens Advanced Therapy Ultra Healing Lotion: Dimethicone, lanolin, cetyl alcohol,
isopropyl myristate, and glycerin
• Keri Original Dry Skin Lotion: Mineral oil, lanolin oil, glyceryl stearate, and propylene glycol
• Moisturel Cream and Lotion: Petrolatum, dimethicone, cetyl alcohol, and glycerin
• Neutrogena Body Oil: Isopropyl myristate and sesame oil
• Pacquin Plus Dry Skin Hand and Body Cream: Lanolin anhydrous, cetyl alcohol, and glycerin
• Vaseline Dermatology Formula Lotion: White petrolatum, mineral oil, dimethicone, glyceryl
stearate, cetyl alcohol, and glycerin
26-5. Dermatitis
Introduction
Dermatitis is a nonspecific term describing a variety of inflammatory dermatologic conditions

characterized by erythema. It is a general term describing any eczematous rash of unknown etiology
that cannot be classified among the major endogenous dermatoses. Eczema and dermatitis are often
used interchangeably.
Types and Classification
Several of the major classifications or types of dermatitis are
• Atopic dermatitis (atopic eczema)
• Chronic dermatitis (hand dermatitis)
• Contact dermatitis (irritant and allergic)

Atopic dermatitis (atopic eczema)
Atopic dermatitis occurs primarily in infants and children. It may disappear before adulthood. The
cause is unknown but is possibly genetic.
Atopic dermatitis is usually seen on the face, knees, elbows, and neck. It is frequently seen with
asthma, allergic rhinitis, and urticaria. Exacerbating factors include soaps, detergents, chemicals,
temperature changes, molds, and allergens.
Chronic dermatitis (hand dermatitis or hand eczema)
Chronic dermatitis is a stubborn itchy rash referred to as eczema that occurs in certain persons with
sensitive or irritable skin. The skin is very dry and easily irritated by overuse of soaps or detergents
and by rough woolen clothing.
The condition is exacerbated by very hot or very cold weather. It is probably genetically
determined. No permanent cure exists.
The condition usually can be controlled by enhancing skin hydration with emollients and
moisturizers and by using hydrocortisone cream to relieve itching.
Contact dermatitis
Irritant contact dermatitis (chemical contact dermatitis)

The condition is caused by exposure to irritating substances producing mechanical or chemical
trauma. Examples include soap, solvents, paints, abrasive cleansers, cosmetics, lubricants,
antiseptics, cacti, rose hips, thorns, peppers, and tobacco.
Irritant contact dermatitis is not a sensitization, but direct toxicity to skin tissue.
Allergic contact dermatitis

The condition is a process of sensitization with reaction on elicitation. Over 50% of all dermatitis is
allergic contact dermatitis.
Examples of reactive elements include benzocaine, zinc pyrithione (ZPT), neomycin, sodium
bisulfite, perfumes, many cosmetics, skin lubricants, antiseptic creams, rubber and epoxy glues,
poison ivy and oak, and many other common substances.
Treat dermatitis by applying a corticosteroid, according to the following principles:

• Ointments and creams are more lubricating than solutions, lotions, or gels.
• Ointments should be recommended if skin is dry.
• Lotions or gels should be recommended for a weeping, eczematous dermatitis.
• Lotions, solutions, and gels are also easier to use in hairy areas of the body.
• Apply small amounts of corticosteroid cream or ointment, and massage in gently but thoroughly.
• Apply the moderate- and high-strength cortisones only once daily.
• Improvement should begin within 1 week.
• Avoid excess soap, and keep skin lubricated with moisturizers.
• Treat itching with camphor, menthol, phenol, or local anesthetics.
• Occasionally with severe cases (less than 5%), patients may have to use systemic corticosteroids
for 1-2 weeks.
Drug Therapy
Topical corticosteroids
See
Table 26-5 for information about topical corticosteroids.
Adverse effects
• Striae may result in skin folds.
• Thinning of epidermis occurs where subcutaneous vessels become visible.
• The more potent types can cause or aggravate acne or rosacea on the face.
• Percutaneous absorption can lead to systemic effects (see Chapter 14 on endocrine drugs for
complete list of systemic adverse effects).
• Hyperglycemia
• Glycosuria
• Hypothalamic-pituitary-adrenal axis suppression, which could pose a threat in case of surgery,

systemic illness, or trauma or injury
• Percutaneous absorption leads to systemic effects most likely with the following:
• The higher potency types of agents
• Inflamed skin (also in infants and children)
• Long-term use or use over a large area of the skin
• Caution: Occlusion markedly increases absorption of topical corticosteroids and should

therefore be used cautiously in limited areas and reserved for severe, resistant lesions.
Topical antipruritics
Topical antipruritics include the following:
• Local anesthetics (benzocaine up to 20%, pramoxine 1%)
• Benzyl alcohol
• Colloidal oatmeal (Aveeno)
• Others (camphor, menthol, phenol)
Emollients
• Petrolatum
• Lanolin
• Mineral oil
[Table 26-5. Typical Pharmaceutical Ingredients]
Topical immunomodulators
Topical immunomodulators are approved for atopic dermatitis. They inhibit activation of T-cells
and release of certain inflammatory mediators (cytokines).
The medication is applied bid, with onset in 1-3 weeks. Side effects include stinging, burning,
pruritus, and rare flu-like symptoms. Patients should be cautioned to use sunscreen.
Immunomodulator products are as follows:
• Tacrolimus (Protopic) 0.03% and 0.1% ointment

• Pimecrolimus (Elidel) 1% cream
Oral corticosteroids
Corticosteroids are the only systemic anti-inflammatory agents that are effective.
Oral antihistamines
Oral antihistamines have very limited effectiveness but are possibly antipruritic.
26-6. Poison Ivy, Poison Oak, and Poison Sumac Allergy (Rhus Dermatitis)
Introduction
Allergic reaction occurs to sap (urushiol) of some plants of the genus Rhus (poison ivy, poison oak,
poison sumac). Rhus dermatitis is the most common form of allergic contact dermatitis.
Direct contact with leaves, roots, or branches is not required to get a rash. Sap can reach skin
indirectly from clothing, a pet, or burning (volatilization).
A Rhus allergy is acquired; individuals are not born with it. Most persons are sensitized to Rhus
because it is such a common plant; however, some people are never allergic to it. No effective way
exists to desensitize a person with an allergy to Rhus plants.
Types and Classification
• Mild: Localized patches of pruritus and erythema develop, followed by appearance of vesicles
and papules on the upper or lower extremities.
• Moderate: Extensive pruritus and irritation develop, with severe vesicles and appearance of
bullae and edematous swelling.
• Severe: Extreme pruritus, irritation, and severe vesicle and bullae formation appear. Extensive
involvement occurs, widespread over the body, face, or both. Extensive edema of the extremities
or face develops. Eye, genitalia, or mucous membrane are involved.
• Rhus dermatitis is not contagious.
• Fluid in blisters does not spread rash.
• Rash appears after a latent period that varies from 4 hours to 10 days, depending on an individual's
sensitivity and the amount of plant contact.
• When more rash appears after treatment has begun, these are areas with a longer latent period.
• Symptoms may last from 5 to 21 days following initial rash.
• Secondary infections can occur if scratching excoriates the skin and the abrasions become
infected.
Rhus dermatitis is self-limited. Mild cases will clear without treatment within 7-14 days.
The goal of treatment is to prevent itching and excessive scratching and possible secondary skin
infections.
Treatment options
• Mild cases: Use topical antipruritics, such as calamine, camphor, menthol, phenol, or local
anesthetics to prevent itching and topical hydrocortisone cream or ointment.
• Moderate cases: Use topical high-potency corticosteroids for small areas.
• Severe cases: Use systemic corticosteroids daily up to 2 weeks. Severe rash needs systemic
corticosteroids to ease the misery and disability. Systemic corticosteroids are usually needed
during early severe stages because remedies applied to skin may not penetrate deeply enough.
Therapy
OTC topical therapy
Astringents and protectants

Compresses, soaks, or wet dressings will dry the oozing, reduce the weeping, aid in removal of
crusts, and soothe the skin. They include
• Aluminum acetate solution 1:40 ratio (Burow's solution)
• Aluminum sulfate (Domeboro powder)
• Calamine lotion
• Other products such as aluminum hydroxide gel, kaolin, zinc acetate, zinc carbonate, and zinc
oxide
Local anesthetics
These products may contain benzocaine up to 20%, pramoxine 1%, and benzyl alcohol. They
include
• Caladryl lotion: Calamine and pramoxine 1%
• Ruli calamine spray: Calamine, benzocaine, and camphor
• Ivarest 8-Hour Medicated Cream: Calamine and diphenhydramine 2%
• Ivy Dry Cream: Benzyl alcohol, camphor, menthol, and zinc acetate
Other products
Other products include
• Hydrocortisone 1% products
• Colloidal oatmeal (Aveeno) for temporary skin protection from exposures
• Cool compresses
Prescription topical therapy
Use topical medium- to high-potency corticosteroids (see discussion on allergic contact dermatitis
in Section 26-5).
Prescription systemic corticosteroid therapy
Use of systemic corticosteroids is the only therapy that will actually reduce the severity and
duration of the allergic response. See the discussion on allergic contact dermatitis in Section 26-5
and the discussion on endocrine disorders in Chapter 14 for complete details.
Effects of oral corticosteroids are dramatic (patients can take up to 40-100 mg prednisone for 2 or 3
weeks if necessary); however, many patients clear up quickly with a corticosteroid dosepak (e.g.,
Decadron or Medrol). Extremely severe cases or large-scale rash may require parenteral dose of
corticosteroid (100 mg prednisone equivalent).
Other recommendations
Prevention
• Avoidance: Identify the plants—"leaves of three, let it be."
• Removal: Washing with soap and water within 15 minutes of exposure may reduce the extent and
duration of dermatitis.
• Use of bentoquatam 5% solution: Marketed under the trade name Ivy Block, this lotion is an
organoclay. It is the only barrier product approved by the FDA. Patient instructions are to apply
the lotion 15 minutes before possible plant contact and reapply every 4 hours.
26-7. Scaly Dermatoses
Introduction
There are three common forms of scaly dermatoses: dandruff, seborrhea, and psoriasis.
Dandruff
Dandruff is a chronic, noninflammatory scalp condition resulting in excessive scaling of the scalp
epidermis. It is a common condition affecting 20% of the population. Though not a serious disorder,
dandruff can be cosmetically unsightly.
Scaling and pruritus occur, causing white flakes to accumulate on the scalp.
Pathophysiology
Increased epidermal cell turnover rate of approximately twice normal (time reduced from 25-30
days to 13-15 days) prevents complete keratinization of desquamated cells due to unknown
processes. Dandruff may be related to increased Pityrosporum ovale (P ovale), a fungal scalp
organism.
Treatment
Routine shampooing with mild hypoallergenic shampoo is essential.
Cytostatic agents
Cytostatic agents suppress cell turnover. The goal is to reduce the epidermal rate of turnover of
scalp cells. Agents and their mechanisms of action are as follows:
• ZPT (0.3-2%): Products include Denorex, Head and Shoulders, Sebulon, X-Seb, and Zincon.
ZPT has antifungal effect and reduces cell turnover rate.
• Selenium sulfide 1%: Products include Head and Shoulders Intensive Treatment, Selsun Blue
1%, and Selsun 2.5%. Selenium sulfide reduces the cell rate turnover and inhibits growth of P
ovale.
• Coal tar: Products include Balnetar, Denorex, DHS Tar, Ionil T, Neutrogen T, Pentrax, and
Polytar. Coal tar reduces the number and size of epidermal cells.
Patient should be counseled that contact time with cytostatic agents is very important for
effectiveness. Advise patients to rub shampoo in well and leave it in up to 5 minutes before rinsing
it out.
Keratolytic agents
Keratolytic agents include the following:
• Salicylic acid (1.8-3%): Products include Ionil, Neutrogena, Scalpicin, and Sebucare. Salicylic
acid can lower the pH of tissues, thereby increasing the water concentration of epidermal cells,
which softens and destroys the stratum corneum. It causes the upper skin layer to become
inflamed and soft, followed by desquamation. This keratolytic action removes the scales of
dandruff.
• Sulfur (2-5%): Products include Sulfoam, Sulray, and Exsel. Sulfur possibly exerts an antifungal
effect. Sulfur is usually found in combinations with salicylic acid.
• Combination of sulfur and salicylic acid: Products include Meted and Sebulex.
Antifungals
Antifungals include the following:
• Ketoconazole (1%) shampoo (Nizoral AD)
• Ciclopirox 1% shampoo (Loprox)
Ciclopirox is active against P ovale. Patients should be counseled to use it twice weekly or every 3
or 4 days. Stress adequate contact time for a minimum of 3 minutes. Adverse effects include
itching, stinging, or irritation.
Seborrhea (Seborrheic Dermatitis)
Seborrhea is a chronic inflammatory skin disease in areas of greatest sebaceous gland activity—on
the scalp and other hairy areas such as the face, trunk, armpits, and groin. Seborrhea is not
contagious. It persists for life, but it can be controlled.
• Scaling rash accompanied by pruritus
• Yellowish, greasy scales unlike the dry scales of dandruff
• Inflammation, often accompanied by erythema
• Fluctuation in severity, characterized by exacerbations and remissions
• Most common on the face, eyebrows, and eyelashes, but not on the extremities
• Aggravated and worsened by nervous stress and poor health
Pathophysiology
• Accelerated cell turnover rate is approximately three times normal rate, probably as few as 9-10
days.
• Seborrhea has a higher cell turnover rate than dandruff, but less than psoriasis.
• P ovale may be causative, but this is not universally accepted.
Treatment
Treatment is similar to that for dandruff, but seborrhea is more difficult to treat. Overuse of
selenium can make the scalp oily and actually exacerbate seborrhea.
Topical corticosteroids (e.g., Cortaid) are used to control itching and inflammation (up to 7 days)
Add the topical antifungal ketoconazole 1% shampoo (Nizoral AD) or ciclopirox 1% shampoo
(Loprox). The combination is active against P ovale. Patients should be counseled to use it twice
weekly, every 3 or 4 days. Stress adequate contact time; leave it in for at least 3 minutes. Adverse
effects include itching, stinging, or irritation.
"Cradle cap" (infantile seborrheic dermatitis)
Cradle cap is seborrhea of the scalp in newborns or infants. It is most common in the first few
months of life. It is usually on top of head and may be due to poor washing.
Cradle cap is probably not related to fungal infection. It is treated as follows:
• Massage with oils.
• Use nonmedicated shampoos.
• Use milder keratolytics (Meted and Sebulex) two or three times per week.
Psoriasis
Psoriasis is a chronic inflammatory papulosquamous erythematous skin disease. It is marked by the

presence of silvery scales with sharply delineated edges. Lesions are usually localized, but can
gradually grow to cover large areas.
Psoriasis can have significant physiological and psychological effects. It affects 1-3% of the
population, 98% Caucasian.
Classification
• Type I: Characterized by early age of onset, family history, and increased frequency of human
lymphocyte antigen
• Type II: Characterized by development later in life and no family history
Pathophysiology
A hyperproliferative skin condition results from skin cell turnover rate of approximately 10-20
times normal. Skin cells of psoriatic plaque reach the outermost layer in 3-4 days.
A genetic predisposition contributes, as well as exposure of the skin to trauma or triggering factors
such as stressful incidents.
• Plaque is most common and is known as psoriasis vulgaris.
• Plaque is known also as scales—silvery on top and pink to red beneath.
• Plaque may be found anywhere on the body, but more likely on scalp, sacral area, and extensor
surfaces of knees and elbows (less common on face).
• Borders of plaque are sharp with inflammation surrounding the plaque.
• Psoriasis is a chronic condition and varies from mild forms of the disease to very severe, with
such extensive coverage that it hinders social and work life.
• It is marked by spontaneous exacerbations and remissions.
Treatment
Topicals
Topical treatments are as follows:
• Topical corticosteroids
• Coal tar (contained in Denorex, DHS, Ionil T, MG217, Neutrogena T, Pantene Pro-V, Polytar,
Tegrin, and X-Seb T Plus)
• Keratolytics (salicylic acid, sulfur)
• Combinations of salicylic acid, sulfur, and coal tar (Sebutone)

• Retinoids (tretinoin, adapalene, tazarotene, alitretinoin)
• Anthralin (Anthraforte, Anthranol, Dritho-Scalp)
• Calcipotriene (Dovonex ointment, cream, and solution—a vitamin D3 analog)
Caution: If used in conjugation with PUVA (psoralens with ultraviolet-A) therapy, calcipotriene
should be applied after light treatment, because PUVA inactivates this product.
Systemic treatment
Systemic treatment may involve the following:
• Oral corticosteroids
• Antimetabolites, such as methotrexate and cyclosporine
• Psoralens (combined with ultraviolet light therapy)
• Immunosuppressants, such as alefacept (Amevive) and etanercept (Enbrel)
• Retinoids, such as acitretin (Soriatane)
Vitamin A analogs are reserved for severe and extensive psoriasis. Their effectiveness approaches
that of methotrexate or cyclosporine when combined with ultraviolet light therapy. Adverse effects
include dry lips, skin, nail changes, dry eyes, hair loss, hyperlipidemia, pancreatitis, hepatotoxicity,
myalgias, and arthralgias. Such drugs are teratogenic. The above listed AE are primarily with
systemic therapy; however, topical therapy may also be teratogenic.
Other therapy
Ultraviolet light therapy is also used, often following coal tar applications or concurrent with oral
psoralens.
26-8. Pediculosis
Introduction
Head lice is the primary or most common form of pediculosis. Lice are very common, especially in
schoolchildren. They are transmitted by direct contact with the head of an infected individual or
through fomites (inanimate objects capable of transmitting disease, such as shared combs, brushes,
or headwear). Lice are most common in August and September, after long holidays or summer
camps.
Body lice are a less common form that usually occur in individuals who do not change clothing
often (e.g., the homeless).
Pubic lice (crab lice) are transferred through sexual contact and are found primarily in pubic areas,
but they can also affect armpits.
Classification
There are three types of human pediculosis:
• Head lice: Pediculus humanus capitis
• Body lice: Pediculus humanus corporis (same species as head lice)
• Pubic lice: Pthirus pubis (different species)
• Pruritus is the most common symptom.
• Because lice are often symptomatic, diagnosis is made visually by seeing live lice.
• The flat, gray-brown adult lice are difficult to locate or visualize; the nits (larvae) firmly attached
to hair shafts may be more visible.
Drug Therapy
Synergized pyrethrins (0.17-0.33%)
This drug is a natural chemical derived from chrysanthemums that is synergized by addition of 2-
4% piperonyl butoxide (petroleum derivative). Trade names include A-200, End-Lice, Lice-Enz,
Pronto, R&C shampoo, and Rid.
Mechanism of action
Transmission of nerve cell impulses is blocked in lice, causing paralysis.
Patient counseling
• Wash and dry hair and apply for 10 minutes.
• Use a lice-nit combination to remove dead lice and nits following rinsing.
• Treat all family members.
• Avoid contact with the eyes, mouth, and nose
• Do not use on irritated or inflamed scalp.

• Repeat treatment in 1 week to 10 days.

Adverse effects include irritation, erythema, and itching.
Permethrin 1% and 5%
Permethrin is a synthetic chemical derivative of pyrethrin. Permethrin 1% is available under the

trade name Nit Cream Rinse. Permethrin 5%, at prescription-only strength, is available under the
trade names Acticin and Elimite Cream.
The 1% OTC-strength treatment is approved for head lice only; however, it is effective against
pubic lice. The 5% prescription-strength treatment is approved for scabies l (mites) infestation.
Patients prefer these treatments because of single-application effectiveness.
Mechanism of action
• Transmission of nerve cell impulses is blocked in lice, causing paralysis.
Patient information
• Apply to washed hair and scalp.
• Leave on hair for 10 minutes, and then rinse.
• After rinsing, comb hair with lice comb to remove lice and nits.
• This is a one-time treatment; do not repeat for 10 days.
• All family members should be treated.
Adverse effects
Scalp irritation, pruritus, and stinging may occur. This medication is contraindicated in patients who
are allergic to chrysanthemums and in children under age 2.
Lindane (Kwell shampoo, cream, and lotion; prescription only)
Formerly named gamma benzene hexachloride, lindane is effective against head lice and public lice
and against scabies (caused by Sarcoptes scabiei).
Adverse effects
Lindane is absorbed significantly through the skin and has been reported to have significant
neurotoxic effects, especially in infants and children. Central nervous system effects reported
include convulsions, dizziness, lack of coordination, restlessness, and irritability. Other effects
include rapid heartbeat, muscle cramps, and vomiting.
The OTC medications are considered much safer, especially in children.
Nondrug recommendations
• Change clothing daily.
• Treat infested clothes, and shower daily.
• All household contacts should be inspected and treated if necessary.
• All bed linens and clothes should be dry cleaned or washed in the hot water cycle and dried on the
heated-air cycle for at least 20 minutes.
• Wash hairbrushes, combs, and toys in hot water for at least 10 minutes.
• Treat surrounding environment (bedding, pillows, carpets, draperies, and furniture) with A-200
Control Spray or Rid Control Spray.
26-9. Warts
Introduction
Warts (verrucae) are harmless skin growths resulting from an infectious disease caused by the
human papillomavirus.
Classification
• Common warts (verruca vulgaris) are on fingers, hands, and knees.
• Common flat warts (verruca plana) are on face, hands, and legs.
• Plantar warts (verruca plantaris) are on the soles of the feet.
• Anogenital warts (verruca genitalia) are on the anogenital area.
• Warts are contagious, and may spread on the body.
• Warts are more common in children and immunocompromised patients.
• Warts on the face or hands protrude.

• Warts occurring on pressure areas such as the bottom of the feet (plantar warts) grow inward from
the pressure of standing and walking, are often painful, and may be confused with corns.
Warts can be eliminated by the following:
• Direct application of caustics, such as salicylic acid, formalin, lactic acid, trichloroacetic acid, and
podophyllin
• Freezing (cryotherapy) with liquid nitrogen or with dimethyl ether and propane
• Surgery
OTC drug therapy
Salicylic acid
Patients should be counseled as follows:
• Use topical salicylic acid preparations on a daily basis until the wart is removed.
• Because warts are contagious, use special care in washing hands before and after treatment, and
use a separate towel for drying other parts of the body.
• Do not use salicylic acid on irritated, broken, or infected skin.
• If the wart remains after 12 weeks of continuous treatment, see a dermatologist or podiatrist.
Salicylic acid products are contraindicated in patients with diabetes and other patients with poor
circulation because reduced sensation in the foot delays awareness of skin breakdown, allowing
possible development of infection that can lead to sepsis. Diabetic patients should see a physician or
podiatrist for removal of warts.
OTC salicylic acid products are as follows:
• Salicylic acid 17% in flexible collodion vehicle: Compound W gel and liquid, Dr. Scholl's Fast
Acting Liquid, Duofilm, Wart-Off, and Off-Ezy Wart Remover Kit
• Salicylic acid 40% embedded in pads or discs: Compound W One Step Pads, Dr. Scholl's Clear
Away, DuoFilm, and Dr. Scholl's Clear Away Wart Remover Patch
Cryotherapy
Dimethyl ether and propane is FDA approved for OTC removal of common warts and plantar
warts.
Cryotherapy irritation leads the host to produce an immune response against the causative virus
(similar to liquid nitrogen, which can be administered only by a primary care provider). As a result
of freezing, a blister will form under the wart. After about 10 days, the frozen skin and wart fall off,
revealing newly formed skin underneath.
Cryotherapy products are as follows:
• Dimethyl ether and propane: Dr. Scholl's Freeze Away Wart Remover and Wartner Wart
Removal System are approved for removal of common warts.
• Dimethyl ether, propane, and isobutane: Compound W Freeze Off is approved for removal of
common warts and plantar warts.
Patient instructions are as follows:
• Place the applicator in the spray can, which becomes very cold (-55°C)
• After the applicator is saturated, hold it on the wart for a product-specific time period to freeze the
wart (20 seconds for Wartner; 40 seconds for Compound W).
• The process may be repeated after 10 days as many as three or four times for persistent warts.
• Caution: Do not use in children under age 4, diabetics, or pregnant or breastfeeding females; on
the face, armpits, breasts, buttocks or genitals; on irritated skin; or on mucous membranes (e.g.,
mouth, nose, and anus).
26-10. Corns and Calluses
Introduction
Corns and calluses are excessive growth of the upper keratinized layer of the skin. They are more
common in women than in men.
Diabetics have an increased incidence of calluses on their feet because of the loss of sensation,
preventing them from noticing the pressure that would otherwise be uncomfortable.
Classification
• Hard corns (heloma durum): Corns overlying a bony prominence such as the toes or bottom of
the heel
• Soft corns (heloma molle; interdigital corns): Corns between the toes (especially the fourth and
fifth)
• Calluses (callosities): Superficial patches of hornified epidermis; flattened, but thickened with no
central core
Clinical Presentation and Pathophysiology
Corns and calluses are caused by excessive growth of the upper keratinized layer of the skin
(hyperkeratosis), resulting from friction or pressure, usually from improper or tight-fitting shoes.
Treatment
The only FDA-approved OTC medication is salicylic acid formulated in flexible collodion, plasters,
disks, or pads.
Mechanism of action
Salicylic acid produces a keratolytic action, which increases hydration and lowers the pH of the
outer skin, initially softening and then destroying the outer layer of skin.
Patient counseling
• Do not apply to irritated, infected, or reddened skin.
• If discomfort persists after using for 14 days, see a physician or podiatrist.
• Salicylic acid products are contraindicated in diabetics.
Salicylic acid products are contraindicated in patients with diabetes and other patients with poor
circulation because reduced sensation in the foot delays awareness of skin breakdown, allowing
possible development of infection that can lead to sepsis. Refer diabetics to a physician or podiatrist
for removal of corns or calluses.
OTC salicylic acid (SA) corn and callus products
• Freezone Corn and Callus Remover 13.6% SA
• Freezone One Step Corn Remover 40% SA
• Mediplast 40% SA plaster, cut to size
• Mosco Corn and Callus Remover 17.6% SA
• Off Ezy Corn and Callus Remover 17% SA
• One Step Callus Remover 40% SA

• Dr. Scholl's Corn and Callus Remover Liquid 12.6% SA
• Dr. Scholl's Corn or Callus Cushion Gel 40% SA
• Dr. Scholl's One Step Corn or Callus Remover Disc 40% SA
26-11. Key Points
Acne
• Acne occurs primarily in the teenage years because of the increase of androgens during puberty
that produces increased activity of the sebaceous glands.
• Isotretinoin (Accutane) is the drug of choice for nodulocystic acne (type IV acne), which, if left
untreated, will lead to extensive scarring.
• Isotretinoin is contraindicated in pregnancy because of the high incidence of serious birth defects.
• The most common side effects of isotretinoin are cheilitis (dry, chapped lips), dry skin, and dry
eyes.
Fungal Infections of the Skin
• The most efficacious nonprescription topical antifungal is terbinafine (Lamisil).
• Systemic antifungal therapy is required for treatment of tinea capitis (ringworm of the scalp) and
tinea unguium (fungal infection of the toenails and fingernails).
Hair Loss
• Androgenic alopecia—predominantly seen in males—is due to the conversion of testosterone to

dihydrotestosterone, which binds to the hair follicles and causes them to produce progressively
thinner hair.
• In the treatment of androgenic alopecia, minoxidil (Rogaine) should be applied and left on the
scalp for 4 hours for maximum effects.
• Finasteride (Propecia) decreases the effect of androgens on hair follicles by inhibiting 5- -

reductase, which prevents the conversion of testosterone to dihydrotestosterone.
Dry Skin
• Dry skin occurs primarily in older adults because of decreased sebum production and decreased
moisture-binding capacity of the skin.
• Products containing urea and lactic acid improve the skin's moisture-binding capacity, thereby
increasing skin hydration.
Dermatitis
• Contact dermatitis, whether irritant or allergic, is initially treated with topical corticosteroid
products.
• The absorption and subsequent adverse systemic effects of topical corticosteroids are increased in
infant skin and with occlusion, the use of high-potency agents, and long-term use.
Poison Ivy, Poison Oak, and Poison Sumac
• Poison ivy, poison oak, and poison sumac are examples of causes of allergic contact dermatitis,
which are the result of contact with the sap of plants of the genus Rhus.
• Severe cases of poison ivy, poison oak, or poison sumac require systemic corticosteroids to relieve
symptoms, decrease the severity of the rash, and shorten the course of the disorder.
Scaly Dermatoses
• The cytostatic agents that suppress cell rate turnover—zinc pyrithione (Head and Shoulders) and
selenium sulfide (Selsun Blue)—are the primary agents of choice for treatment of dandruff.
• Seborrhea usually requires topical corticosteroids or the topical antifungal ketoconazole for
effective treatment.
• Psoriasis is a chronic inflammatory disease characterized by inflammation and silvery scales

(known as plaques) with sharp delineated edges.
• Treatment of advanced psoriasis may require systemic corticosteroids or antimetabolites in

addition to topical treatments for effective management of the disease.
Pediculosis
• Head lice (Pediculus humanus capitis) occur most commonly in elementary schoolchildren in the
months of August and September.
• Permethrin (Nix) is the nonprescription agent of choice for treatment of head lice because it
usually does not have to be repeated in 7-10 days as do other available nonprescription
pediculicidal agents (synergized pyrethrins).
Corns and Warts

• Nonprescription products for the treatment of corns and warts contain salicylic acid.
• Self-treatment for corns or warts with over-the-counter agents is not recommended for diabetic
patients because of reduced sensation in their feet that delays awareness of possible development
of infections and can lead to sepsis.
• Warts result from an infection of the human papilloma virus and, therefore, are contagious and
may spread on the body.
• Warts may be eliminated by surgery, freezing with liquid nitrogen (cryotherapy), or the direct
application of caustics (e.g., salicylic acid, formalin, lactic acid, trichloroacetic acid, or
podophyllin).
26-12. Questions
Initial treatment of mild to moderate acne would include which of the following?
I. Topical antimicrobials
II. Topical retinoids
III. Isotretinoin
1.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

Acne is due to which of the following?
I. Increased sebum production

II. Obstruction of hair follicle openings
III. Inflammation
2.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

Patients using topical retinoids such as tretinoin (Retin-A) should be counseled to do which of
the following?
I. Use sunblock before exposure to sunlight.

II. Do not use tretinoin with astringents, drying agents, or abrasive soaps.
III. Expect rapid improvement within 2 or 3 days of starting therapy.
3.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

The most common side effects of isotretinoin (Accutane) include which of the following?
I. Cheilitis (dry chapped lips)

II. Acute depression
III. Decreased night vision
4.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

Which of the following is an important contraindication and precaution to the use of
isotretinoin?
A. Hypertension
5.
B. Migraines
C. Allergic rhinitis
D. Pregnancy
E. Streptococcal infections

Which of the following is the most efficacious nonprescription topical antifungal?
A. Tolnaftate (Tinactin)
6. B. Terbinafine (Lamisil)
C. Miconazole (Micatin)
D. Undecylenic acid (Desenex)
E. Clotrimazole (Lotrimin AF)

Which of these fungal infections may be treated effectively with the use of topical antifungal
agents?
I. Tinea capitis (ringworm of the scalp)

II. Tinea unguium (fungal infection of the toenails and fingernails)
III. Tinea corporis (ringworm of the skin)
7.
7.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

Tinea pedis is also known as
A. athlete's foot.
8. B. jock itch.
C. onychomycosis.
D. ringworm of the scalp.
E. ringworm of the skin.

The treatment of choice for tinea unguium would be
A. clotrimazole.
9. B. miconazole.
C. undecylenic acid.
D. griseofulvin.
E. tolnaftate.

All of the following are true regarding androgenic alopecia except
A. it is predominantly seen in males.

B. it is caused by the conversion of testosterone to dihydrotestosterone, which binds to the hair
10. follicles, causing them to produce progressively thinner hair.
C. hair growth stimulation is temporary and lasts only as long as therapy continues.
D. hair loss in the frontotemporal area responds to treatment better than hair loss on the crown.
E. Early hair loss occurring recently in young males is more likely to respond than later hair
loss at an older age.

All of the following are true regarding the patient instructions for the proper use of minoxidil
except
A. it should be applied on the scalp and left for 4 hours for maximum effect.
11. B. the patient should not swim, shampoo, or walk in rain soon after the application of
minoxidil.
C. do not use on infected, irritated, inflamed, or sunburned skin.
D. the patient must continue therapy to maintain effectiveness.
E. women with alopecia should use the 5% strength of minoxidil rather than the 2% strength.

Adverse effects of minoxidil include which of the following?
I. Hypertrichosis
II. Dermatitis and pruritus of the scalp
III. Hepatic damage
12.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

The mechanism of action of finasteride (Propecia) to reduce male baldness is
A. a direct effect on hair follicles to deepen hair roots.

B. inhibition of the enzyme 5- -reductase, which blocks the conversion of testosterone to
13. dihydrotestosterone.
C. increased cutaneous blood flow to the hair follicles on the scalp because of vasodilation.
D. increased cutaneous blood flow to the hair follicles on the scalp because of opening the
potassium channel.
E. increased development of new hair follicles on the scalp.

All of the following are true regarding finasteride except
A. it is contraindicated in females of child-bearing age.

B. it was originally approved for treatment of benign prostatic hypertrophy.
14.
C. improvement lasts only as long as treatment continues (new hair will be lost within 1 year of
stopping treatment).
D. it must be taken on an empty stomach for complete absorption.
E. 2% of males report reversible sexual dysfunction while taking it.

All of the following regarding dry skin are true except
A. it occurs primarily in older adults.

B. it occurs most commonly in the summer months.
15.
C. it is caused by decreasing sebum production and decreased moisture-binding capacity of the
skin.
D. flaking, scaling, xerosis, and pruritus are common manifestations of dry skin.
E. excessive cleansing and bathing removes lipids and worsens dry skin.

All of the following statements are true regarding the treatment of dry skin except
A. hydrocortisone should be used only for short-term therapy of dry skin to relieve itching.
B. urea-containing products improve the skin's moisture-binding capacity.
C. lactic acid is a keratolytic agent that removes the upper epidermal skin cells and relieves the
16.
itching of dry skin.
D. emollients and moisturizers are helpful in the treatment of dry skin, especially when applied
immediately after bathing.
E. although colloidal oatmeal may be helpful in the treatment of dry skin, patients should be
cautioned about the possibility of falling because of a slippery bathtub.

The agents of choice for the initial treatment of contact dermatitis, whether irritant or allergic,
are
A. topical antihistamines.
17.
B. oral antihistamines.
C. topical corticosteroids.
D. local anesthetics.
E. coal tar products.

An increase in topical corticosteroid systemic absorption with subsequent systemic side effects
may be seen in which of the following?
I. Occlusion
II. Infant's skin
III. Long-term use of high-potency agents
18.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

All of the following are true regarding poison ivy except
A. it is an example of allergic contact dermatitis.

19. B. it is the result of contact with the sap of plants of the genus Rhus.
C. the treatment of choice is desensitization.
D. it may be caused by direct or indirect contact (e.g., with clothing or pets).
E. skin eruptions may occur from several hours up to 10 days following contact with the plants.

The treatment of choice for severe or extensive cases of poison ivy or poison oak is
A. a local anesthetic such as benzocaine.

20. B. bentoquatam (Ivy Block).
C. a camphor and menthol antipruritic.
D. colloidal oatmeal.
E. a systemic corticosteroid.

Which of the following agents for treatment of dandruff are cytostatic agents that suppress cell
rate turnover?
I. Zinc pyrithione (Head and Shoulders)

II. Selenium sulfide (Selsun Blue)
III. Salicylic acid (Ionil)
21.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

All of the following statements are true regarding seborrhea except
A. it is a chronic inflammatory skin disease seen in areas of greatest sebaceous gland activity.
B. it fluctuates in severity and is worsened by stress and poor health.
22.
C. moderate to severe cases require topical corticosteroids or the topical antifungal
ketoconazole for effective treatment.
D. it is called cradle cap when it occurs in infants.
E. it most commonly occurs on the legs and arms.

Which of the following are characteristic of psoriasis?
I. Chronic inflammation
II. Silvery scales (known as plaques) with sharply delineated edges
III. Spontaneous exacerbations and remissions
23.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

Treatment of advanced psoriasis may require topical therapy combined with which of the
following systemic agents?
I. Corticosteroids
II. Antimetabolites such as methotrexate
III. Anthralin
24.
24.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

All of the following are true statements regarding head lice (Pediculus humanus capitis) except
A. it occurs most commonly in elementary schoolchildren.

25. B. it occurs most commonly in the spring months of April and May.
C. it is transmitted by direct contact.
D. pruritus is the most common symptom.
E. head lice is the most common type of pediculosis infestation.

All of the following statements are true regarding treatment of pediculosis with synergized
pyrethrins (piperonyl butoxide and pyrethrins) except
A. inspect all family contacts, and treat if necessary.

26.
B. apply after washing and drying the hair, and leave on overnight.
C. remove dead lice and nits after treatment with a lice or nit comb.
D. repeat treatment in 7-10 days.
E. avoid contact with the eyes, nose, and mouth.

The most effective nonprescription agent for treatment of head lice is which of the following
agents?
A. Permethrin (Nix)
27.
B. Synergized pyrethrins (A-200)
C. Lindane (Kwell)
D. Ketoconazole
E. Salicylic acid

Nonprescription products for the treatment of corns and warts contain which of the following
agents?
A. Salicylic acid
28.
B. Ketoconazole
C. Lactic acid
D. Acetylsalicylic acid
E. Hydrocortisone

All of following are true statements regarding corns except:
A. They are excess growth of the upper keratinized layer of skin.
B. Salicylic acid is available in pads, disks, or flexible collodion for removal of corns.
29. C. Self-treatment for corns or warts with OTC agents is not recommended for diabetic patients
because of the reduced sensation in their feet, which delays awareness of development of
infections and may lead to sepsis.
D. They are contagious and may spread on the body.
E. They are usually caused by pressure or friction from improper or tight-fitting shoes.

All of the following are true statements regarding warts except
A. they result from infection with the human papillomavirus.

30. B. they are contagious.
C. they may spread on the body.
D. plantar warts are located on the fingers, hands, and knees.
E. they are more common in children and immunocompromised patients.

Warts may be eliminated by which of the following procedures?
I. Surgery
II. Freezing with liquid nitrogen (cryotherapy)
III. The direct application of caustics (e.g., salicylic acid)
31.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

26-13. Answers
D. Topical antimicrobials and topical retinoids are the agents of choice for mild to moderate
1. acne. Isotretinoin (Accutane) is reserved for nodulocystic acne (type IV acne), which, if left
untreated, will lead to extensive scarring.

E. Acne is primarily due to (a) hormonal changes occurring at or near puberty that increase
sebum production and obstruct the hair follicle opening and (b) the breaking down of
2.
triglycerides to free fatty acids caused by enzymes from Propionibacterium acnes, which causes
inflammation.

D. Topical retinoid therapy will sensitize skin to ultraviolet light rays; therefore, patients
should use sunblock prior to sun exposure. Patients using topical retinoids should use only
3.
mild soaps for cleansing the face and avoid astringents, drying agents, and abrasive soaps.
Improvement will usually occur within 2-3 weeks after initiation of therapy.

A. Cheilitis (dry chapped lips), together with dry skin and dry eyes, are the most common side
4.
effects of isotretinoin therapy.

D. Isotretinoin is contraindicated in pregnancy because of the high incidence of serious birth
5.
defects.

6. B. Terbinafine (Lamisil) is the most effective nonprescription topical antifungal.

C. Topical antifungal agents are the first line of therapy against tinea corporis (ringworm of the
7. skin). However, systemic antifungal therapy is usually required for treatment of tinea capitis
(ringworm of the scalp) and tinea unguium (fungal infection of the toenails and fingernails).

8. A. Tinea pedis is also known as athlete's foot.

D. The treatment of choice for tinea unguium (fungal infection of the toenails and fingernails)
9. is a systemic antifungal agent such as griseofulvin. Topical therapy is generally not effective
for fungal infections of the nails.

D. Hair loss in the crown responds to treatment better than hair loss of the frontotemporal
10.
areas.

E. Women with alopecia should use only the 2% strength of minoxidil. Studies indicate that
there is no greater degree of effectiveness with the 5% strength and the incidence of adverse
11.
effects (including increased growth of facial hair) is much greater in women using the 5%
preparation.

D. Common adverse effects of minoxidil include hypertrichosis (increased hair growth in areas
12. other than the scalp) and dermatitis and pruritus of the scalp. Systemic side effects with topical
minoxidil are rare and do not include hepatic damage.

B. The mechanism of action of finasteride to reduce male baldness is blocking of the
13.
conversion of testosterone to dihydrotestosterone by inhibiting the enzyme 5-±-reductase.

D. Finasteride does not have to be taken on an empty stomach. It may be taken with or without
food. Finasteride was originally approved for treatment of benign prostatic hypertrophy.
14. Improvement of alopecia lasts only as long as treatment continues, finasteride is
contraindicated in females of childbearing age, and 2% of males report reversible sexual
dysfunction.

15. B. Dry skin occurs most commonly in the winter months and is often referred to as winter rash.

C. Lactic acid is used in the treatment of dry skin, not as a keratolytic agent, but as an agent
16.
that increases skin hydration.

C. Topical corticosteroids are the agents of choice for the initial treatment of irritant or allergic
contact dermatitis. If the condition is severe or widespread, oral corticosteroids may be useful.
17. Oral or topical antihistamines have minimal effect in the course of the treatment of contact
dermatitis, possibly producing some antipruritic effect, but not affecting the course of the
disorder.

E. Topical corticosteroid systemic absorption is increased on an infant's skin and with
18. occlusion, long-term use, and use of high-potency agents. Systemic corticosteroids' adverse
effects may be severe and include adrenocortical suppression.

C. Desensitization has no place in the treatment of poison ivy, and most studies indicate
19.
desensitization is not an effective method to prevent poison ivy.

E. Systemic corticosteroids are the treatment of choice for severe or extensive cases of poison
20. ivy or poison oak. Topical agents are limited in effectiveness and do not alter the course of the
disease.

D. Zinc pyrithione (Head and Shoulders) and selenium sulfide (Selsun Blue) are cytostatic
21. agents used in the treatment of dandruff that suppress cell rate turnover. Salicylic acid is a
keratolytic agent.

E. Seborrhea most commonly occurs on the face, especially eyebrows and eyelashes, but not
22.
on the extremities.

E. Psoriasis is a chronic inflammatory disease marked by silvery scales (known as plaques)
23.
with sharp delineated edges and characterized by spontaneous exacerbations and remissions.

D. Treatment of advanced psoriasis may require topical therapy combined with either oral
24.
corticosteroids or antimetabolites such as methotrexate.

25. B. Head lice occur most commonly in the months of August and September.

B. Synergized pyrethrins should be applied after washing and drying the hair and left on for 10
26.
minutes, not overnight.

A. Permethrin (Nix) does not have to be repeated in 7-10 days as does the other available
27. nonprescription pediculicidal agent, synergized pyrethrins (A-200). Lindane (Kwell) is not
available over the counter, and significant neurologic toxicities have been reported with its use.

A. Nonprescription products for the treatment of corns and warts contain salicylic acid as the
28.
active therapeutic agent.

D. Corns are not contagious and may not spread on the body. Corns are an excess growth of
the upper keratinized layer of skin, usually caused by pressure or friction from improper or
tight-fitting shoes. Salicylic acid is available OTC for removal of corns in pads, disks, or
29.
flexible collodion. Self-treatment for corns or warts with OTC agents is not recommended for
diabetic patients because of the reduced sensation in their feet, which delays awareness of the
development of infections and could lead to sepsis.

D. Plantar warts are not located on the fingers, hands, or knees; they are located on the soles of
30.
the feet.

E. Warts may be eliminated by surgery, freezing with liquid nitrogen (cryotherapy), or direct
31.
application of caustics (e.g., salicylic acid).

26-14. References
Arndt KA. Manual of Dermatologic Therapeutics. 5th ed. Boston: Little, Brown; 1995.
Arndt KA, Wintroub BU, Robinson JK, et al., eds. Primary Care Dermatology. Philadelphia: WB
Saunders; 1997.
Berardi RR, Ferreri SP, Hume AL, et al., eds. The Handbook of Nonprescription Drugs. 16th ed.
Washington, D.C.: American Pharmaceutical Association; 2009.
Burnham TH, ed. Drug Facts and Comparisons. Baltimore: Lippincott Williams & Wilkins; 2005.
Champion RH, Burton JL, Burns DA, eds. Textbook of Dermatology. 6th ed. Oxford, U.K.:
Blackwell Scientific Publications; 1998.
Covington, TR. Nonprescription Drug Therapy: Guiding Patient Self-Care. Baltimore: Lippincott
Williams & Wilkins; 2003.
DiPiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 5th
ed. Stamford, Conn.: Appleton & Lange; 2004.
Epstein E. Common Skin Disorders. 6th ed. Philadelphia: WB Saunders; 2008.
Fitzpatrick JE. Dermatology Secrets in Color. 2nd ed. Philadelphia: Hanley and Belfus; 2001.
Freedberg IM, Eisen AZ, Wolff K, et al., eds. Fitzpatrick's Dermatology in General Medicine. 5th
ed. New York: McGraw-Hill; 1999.
Habif TP, Campbell JL, Quitadamo MJ. Skin Disease: Diagnosis and Treatment. St. Louis, Mo.:
Mosby; 2001.
Herfindal T, Gourley D, eds. Textbook of Therapeutics. 6th ed. Baltimore: Lippincott Williams &
Wilkins; 2000.
Odom RB, James WD, Berger TG, eds. Andrew's Diseases of the Skin: Clinical Dermatology.
Philadelphia: WB Saunders; 2000.
Pray WS. Nonprescription Product Therapeutics. Hagerstown, Md.: Lippincott Williams &
Wilkins; 1999.
Top OTC/HBC brands in 2002. Drug Topics. 2003; 145:33-34.
Wolverton SE, ed. Comprehensive Dermatologic Drug Therapy. Philadelphia: WB Saunders; 2001.
27. Nonprescription Medications - Amanda Howard-Thompson, PharmD, BCPS
27-1. Cough, Cold, and Allergy
Introduction
The Consumer Health Care Products Association announced in October 2008 that manufacturers
were voluntarily updating all cough and cold products to state "do not use" in children under age 4.
These actions have not changed the official U.S. Food and Drug Administration (FDA) monograph
for these drug products. The American Academy of Pediatrics would like the age limit increased to
age 6 because of lack of clear evidence of efficacy. The FDA is currently investigating the use of
these products in children age 4-6 to determine if further restriction is needed.
Cough
Selected cough products are shown in

Table 27-1.
Etiology
• Upper respiratory infection (viral or bacterial)
• Sinusitis
• Rhinitis
• Asthma and chronic obstructive pulmonary disease
• Gastroesophageal reflux disease
• Congestive heart failure
• Drug-induced cough
Cough characteristics
• Productive
• Nonproductive
Pathophysiology
A cough is an important defense mechanism to rid the airways of mucus and foreign bodies. A
cough may be acute (< 3 weeks duration) or chronic (> 3 weeks duration).
Nonprescription treatment
Antitussives and cough suppressants

Antitussives and cough suppressants may be narcotic or nonnarcotic.
Codeine
Codeine, a narcotic, is the gold standard of antitussives:
• Availability: Without prescription in some states
• Mechanism of action: Centrally mediated suppression of cough
• Adult dose: 10-20 mg q4-6h (120 mg/d maximum)
• Role in therapy: Primarily for night cough
• Side effects: Sedation, nausea, and constipation
Dextromethorphan
Dextromethorphan is only category I over-the-counter (OTC) nonnarcotic antitussive:
• Mechanism of action: Centrally mediated suppression of cough
• Adult dosage: 10-30 mg q4-8h (120 mg/d maximum)
• Role in therapy: Nonproductive cough
• Side effects: Drowsiness and gastrointestinal (GI) effects
• Drug interactions: Monoamine oxidase (MAO) inhibitors
Diphenhydramine
Diphenhydramine is a category II antitussive:
• Mechanism of action: Centrally mediated suppression of cough center and anticholinergic
• Adult dosage: 25 mg q4h (75 mg/d maximum)
[Table 27-1. Selected Examples of Nonprescription Cough Products]
Expectorant
Guaifenesin (Robitussin, Mucinex, Humibid) is the only category I OTC expectorant:
• Mechanism of action: Thinning of mucus to enhance clearance

• Adult dosage:
• Immediate-release 200-400 mg q4h (maximum 2,400 mg/d)
• Extended-release: 600-1,200 mg q12h (maximum 2,400 mg/d)
• Role in therapy: Productive cough
• Side effects: GI discomfort
• Patient education: Increase fluid intake.
Topical antitussives
Of the volatile oils, only camphor and menthol are FDA approved:
• Mechanism of action: Local anesthetic effect in nasal mucosa
• Product availability: Lozenge, ointment, and steam inhalation
• Patient education: Ointment and solution are toxic if ingested.
Sore throat remedies

Sore throat remedies include the following:
• Saline gargle
• Sprays and lozenges:
• Benzocaine: Chloraseptic lozenges and Cepacol lozenges
• Dyclonine: Cepacol Spray
• Phenol: Chloraseptic Gargle
• Menthol: Halls
Common Cold
Etiology
• Usually viral, most commonly rhinoviruses
• Transmitted through hand-to-hand contact followed by touching eyes or nasal mucosa

Pathophysiology
A cold results in the release of numerous inflammatory mediators, primarily cytokines.
• Sore throat, nasal symptoms, watery eyes, sneezing, cough, malaise, and low-grade fever occur.
• High fever and myalgias are more characteristic of influenza.
• There is a gradual onset with slow progression.
• Duration is 1-2 weeks.
Treatment
Nonpharmacologic therapy
• Humidifiers
• Increase fluid intake
• Rest
Nonprescription medication treatment (symptomatic)
• Decongestants for nasal congestion
• Antihistamines for excess nasal discharge
• Analgesics for related pain or headaches
• Local anesthetic lozenges or sprays for sore throat (pharyngitis)
Allergic Rhinitis
Etiology
Allergic rhinitis results from exposure to perennial or seasonal allergens, which lead to the
development of nasal symptoms.
Pathophysiology
The pathophysiology of allergic rhinitis is complex, involving numerous mediators (primarily

histamine) and cell types (mast cells).
• Nasal: Congestion, rhinorrhea, nasal pruritus, sneezing, and postnasal drip
• Ocular: Itching, lacrimation, redness, and irritation
• General: Headache, malaise, mood swings, and irritability
Treatment
Patients should avoid the offending allergens:
• Limit outside exposure during periods of high pollen.
• Avoid indoor and outdoor mold.
• Avoid dust, especially in the bedroom.
• Avoid pet dander, especially cats.
Pharmacotherapeutic options
• Mild allergies: Patients should use antihistamines as needed.
• Moderate allergies: Patients should use an antihistamine plus decongestant for nasal symptoms
and an ophthalmic antihistamine for ocular symptoms.
• Chronic allergies: Use cromolyn sodium (Nasalcrom) nasal spray and scheduled nonsedating
antihistamine.
[
Table 27-2. Selected Nonprescription Antihistamine Products]
Nonprescription Therapy for Treatment of the Common Cold and Allergies
Selected products for treating the common cold and allergies are shown in Tables 27-2,
27-3, and
27-4.
Antihistamines
Selected antihistamines are described in Table 27-2.

Pharmacology
• Antihistamines are H1-receptor antagonists.
• First-generation antihistamines are nonselective and sedating.
• Second-generation antihistamines are peripherally selective, have low incidence of sedation, and
have no anticholinergic effects.
Side effects
• Sedation
• Anticholinergic effects (primarily with first-generation antihistamines)
• Dry mouth
• Dry eyes
• Urinary retention
[Table 27-3. Selected Nonprescription Oral Decongestant Products]
[Table 27-4. Selected Nonprescription Cold, Allergy, and Sinus Combination Products]
• Constipation
• Paradoxical stimulation in some children and elderly patients
Precautions and contraindications
• Do not drive or operate heavy machinery.
• Avoid use with alcohol.
• Prostatic hyperplasia can occur.
• Narrow-angle glaucoma is possible.
Oral decongestants
Selected oral decongestant products are described in Table 27-3.
Pharmacology
• -adrenergic agonists and vasoconstrictors
• Constriction of blood vessels to decrease blood supply to nasal mucosa and decrease mucosal
edema
• No effect on histamine or allergy-mediated reaction
Regulation
The 2005 Combat Methamphetamine Epidemic Act has the following requirements:
• Pseudoephedrine must be kept either behind the counter or in a locked cabinet.
• Quantity is limited to 3.6 g/d and 9 g/month per patient.
• Pharmacists must maintain a logbook with the following information: product name, quantity
sold, patient's name and address, and time and date of sale.
• Patients must show valid identification and sign a logbook.
Side effects
These products are relatively safe with no dependence. They can be used long term. The most
common side effects are as follows:
• Nervousness
• Irritability
• Restlessness
• Insomnia
Less common side effects include the following:
• Increased heart rate
• Increased blood pressure
• Irregular heartbeat
• Palpitations
• Hypertension: These agents are generally accepted with mild or well-controlled hypertension;
they should not be used with uncontrolled hypertension.
• Heart disease (arrhythmias and ischemic heart disease): They increase the heart rate.
• Diabetes: They have a minimal effect on blood sugar level.
• Hyperthyroidism: This condition is more sensitive to sympathomimetics.
• Enlarged prostrate: Benign prostatic hyperplasia (BPH) is exacerbated by constricting smooth

muscle of the bladder neck.
• Narrow-angle glaucoma: Dilation increases intraocular pressure.
• Blood pressure: MAO inhibitors interact with decongestants to increase blood pressure.
Topical decongestants
Pharmacology
• -adrenergic agonists act locally as vasoconstrictors.
• These agents constrict blood vessels, decrease blood supply to nose, and decrease mucosal edema.
• They have no effect on histamine or allergy-mediated reaction.
Side effects
Minimal systemic absorption results in few side effects. Local effects may include burning, nasal
irritation, and sneezing.

Rhinitis medicamentosa (rebound congestion) may occur if duration of use is > 3-5 days.
Dosage forms
Sprays
Sprays are the simplest dosage delivery. A large surface area is covered. Imprecise dosing and
contamination of the bottle are possible. Products include the following:
• Short-acting: Phenylephrine (Neo-Synephrine and Vicks Sinex)
• Longest-acting: Oxymetazoline (Afrin and Mucinex)
Drops
Drops are preferred for use in small children. They cover a small surface area. They pass to the
larynx, where they may be swallowed and result in systemic effects.
Nasal inhaler
A nasal inhaler requires an unobstructed airway to deliver drug to the nasal mucosa. Nasal inhalers
contain sympathomimetic amines, as well as camphor and menthol. Medications lose efficacy after
2-3 months. Products include the following:
• Propylhexedrine (Benzedrex inhaler)
• Levodesoxyephedrine (Vicks inhaler)
Nasal saline solution
This solution is very safe and is good for use in infants and children. It can be used with oral
decongestants. Products include the following:
• Saline drops (Ayr)
• Saline sprays (Ayr, Ocean Nasal Spray, and HuMist)
Cromolyn (Nasalcrom)
Cromolyn is used to prevent and treat allergic symptoms:
• Pharmacology: Mast cell stabilizer; prevention of the mast cells from releasing inflammatory
mediators
• Dosage: One spray per nostril q4-6h up to four to six times daily
• Onset of action: Approximately 1 week; 2-3 weeks for maximal effect
• Efficacy: Not efficacious if taken prn; must be taken on a scheduled basis
• Side effects: Nasal irritation, nasal burning, stinging, sneezing, cough, unpleasant taste
Analgesics
Analgesics treat the pain, fever, and headaches associated with cold, flu, or allergies. Medications
include the following:
• Aspirin (mostly replaced now by acetaminophen and nonsteroidal anti-inflammatory drugs

[NSAIDs])
• Acetaminophen (N-acetyl-para-aminophenol, or APAP)
• NSAIDs
• Ibuprofen
• Ketoprofen
• Naproxen
27-2. Constipation
• Patient has difficult or infrequent passage of stools.
• Patient may complain of abdominal or rectal fullness.
Etiology
Table 27-5 shows the common causes of constipation.
Treatment
• Increase fluid intake.
• Increase dietary fiber.
• Exercise.
• Establish good bowel habits.
Nonprescription medication therapy
Bulk-forming laxatives
Selected bulk-forming laxative products are described in
Table 27-6.
Mechanism of action
Natural or semisynthetic hydrophilic polysaccharide derivatives are present in bulk-forming
laxatives. They absorb water to soften stool, increase bulk, and facilitate peristalsis and elimination.
Effects may not be seen for 2-3 days.
Role in therapy
Bulk-forming laxatives are the safest, most natural therapy for constipation. They are the most often
recommended medication for chronic use.
[Table 27-5. Common Causes of Constipation]
[Table 27-6. Additional Nonprescription Treatments of Constipation Not Listed in Text]

Drug interactions
• These laxatives may bind with digoxin, warfarin, and other drugs.
• Calcium complexes may bind with tetracycline, inhibiting its absorption.
• Recommend separating doses from other medications.
Side effects
• Potential exists for allergic reaction or anaphylaxis.
• Inhalation of powder is reported to cause bronchospasm.
• Caution diabetics about sugar content of some products.
Emollient laxatives (stool softeners)

Emollient laxatives act as surfactants, absorbing water into the stool. Effects may take 2-3 days.
Emollient laxatives may cause systemic absorption of mineral oil; therefore, concurrent use is
contraindicated.
Emollient laxatives are often used in combination products. They are useful for patients who should
avoid straining during the following:
• Rectal surgery
• Postpartum time period
• Recent myocardial infarction
Selected emollient laxative products are described in Table 27-6.
Stimulant laxatives
Stimulant laxatives stimulate bowel motility through localized mucosal irritation. They increase
secretion of fluids into bowel. They can cause cramping. Impaired colon function occurs with
chronic use.
Dangers of chronic stimulant laxative use include the following:
• Laxative habit
• Cathartic colon
• Melanosis coli
• Loss of fluids on electrolytes
• Cramping pains
Anthraquinones
Senna (Senokot and Ex-Lax) is an anthraquinone:
• Pharmacology: Anthraquinones are absorbed into bloodstream with action on the large intestines.
Onset of effects is 6-12 hours. This medication should be taken at bedtime.
• Side effects: Such effects include discoloration of urine, stimulant habituation, and melanosis coli
(i.e., dark pigmentation of colonic mucosa).
• Precautions and contraindications: Do not take while breast-feeding.
Diphenylmethanes
Bisacodyl (Dulcolax tablets or suppositories) is a diphenylmethane. Minimal systemic absorption
occurs with this drug. Bisacodyl is the only stimulant compatible with breastfeeding. This
medication is enteric coated: do not crush or take with antacids. The onset of effects varies with
route of administration:
• Oral: 6-8 hours
• Rectal: 15-60 minutes
Stimulant oils
Castor oil is a stimulant oil that acts on small intestine. It is a strong cathartic and may induce fluid
or electrolyte disturbances. Onset is rapid: 2-6 hours. Castor oil is contraindicated in pregnancy
because it may induce labor.
Hyperosmotic laxatives
Glycerin
Glycerin has an osmotic effect and is a local irritant that stimulates bowel movement. Onset of
action is usually within 30 minutes. Glycerin suppositories are safe for infants.
Products include Fleets Babylax Liquid and Fleet Glycerin Suppository.
Polyethylene glycol 3350

Polyethylene glycol 3350 was approved for OTC status in October 2006. Its mechanism of action is
similar to that of glycerin. This agent is meant for short-term therapy for constipation. Onset of
action is usually within 1-3 days. The adult dosage is 17 grams of powder in 4-8 ounces of water.
Side effects are as follows:
• Bloating
• Abdominal discomfort
• Cramping
• Flatulence
Products include MiraLAX.
Saline laxatives
With saline laxatives, nonabsorbable cations create osmotic gradient to pull water into intestine.
Onset varies depending on the route of administration:
• Rectal: 5-30 minutes
• Oral: 30 minutes to 4 hours
Twenty percent of magnesium may be absorbed systemically.
Saline laxatives are contraindicated in patients with impaired renal function (magnesium- or
phosphate-containing), congestive heart failure, or hypertension (sodium-containing).
Selected saline laxative products are described in Table 27-6.
Lubricant laxatives
Selected lubricant laxative products are as follows:
• Mineral oil: Liquid petrolatum
• Olive oil: "Sweet oil"
Lubricant laxatives soften the feces by emulsifying the contents of the intestinal tract. Onset of
action is 6-8 hours.
These agents may decrease absorption of fat-soluble vitamins and some drugs. They are
contraindicated in children and elderly patients because of the risk of aspiration and lipid
pneumonitis. Do not administer with stool softeners.
Enemas
Enemas include Fleet Enema (monobasic and dibasic sodium phosphates). They have the following
characteristics:
• Oil retention
• Soap suds
• Warm tap water
Special patient populations

Care must be taken with patients who are pregnant:
• Hormonal changes cause smooth muscle relaxation early in pregnancy.
• An enlarged uterus compresses the colon.
• Recommend only bulk-forming laxatives or stool softeners.
27-3. Diarrhea
Diarrhea is the abnormal increase in frequency of stools and stool looseness. It may be acute (< 14
days) or chronic (> 4 weeks).
Etiology
Common causes of diarrhea are shown in

Table 27-7.
Complications
• Dehydration (especially in infants and elderly patients)
• Electrolyte abnormalities
Nonpharmacologic Treatment
• Administer oral rehydration therapy, such as Pedialyte.
• Avoid fatty and spicy foods and those with high sugar content.
[Table 27-7. Common Causes of Diarrhea]
Nonprescription Medication Therapy
Loperamide (Imodium AD)
Loperamide is a synthetic opioid agonist that slows GI motility. The dosage is 4 mg initially and
then 2 mg after each loose stool. For OTC use, maximum dose is 8 mg/d, but it can be increased to
16 mg/d with medical supervision.
The medication is well tolerated, but side effects are as follows:
• Constipation
• Dizziness
• Dry mouth
Precautions and contraindications are as follows:
• Loperamide is not recommended for children under age 6 without medical supervision.
• It should not be used if the patient has bloody or black stool; consult physician before use if the
patient has a fever, mucus in stool, or a history of liver disease.
• Antiperistaltic action could worsen effects of invasive or inflammatory bacterial infection.
Bismuth subsalicylate
Bismuth subsalicylate (Pepto-Bismol) reacts with stomach acid to form salicylic acid and bismuth
oxychloride. It reduces frequency of diarrhea and improves stool consistency. It has a direct
antimicrobial effect; therefore, it is effective in traveler's diarrhea.
Side effects include the following:
• Salicylate toxicity (tinnitus)
• Bismuth toxicity (neurotoxicity)
• Gray-black discoloration of tongue or stool
The medication is contraindicated in the following:
• Aspirin allergy
• Children and teens with viral illness (Reye's syndrome)
• Patients having a history of GI bleeding, or using warfarin
New labeling recommends a physician should be consulted prior to use in patients younger than age
12.
27-4. Nausea and Vomiting

Definitions
• Nausea: The sensation that one is about to vomit.
• Vomiting: The forceful expulsion of gastric contents through the mouth.
Physiology
Vomiting is coordinated by the vomiting center in the medulla. Stimuli from the peripheral nervous
system and within the central nervous system (CNS) act on the vomiting center. Responding to
these impulses, the vomiting center stimulates the abdominal muscles, stomach, and esophagus to
induce vomiting.
Etiology
Common causes of nausea and vomiting are shown in

Table 27-8.
Complications
• Dehydration
• Electrolyte imbalance
• Aspiration
• Malnutrition
• Acid-base disturbances
In addition to the medications described in this section,

Table 27-9 describes drugs of choice for the nausea or vomiting associated with motion sickness.
Antihistamines
Antihistamines cross the blood-brain barrier to depress vestibular excitability.
Phosphorated carbohydrate solution (Emetrol)
This agent is a hyperosmolar solution. It is a mixture of levulose (fructose), dextrose (glucose), and
phosphoric acid. It is buffered to a pH of 1.5. It reduces gastric muscle contraction through an
unknown direct effect. It must not be diluted (which raises the pH).
Bismuth salts (Pepto-Bismol)
Bismuth salts are available as nonprescription suspension, caplet, and chewable tablet. See Section
27-3 for additional information.
Histamine 2-receptor antagonists
Histamine 2-receptor antagonists (H2RAs) may provide symptomatic relief by inhibiting gastric
acid secretion. Potential drug interactions occur with cimetidine.
Side effects are as follows:
• Headache
• Constipation
• Diarrhea
See Section 21-1 on peptic ulcer disease in Chapter 21 for additional information on H2RAs.
Antacids
Antacids may treat nausea, dyspepsia, and stomach upset associated with excessive intake of food
or drink. They are combinations of magnesium hydroxide, sodium salts, aluminum hydroxide,
calcium carbonate,
[Table 27-8. Common Causes of Nausea and Vomiting]
[Table 27-9. Nonprescription Drugs of Choice for Prevention of Motion Sickness]
and magnesium carbonate. The usual adult dosage is 15 mL 30 minutes after meals and at bedtime.
• Constipation
• Diarrhea
• Sodium overload
Antacids may decrease absorption of some medications. Therefore, administer other medications 1-
2 hours before or after antacids.
Nausea may be associated with pregnancy, especially during the first trimester. Nonpharmacologic
therapy is recommended in such cases:
• Eat small, frequent meals.
• Avoid rich, fatty foods.
• Snack on salty crackers or pretzels.
Refer the patient to the primary care provider if pharmacologic therapy is being considered.
27-5. Pain and Fever
Pathophysiology of Pain
Nociceptors are peripheral pain receptors. They send pain stimuli to the spinal cord through
afferent, nociceptive nerves. Impulses then pass to the brain through dorsal root ganglia.
Pathophysiology of Fever
The core temperature is the temperature of the blood surrounding the hypothalamus. The
thermoregulatory center in the anterior hypothalamus controls body temperature through
physiologic and behavioral mechanisms. Pyrogens—fever-producing substances—increase the
thermoregulatory set point, raising the body temperature.
Selected analgesic and antipyretic products are shown in

Table 27-10.
Acetaminophen
Acetaminophen exerts analgesic and antipyretic activity through central inhibition of prostaglandin
synthesis. It does not have peripheral anti-inflammatory activity.
Acetaminophen is generally well tolerated; however, hepatotoxicity is a possible side effect.
[Table 27-10. Selected Analgesic and Antipyretic Products]
Drug interactions can occur as follows:
• Alcohol: Risk of hepatotoxicity is increased.
• Warfarin: Higher doses may enhance hypoprothrombinemic effect of warfarin.
Patients should be aware of the following precautions and contraindications:

• Increased risk of hepatotoxicity
• Dose > 4 g/d
• Preexisting liver disease
• Alcohol use
• Fasting
Use is accepted during pregnancy and breast-feeding.
Salicylates
Salicylates inhibit peripheral prostaglandin synthesis. They reduce pain, inflammation, and fever.
Acetylated salicylates (e.g., aspirin) inhibit platelet aggregation. Nonacetylated salicylates (e.g.,
prescription salsalate, choline magnesium salicylate) do not have significant antiplatelet activity.
Several side effects are associated with salicylates:
• Gastritis
• Gastric ulcers and bleeding
• Allergy and hypersensitivity:
• Rare (< 1%) in the general population
• Higher risk in individuals with asthma and nasal polyps
• Reye's syndrome, a potentially fatal illness associated with salicylate use in children and teens
with concurrent viral illness (influenza, varicella-zoster)
Drug interactions may occur:
• Alcohol: Gastrointestinal toxicity is enhanced.
• Methotrexate: Salicylates displace methotrexate from protein-binding sites.
• Warfarin: Salicylates enhance hypoprothrombinemic effects of warfarin.
Patients should be aware of the following precautions and contraindications:
• Bleeding disorders
• Hemophilia
• Peptic ulcer disease
• Children or teenagers with viral illness (Reye's syndrome)
• Gout
Salicylates should be avoided in the third trimester of pregnancy.
Nonsteroidal anti-inflammatory drugs
NSAIDs provide peripheral inhibition of prostaglandin synthesis. They offer analgesic, antipyretic,
and anti-inflammatory activity.
The ketoprofen (Orudis KT) OTC formulation was discontinued by the manufacturer because of
lack of consumer demand.
• Gastrointestinal effects, including bleeding
• Rash
• High incidence of cross-reactivity in individuals with aspirin allergy
Drug interactions may occur as follows:
• Warfarin: Increased bleeding risk
• Alcohol: Increased risk of gastrointestinal bleeding
• Methotrexate: Decreased methotrexate clearance
• Antihypertensives:
• Angiotensin-converting enzyme (ACE) inhibitors: Decreased hypotensive effects, hyperkalemia
• -blockers: Decreased hypotensive effects
• Potassium-sparing diuretics: Hyperkalemia
• Digoxin: Decreased renal clearance, risk of digoxin toxicity

Precautions and contraindications are as follows:
• Alcohol (increased risk of GI bleeding)
• Renal impairment
• Congestive heart failure
Special patient populations should be aware of the following:
• Ibuprofen and naproxen are compatible with breastfeeding.
• Avoid NSAIDs in third trimester of pregnancy.
27-6. Ophthalmic Disorders
Dry Eye
• Definition: Tear film instability caused by a deficiency of any component of the tear film
• Clinical presentation: Ocular discomfort, blurred vision, desire to rub the eyes, and burning or
redness
Etiology
• Aqueous tear deficiency
• Exposure to dry air
• Keratoconjunctivitis sicca
• Sjogren's syndrome
• Blepharitis
• Vitamin A deficiency
• Allergic conjunctivitis
• Contact lenses
• Drug-induced (anticholinergic agents and antihistamines) condition
Nonpharmacologic treatment
• Avoid known irritants.
• Use a cool-mist humidifier or warm-steam vaporizer.
Table 27-11 describes the pharmacologic treatment of dry eyes.
Loose Foreign Material in the Eye
Symptoms
Symptoms include irritation, inflammation, involuntary tearing, uncontrollable blinking, and

discomfort.
Etiology
Foreign materials may include dirt, an eyelash, or particles suspended by the tears.
Eyewashes are isotonic, buffered solutions of sterile water. They should not be used if the patient
has open wounds near the eye. Contact lens wearers should remove their lenses prior to using
eyewashes. Use of eye cups should generally be avoided.
Redness Caused by Minor Irritation
Etiology
Eye redness can be caused by airborne pollutants (gases or smoke), chlorinated water, infectious
diseases, or glaucoma.
Ophthalmic vasoconstrictors, as described in

Table 27-12, are used to treat eye redness.
The medications constrict blood vessels of the conjunctiva. Instill 1-2 drops in the affected eye up
to four times daily. Minimize systemic absorption by closing the eye after instillation and occluding
the tear duct with a finger (punctual occlusion).
These agents are contraindicated in patients with narrow-angle glaucoma because they cause
mydriasis. Contact lens wearers also should avoid ophthalmic vasoconstrictors.
A rebound hyperemia can occur, especially with overuse. Tachycardia and aggravate arrhythmias
can occur if absorbed systemically.
[Table 27-11. Pharmacologic Treatment of Dry Eyes]
[Table 27-12. Ophthalmic Vasoconstrictors]
Ocular decongestants should be avoided in patients with heart disease, high blood pressure, an
enlarged prostate, or narrow-angle glaucoma.
Allergic Conjunctivitis
Symptoms
Symptoms include chronic and recurring itching. Eyes are slightly red and tear and burn, but they
have little discharge.
Etiology
Animal hair, pollen, ragweed, or plants are possible allergens.
Antihistamine and mast cell stabilizer

Ketotifen fumarate 0.025% (Zaditor and Alaway), an antihistamine and mast cell stabilizer, may be
used to treat allergic conjunctivitis. Instill 1 drop q8-12h in the affected eye. Use in patients e 3
years of age. Relief is provided within minutes, and effects may last up to 12 hours.
Combination products
The following combination products containing an ophthalmic vasoconstrictor and an ocular
antihistamine may be used:
• Naphazoline + pheniramine (Naphcon A, Visine A, and Opcon-A)
• Naphazoline + antazoline (Vasocon-A)
Instill 1-2 drops in the affected eye up to four times daily.
Combination products containing ocular decongestants should be avoided in patients with heart
disease, high blood pressure, enlarged prostate, or narrow-angle glaucoma.
Conditions Requiring Referral to a Physician or Eye Care Specialist
Corneal edema
Symptoms
Symptoms include foggy vision, haloes around lights, photophobia, irritation, sensation of a foreign
body, and extreme pain.
Etiology
Prolonged contact lens wearing, infection, glaucoma, and iritis are possible causes.
Sodium chloride (2-5%) can be used to treat corneal edema. Instill 1-2 drops in the affected eye
every 6 hours. If eye drops do not provide relief, add ointment to therapy.
Foreign body in the eye
Foreign bodies include metal shavings, wood splinters, and dust. Improper removal may lead to
permanent damage.
Ocular trauma
Automobile accidents and sports injuries can result in ocular trauma.
Chemical exposure
If chemical exposure occurs, follow these steps:
• Remove contact lenses.
• Flush eye immediately with lukewarm water for at least 15 minutes.
• Do not place drops in the eyes.
27-7. Otic Disorders
Impacted Cerumen
Cerumen-softening agents
Cerumen-softening agents are used as follows:
• Instill in ear.
• Follow with warm water irrigation using otic syringe.
Various types of agents are available:
• Carbamide peroxide 6.5% in anhydrous glycerin: Products include Debrox and Murine
Earwax Removal System. This agent softens ear wax and facilitates its removal.
• Hydrogen peroxide and water: A 1:1 solution of warm water and 3% hydrogen peroxide is
used. This mixture is not an effective drying agent.
• Glycerin: This emollient and humectant may facilitate the removal of ear wax.
• Olive oil: Sometimes called sweet oil, olive oil can also be used.
Water-Clogged Ears
A solution of 95% isopropyl alcohol in 5% anhydrous glycerin (Swim Ear or Auro Dri Drops) may
be used to treat water-clogged ears. This solution is the only FDA-approved ear-drying aid.
A compounded solution 50:50 acetic acid (5%) + isopropyl alcohol (95%) may also be used. This
combination is recommended by the American Academy of Otolaryngology.
Boils
Boils occur when hair follicles in the ear canal become infected. They are usually self-limiting.
They are treated by applying a warm compress.
27-8. Home Monitoring and Test Devices
Fertility Prediction Tests
Basal thermometry
Temperatures can be taken orally, rectally, and vaginally. Temperatures are taken every morning
before arising.
Resting temperatures are usually below normal for first part of the reproductive cycle. Temperatures
are closer to normal after ovulation.
Temperature results are plotted graphically against time to assess spikes (ovulation). Tests are very
user dependent.
Bioself, Fertility Indicator

This device is used to take digital temperature readings. The user must input the first day of menses
into the device. The device calculates user's average cycle length and predicts the user's most fertile
period.
Each morning, the indicator displays a prediction (90% effective). The device indicates if the user is
in a nonfertile phase, if conception is possible, or if the user is in the most fertile phase. The user
can obtain a printout through modem download.
Ovulation prediction kits
This test contains antibodies that bind to the lutenizing hormone (LH) in urine. An LH surge is
detected by a difference in color or color intensity from one day to the next.
Early morning urine collection is recommended. The user must know the length of the past three
cycles before using. Testing usually begins 2-4 days prior to ovulation (based on the average of the
past three cycles).
Pregnancy detection
Early testing is very important. Tests detect levels of human chorionic gonadotropin (hCG) in urine
(within 1-2 weeks after conception). Antibodies designed to react with hCG form the shape of a
straight line, check, or plus sign. If the user is pregnant, color is produced.
Pregnancy tests are 98-100% accurate; however, human error decreases that rate to 50-75% (see
Table 27-13).
Important tips for patients using pregnancy tests follow:
• Use of first morning urine to test is encouraged because hCG is more concentrated.
• If use of first morning urine is not possible, the patient should restrict fluids 4-6 hours before urine
collection.
• Use only supplied collection devices.
• Try to test the sample immediately after collection. If this is not possible, allow refrigerated
samples to come to room temperature.
[Table 27-13. Causes of Error in Home Pregnancy Testing]
• If the test is negative, wait 1 week and retest if the cycle has not yet started.
• If the test is positive, contact an obstetrician-gynecologist immediately and start prenatal vitamins.
Urinary Tract Infection Tests
Two categories are available:
• Tests for nitrites in urine (UTI Bladder Infection Test)
• Tests for nitrites and leukocyte esterase (AZO strips)

Both are specific only for gram-negative organisms.
Inaccurate results are possible in the following circumstances:
• False-negative result: Vegetarian diet, vitamin C, or tetracycline
• False-positive result: Phenazopyridine
Hypertension
Mercury column devices
These devices use a blood pressure reference standard. Routine home use is discouraged because
the devices are cumbersome.
Aneroid devices
Aneroid devices are light, portable, and affordable. Many come with an attached stethoscope. They
require good eyesight and hearing for effective use (large-print devices are available).
Digital devices
Digital devices are less accurate than aneroid devices.
CholesTrak Home Cholesterol Test
This test checks for total cholesterol only. Results are available without the need for a lab.
Biosafe Total Cholesterol Panel
Fingerstick blood is placed on a small collection card. The sample is mailed to Biosafe Lab. Results
for a whole lipid profile are given. A licensed doctor reviews the results before they are sent to the
patient.
Cardiocheck
Cardiocheck has the potential to test for TC (total cholesterol), HDL (high-density lipoprotein), and
TG (triglycerides). LDL (low-density lipoprotein) must be calculated.
The unit stores results. It is reusable.
Fecal Occult Blood Tests

Three categories are available:
• Toilet tests (EZ-Detect Stool Blood Test), which use biodegradable paper that is placed in the
toilet bowl after a bowel movement
• Stool wipes (LifeGuard)
• Manual stool application tests (Colon-Test-Sensitive)
A colorimetric assay is used for hemoglobin. A blue-green color indicates a positive test.
Tests are more likely to detect lower GI problems. False-positive test can occur with the ingestion
of red meat or vitamin C.
Acquired Immune Deficiency Syndrome (AIDS)
Home Access and Home Access Express HIV-1 tests check for antibodies to HIV (human
immunodeficiency virus). Patients should be aware that it can take 3 weeks to 6 months before
antibodies are detectable following infection.
A fingerstick blood sample is placed on the specimen card. The card is mailed to the lab within 10
days. Home Access provides results in 7 days. Home Access Express provides results in 3 days.
27-9. Smoking Cessation
Introduction
Unless the patient has contraindications, pharmacotherapy should be offered to all patients
attempting to quit smoking (
Table 27-14).
First-line agents double long-term smoking abstinence rates:
• Nicotine replacement therapy (NRT):
• Nicotine gum (Nicorette and generic): OTC
• Nicotine patch (Nicotrol, Nicoderm CQ, and generic): OTC
• Nicotine lozenge (Commit): OTC
• Nicotine inhaler (Nicotrol inhaler): prescription only
• Nicotine nasal spray (Nicotrol NS): prescription only

[Table 27-14. The "5 A's" Clinicians Should Use to Assist Patients in Smoking Cessation]
• Bupropion SR (Zyban): prescription only
• Varenicline (Chantix): prescription only
Second-line agents are available if patients fail or cannot tolerate first-line agents:
• Clonidine
• Nortriptyline
Combination NRT
Combining the nicotine patch with a self-administered form of NRT (either the nicotine gum or
nicotine nasal spray) is useful for some patients. Combined treatment should be recommended if the
patient is unable to quit using a single type of first-line pharmacotherapy.
Side Effects
NRT can have various side effects:
• Gum
• Patients may experience an unpleasant taste, mouth irritation, jaw muscle soreness,
hypersalivation, hiccups, and dyspepsia.
• Gum can stick to dental work.
• Warn patients against chewing the gum too fast.
• Patients with temporomandibular joint pain may want to avoid gum.
• Lozenge
• Mouth irritation, nausea, hiccups, cough, heartburn, headache, flatulence, and insomnia can
occur.
• Do not use more than one lozenge at a time.
• Patch
• Local skin reactions (erythema, burning, pruritis) can occur. Treat by rotating sites or applying
hydrocortisone or triamcinolone cream.
• Vivid or abnormal dreams, insomnia, and headache can arise. These effects are more common
in the 24-hour patch. Patients can minimize the effects by using the 16-hour patch or by
removing the patch at night before bed.
Contraindications and Precautions
Cardiovascular disease is a contraindication in the following cases:
• < 2 weeks following myocardial infarction
• Serious arrhythmias
• Serious or worsening angina
Esophagitis and peptic ulcer disease is contraindicated with the gum form.
NRT patients should seek medical advice if they are pregnant or breast-feeding.
Patients should not smoke while using NRT.
Allergies, asthma, and sinus conditions are contraindicated with the nasal spray.
27-10. Natural and Herbal Products
Complementary and Alternative Medicine Definitions
• Conventional treatment: Medical practices widely accepted and practiced by the mainstream
medical community
• Complementary therapy: Therapy used in addition to conventional treatments.
• Alternative therapy: Therapy used instead of conventional treatments.
• Dietary supplement: According to the Dietary Supplement and Health Education Act of 1994, "a
product intended to supplement the diet that . . . contains one or more of the following dietary
ingredients: a vitamin, mineral, herb, or other botanical, amino acid; a dietary substance for use
by man to supplement the diet by increasing the total daily intake; or a concentrate, metabolite,
constituent, extract, or combination of these ingredients"
Regulation of Dietary Supplements
Dietary supplements are not regulated as closely as drugs.

Table 27-15 provides a comparison.
The following agencies are responsible for regulation:

• U.S. Food and Drug Administration: Regulates labeling, safety, and manufacturing
• U.S. Federal Trade Commission: Regulates advertising
[Table 27-15. Drugs versus Dietary Supplements]
Herbal Products
Alpha lipoic acid
Common uses
Alpha lipoic acid is used for diabetic peripheral neuropathy.
Proposed mechanisms
This product is thought to be a cofactor for several enzymes required for glucose metabolism. It is
believed to allow for increased glucose uptake and is considered a chelating and antioxidant agent.
Dosage
The dosage is 600 mg tid orally, taken on an empty stomach and separated at least 2-3 hours from
the ingestion of antacids.
Side effects
Side effects include headache, nausea, allergic rash, and hypoglycemia.
Contraindications
Patients with thyroid disease should not take this product.
Asian ginseng (Panax ginseng)
Common uses
Asian ginseng is taken to decrease fatigue and enhance concentration.
Proposed mechanisms
This product is thought to suppress and stimulate the CNS. Corticosteroid activity and
hypoglycemic activity are considered to occur.
Dosage
The dosage is 1-2 g of crude root or 100-400 mg of ginseng extract tid.
Side effects
Side effects are hypertension; euphoria, restlessness, nervousness, and insomnia; rash; edema; and
diarrhea.
Contraindications
Contraindications are as follows:
• Renal failure
• Acute infection
• Pregnancy and lactation
• Active bleeding (peptic ulcer)
Ginseng should be stopped 7-10 days prior to surgery to avoid potential bleeding complications.
Precautions
Caution is warranted in the following circumstances:
• Cardiovascular disease
• Hypertension with or without medical treatment
• Diabetes (specifically with patients receiving medications that may cause hypoglycemia or having
diagnosis of hypoglycemia unaware)
• History of hypotension
Interactions
• Risk with anticoagulants and antiplatelet agents (aspirin, ticlopidine, clopidogrel, dipyridamole,
warfarin) and other herbs (ginkgo, garlic)
• Stimulants (including caffeine)
• Antipsychotics
Coenzyme Q10 (Ubiquinone)
Common uses
Coenzyme Q10 (CoQ10) is commonly used for cardiovascular conditions.
Proposed mechanisms
CoQ10 is a cofactor for many functions associated with energy production. It is a powerful
antioxidant that helps in the regeneration of other antioxidants. It also stabilizes membranes and
may have vasodilatory and inotropic effects.
Dosage
For heart failure, cardiomyopathy, and hypertension, the dosage is 100 mg qd bid.
Side effects
Side effects include nausea, GI distress, headache, irritability, and dizziness.
Interactions
• CoQ10 has a similar structure to synthetic vitamin K, which may cause a decrease in international
normalized ratio (INR) levels if used concomitantly with warfarin.
• HMG CoA (3-hydroxy-3-methylglutaryl-coenzyme A) reductase inhibitors reduce serum levels of

CoQ10.
Echinacea purpurea
Common uses
Echinacea purpurea is used for colds and other respiratory tract infections. It is used topically for
poorly healing wounds and chronic ulcerations.
Proposed mechanisms
This product is thought to stimulate the immune system. It is believed to increase white blood cells
and provide antiviral, antifungal, and anti-inflammatory action.
Dosage
Dosing should begin at the onset of viral symptoms. On day 1, take 50-100 mg tid. Then take 250
mg qid. Continue treatment until 24-48 hours after symptoms abate.
Side effects
Allergic reactions can occur. Limit use to 6-8 weeks at a time.
Contraindications
This product should not be taken by patients with severe systemic illness (HIV/AIDS, multiple
sclerosis, tuberculosis) or autoimmune disorders (rheumatoid arthritis).
Interactions
Potentially severe allergic response, including anaphylaxis, may occur in individuals with asthma or
allergies to members of the daisy family (ragweed, daisies, chrysanthemums, marigolds).
Immunosuppressive agents may interact with this product.
Fish oil
Common uses
Fish oil is often taken to improve cardiovascular health and by patients with hypertriglyceridemia,
rheumatoid arthritis, or psoriasis.
Proposed mechanisms
Fish oil provides a source of omega-3 fatty acids (docosahexaenoic acid and eicosapentaenoic acid).
It is considered to increase anti-inflammatory cytokines and decrease pro-inflammatory cytokines. It
is thought to decrease the intestinal absorption of cholesterol and inhibit the synthesis and
degradation of very-low-density lipoprotein particles.
Dosage
• General use: 1-2 g daily
• Hypertriglyceridemia: 2-4 g daily
• Rheumatoid arthritis: 4 g daily
• Psoriasis: 3-4 g daily
Side effects
Side effects include GI distress and fish burp, which may be avoided by using enteric-coated
products, taking with meals, or keeping the capsules in the freezer.
Interactions
At doses > 4 g daily, increased bleeding risk is present; therefore, patients on anticoagulation or
antiplatelet therapy should be limited to 3 g daily.
Garlic (Allium sativum)
Common uses
Garlic is taken to lower cholesterol, prevent atherosclerosis, treat bacterial and fungal infections,
and prevent various cancers.
Proposed mechanisms
Garlic is considered to exhibit antimicrobial action through sulfur-containing compounds, inhibit
platelet aggregation, act as a free radical scavenger, stimulate fibrinolysis, and lower cholesterol and
lipid levels by inhibition of HMG-CoA reductase.
Dosage
Dosage is as follows:
• 4 g fresh minced garlic bulb
• 600-900 mg/d (100 mg garlic powder tablets)
• 3-5 mg allicin daily
Side effects
Side effects include malodorous breath and smell of garlic that may permeate the skin; GI
discomfort, heartburn, and gas; and dermatitis and allergic reactions.
Contraindications
Active bleeding (peptic ulcer) can occur. Garlic should be stopped 7-10 days prior to surgery to
avoid potential bleeding complications.
Interactions
• Anticoagulants and antiplatelet agents: Aspirin, ticlopidine, clopidogrel, dipyridamole,

warfarin, ginkgo, ginseng
• Saquinavir AUC (area under curve): 50% decrease in healthy volunteers
Ginger
Common use
Ginger is used as an antiemetic.
Proposed mechanism
It is thought to stimulate gastric secretions and peristalsis.
Dosage
• Pregnancy-induced nausea or vomiting: Dried ginger 250 mg qid
• Motion sickness: Two 500-mg capsules of dried powdered ginger root taken 30 minutes prior to
travel, followed by one to two more 500-mg capsules as needed every 4 hours
Side effects
Heartburn and dermatitis may occur.
Interactions
Ginger may increase the risk of hypoglycemia. It alters platelet function at doses > 1 g/d. Use with
caution in patients receiving antiplatelet and anticoagulation therapy.
Ginkgo biloba
Common uses
Ginkgo biloba is used to enhance memory and concentration. It is used to treat or prevent
Alzheimer's disease and vascular dementias. It is also used to treat intermittent claudication,
vertigo, and tinnitus.
Proposed mechanisms
Ginkgo biloba is thought to increase blood flow, act as an antioxidant, and inhibit platelet
aggregation.
Dosage
Recommend a standardized product, 120-240 mg/d divided bid or tid.
Side effects
• Mild: GI distress, headache, and dizziness can occur.
• Serious: Spontaneous bleeding has been reported (e.g., subdural hematomas and subarachnoid
hemorrhage).
Interactions
This product may interact with both medications (aspirin, ticlopidine, clopidogrel, dipyridamole,
warfarin) and herbs (garlic, ginseng). Interactions are due to antiplatelet or anticoagulant activity.
Contraindications
Ginkgo should be stopped 7-10 days prior to surgery to avoid potential bleeding complications.
Glucosamine and chondroitin sulfate
Common uses
Glucosamine and chondroitin sulfate products are used for osteoarthritis.
Proposed mechanisms
This product serves as a precursor to glycosaminoglycans, which make up cartilage and synovial
fluid. It may help regenerate cartilage and replete synovial fluid.
Dosage
Dosage is as follows:
• Glucosamine: 500 mg tid (with meals) glucosamine sulfate
• Chondroitin: 400 mg tid
These agents are often in a combination product; however, glucosamine has more evidence
supporting its use. Full effects may not be seen for 6-8 weeks.
Side effects
Mild GI effects such as nausea and heartburn may occur. Little is known about the long-term use of
this product.
Contraindications
Patients with severe shellfish allergy should not take this product.
Green tea
Common uses
Green tea is taken as a performance enhancer and to protect from the development of cardiovascular
disease and cancer.
Proposed mechanisms
Green tea contains caffeine, which has a stimulant effect, and antioxidants (EGCG
[Epigallocatechin gallate]), which protect against oxidative damage.
Dosage
The common consumption in Asian countries is 3 cups daily. Dosage varies from 1-10 cups daily.
Side effects
GI irritation and both CNS and cardiac stimulation can occur because of caffeine content. Green tea
can contain a range of 8-30 mg of caffeine per tea bag.
Drug interactions
Large doses may decrease INR levels, although brewing destroys most of the vitamin K content.
Kava-kava
Common uses
Kava-kava is used for anxiety or stress.
Proposed mechanisms
Kava-kava possibly binds at GABA ( -aminobutyric acid) receptors. It possibly acts as a dopamine
antagonist.
Dosage
The dosage is 100 mg two to three times daily.
Side effects
Side effects are similar to those that occur with alcohol (i.e., it adversely affects motor reflexes and
judgment for driving or operating heavy machinery), but kava-kava does not act as a CNS
depressant.
Mydriasis and extrapyramidal symptoms may occur.
Yellow, flaking, and scaly skin and eye redness are possible effects.
Liver failure, leading to transplantation or death, is a serious concern (

Table 27-16).
Contraindications
Patients who have preexisting liver disease or who regularly ingest alcohol should not take this
product.
Precautions
Patients should be counseled as follows:
• Do not take for > 4 weeks.
• Discontinue immediately if jaundice occurs.
Interactions
• L-dopa: Decreased effectiveness
• Barbiturates, benzodiazepines, and alcohol: Additive sedative effects
Melatonin
Common uses
Melatonin is commonly used for sleep disorders and to reset the sleep-wake cycle (jet lag).
Proposed mechanisms
Melatonin mimics endogenous release of melatonin from the pineal gland. Concentrations increase
significantly 1-2 hours before sleep.
Dosage
Dosages are as follows:
• Insomnia: 0.3-5 mg 30 minutes prior to bedtime
• Jet lag: 2-5 mg in the evening between 5:00 pm and 10:00 pm on the day of arrival and at
bedtime for 2-5 days after arrival
Long-term administration is not recommended.
[Table 27-16. Natural Products Associated with Serious Toxicity]
Side effects
Melatonin may worsen depression. Other side effects include headache and confusion. Melatonin is
possibly an immune stimulant.
Interactions
When melatonin is taken with benzodiazepines, anxiolytic effects are enhanced.
Probiotics
Common uses
Probiotics are taken for antibiotic-induced diarrhea, GI disorders, atopic dermatitis, and allergies.
Proposed mechanisms
Probiotics contain Lactobacillus sp, Bifidobacteria sp, or Sacchromyces boulardii. They are thought
to decrease intestinal permeability, normalize gut flora, and decrease inflammatory responses. They
possess immunomodulating activity.
Dosage
Lactobacillus sp and Bifidobacteria sp are dosed at 1 billion to 10 billion colony-forming units per
day. Sacchromyces boulardii is dosed at 250-500 mg bid-qid.
Side effects
Bloating, flatulence, and diarrhea may occur.
Contraindications
Because of reports of systemic infection, immunocompromised patients should avoid use.
Interactions
Probiotics may decrease antibiotic absorption; therefore, antimicrobial agents should be
administered several hours apart from taking probiotics.
Saw palmetto (Serenoa repens)
Common uses
Saw palmetto is used for benign prostatic hyperplasia.
Proposed mechanism
It inhibits 5 -reductase and dihydrotestosterone binding to androgen receptors.
Dosage
For a product with 80-90% fatty acids, the dose is 160 mg bid or 320 mg qd. Take with morning
and evening meals to decrease GI upset. Treatment usually lasts for 3 months.
Side effects
Rarely, GI upset, headache, or hypertension may occur. Urinary tract symptoms (urine retention,
dysuria) are possible. Impotence may occur.
Precautions
Recommend a thorough prostate exam and discussion with physician before starting treatment to
rule out prostate cancer.
St. John's wort (Hypericum perforatum)
Common uses
St. John's wort is used to treat depression and anxiety.
Proposed mechanisms
This product is thought to inhibit dopamine, serotonin, and norepinephrine reuptake and to decrease
IL-6 (interleukin-6) concentrations.
Dosage
This product is standardized to 0.3% hypericin or 5% hyperforin. The recommended dose is 300-
600 mg tid.
Side effects
Mild GI distress, paresthesias, dizziness, fatigue, insomnia, itching, dry mouth, and loss of libido
can occur. Photosensitivity can occur: recommend sun avoidance or sunscreen.
Interactions
Interactions are well documented and clinically significant.
Antidepressants (SSRIs [selective serotonin reuptake inhibitors] and TCAs [tricyclic

antidepressants]) interact with this product because of a similar mechanism of action resulting in
serotonin syndrome.
St. John's wort is an inducer of CYP (cytochrome) 450-3A4, 1A2, and 2C9, causing decreased
levels of medications and possibly resulting in reduced therapeutic effects. Medications affected
• Cyclosporine
• Indinavir
• Digoxin
• Oral contraceptives (Estradiol component)
27-11. Sleep Aids and Stimulants
Insomnia
Nonpharmacologic treatment of insomnia
Nonpharmacologic treatments include the following:
• Establish regular waking and sleeping schedule.
• Exercise regularly.
• Do not nap during the daytime.
• Avoid caffeine, especially after noon.
• Avoid large meals close to bedtime.
• Participate in a relaxing activity at bedtime (e.g., reading or hot bath).
Nonprescription medication treatment
Selected nonprescription products are described in

Table 27-17.
Antihistamines
Administer diphenhydramine 25-50 mg 30-60 minutes before bedtime (elderly patients, 25 mg).
Antihistamines block histamine1 and muscarinic receptors. They should be used for short-term
management of occasional insomnia in conjunction with good sleep hygiene. Do not exceed 14
days of therapy (to avoid tolerance).
Side effects
Sedation, especially the next morning, may occur. Anticholinergic effects may occur as follows:
• Dry mouth or eyes
• Constipation
• Urinary retention
• Confusion (elderly patients)
Contraindications and precautions

Patients with benign prostatic hyperplasia, dementia, or narrow-angle glaucoma should not use this
medication.
[Table 27-17. Selected Nonprescription Products for Insomnia]
Drowsiness
Nonpharmacologic treatment of drowsiness
Good sleep hygiene is preferable to drug therapy (see previous discussion of insomnia).
Nonprescription medication treatment

Caffeine is the only FDA-approved nonprescription stimulant. It acts as a CNS stimulant.
Physical dependence can develop. Taking 50-200 mg results in increased alertness and decreased
fatigue. Taking > 200 mg can result in nervousness, insomnia, and irritability.
Precautions exist with patients with peptic ulcer disease, cardiac dysrhythmias, and anxiety
disorders.
Patients who are pregnant should restrict their caffeine intake to < 300 mg daily. Patients who are
breast-feeding should be aware that 1% of caffeine crosses into breast milk; peak effect is 1 hour
after consumption.
27-12. Overweight and Obesity
Clinical Indicators
The National Heart Lung and Blood Institute of the National Institutes of Health (NHLBI) and
World Health Organization definition is based on body mass index (BMI):
• Overweight = BMI 25-29.9
• Obese I = BMI 30-34.9
• Obese II = BMI 35-39.9
• Obese III = BMI 40
NHLBI also assesses a patient's morbidity and mortality risk with regard to waist circumference:
• Males with a waist circumference > 40 inches
• Females with a waist circumference > 35 inches
These persons are at increased risk of developing type 2 diabetes and cardiovascular disease.
Nonpharmacologic Therapy
Nonpharmacologic therapy involves lifestyle modification.
Caloric restriction
Usually restriction of calories sufficient to create a deficit of 800-100 kcal/d is recommended. A

low calorie diet results in a typical weight loss of 1-2 lbs/week. Portion control is essential.
Altered proportions of food groups is an important lifestyle modification:

• Fat: < 30% of total calories from fat and < 8-10% of total calories from saturated fat
• Carbohydrates: 45-65% of total calories
• Protein: 10-35% of total calories
Use of food additives
Artificial sweeteners and fat substitutes can be helpful.
Physical Activity
Increasing physical activity is recommended:
• For reduction of chronic disease: Engage in 30 minutes of moderate intensity exercise most
days of the week.
• For prevention of body weight gain over time: Engage in 60 minutes of moderate to vigorous
intensity exercise most days of the week.
• For sustaining weight loss: Engage in 60 minutes of moderate intensity exercise most days of the
week.
Behavioral therapy
Behavioral therapy involves environmental modification, modified thinking patterns, maintenance

of a healthy attitude, and social support.
Orlistat (Alli)
The FDA approved orlistat for nonprescription status in 2007. Orlistat decreases the absorption of
dietary fats and inhibits gastric and pancreatic lipases.
Indication
Orlistat is indicated for use in patients 18 years of age who are overweight (BMI 25) in
conjunction with lifestyle modification.
Dose
Patients should take one 60 mg capsule before meals. They do not have to take the medication if the
meal does not contain fat.
Side effects
• Flatulence with oily spotting
• Loose and frequent stools
• Fatty stools
• Fecal urgency
• Incontinence
Decreasing the amount of ingested fat can minimize these effects. Effects generally resolve within a
few weeks of initiating therapy.
Contraindications
Patients on cyclosporine and patients with malabsorption disorders should not use this medication.
Patients with a history of thyroid disease, cholelithiasis, nephrolithiasis, or pancreatitis should
consult a primary care physician prior to use.
Interactions
Decreased absorption of fat-soluble vitamins (especial D & E) occurs. Take a multivitamin at
bedtime or separate it from orlistat dose by at least 2 hours.
Concern exists over Vitamin K absorption and possible effects on warfarin; therefore, recommend
increased monitoring.
27-13. Key Points
Cough, Cold, and Allergy
• Cough and cold products are not to be used in children < 4 years of age.
• Nonprescription drug therapy for the common cold includes symptomatic management using
decongestants (nasal congestion), antihistamines (excess nasal discharge), analgesics (headache),
and local anesthetic lozenges or sprays (pharyngitis).
• Nonprescription treatment of allergies includes systemic antihistamines (sedating or nonsedating),

ocular antihistamines, decongestants (if nasal congestion), and cromolyn (scheduled, not as
needed).
• Cough can be relieved by a product containing a cough suppressant (dextromethorphan). An

expectorant (guaifenesin) should be recommended to enhance clearance of mucus.
Constipation
• Diet and lifestyle changes should always be recommended to prevent or treat constipation
(exercise and an increase in fiber and fluid intake).
• Bulk-forming laxatives and stool softeners are the safest products to prevent and treat constipation
and can be used chronically.
• Stimulant laxatives should be used only occasionally to prevent laxative dependence or other
complications.
Diarrhea
• Loperamide or bismuth subsalicylate may be recommended to treat diarrhea.
• Maintaining adequate hydration is very important, especially in young children and elderly
patients.
Nausea and Vomiting
• Nonprescription treatment options for nausea and vomiting include antihistamines (meclizine,
dimenhydrinate) and phosphorated carbohydrate solution (Emetrol).
• H2RAs (cimetidine, ranitidine); antacids; or bismuth salts (Pepto-Bismol) may relieve gastric
discomfort or indigestion.
Pain and Fever
• Pain and fever may be treated with aspirin and other salicylates, NSAIDs, or acetaminophen.
• Aspirin and NSAIDs inhibit platelet aggregation. Nonacetylated salicylates and acetaminophen do
not have antiplatelet activity.
• Salicylates and NSAIDs can cause gastropathy, including gastritis, gastric ulcers, and gastric
bleeding. They may decrease the effectiveness of some antihypertensives and may have
deleterious effects on kidney function.
• Acetaminophen does not have anti-inflammatory activity and can be hepatotoxic in excessive
doses (> 4 g/d) or when used concurrently with alcohol.
Ophthalmic Disorders
• Dry eyes can be treated with artificial tears or ocular emollients.
• Ophthalmic vasoconstrictors (ocular decongestants) cause vasoconstriction in the conjunctiva to

treat redness. Naphazoline is the ocular decongestant of choice. Ocular decongestants are
contraindicated in patients with narrow-angle glaucoma because of the potential to cause
rebound.
• Ketotifen fumarate is the safest and most effective product for the treatment of allergic
conjunctivitis. Twice daily dosing and safety of this product for children e 3 years of age make it
the primary therapy for patients with this condition.
Otic Disorders
• Impacted cerumen can be treated with cerumen-softening agents (carbamide peroxide in

anhydrous glycerin + alcohol; hydrogen peroxide + water).
• Water-clogged ears may be managed with the commercial preparation of isopropyl alcohol +
anhydrous glycerin or with compounded acetic acid + isopropyl alcohol.
Home Monitoring and Testing Devices
• Other testing devices that were not discussed in detail in this chapter include diabetic meters, male
fertility tests, illicit drug use tests, and the hepatitis C test.
• When counseling patients on the use of these devices, it is important to ensure that they
understand the directions for use (appropriate timing and causes of false-positive and false
negative results), check for expiration dates, and make certain the product is developed to give
them the results they are seeking.
Smoking Cessation
• First-line agents for pharmacotherapy in smoking cessation are as follows:
• Nicotine gum (Nicorette, generic) OTC
• Nicotine patch (Nicotrol, Nicoderm CQ) OTC
• Nicotine inhaler (Nicotrol inhaler)
• Nicotine nasal spray (Nicotrol NS)
• Bupropion SR (Zyban)
• Varenicline (Chantix)
• Contraindications and precautions for nicotine replacement therapy are as follows:
• Cardiovascular disease
• < 2 weeks post-myocardial infarction

• Serious arrhythmias
• Serious or worsening angina
• Esophagitis and peptic ulcer disease (gum)
• Patients should seek medical advice if pregnant or breast-feeding.
• Patients should not smoke while using nicotine replacement therapy.
Natural and Herbal Products
• Herbal products that should be stopped 7-10 days prior to surgery include ginkgo, garlic, and
ginseng.
• St. John's Wort takes several weeks to see effect and has the potential for serious drug
interactions.
Sleep Aids
• Diphenhydramine should be used for short-term management of occasional insomnia in

conjunction with good sleep hygiene.
Stimulants
• Caffeine, a CNS stimulant, is the only nonprescription stimulant approved by the FDA.
• The recommended dosage of 50-200 mg may increase alertness and decrease fatigue.
• Doses exceeding 200 mg may cause nervousness, insomnia, and irritability.
Overweight and Obesity
• Overweight and obese persons in the United States have reached epidemic proportions. This
condition is significant because it is associated with increased morbidity from cardiovascular
disease, diabetes, gall bladder disease, osteoarthritis, respiratory problems, and several different
types of cancer.
• Orlistat (Alli) is an FDA-approved nonprescription medication used for the treatment of

overweight patients 18 years of age. This medication has many side effects that patients may
find unpleasant, and as a result, patients should be counseled on these side effects and ways to
avoid them. The use of this medication may decrease the absorption of fat-soluble vitamins from
the GI tract.
27-14. Questions
Which of the following is the primary advantage of recommending dextromethorphan instead

of codeine?
A. It is twice as effective as codeine in suppression of cough.

1.
B. It has less dependence potential.
C. It has peripheral rather than central action.
D. It is less expensive.
E. It is much longer acting than codeine.

All of the following statements regarding guaifenesin are correct except
A. it is the only OTC expectorant approved by the U.S. Food and Drug Administration (FDA).
2. B. it requires large amounts of water to be effective.
C. it is available OTC as Robitussin.
D. it may cause a decrease in platelet aggregation and an increase in bleeding time.
E. it is available in some prescription cough and cold formulations.

All of the following statements regarding diphenhydramine are true except
A. it is less likely to cause drowsiness than other OTC antihistamines.

3. B. it is the active ingredient in some OTC products for insomnia.
C. it is available OTC under the trade name of Benadryl.
D. a small percentage of children may exhibit a paradoxical CNS stimulant effect.
E. elderly patients may experience delirium or confusion with diphenhydramine.

All of the following statements about the routine use of oral decongestants in treating the
common cold are true except
A. They cannot be used in patients on MAO inhibitor antidepressants.

4.
B. They are relatively safe, with no dependence.
C. They are absolutely contraindicated in patients with controlled diabetes and mild
hypertension.
D. The most common side effects are nervousness and insomnia.

All of the following are correct generic and trade name combinations except
A. Chlor-Trimeton = chlorpheniramine
5. B. Tavist = diphenhydramine
C. Claritin = loratadine
D. Nasalcrom = cromolyn
E. Zyrtec = cetirizine

Which of the following is not a side effect of loperamide?
A. Sedation
6. B. Dizziness
C. Dry mouth
D. Drowsiness
E. Insomnia

Which of the following is not an adverse effect of Pepto-Bismol?
A. Anticholinergic effects, dry mouth, and dry eyes

7. B. Tinnitus
C. Cross-sensitivity to aspirin allergy
D. Grayish-black tongue
E. Dark stools

Which of the following drugs exhibits analgesic and antipyretic properties, but not peripheral
anti-inflammatory properties?
A. Ibuprofen
8.
B. Sodium salicylate
C. Acetaminophen
D. Magnesium salicylate
E. Naproxen

Which drug does not interact with NSAIDs?
A. Methotrexate
9. B. Warfarin
C. Antihypertensive agents
D. Diphenhydramine

Mary is a 32-year-old female with asthma and serious aspirin sensitivity. She comes to the
pharmacist seeking assistance in selecting a nonprescription product for aches and pains.
Which of the following should the pharmacist recommend for Mary?
10. A. Ibuprofen
B. Naproxen
C. Acetaminophen
D. A and B only
E. All of the above

Nonprescription antiemetics are primarily useful for preventing which type of nausea?
A. Nausea caused by alterations in the vestibular apparatus

11. B. Nausea caused by drugs acting centrally on the chemoreceptor trigger zone
C. Nausea caused by visceral pain
D. Nausea caused by cortical stimulation from smells or sight
E. Nausea caused by afferent impulses from the gastrointestinal tract

A mother requests advice for her 6-month-old child, who has been constipated for the past 2
days after beginning cereal feedings. Which of the following agents would be the best laxative
agent to recommend?
12. A. Dulcolax
B. Fletcher's Castoria
C. Mineral oil
D. Glycerin suppositories
E. Milk of magnesia

All of the following statements about stool softeners are true except
A. they are not safe to use in pregnancy.

13. B. the onset of action is usually within 1-2 days.
C. they are useful in patients with constipation who have hemorrhoids.
D. extra water helps their effectiveness.
E. they are often combined with mild stimulant laxatives.

All of the following statements about bisacodyl are true except
A. it should not be taken concurrently with antacids.

14. B. it can be crushed or chewed if needed.
C. it should not be recommended in pregnancy.
D. it is available in oral tablet and suppository dosage forms.
E. it is the active ingredient in Dulcolax.

Which of the following antihistamines are available in OTC products for insomnia?
A. Diphenhydramine
15. B. Cetirizine
C. Loratadine
D. B and C
E. All of the above

Baby Matthew is 1 year old and weighs 24 lb. He has a fever of 102°F, is irritable, seems
uncomfortable, and is not sleeping well. His mother is confused by the assortment of fever
relief products. You recommend acetaminophen. Which product and dosage do you
recommend?
16.
A. Tylenol Infant Drops 80 mg/0.8 mL; give 1.6 mL q4-6h
B. Tylenol Children's Liquid 160 mg/5 mL; give 2 tsp. q6-8h
C. Advil Infant Drops 50 mg/1.25 mL; give 1.25 mL q4-6h
D. Motrin Children's Suspension 100 mg/5 mL; give 2.5 mL q6-8h
E. Tylenol Infant Drops 80 mg/0.8 mL; give 3.2 mL q4-6h

The next morning, baby Matthew's mother returns to your pharmacy. Her pediatrician
recommended alternating the maximum dose of ibuprofen with the acetaminophen, and she is
asking for help selecting an ibuprofen product and dosage. Which do you recommend?
17. A. Advil Infant Drops 50 mg/1.25 mL; give 0.625 mL q8h

B. Motrin Children's Suspension 100 mg/5 mL; give 2 tsp q4h
C. Motrin Infant Drops 50 mg/1.25 mL; give 2.5 mL q6h
D. Advil Children's Chewable Tablet 50 mg; give one tablet q8h
E. Advil Children's Chewable Tablet 50 mg; give one-half tablet q4h

Which of the following tests does not require a blood sample?
A. Cholesterol test
18. B. Ovulation prediction tests
C. HIV tests
D. Hepatitis C test
E. Accu-Chek Advantage

B. R. is a 62-year-old obese male who has been diagnosed by his physician with benign
prostatic hyperplasia. Which of the following herbal remedies might be used to treat his
symptoms?
19. A. Ginseng
B. Echinacea
C. DHEA
D. Garlic
E. Saw palmetto

Which of the following products should be discontinued prior to surgery?
A. Ginkgo biloba
20. B. Gentian root
C. Glutamine
D. Glucosamine
E. Folic acid

Cough and cold products are not to be used in children less than _____ years of age.
A. 2
21. B. 4
C. 6
D. 8
E. 12

When a patient is considering the use of nonprescription orlistat, which of the following
vitamins may the patient need as additional supplementation because of decreased absorption?
22. A. B12
B. B6
C. D
D. C

27-15. Answers
B. Although there have been reports of limited recreational abuse of dextromethorphan, its
1.
potential for dependence and addiction is significantly less than that of codeine.

D. Guaifenesin does not have any effects on platelet aggregation or bleeding time. It is the only
2. FDA-approved OTC expectorant, works better with increased fluid intake, and is included in
Robitussin products.

3. A. Diphenhydramine, an ethanolamine, is the most sedating OTC antihistamine.

C. Systemic decongestants are not recommended in individuals with uncontrolled diabetes or
4. hypertension because of their sympathomimetic effects. They are contraindicated with MAO
inhibitors and can commonly cause nervousness or insomnia.

5. B. Tavist contains clemastine.

E. Sedation, dizziness, dry mouth, and drowsiness are common side effects of loperamide.
6.
Insomnia is not.

A. Common adverse effects of Pepto-Bismol include tinnitus and grayish-black tongue or
7. stools. Pepto-Bismal does contain a salicylate and, therefore, should not be used in individuals
with aspirin allergy.

C. Acetaminophen is a centrally acting antipyretic and analgesic, but it does not exhibit
8.
peripheral anti-inflammatory activity. Salicylates and other NSAIDs do.

D. NSAIDs can significantly decrease methotrexate clearance, enhance the effect of warfarin,
9. and blunt the hypotensive effect of hypertensive medications. There is no known interaction
with diphenhydramine.

C. All NSAIDs and aspirin-containing products should be avoided in individuals with aspirin
10.
sensitivity. Acetaminophen can be recommended in this setting.

A. Nonprescription antiemetics are antihistamines that exert their effect by inhibiting histamine
11. in neural centers controlling vomiting, salivation, and vestibular excitability, making them
especially well suited for motion sickness.

D. Glycerin suppositories are safe for infants. The other agents should not be used in this
12.
patient population.

A. Stool softeners are safe to use in pregnancy and usually exert their effect within 1-2 days.
Stool softeners are recommended for individuals in whom hard stools or straining could cause
13. pain or complications (e.g., hemorrhoids, postoperative or postpartum time periods, or post-
myocardial infarction). Increased fluid intake enhances their effectiveness. They are frequently
used in combination products containing stimulant laxatives.

B. Because bisacodyl is an enteric-coated product, it should not be taken with antacids or be
14. crushed, chewed, or broken. It should not be used in pregnancy. It is available in both oral
tablets and rectal suppositories.

A. Diphenhydramine is an ethanolamine used in sleeping aids. Cetirizine and loratadine are
15.
nonsedating antihistamines.

16. A. The pediatric dosage of acetaminophen is 10-15 mg/kg q4-6h:

24 lb × kg/2.2 lb = 10.9 kg × 10-15 mg/kg = 109.0-163.5 mg

Tylenol Infant Drops 80 mg/0.8 mL; 1.6 mL = 160 mg acetaminophen

17. C. The pediatric dosage of ibuprofen is 5-10 mg/kg q6-8h:

24 lb × kg/2.2 lb = 10.9 kg × 5-10 mg/kg = 54.5-109.0 mg

Motrin Infant Drops 50 mg/1.25 mL; 2.5 mL = 100 mg ibuprofen

B. Cholesterol, HIV, hepatitis C, and blood glucose tests all require a blood sample. Most
18.
ovulation prediction tests use urine.

E. Saw palmetto may have some efficacy in treating benign prostatic hyperplasia, although the
19.
patient should be evaluated by a physician to rule out prostate cancer.

A. Ginkgo biloba has antiplatelet activity and should, therefore, be withheld prior to surgical
20.
procedures.

B. The Consumer Health Care Products Association announced in October 2008 that
21. manufacturers were voluntarily updating all cough and cold products to state "do not use" in
children under 4 years of age.

C. Vitamin D is a fat-soluble vitamin that may have decreased absorption with concomitant
22. orlistat use despite multivitamin supplementation. A multivitamin is best taken at bedtime or
separate from an orlistat dose by at least 2 hours.

27-16. References
Berardi RR, ed. Handbook of Nonprescription Drugs: An Interactive Approach to Self Care. 16th
ed. Washington, D.C.: American Pharmacists Association; 2009.
Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: Clinical Practice
Guideline. Rockville, Md.: U.S. Department of Health and Human Services; 2008.
Pray WS. Nonprescription Product Therapeutics. 2nd ed. Baltimore: Lippincott Williams &
Wilkins; 2006.
Robbers JE, Tyler VE. Tyler's Herbs of Choice: The Therapeutic Use of Phytomedicinals. New
York: Hayworth Herbal Press; 1999.
Scott GN, Elmer GW. Update on natural product-drug interactions. Am J Health-Syst Pharm. 2002;
59:339-47.
28. Asthma and Chronic Obstructive Pulmonary Disease - Timothy H. Self, PharmD
28-1. Asthma
Introduction
Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements
play a role, in particular mast cells, eosinophils, T-lymphocytes, neutrophils, and epithelial cells. In
susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness,
chest tightness, and cough, particularly at night and in the early morning. Asthma affects about 22
million Americans and is the most common cause of missed school days for children. Morbidity
and mortality caused by asthma are unacceptably high; death rates are greatest in inner-city African
Americans and Hispanics.
• Childhood-onset (atopic): Positive family history of asthma, allergy to tree or grass pollen, house
dust mites, cockroaches, household pets, and molds
• Adult-onset: Frequently a negative family history and negative skin tests to common
aeroallergens
Classification of severity for children over 12 and adults is shown in

Figure 28-1. This classification is extremely important in defining treatment options (see
Figures 28-2 to
28-4). Classification of severity is taken from the National Institutes of Health (NIH) National
Asthma Education and Prevention Program, Expert Panel Report 3, 2007 (EPR-3). See EPR-3 for
classification of severity for ages 0-4 years and 5-11 years.
• Episodic wheezing, coughing, chest tightness, and shortness of breath that is worse at night, in the
early morning, and with exercise
Pathophysiology
• Asthma is an inflammatory airway disease and also a disease with bronchospasm.
• Common triggers of symptoms include aeroallergens; respiratory viral illness; exercise (especially
in cold, dry air); environmental smoke; and fumes.
• Drug-induced asthma includes that caused by aspirin, nonsteroidal anti-inflammatory drugs

(NSAIDs), and -blockers. Low to moderate-dose 1-selective agents such as atenolol or
metoprolol XL can be used if the patient has concurrent post-myocardial infarction or congestive
heart failure and does not have severe asthma; COX-2 inhibitors can be used in aspirin-sensitive
asthma.
• There is a complex interaction among inflammatory cells (e.g., mast cells, eosinophils, Th2-type
lymphocytes); mediators (e.g., leukotrienes); and cytokines (e.g., IL-4, IL-5).
• The result is airway inflammation (mucus and swelling in the lining of the airways) and airway
hyperreactivity.
• Early-phase response to inhaling an aeroallergen occurs immediately; late-phase response occurs

4-12 hours later.
• Asthma is commonly worsened by poorly controlled concurrent allergic rhinitis, sinusitis, and
gastroesophageal reflux disease (GERD); it may also worsen in the premenstrual or
perimenstrual period.
Diagnostic Criteria
• The main basis for diagnosis is a detailed history of episodic symptoms that are typically worse at
night and in the early morning and that are associated with common triggers.
[Figure 28-1. Classification of Asthma Severity (Ages e 12 and Adults)]
[Figure 28-2. Stepwise Approach for Managing Infants and Young Children (0-4 Years of Age)]
• Reversible airway obstruction (improvement in pulmonary function tests [FEV1] of > 12% after
inhaling a short-acting ²2 agonist) is often detected.
• Exclude alternate diagnoses (e.g., chronic obstructive pulmonary disease, vocal cord dysfunction).
• Optimal long-term management of asthma includes four major areas: objective assessment and
monitoring, environmental control, pharmacologic therapy, and patient education as a
partnership.
[
Figure 28-3. Stepwise Approach for Managing Asthma in Children 5-11 Years of Age: Treatment]
[Figure 28-4. Stepwise Approach for Managing Asthma 12 Years of Age and Adults: Treatment]
• Treatment goals are to achieve asthma control by reducing impairment:
• Prevent chronic and troublesome symptoms (e.g., coughing or breathlessness in the daytime,
during the night, or after exercise).
• Require infrequent use (< 2 days/week) of inhaled SABA for quick relief of symptoms.
• Maintain (near) "normal" pulmonary function.
• Maintain normal activity levels (including exercise and other physical activity and attendance at
work or school).
• Meet patients' and families' expectations of and satisfaction with asthma care.
• Treatment goals are to achieve asthma control by reducing risk:
• Prevent recurrent exacerbations of asthma and minimize the need for ED visits or
hospitalization.
• Prevent progressive loss of lung function; for children, prevent reduced lung growth.
• Provide optimal pharmacotherapy with minimal or no adverse effects.
• A stepwise approach to managing asthma is shown in Figure 28-2 (ages 0-4), Figure 28-3 (ages 5-
11), and Figure 28-4 (ages 12 and adults). These treatment guidelines are from EPR-3. See
Table 28-1 for long-term control medications.
• Inhaled corticosteroids are the most efficacious drugs for long-term management of persistent
asthma. Addition of a long-acting inhaled ²2 agonist is recommended for patients with moderate
or severe persistent asthma.
• Omalizumab (Xolair): Anti-IgE therapy is primarily indicated for severe persistent asthma patients
who have frequent emergency department visits and hospitalizations despite optimal therapy. It is
given subcutaneously every 2-4 weeks.
• Drug therapy is used for acute exacerbations of asthma. See

Table 28-2 for quick-relief medications and
Figure 28-5 for management of asthma exacerbations.
Monitoring
• Optimal management for the great majority of patients will result in a dramatic reduction in
symptoms (including nocturnal and early morning symptoms), as well as reduced acute care
visits, fewer lost work or school days, and reduced need for quick-relief medications.
• Monitoring peak expiratory flow (PEF) using a peak flow meter at home is required. Green zone
is 80-100% of personal best value. Yellow zone is 50-79% of personal best and indicates that
consultation with a health care professional is advisable. Red zone, or < 50% of personal best,
indicates that a written action plan should be implemented, and if there is no quick response,
immediate medical attention should be sought.
• Spirometry is performed in the physician's office
Mechanism of Action
For more details, see the section on mechanism of action in EPR-3.
Long-term control medications
Corticosteroids
• Corticosteroids are anti-inflammatory. They block late reaction to allergen and reduce airway
hyperresponsiveness. They inhibit cytokine production, adhesion protein activation, and
inflammatory cell migration and activation.
• Corticosteroids reverse 2-receptor downregulation and inhibit microvascular leakage.
Cromolyn and nedocromil

(Note: Since the release of EPR-3, cromolyn nebulizer solution and nedocromil MDI became
unavailable in the United States in 2008. Cromolyn MDI may be available in the United States
through the end of 2009. These drugs are included here for completeness.)
• Cromolyn and nedocromil are anti-inflammatory. They block early and late reaction to allergen,
interfere with chloride channel function, stabilize mast cell membranes, and inhibit activation
and release of mediators from eosinophils and epithelial cells.
• Cromolyn and nedocromil inhibit acute response to exercise, cold dry air, and SO2.
Long-acting ² 2 agonists
• With bronchodilation, smooth muscle relaxation follows adenylate cyclase activation and an
increase in cyclic adenosine monophosphate (AMP), producing functional antagonism of
bronchoconstriction.
• In vitro, long-acting 2 agonists (LABAs) inhibit mast cell mediator release, decrease vascular
permeability, and increase mucociliary clearance.
• Compared with short-acting inhaled 2 agonist, salmeterol has a slower onset of action (15-30
minutes). Formoterol has an onset of action within 3 minutes. Both LABAs have a duration of
action 12 hours.
[Table 28-1. Long-Term Asthma Control Medications]
[Table 28-2. Quick-Relief Asthma Medications]

Methylxanthines
• With bronchodilation, smooth muscle relaxation results from phosphodiesterase inhibition and
possibly adenosine antagonism.
• Methylxanthines may affect eosinophilic infiltration into bronchial mucosa as well as decrease T-
lymphocyte numbers in epithelium.
• Methylxanthines increase diaphragm contractility and mucociliary clearance.
Leukotriene modifiers
• Leukotriene receptor antagonist; selective competitive inhibitor of CysLT1 receptors
• 5-Lipoxygenase inhibitor
Anti-IgE therapy
• Omalizumab (Xolair) is a humanized monoclonal anti-IgE antibody that binds circulating IgE,
thus inhibiting the allergic inflammatory cascade that results when aeroallergens bind to IgE on
mast cells.
Quick-relief medications
Short-acting inhaled ² 2 agonists
• With bronchodilation, smooth muscle relaxation follows adenylate cyclase activation and an
increase in cyclic AMP, producing functional antagonism of bronchoconstriction.
Anticholinergics
• With bronchodilation, there is competitive inhibition of muscarinic cholinergic receptors.
• Anticholinergics reduce intrinsic vagal tone to the airways. They may block reflex
bronchoconstriction secondary to irritants or to reflux esophagus.
• Anticholinergics may decrease mucus gland secretion.
• Patient education is absolutely essential for optimal asthma management.
• Emphasize the need to take controller-preventer medications every day, even when the patient
feels well and is having no breathing problems.
• Instruct the patient regarding the dangers of overuse of short-acting inhaled 2 agonists. (The
patient should contact a physician if the usual dose does not give quick relief or start the written
action plan given by physician.)
• Demonstrate the correct use of the metered dose inhaler (MDI), the MDI plus spacer, and the dry
powder inhaler (DPI), and then observe the patient using the devices. Most patients do not
perform well initially; the devices can be difficult to use at first (see
Figure 28-6 for MDI or MDI
[Figure 28-5. Management of Asthma Exacerbations: Emergency Department and Hospital-Based

Care]
[Figure 28-6. Steps for Using an Inhaler]
[
Table 28-3. Directions for Use of Peak Flow Meter]
spacer use). For DPIs, remember to stress that inhalation must be rapid and deep.
• Demonstrate correct use of peak flow meters, and observe the patient using them (Table 28-3).
Explain about the green, yellow, and red zones (including the written action plan).
• Teach how to prevent exercise-induced asthma.
• Be sure patients receive an influenza vaccination every fall.
Adverse Drug Effects
For more details, see the section on adverse drug effects in EPR-3.
Long-term control medications
Inhaled corticosteroids
• Inhaled corticosteroids may cause coughing, dysphonia, and oral thrush (candidiasis).
• In high doses, systemic effects may occur, although studies are not conclusive, and the clinical
significance of these effects (e.g., adrenal suppression, osteoporosis, growth suppression, skin
thinning, and easy bruising) has not been established.
Cromolyn and nedocromil
• Approximately 15-20% of patients complain of an unpleasant taste from nedocromil. Cromolyn is

quite safe with very few side effects.
Long-acting inhaled ² 2 agonists
• Tachycardia, skeletal muscle tremor, hypokalemia, or prolongation of QTc interval can occur in
an overdose.
• Always use in combination with inhaled corticosteroid in long-term management of asthma. (Use
alone could mask inflammation and increase risk of severe exacerbations.)
Methylxanthines
• Dose-related acute toxicities include tachycardia, nausea and vomiting, tachyarrhythmias

(supraventricular), central nervous system stimulation, headache, seizures, hematemesis,
hyperglycemia, and hypokalemia.
• Adverse effects at usual therapeutic doses include insomnia, gastric upset, aggravation of ulcer or
reflux, increase in hyperactivity in some children, and difficulty in urination in elderly males with
prostatism.
Leukotriene modifiers
• Montelukast and zafirlukast are usually well tolerated.
• Zileuton can cause liver dysfunction.
Quick-relief medications
Short-acting inhaled ² 2 agonists
• Tachycardia, skeletal muscle tremor, hypokalemia, increased lactic acid, headache, and rarely
hyperglycemia can occur.
• In general, the inhaled route causes few systemic adverse effects; patients with preexisting
cardiovascular disease, especially the elderly, may have adverse cardiovascular reactions with
inhaled therapy.
Anticholinergics
• Drying of mouth and respiratory secretions, increased wheezing in some individuals, and blurred
vision if sprayed in eyes can occur.
Systemic corticosteroids
• With short-term use, reversible abnormalities in glucose metabolism, increased appetite, fluid
retention, weight gain, mood alteration, hypertension, peptic ulcers, and rarely aseptic necrosis of
the femur can occur.
• Consideration should be given to coexisting conditions that could be worsened by systemic

corticosteroids, such as herpes virus infections, varicella, tuberculosis, hypertension, peptic ulcer
disease, and strongyloidiasis.
• For zafirlukast, administration with meals decreases bioavailability. Take at least 1 hour before or
2 hours after meals.
• Zileuton and zafirlukast may increase the effect of warfarin and increase theophylline levels.
• Well-known inducers of cytochrome P450 (carbamazepine, phenobarbital, phenytoin, and

rifampin) are documented to decrease the effect of systemic corticosteroids.
• Examples of drugs that may increase the effect of systemic corticosteroids include erythromycin,
clarithromycin, itraconazole, oral contraceptives, and conjugated estrogen.
Parameters to Monitor
• Refill record for daily controller-preventer medications and quick-relief medications
• Reduction in symptoms (including nocturnal and early morning symptoms)
• Emergency department visits, hospitalizations, and unscheduled office visits
• Need for "bursts" of systemic corticosteroids
• Lost work or school days and the need for quick-relief medications
• PEF using a peak flow meter at home
In addition, if the patient also has rhinitis or GERD, monitor refills to ensure optimal control. (If
rhinitis and GERD are not well controlled, asthma control will likely suffer.)
Kinetics
• Theophylline is no longer used extensively in asthma, but when it is used, knowledge of its
kinetics is essential because of its high risk.
• Other drugs, disease states, smoking, age, and diet can all affect theophylline kinetics and dose
requirements (see
Table 28-4).
• Therapeutic serum theophylline concentrations are 5-15 mcg/mL (not the old recommendation of
10-20 mcg/mL; see EPR-3).
• Elimination half-life in an otherwise healthy nonsmoking adult is about 8 hours. In a smoker, it is

about 4 hours, and in a small child (1 year or older), it is about 4 hours.
• Neonates have greatly prolonged elimination half-life.
• Elimination half-life in decompensated heart failure or cirrhosis is about 24 hours.
• Volume of distribution is about 0.5 L/kg.
• High-fat meals may cause "dose dumping" for some products (check product literature).
Other
• MDIs should be stored at room temperature, between 59°F and 86°F; if left in a car in freezing or
near-freezing temperatures, aerosol particles will be too large to inhale into the lungs.
• MDIs should be "primed" (one dose released) only with first use or in the case of a prn agent used
only once every 2 weeks. (Frequent priming is unnecessary and wastes expensive medications.)
• HFA MDIs need special attention regarding weekly cleaning of the actuator (see manufacturers'
instructions)
• MDI dust cap should be left on inhaler when not in use. Check mouthpiece for foreign objects
before inhaling.
Nondrug Therapy
• An essential component of optimal asthma management is environmental control.
• Without good control of the environment at home, school, and work, drug therapy will often be
inadequate.
• Have the patient identify known asthma triggers, and help the patient identify potential triggers
not yet realized. (Do not forget someone smoking at home or work!)
28-2. Chronic Obstructive Pulmonary Disease (COPD)
Introduction
COPD is characterized by airflow limitation that is not fully reversible. The airflow limitation is
usually both progressive and associated with an abnormal inflammatory response of the lungs to
noxious particles or gases. COPD is a major cause of death and suffering in the United States and
around the world. It is the fourth leading cause of chronic morbidity and mortality in the United
States.
Some clinicians still refer to chronic bronchitis and emphysema in characterizing different levels of
COPD (e.g., emphysema patients have destructive damage to the alveolar walls, whereas chronic
bronchitis is associated with chronic productive cough). According to the Global Initiative for
Chronic Obstructive Lung Disease (GOLD) 2008 update, COPD severity classification is as
follows:
[Table 28-4. Factors Affecting Serum Theophylline Levels]
• I. Mild: FEV1/FVC < 0.7 and FEV1 80% predicted
• II. Moderate: FEV1/FVC < 0.7 and 50% < FEV1 < 80% predicted
• III. Severe: FEV1/FVC < 0.7 and 30% d FEV1 < 50% predicted
• IV. Very severe: FEV1/FVC < 0.7 and FEV1 < 30% predicted or FEV1 < 50% predicted plus
chronic respiratory failure.
In addition, examples of factors affecting the severity of this disease include frequency of
exacerbations, presence of other disease states, overall health status, and severity of symptoms.
• Shortness of breath
• Cough and sputum production
• Usually, a history of cigarette smoking for several years
• In the more severe form, respiratory failure and heart failure
Pathophysiology
• COPD is usually caused by long-term smoking; it may also be caused by exposure to other
noxious particles and gases.
• Chronic inflammation is found throughout the airways but via different inflammatory cells and
mediators than those that cause asthma. Thus, the response to inhaled corticosteroids is much less
than that seen with asthma.
• An imbalance of proteinases and antiproteinases is found in the lung.

• A rare hereditary cause of emphysema is 1-antitrypsin deficiency.
• Pathologic changes are found in the central and peripheral airways as well as the alveoli and
pulmonary vasculature.
• The following pathological changes are also found:
• Mucus hypersecretion
• Ciliary dysfunction
• Airflow limitation
• Lung hyperinflation
• Gas exchange abnormalities
• Secondary pulmonary hypertension
• Cor pulmonale
Diagnostic Criteria
• History of cigarette smoking or exposure to other noxious particles or fumes
• Chronic cough and sputum production
• Spirometry (e.g., reduced FEV1)
• Other lung diseases ruled out
• Management of COPD includes the following principles and goals: prevent progression of
disease, relieve symptoms, enhance health status, increase exercise tolerance, prevent and treat
exacerbations and complications, and decrease mortality.
• Bronchodilators are central to the symptomatic treatment of COPD; these agents will increase
exercise capacity without necessarily improving the FEV1.
• Inhaled bronchodilators are preferred to oral bronchodilators for initial therapy; the specific choice
of agent depends on patient response.
• Long-acting inhaled bronchodilators are more effective and convenient but more expensive.
Examples of long-acting bronchodilators include the once-daily anticholinergic tiotropium
(Spiriva) and twice-daily LABAs (formoterol and salmeterol—discussed in Section 28-1).
• Short-acting inhaled 2 agonists are preferred for prn use in patients already receiving LABAs and
anticholinergics.
• Inhaled corticosteroids are reserved for COPD patients with severe or very severe disease (Stage
III or IV) and frequent exacerbations.
• Theophylline is an option for maintenance therapy in patients who are not optimally controlled
with ²2 agonists and anticholinergics.
Therapy at each stage
(See the GOLD 2008 update.)
For each stage, patients should avoid risk factors (e.g., cease smoking) and receive an influenza
vaccine each autumn. Also, pneumococcal vaccine should be administered per current guidelines.
• Stage I: Mild COPD
• Use short-acting bronchodilator as needed.
• Stage II: Moderate COPD
• Add scheduled therapy with one or more long-acting bronchodilators and rehabilitation.
• Stage III: Severe COPD
• Use scheduled therapy with one or more long-acting bronchodilators.
• Add inhaled corticosteroids if patient has recurrent exacerbations.
• Stage IV: Very severe COPD
• Same treatments as for stage III, and consider surgical treatment.
• Long-term O2 therapy if patient experiences chronic respiratory failure.
Drug therapy for acute exacerbations of COPD
• Inhaled albuterol, ipratropium, or both
• Systemic corticosteroids (e.g., prednisolone 30 mg/d for 14 days)

• O2
• Oral antibiotics for purulent sputum as well as increased sputum volume and increased dyspnea
• Choice of oral antibiotic depends on severity:
• Mild exacerbation: Use amoxicillin, doxycycline, or trimethoprim-sulfamethoxazole

(alternatives include -lactam plus -lactamase inhibitor, azithromycin, or second- or third-
generation cephalosporins).
• Moderate exacerbation: Use a -lactam plus -lactamase inhibitor (alternatives are respiratory
fluoroquinolones such as moxifloxacin or levofloxacin).
• Severe exacerbation with risk factors for Pseudomonas aeruginosa infection: Use
ciprofloxacin or levofloxacin (high dose, 750 mg). If parenteral treatment is needed, use the
same fluoroquinolones or an antipseudomonal ²-lactam.
Monitoring
• Spirometry: FEV1
• Symptoms of dyspnea, cough, sputum production, and change in sputum color and volume
• PaO2
• Exercise tolerance or fatigue
Long-term drug therapy
• See content under Section 28-1 for specific drugs.
• Tiotropium is a once-daily anticholinergic bronchodilator that is an option for step 1 treatment of

moderate to severe COPD. It is administered by a DPI (HandiHaler). Each dose must be loaded,
and deep inhalation does not have to be forceful but must be sufficient to hear the capsule
vibrate. Another tiotropium delivery device, Respimat Soft Mist Inhaler (multidose), is available
outside the United States.
Nondrug therapy
• Smoking cessation—nicotine replacement therapy, bupropion (Zyban), varenicline (Chantix),

support groups, and counseling
• Oxygen therapy
• Nutritional support
• Psychosocial support
• Pulmonary rehabilitation
Smoking cessation is the most important of these therapies.
28-3. Key Points
Asthma
• Asthma is primarily an inflammatory airway disease.
• It is commonly undertreated, resulting in much unnecessary suffering and economic loss.
• Managing patients via the principles of the National Institutes of Health guidelines (EPR-3) has
been clearly shown to reduce emergency department visits and hospitalizations and to improve
patient quality of life.
• Optimal long-term management includes objective assessment, environmental control, drug

therapy, and patient education working in a partnership.
• Patients with persistent asthma need daily controller therapy (anti-inflammatory agents).
• Inhaled corticosteroids are the most efficacious agents to control asthma and are the preferred
first-step drug treatment for all ages of mild persistent asthma.
• Inhaled long-acting inhaled 2 agonists are the preferred treatment to add to inhaled
corticosteroids for patients with moderate persistent or severe persistent asthma.
• Short-acting inhaled 2 agonists are the agents of choice for quick relief of symptoms.
• Pharmacists should teach patients how to use inhalers (MDI, MDI-spacer, and DPI) by
demonstrations and observation of the patient.
• Pharmacists should instruct patients on how to use peak flow meters, including color-coded zone
management with a written action plan. Written action plans may be peak flow based, symptom
based, or both.
• Patients must clearly understand the purpose of daily controller or preventer medications versus
quick-relief medications. Show patients airway models or colored pictures of normal versus
inflamed airways.
Chronic Obstructive Pulmonary Disease

(See the GOLD 2008 update.)
• The overall approach to managing stable COPD should be characterized by a stepwise increase in
treatment and should be tailored to reduce symptoms and enhance quality of life.
• Health education can play a role in improving skills, ability to cope with COPD, and health status.
It is effective in accomplishing certain goals, including smoking cessation in some patients.
• None of the existing medications for this disease has been shown to modify the long-term decline
in pulmonary function that is the hallmark of this COPD. Drug treatment for COPD is used to
improve symptoms or decrease complications.
• Bronchodilators are central to the symptomatic management of this disease. They include 2
agonists, anticholinergics, and theophylline.
• Inhaled therapy with long-acting agents is preferred for reasons of efficacy and convenience.
• Combining bronchodilators may improve efficacy and decrease the risk of side effects compared
with increasing the dose of a single bronchodilator.
• Regular treatment with inhaled corticosteroids should be prescribed only for symptomatic patients
with severe or very severe COPD and recurrent exacerbations.
• Chronic treatment with systemic corticosteroids should be avoided because risks outweigh
benefits.
• The long-term administration of oxygen (> 15 hours per day) to COPD patients with chronic
respiratory failure has been shown to increase survival.
• Patients with COPD benefit from exercise training programs; they show improvement with
respect to both exercise tolerance and symptoms of fatigue and dyspnea.
• Influenza vaccine can reduce serious illness in COPD patients. Pneumocococcal polysaccharide
vaccine is recommended for patients with COPD who are 65 years of age or older and for
patients under 65 years of age who have an FEV1 < 40% predicted.
28-4. Questions
Asthma is primarily due to which underlying problem?
A. Pulmonary fibrosis
1. B. Infection
C. Inflammation
D. Bronchospasm
E. Granulomas

Which objective measure for routine monitoring of asthma is available at home?
A. PEF
2. B. FEV1
C. FVC
D. O2 saturation
E. PD20

Which device requires slow inhalation?
A. Diskus
3. B. Turbuhaler
C. Aerolizer
D. MDI
E. Rotadisk

How many seconds is optimal for breath holding after inhaling from an MDI?
A. 4
4. B. 5
C. 15
D. 2
E. 10

When a peak flow meter is used, what percentage of the personal best value is the yellow
zone?
A. < 50
5.
B. < 60
C. 50-79
D. 60-89
E. 40-60

What are the trade names for long-acting inhaled ²2 agonists?
A. Foradil and Serevent

6. B. Pulmicort and Flovent
C. Aerobid and Combivent
D. Maxair and Atrovent
E. Flovent and Ventolin

Which disease states decrease theophylline elimination and often result in reduced dosage
requirements?
A. Hepatitis
7.
B. Heart failure (decompensated)
C. Hypertension
D. A, B, and C
E. A and B

Which drugs are preferred for long-term treatment of moderate persistent asthma?
A. Budesonide + formoterol
8. B. Fluticasone + salmeterol
C. Beclomethasone + ipratropium
D. A or B
E. B or C

Which drug is a once-daily anticholinergic bronchodilator?
A. Atrovent
9. B. Serevent
C. Foradil
D. Spiriva
E. Proventil

For patients with asthma or COPD exacerbations who are not responding adequately to inhaled
bronchodilators, what is the agent of choice to add to manage the acute exacerbation?
A. Fluticasone
10.
B. Budesonide
C. Cromolyn
D. Theophylline
E. Prednisone

Which drug may increase serum theophylline concentrations?
A. Clarithromycin
11. B. Hydrochlorothiazide
C. Carbamazepine
D. Rifampin
E. Phenytoin

Which side effect of inhaled corticosteroids is reduced by spacer devices?
A. Hoarseness
12. B. Decreased bone density
C. Thinning of skin
D. Oropharyngeal candidiasis
E. Cataracts

The therapeutic range for theophylline per the NIH guidelines for asthma management is
A. 5-15 mcg/mL
13. B. 8-12 mcg/mL
C. 10-20 mcg/mL
D. 15-25 mcg/mL
E. 10-15 mcg/mL

Which asthma controller drug is given qhs?
A. Accolate
14. B. Singulair
C. Xolair
D. Intal
E. Medrol

Which disease state may worsen asthma?
A. Coronary artery disease

15. B. GERD
C. Diabetes
D. Hypertension
E. Arthritis

Which class of drugs is indicated only in severe COPD patients who have frequent
exacerbations?
A. Long-acting inhaled ²2 agonists

16.
B. Anticholinergics
C. Short-acting inhaled ²2 agonists
D. Inhaled corticosteroids
E. Methylxanthines

The next two questions relate to Case Study 28-1.

Case Study 28-1 Medication Profile

Patient
Thomas Johnson
name
Address 5689 Washington St.
Date of birth 9-15-55
Drug
Aspirin sensitivity
allergies
Height 5'10"
Weight 75 kg
(1) Asthma (childhood onset,
Diagnosis
moderate persistent)
(2) Allergic rhinitis
(3) Hypertension
Medications
Drug and
Date Rx # MD strength Quantity Sig Refills
Accolate 20
3/16 94385 Betts 60 1 bid 3
mg
2 puffs
3/16 94386 Betts Albuterol MDI 1 6
q4h
bid as
3/16 94387 Betts Flonase 1 3
dir.
T. Lopressor 50
3/25 95523 60 1 bid 6
Jones mg
2 puffs
3/27 95734 Betts Albuterol MDI 1 5
q4h
Pharmacist notes: 3/16—discussed proper use of MDI and observed patient use. Coached Mr.
Johnson to inhale slowly (he was inhaling fast); he used the MDI correctly for the other steps.
Which class of drugs is preferred in Mr. Johnson for optimal control of asthma?
A. Anticholinergics
17. B. Inhaled corticosteroids
C. Methylxanthines
D. Mast cell stabilizers
E. Oral corticosteroids

What is an appropriate alternative to Lopressor in Mr. Johnson?
A. An ACE inhibitor
18. B. Propranolol 40 mg bid
C. Clonidine
D. Hydralazine
E. Atenolol 200 mg daily

The next two questions relate to Case Study 28-2.
Case Study 28-2 Medication Profile

Patient
Mrs. S. T. Adams
name
Address 7129 James Ave.
Date of birth 1-16-37
Drug
Sulfonamides
allergies
Height 5'3"
Weight 55 kg
(1) COPD—53 pack/year Hx
Diagnosis
smoking (quit 2 years ago)
(2) Cirrhosis
Medications
Drug and
Date Rx # MD strength Quantity Sig Refills
Serevent
2/18 84389 Jones 1 1 bid 6
Diskus
Albuterol 2 puffs
2/18 84390 Jones 1 6
MDI q4h prn
2 puffs
2/18 84391 Jones Atrovent MDI 1 6
q6h
Uniphyl 600 1 qd 6
2/18 84392 Jones 30 2
mg PM
Pharmacist Notes: 2/18—discussed proper use of Diskus and observed patient use; taught Mrs.
Adams to inhale deeply and rapidly (she was inhaling slowly for < 2 seconds). Also observed use
of MDI (she forgot to exhale gently before pressing down on MDI).
What concerns should the pharmacist have in this situation regarding theophylline?
A. Cirrhosis is well documented to decrease elimination of theophylline.

19. B. The milligrams per kilogram dose is too low.
C. Mrs. Adams should be on a q12h product.
D. Theophylline SR should be dosed in the morning, not evening.
E. Long-acting inhaled ²2 agonists increase theophylline clearance.

The patient has a friend who has COPD and has told her about Spiriva. Mrs. Adams wants to
know the opinion of the pharmacist. You would say:
A. I'll call your doctor and suggest a new prescription for Spiriva.
B. Spiriva is a third-line drug for COPD; I would not use it now.
20.
C. Spiriva is a good drug, but I want to talk to your doctor about starting a medicine called
Flovent.
D. Since you have a prescription for Atrovent, I will call your doctor and suggest changing
from Atrovent to Spiriva.
E. I think Symbicort would be better for you.

Which drug is best for long-term management of mild persistent asthma?
A. Cromolyn
21. B. Montelukast
C. Nedocromil
D. Theophylline
E. Budesonide

Which total daily dose of prednisone is best for home management of an acute exacerbation of
asthma in a 60-kg adult?
A. 5.0 mg
22.
B. 60.0 mg
C. 10.0 mg
D. 20.0 mg
E. 7.5 mg

Which drug is most likely to cause an asthma exacerbation in a patient sensitive to aspirin?
A. Ibuprofen
23. B. Acetaminophen
C. Celecoxib
D. Salsalate
E. Sodium salicylate

Which type of inhaler does not work well in very cold temperatures?
A. Diskus
24. B. Turbuhaler
C. Aerolizer
D. MDI
E. Rotahaler

28-5. Answers
C. Although asthma certainly does have a bronchospastic component, it is primarily due to

1. inflammation, so good control of inflammation dramatically reduces bronchospasm. A good
indicator of disease control is the rare need for short-acting inhaled ²2 agonists.

A. Peak flow meters are inexpensive and relatively easy to use. Good measurement of peak
2. expiratory flow requires appropriate technique, and if good technique is used, patients have
valuable objective evidence of asthma control (or exacerbation).

D. Dry powder inhalers for asthma therapy that are currently available require rapid inhalation.
3.
MDIs require slow inhalation to minimize impaction of aerosol in the mouth and throat.

E. Ten seconds is best; there is no need to hold longer. If 10 seconds is uncomfortable, 4-5
4.
seconds is acceptable.

C. The yellow zone is 50-79%, which indicates suboptimal control. (The red zone is < 50%,
5. which indicates that the crisis action plan should be started and medical attention should be
sought.)

6. A. Foradil (formoterol) and Serevent (salmeterol).

E. Hepatitis and decompensated heart failure both can dramatically reduce theophylline
7.
clearance.

8. D. (A. budesonide + formoterol or B. fluticasone + salmeterol.) See Figures 28-2 and 28-3.

D. Atrovent is also a quick-relief agent, but it is not as efficacious in asthma and has a slower
9.
onset than albuterol and other short-acting inhaled ²2 agonists.

E. Prednisone or other systemic corticosteroids (e.g., methylprednisolone) are well
10.
documented to be efficacious in asthma and acute exacerbations of COPD.

A. Clarithromycin is documented to increase serum concentrations. Hydrochlorothiazide does
11. not affect serum theophylline concentrations, and the remaining choices are all documented to
decrease serum theophylline concentrations.

D. Oropharyngeal candidiasis or thrush is correct. The other side effects are not reduced by
12.
spacers.

A. The currently accepted range for asthma is 5-15 mcg/mL (not the old range of 10-20
13. mcg/mL). There is no benefit in exceeding 15 mcg/mL, and many patients receive benefit at
lower doses.

B. Because asthma is a disease of circadian rhythm and is worse between 2:00 am and 6:00
14.
am, it is best to give this once-daily drug at bedtime.

B. GERD can worsen asthma if it is not properly treated. The exact mechanisms are debated,
15.
but there is excellent documentation that asthma improves if this condition is well managed.

D. This class of drugs should not be used routinely in COPD patients with mild disease. In
severe disease, inhaled corticosteroids are indicated, especially if there are frequent
16.
exacerbations. Remember that in asthma, inhaled corticosteroids are the best agents for long-
term control, but in COPD their role is limited.

B. Inhaled corticosteroids are the preferred treatment (see Figures 28-2 and 28-3 for treatment
choices). The pharmacist should share the NIH guidelines with Mr. Johnson's prescriber to
17. help ensure optimal care. In addition, the pharmacist should educate the patient regarding the
purpose of the medications and proper use of inhalers (e.g., the pharmacist should observe the
patient using the device).

A. An ACE inhibitor should be efficacious with few side effects (monitor for cough); ²-
blockers should be avoided in Mr. Johnson unless he is post-myocardial infarction or had
18.
congestive heart failure (in which case, use a low dose of a ²1-selective blocker and monitor
carefully).

A. Cirrhosis is well documented to decrease elimination of theophylline. Ensure a check of a
19. steady-state theophylline level (peak) and anticipate dose reduction (usually 50% dose
reduction in liver disease).

D. Because the patient has prescriptions for Atrovent and Serevent, a logical change here
20. would be to discontinue the short-acting anticholinergic Atrovent and add the long-acting
once-daily anticholinergic tiotropium (Spiriva).

E. Budesonide is an inhaled corticosteroid, the class of drugs recommended to treat even mild
21.
persistent asthma.

B. Sixty milligrams is an appropriate dose. If it is started as soon as the patient is in the red
22. zone and not responding quickly to short-acting inhaled ²2 agonists, usually only a few days of
treatment will be required (usually < 1 week).

A. Ibuprofen has the same mechanism of action as aspirin and will predictably trigger
symptoms in an aspirin-sensitive patient (i.e., increased production of leukotrienes). COX-2
23.
inhibitors are safe (celecoxib). Acetaminophen is the choice agent for minor pain in these
patients.

D. MDIs release large aerosol particles that do not penetrate deeply into the lungs in cold
24.
temperatures. Dry powder inhalers are acceptable.

28-6. References
Asthma
Berger WE, Qaquandah PV, Blake K, et al. Safety of budesonide inhalation suspension in infants
aged six to twelve months with mild to moderate persistent asthma or recurrent wheeze. J
Pediatr. 2005; 146:91-95.
Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy:
Evidence-based guidelines: American College of Chest Physicians/American College of Asthma,
Allergy, and Immunology. Chest. 2005;127:335-71.
Fanta CH. Asthma. N Engl J Med. 2009;360: 1002-14. (Drug Therapy Review)
Hendeles L, Jenkins J, Temple R. Revised FDA labeling guideline for theophylline oral dosage
forms. Pharmacotherapy. 1995;15:409.
National Institutes of Health (NIH). Expert Panel Report 3: Guidelines for the Diagnosis and
Management of Asthma, 2007. NIH Publication 07-4051. Bethesda, Md.: NIH. Available at:
www.nhlbi.nih.gov/guidelines/asthma/asthsumm.htm.
Self TH, Chrisman CR, Mason DL, Rumbak MJ. Reducing emergency department visits and
hospitalizations in African American and Hispanic patients with asthma: A 15-year review. J
Asthma. 2005;42:807-12.
Shannon M. Life-threatening events after theophylline overdose: A 10-year prospective analysis.

Arch Intern Med. 1999;159:989-94.
Strunk RC, Bloomberg GR. Omalizumab for asthma. N Engl J Med. 2006;354:2689-95.
Weiss KB, Sullivan SD. The health economics of asthma and rhinitis: I. Assessing the economic
impact. J Allergy Clin Immunol. 2001;107:3-8.
Chronic Obstructive Pulmonary Disease
Calverley P, Pauwels R, Vestbo J, et al. Combined salmeterol and fluticasone in the treatment of
chronic obstructive pulmonary disease: A randomised controlled trial. Lancet. 2003;361:449-56.
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease. Gig Harbor, Wash.:
Medical Communications Resources. Available from: www.goldcopd.org.
Gross NJ. Tiotropium bromide. Chest. 2004;126: 1946-53.
Pauwels R, Lofdahl CG, Laitinen LA, et al. Long term treatment with inhaled budesonide in
persons with mild COPD who continue smoking. N Engl J Med. 1999;340:1948-53.
Rigotti NA. Treatment of tobacco use and dependence. N Engl J Med. 2002;346:506-12.
Tashkin DP, Celli B, Senn S, et al. A 4-year trial of tiotropium in chronic obstructive pulmonary
disease. N Engl J Med. 2008;359:1543-54.
Wedzicha JA, Calverley PMA, Semungal TA, et al. The prevention of chronic obstructive
pulmonary disease exacerbations by salmeterol/fluticasone propionate or tiotropium bromide.
Am J Respir Crit Care Med. 2008;177:19-26.
29. Infectious Disease - Joyce E. Broyles, PharmD, BCNSP
29-1. General Principles of Infectious Disease
Introduction
Several infectious disease topics are addressed in other chapters of this review, including common
colds in Chapter 27, HIV (human immunodeficiency virus) and acquired immune deficiency
syndrome (AIDS) in Chapter 31, and otitis media in Chapter 33. For additional information about
specific anti-infective agents, see Chapter 30.
Diagnosis
Diagnosis of most infectious diseases consists of isolation and identification of microorganisms,

assessment of patient signs and symptoms, and analysis of other laboratory data.
Isolation of organisms
To identify the causative agent of a disease, samples should be taken from appropriate body sites
prior to the initiation of anti-infective therapy. Organisms isolated from body sites that normally are
sterile (blood, urine, and spinal fluid) yield higher predictive value than do organisms isolated from
body sites that normally are bacteriologically colonized (skin or fecal material).
Identification of organisms
To determine the infectious organism's cell morphology and to guide empiric therapy, one must
Gram stain body sites for organisms as soon as possible. After the species of organism has been
determined, one should expose it to standardized concentrations of antibiotics to determine the
concentrations that inhibit growth. The lowest concentration that prevents microbial growth after
18-24 hours is called the minimum inhibitory concentration (MIC). The three breakpoint
concentrations of antibiotics are susceptible, intermediate, and resistant. An antibiotic's breakpoint
concentration is determined by considering (1) tissue concentrations with normal dosing and (2) the
organism's population distribution. The breakpoint concentration determines whether the antibiotic
can be used for therapy.
Physical signs and symptoms of infection (such as fever, redness, swelling, pain, and cough) must
be considered both for initial diagnosis and for assessment of antibiotic effectiveness.
Laboratory tests
In the initial stage of infection, the patient's neutrophil count may increase above normal, and
immature neutrophil forms (bands) may appear; therefore, a white blood cell (WBC) count should
be taken. Later in the course of illness, the neutrophil count may fall to below normal levels.
Inflammatory markers, such as C-reactive protein, erythrocyte sedimentation rate, and tumor
necrosis factor, may increase during infection.
Laboratory tests may not be reliable in patients who are elderly, malnourished, neonatal, or severely
infected.
Treatment Strategies
Anti-infective agents should be used only when a significant infection has been diagnosed, when
one is strongly suspected, or when prophylactic therapy is indicated.
In situations where multiple organisms could be the infecting agent (e.g., pneumonia), empiric
therapy should cover the majority of possible organisms, with de-escalation of antimicrobial
therapy when the causative agent is discovered.
Prophylactic therapy
Anti-infective therapy is aimed at preventing infection. Prophylactic therapy commonly is used after
exposure to infection (e.g., tuberculosis) or before surgical intervention in areas of high bacterial
inoculum (e.g., bowel surgery).
Empiric therapy is directed toward all common pathogens associated with a disease state.
Culture-guided therapy, which usually is narrower spectrum than empiric therapy, covers only the
specific organism that is sensitive to the therapy. Culture-guided therapy is preferred because it is
more cost-effective and because it decreases bacterial resistance from unnecessary antibiotic
exposure.
Choice of Anti-infective Agent
To determine optimal anti-infective therapy or to review the appropriateness of other decisions, a

clinician must answer several questions:
• Is an antibiotic indicated on the basis of the clinical findings?
• Have appropriate specimens been obtained, examined, and sent for culture?
• What organisms most likely are causing the infection?
• If several antibiotics are available to treat the likely or known organism, which agent is best for
the patient? (Patient allergies and concurrent disease states should be considered.)
• Is an antibiotic combination appropriate? (A combination of drugs should be given only when

clinical experience has shown such therapy to be more effective than single-agent therapy in a
particular setting. Such multiple agent regimens can increase the risk of toxic drug effects;
occasionally, they may result in drug antagonism and loss of effectiveness. However, some
combinations of anti-infective agents have demonstrated increased effectiveness that is greater
than their individual effectiveness combined, a phenomenon known as synergy. An example of
synergy is the combination of aminoglycosides with cell wall inhibitors, such as penicillin, in
many Gram-positive organisms.)
• What is the best route of administration? (This decision will depend on the overall plan for the
patient. Oral therapy is preferred for outpatient therapy; many intravenous anti-infectives have
oral forms with similar pharmacokinetic profiles.)
• What is the appropriate dose and dose interval? (Regimen design should take into account patient
size, renal or hepatic function, the disease state to be treated, and pharmacodynamic
considerations of the agents used.)
• Will initial therapy need modification after culture data are returned?
• What is the optimal duration of therapy, and is the development of resistance during prolonged
therapy likely to occur?
Lack of Therapeutic Effectiveness
When anti-infective therapy fails, careful analysis of possible causes should be made prior to
changing the regimen. Factors associated with therapeutic failure include misdiagnosis of the
infection, improper drug regimen, inappropriate choice of antibiotic agent, and resistance of the
infecting agent, as well as situations in which antibiotic therapy may not be effective without
additional interventions (e.g., surgical drainage).
29-2. Common Bacterial, Fungal, and Viral Infections
Meningitis
Meningitis is defined as an inflammation of the meninges that is identified by an abnormal number

of white blood cells in the cerebrospinal fluid (CSF).
Causative agents
A wide variety of organisms is associated with this disease, including many Gram-positive and
Gram-negative organisms.
Patients may present with fever, headache, photophobia, neck rigidity, diarrhea, vomiting, and
altered mental status. Infants may present with a bulging anterior fontanel.
Diagnostic criteria
Analysis of the cerebrospinal fluid may be diagnostic of the infective agent. Bacterial agents are
associated with a large increase in systemic WBCs, presence of WBCs in the CSF, increased CSF
protein, and decreased CSF glucose. Fungal and viral agents exhibit smaller increases in CSF
WBCs, smaller increases in CSF protein, and limited decreases in CSF glucose.
Treatment
Empiric treatment is usually determined by the age of the patient. Because of limited antibiotic
penetration by many agents, the highest safe antibiotic doses are generally used.
Table 29-1 summarizes empiric therapy for meningitis.
Endocarditis
Endocarditis is an infection of the endocardium, the membrane lining the heart chamber and valves.
Causative agents
Most patients have previous damage to the heart (e.g., artificial valve placement) prior to infection.
The most common organisms are Streptococcus and Staphylococcus species.
Patients present with low-grade fever, fatigue, and weakness. A diagnostic finding is the presence
of splinter hemorrhages and petechiae.
Diagnostic criteria
There are no specific laboratory tests for this infection. Most patients present with an elevated
erythrocyte sedimentation rate or C-reactive protein. Visualization of the vegetations on the surface
of the heart is often diagnostic of the disease.
Treatment
According to American Heart Association guidelines, treatment varies depending on the causative
organism and whether or not prosthetic devices are present (which would require longer therapy, if
present).
Table 29-2 describes therapy for endocarditis.
Acute or Chronic Bronchitis
Bronchitis is an inflammation of the bronchioles, often associated with bronchopneumonia. Chronic

bronchitis is mainly associated with heavy smoking.
Causative agents
Viral infections account for half of all cases. Mycoplasma pneumoniae, Streptococcus pneumoniae,
Haemophilus influenzae, Moraxella catarrhalis, and Chlamydia pneumoniae are common bacterial
pathogens.
Patients present with a history of acute productive cough, a low-grade fever, and a clear chest x-ray.
Diagnostic criteria
Sputum cultures typically are not useful in diagnosis because of multiple etiologies; therefore, most
physicians prescribe anti-infectives on the basis of physical findings.
Treatment
Treatment is controversial for most acute illnesses because of the large percentage of viral cases.
Chronic cases are treated, but bacterial resistance can easily
[Table 29-1. Empiric Treatment of Meningitis]
[Table 29-2. Therapy for Endocarditis]
develop from the use of multiple antibiotic treatments.

Table 29-3 describes treatment for acute and chronic bronchitis.
Pneumonia
Pneumonia is an inflammation of the lung parenchyma characterized by consolidation of the

affected part, as well as filling of the alveolar air spaces with exudates, inflammatory cells, and
fibrin. Distribution may be lobar, segmental, or lobular. If pneumonia is associated with bronchitis
(see the previous discussion of bronchitis), it is termed bronchopneumonia.
Causative agents
Multiple bacterial etiologies are possible, depending on predisposing conditions (

Table 29-4).
[Table 29-3. Treatment of Acute and Chronic Bronchitis]
Typically, the onset of illness is abrupt or subacute, with fever, chills, dyspnea, and productive
cough predominating. On physical examination, the patient is tachypneic and tachycardic,
frequently with chest wall retractions and grunting respirations. The complete blood count usually
reflects a leukocytosis with a predominance of polymorphonuclear cells.
Diagnostic criteria
Sputum culture may be useful in identifying some pathogens. However, difficulty in obtaining a
deep sputum culture and problems in culturing some organisms (e.g., Legionella) make positive
identification of the organism difficult.
Treatment
Treatment varies by age group.
Tuberculosis
Tuberculosis is a communicable infectious disease caused by Mycobacterium tuberculosis. It can

produce silent, latent infection as well as active infection. Although infection of any tissue or organ
with M. tuberculosis is possible, the usual site of infection is pulmonary.
[Table 29-4. Empiric Treatment of Pneumonia]
Tuberculosis can present with generalized symptoms of weight loss, fever, and night sweats, along
with persistent cough productive of sputum. In the absence of other symptoms, latent disease is
defined by a positive PPD (purified protein derivative) test.
Diagnostic criteria
Diagnosis often is made by a combination of chest x-ray (which often shows patchy or nodular
infiltrates in the apical areas of the upper lobes or the superior segment of the lower lobes) and
positive PPD skin test. Patients with severe HIV disease may not react to the standard PPD skin
test. Sputum or lung biopsy may be acid-fast stained to reveal the organism. Because of the
extended time period needed to grow the organism, sensitivities to anti-infective agents may take
weeks to months to determine.
Treatment
See
Table 29-5 for a summary of treatments.
Infectious Diarrhea
Diarrhea is defined as an increase in frequency or liquidity of stool (or both) compared to a patient's
normal stool.
[Table 29-5. Treatment of Tuberculosis]
Causative agents
Many disease states, drugs, and infectious organisms have been associated with diarrhea.
The patient may present with several of the following symptoms: fever, chills, nausea, vomiting,
and abdominal cramping.
Diagnostic criteria
Etiology often is determined by patient history and physical examination. Because of the nature of
the disease, cultures often are not diagnostic, except for determination of carrier states.
Treatment
Supportive care (hydration, antipyretics, and antiemetics) is useful. Antimotility agents are
discouraged because of the potential to cause toxic megacolon. Antibacterial therapy is reserved for
severe presentations or for patients with risk factors.
Table 29-6 provides an overview of treatments.
Skin and Soft Tissue Infections
Bacterial infection of the skin can be classified as direct infection of the skin (cellulitis) or
secondary infection of a wound or incision.
Causative agents
Cellulitis usually is infection caused by a single organism. The most common organisms are
Streptococcus pyogenes and Staphylococcus aureus. Secondary infections may be polymicrobial,
including both anaerobic and aerobic organisms.
Skin and soft tissue infections are characterized by erythema and edema of the skin.
[Table 29-6. Treatment of Infectious Diarrhea]
[
Table 29-7. Treatment of Skin and Soft Tissue Infections]
Diagnostic criteria
Diagnosis is usually made from physical examination. Cultures usually are not diagnostic.
Treatment
Treatment is empiric, based on likely organisms (Table 29-7).
Urinary Tract Infections
Urinary tract infections (UTIs) represent a wide variety of clinical syndromes, including urethritis,
cystitis, prostatitis, and pyelonephritis.
Causative agents
The most common agents are Gram-negative facultatively anaerobic rods (coliforms). Hospitalized,
catheterized patients also may acquire Pseudomonas and Staphylococcus species.
Lower urinary tract infections tend to present with dysuria, urgency, frequency, nocturia, and
suprapubic heaviness or pain. Fever is rare. Upper urinary tract infections tend to present with flank
pain and fever.
Diagnostic criteria
Key to the diagnosis of UTIs is the ability to demonstrate significant numbers of organisms present
in an appropriately drawn urine sample. In general, higher numbers of organisms (>105 cells/mL)
are needed to diagnose UTIs in females than in males (>103 cells/mL), because more organisms are
able to ascend the shorter female urethra. In addition, the presence of WBCs in the urine sample
may be a significant clue for infection.
Treatment
A variety of antibacterials may be useful for the treatment of urinary tract infections (
Table 29-8), including
[Table 29-8. Treatment of Urinary Tract Infections]
fluoroquinolones, cephalosporins, trimethoprim-sulfamethoxazole (TMP-SMX), and doxycycline.

Fluoroquinolones are especially useful for the treatment of prostatitis. Length of therapy varies
according to the severity of disease.
Bacterial Venereal Diseases (Gonorrhea and Syphilis)
Venereal diseases are diseases that can be transmitted via sexual intercourse. This section covers
only the major bacterial venereal diseases, which are gonorrhea and syphilis. Viral venereal diseases
(e.g., herpes and hepatitis) will follow in this chapter or other chapters (for HIV, see Chapter 31).
Causative agents
Syphilis is caused by an infection with the spirochete Treponema pallidum, whereas gonorrhea is
caused by the Gram-negative coccus Neisseria gonorrhoeae.
Primary syphilis presents as painless lesions or chancres appearing at the site of infection around 21
days after exposure. The lesions persist for about 8 weeks before disappearing spontaneously.
Secondary syphilis develops 2-6 weeks after the onset of the primary stage and is characterized by a
variety of rashes and flu-like symptoms. These symptoms disappear without treatment within 4-10
weeks. Untreated patients will develop symptoms of tertiary syphilis within 2-25 years after
infection. These symptoms include general paresis, nerve deafness, progressive dementia, and aortic
insufficiency.
Gonorrhea, in contrast, presents as a urethritis within 2-3 days of exposure. Dysuria, urinary
frequency, and purulent discharge are common. The majority of infected patients become
asymptomatic without treatment within 6 months. About 15% of infected women will develop
pelvic inflammatory disease, which can be an indirect cause of future infertility.
Diagnostic criteria
Because T. pallidum cannot be grown in culture, dark-field or indirect fluorescent antibody

microscopic examination is used in conjunction with serologic testing for diagnosis. The most
common tests used are the Venereal Disease Research Laboratory (VDRL) test and the rapid
plasma reagin (RPR) test. Gonorrhea is diagnosed by Gram stain and culture of infected secretions.
Alternative methods of diagnosis include enzyme immunoassay and DNA (deoxyribonucleic acid)
probes. Patients testing positive for any sexually transmitted disease should be screened for the
presence of other venereal diseases.
Treatment
Because of the significant both diseases can potentially cause significant morbidity in infants born
to infected mothers, diagnosis and treatment of pregnant women is of concern. The two organisms
differ sharply in resistance to anti-infective agents. T. pallidum is sensitive to penicillin and has not
developed any significant resistance. N. gonorrhoeae has developed significant resistance not only
to penicillin but also to fluoroquinolones, leaving third-generation cephalosporins as the major
treatment modality (
Table 29-9). Patients diagnosed with gonorrhea should also receive therapy against chlamydia
infection (usually doxycycline 100 mg bid for 7 days or azithromycin 1 g once). All sexual partners
must also be treated.
[Table 29-9. Treatment of Gonorrhea and Syphilis]
Sepsis
Sepsis has been defined by the American College of Chest Physicians as the systemic inflammatory
response syndrome (SIRS) produced in response to infection. SIRS has been defined as requiring
two of the following criteria: temperature > 38°C or < 36°C; heart rate > 90 bpm; respiratory rate
>20 breaths/min or PaCo2 <32 torr; WBC >12,000 cells/mm3 or <4,000 cells/mm3; or >10%
immature (band) forms.
Causative agents
Sepsis may be caused by a variety of organisms, including Gram-negative and Gram-positive

organisms, as well as fungi. Most cases occur in a hospital setting and reflect the institution's
organisms and resistance patterns.
In the early phase, the patient may have fever or hypothermia, rigors, chills, tachycardia, tachypnea,
hyperglycemia, and lethargy. The condition progresses to hypotension, hypoglycemia, myocardial
depression, oliguria, leukopenia, and pulmonary edema, leading to multisystem organ failure.
Diagnostic criteria
In addition to physical signs and symptoms, cultures of blood, urine, and sputum may yield clues
for antibacterial therapy.
Treatment
Local organisms and sensitivities will determine anti-infective therapy. Initial therapy should be
broad, covering all likely organisms, until culture results are obtained. The Medical Letter suggests
the following regimens for life-threatening sepsis in adults: cefotaxime, ceftriaxone, cefepime,
ticarcillin-clavulanic acid, piperacillin-tazobactam, meropenem, or imipenem with an
aminoglycoside (tobramycin, gentamicin, or amikacin). If Gram-positive organisms are suspected,
vancomycin or linezolid may be added to the regimen.
Tick-Borne Systemic Febrile Syndromes (Lyme Disease, Rocky Mountain Spotted Fever,
Ehrlichiosis, and Tularemia)
Tick-borne illnesses are similar in transmission and natural history. The organisms responsible for
these infections are Rickettsia, known for their intracellular growth in host cells. As such, they
cannot be grown in culture media, and serologic tests are used for diagnosis. Patients present with
fever, rash, and flu-like symptoms, as well as a history of tick exposure.
Treatment
See
Table 29-10 for treatment options.
Systemic Fungal Infections
Fungal infections fall into two categories: primary (able to cause infection in both healthy and
immunocompromised patients) and opportunistic (able to cause infection only in
immunocompromised patients). Many fungal infections have a pulmonary focus because of the
aerosol spread of mold spores. The incidence of fungal infection is rising as a result of increased
use of antibacterial agents and the increase in immunocompromised patients.
Patients present with a gradual onset of general malaise, fever, and weakness, which are unrelieved
by antibacterial therapy. Pulmonary infection usually presents with pneumonia-like symptoms.
[Table 29-10. Treatment of Tick-Borne Systemic Febrile Syndromes]
[
Table 29-11. Treatment of Systemic Fungal Infections]
Diagnostic criteria
Diagnosis is made from patient history; cultures (usually blood, sputum, and biopsy of lesions); and
serologic tests.
Treatment
Treatment often is empiric until the organism is isolated (Table 29-11). Because of the relatively
slow growth of most fungi and the lack of commercial testing against antifungal agents, patient
response is used to determine resistance to therapy.
Viral Infections (Hepatitis, Influenza, and the Herpes Simplex Family)
Antiviral therapy is not curative in viral infections but decreases the level of virus so that a patient's
immune system can handle the infection.
Hepatitis
Hepatitis is a general term referring to a generalized inflammation of the liver. Etiologies may be
viral or chemical.
Causative agents
Five viruses (hepatitis types A-E) have been identified as causative agents for hepatitis. Syndromes
may be either acute or chronic.
Patients present with a history of anorexia, nausea, fatigue, and malaise, which usually progresses to
fever, right upper quadrant pain, dark urine, light-colored stools, and worsening of systemic
symptoms. Some patients have no symptoms and little hepatic damage.
Diagnostic criteria
In addition to physical signs, laboratory tests are remarkable for elevations in AST (aspartate
aminotransferase), ALT (alanine aminotransferase), and serum bilirubin.
Treatment
Treatment depends on the viral strain and type of presentation (
Table 29-12). Standard therapies have not been established for hepatitis A, D, or E.
Influenza
Influenza is an acute respiratory viral infection.
Causative agents
Three viruses, influenza A, B, and C, are responsible for most infections.
Patients present with sudden onset of chills, fever, severe prostration, headache, muscle aches, and
a
[Table 29-12. Treatment of Hepatitis]
cough that usually is dry. The primary viral infection may be followed by secondary bacterial
infections.
Diagnostic criteria
Diagnosis is from patient physical signs and symptoms.
Therapy
Therapy may be either prophylaxis or treatment and is determined by viral strain in the community (
Table 29-13). Currently, no therapies exist for influenza C infections.
Herpes simplex family (herpes, cytomegalovirus, chickenpox or shingles)
The herpes simplex family is responsible for three serious viral infections: herpes genital infections,
cytomegalovirus (CMV) infections in the immunocompromised, and varicella zoster infections
(chickenpox and shingles).
Causative agents
Each disease is caused by a slightly different herpes virus.
Clinical presentation varies by disease:
• Genital herpes presents with flu-like symptoms of fever, headache, malaise, and myalgias, in
addition to development of painful pustular or ulcerative lesions on the external genitalia.
• CMV usually presents as retinitis, colitis, or esophagitis.
• Varicella zoster presents with flu-like symptoms with a pustular rash located on body
dermatomes.
Diagnostic criteria
Diagnosis is mostly from signs and symptoms, although tissue samples may be examined for the
presence of the virus using immunofluorescence.
[Table 29-13. Treatment of Influenza]
[
Table 29-14. Treatment of Herpes Virus Infections]
Treatment
Treatment depends on viral and disease state. Treatment is summarized in Table 29-14.
29-3. Key Points
• The hallmark of initial anti-infective therapy is to target the specific organisms associated with the
disease.
• Conversely, after the identification of the organism causing the disease, anti-infective therapy
should be narrowed to cover that specific organism.
• Therapy should reflect not only the best anti-infective agent for the organism but also aspects of
the patient's condition (e.g., renal function and concurrent disease states).
• Combination anti-infective therapy should be reserved for documented clinical efficacy,

therapeutic failure of monotherapy, and polymicrobial infection.
• Clinical signs of infection should be followed to determine patient response to therapy.
• Empiric therapy of meningitis is age specific, reflecting the age-specific nature of the common
pathogens.
• Endocarditis therapy is specific to the organism isolated. The presence of a prosthetic valve
increases the time of therapy.
• Many cases of bronchitis are viral in etiology, making routine antibiotic therapy controversial.
• Empiric pneumonia therapy reflects coverage of both age-related organisms and organisms
associated with patient-specific risk factors.
• Diarrhea therapy mainly should be supportive, with careful use of anti-infectives and antimotility
agents.
• Diagnosis of urinary tract infections varies by numbers of organisms found in the urine. Higher
numbers (>105 cells/mL) are needed to diagnose UTIs in females than in males (>103 cells/mL)
because of the higher numbers of organisms able to ascend the shorter female urethra.
• A frequently overlooked aspect of the treatment of bacterial venereal diseases is the treatment of
sexual partners.
• Initial therapy of sepsis should be broad in scope, covering all likely organisms, until results of
cultures are obtained.
• Because of the long doubling time of most fungi and the difficulty in obtaining sensitivity to
specific antifungal agents, patient response is used to determine resistance to therapy.
• Antiviral therapy is not curative but decreases the level of virus so that a patient's immune system
can handle the infection.
29-4. Questions
The lowest concentration of anti-infective that prevents microbial growth is called the
A. minimum bactericidal concentration.

1. B. minimum bacteriostatic concentration.
C. minimum inhibitory concentration.
D. minimum inhibiting concentration.
E. minimum Schillings concentration.

Laboratory markers of infections, such as C-reactive protein, white blood cell count, and
erythrocyte sedimentation rate, may not be accurate in which patient populations?
I. Elderly patients
II. Patients with chronic obstructive pulmonary disease
III. Malnourished patients
2.
A. I only
B. II only
C. I and III only
D. II and III only
E. I, II, and III

The hallmark of empiric therapy is
A. coverage of the most common pathogen associated with the infection.

3. B. coverage of the common pathogens associated with the infection.
C. coverage of all possible pathogens associated with the infection.
D. coverage of polymicrobial pathogens associated with the infection.
E. coverage of all viral organisms associated with the infection.

When two anti-infective therapies together produce a greater effect than the effects of each
used alone, this phenomenon is termed
A. commensalism.
4.
B. synergy.
C. antagonism.
D. additive.
E. interacting.

Analysis of the cerebrospinal fluid may give valuable clues to the identity of the pathogen in
meningitis. Given the following results, what would be indicative of a fungal infection?
I. Increase in WBCs
II. Decreased glucose
III. Increased protein
5.
A. I only
B. II only
C. I and III only
D. II and III only
E. I, II, and III

Empiric therapy for meningitis for patients up to 1 month of age includes
A. vancomycin and ampicillin.

6. B. aminoglycoside and ampicillin.
C. ceftriaxone and vancomycin.
D. vancomycin and aminoglycoside.
E. ampicillin and ceftriaxone.

When treating penicillin-allergic patients for endocarditis, ______may be used for therapy.
A. vancomycin
7. B. erythromycin
C. cefazolin
D. meropenem
E. nafcillin

Patients presenting with acute bronchitis without risk factors should be treated empirically with
A. supportive care.
8. B. clarithromycin.
C. cefuroxime.
D. ciprofloxacin.
E. erythromycin.

The most common organisms associated with community-acquired pneumonia in adults are
A. Chlamydia pneumoniae, Mycoplasma pneumoniae, and Haemophilus influenzae.

9. B. Streptococcus pneumoniae, Haemophilus influenzae, and Chlamydia pneumoniae.
C. Mycoplasma pneumoniae, Chlamydia pneumoniae, and Streptococcus pneumoniae.
D. Mycoplasma pneumoniae, Streptococcus pneumoniae, and Haemophilus influenzae.
E. Chlamydia pneumoniae, Staphylococcus aureus, and Haemophilus influenzae.

Empiric therapy for patients with hospital-acquired pneumonia should include
A. tobramycin and gentamicin.

10. B. cefotaxime and cefepime.
C. vancomycin and gentamicin.
D. gentamicin and cefepime.
E. cefepime and vancomycin.

Treatment of latent tuberculosis infections in which isoniazid-resistant strains of
Mycobacterium tuberculosis are predominant should include
A. rifabutin and pyrazinamide.

11.
B. rifampin and pyrazinamide.
C. isoniazid, rifampin, and pyrazinamide.
D. isoniazid, rifabutin, and pyrazinamide.
E. ethambutol and rifampin.

The use of antimotility agents in infectious diarrhea is
A. discouraged because of the potential to cause toxic megacolon.

12. B. encouraged because of increased cure rates.
C. discouraged because of increased reinfections.
D. encouraged because of decreased reinfections.
E. discouraged because of lack of efficacy.

Cellulitis usually is associated with
A. Staphylococcus aureus.
13. B. Streptococcus bovis.
C. Peptostreptococcus boydii.
D. Escherichia coli.
E. Klebsiella pneumoniae.

The best empiric regimen to treat prostate infection is
A. ciprofloxacin for 10 days.

14. B. TMP-SMX for 10 days.
C. ciprofloxacin and TMP-SMX for 10 days.
D. ciprofloxacin for 4-6 weeks.
E. TMP-SMX for 4-6 weeks.

Tertiary syphilis in adults should be treated with
A. benzathine penicillin 2.4 million units × 1 day.

15. B. penicillin 50,000 units/kg q12h × 10-21 days.
C. penicillin 4 million units q4h × 10-14 days.
D. benzathine penicillin 2.4 million units q week × 3 weeks.
E. penicillin 150,000 units/kg q12h × 10-21 days.

Candida albicans infections may be treated with
A. itraconazole.
16. B. amphotericin B.
C. voriconazole.
D. caspofungin.
E. ketoconazole.

The antiviral agent with the widest spectrum of activity against influenza is
A. zanamivir.
17. B. rimantadine.
C. amantadine.
D. oseltamivir.
E. acyclovir.

Herpes infections resistant to acyclovir may be treated with
A. famciclovir.
18. B. valacyclovir.
C. foscarnet.
D. ganciclovir.
E. high-dose acyclovir.

In the list that follows, the only organism that can be cultured easily is
A. Treponema pallidum.
19. B. Mycobacterium tuberculosis.
C. Rickettsia rickettsii.
D. Ehrlichia phagocytophila.
E. Francisella tularensis.

Anti-infective therapy always should be used to treat infectious diarrhea caused by which
organism?
A. Escherichia coli
20.
B. Vibrio cholerae
C. Staphylococcus aureus
D. Salmonella
E. Bacillus cereus

J. B. is an 18-year-old white female who just gave birth to her first child. Because she
presented without any prenatal care or history, a full prenatal panel of tests was taken,
including a vaginal swab. Two days after giving birth, she complained of a purulent vaginal
discharge and a low-grade fever. Blood cultures were negative, but the vaginal swab revealed
the presence of Gram-negative cocci. WBCs were elevated at 13,000 cells/mm3. What is J. B.'s
probable infection?
21.
A. Herpes simplex
B. Gonorrhea
C. Syphilis
D. Urinary tract infection
E. Food poisoning

What should be done for J. B. and her baby?
A. Both mother and child should be treated.

22. B. Neither mother nor child should be treated.
C. The child should be treated, but the mother should not.
D. The mother should be treated, but the child should not.
E. Mother, child, and partner should be treated.

L. B. is a 45-year-old white female presenting to the emergency department with a fever of
103°F, flank pain, dysuria, urgency, and frequency. Her laboratory tests are significant for an
increased WBC count of 18,000 cells/mm3 and 3% immature forms (bands). Her urinalysis
revealed >105 cells/mL of Gram-negative rods. What does L. B. have?
23.
A. Herpes simplex
B. Gonorrhea
C. Syphilis
D. Urinary tract infection
E. Food poisoning

What therapy would be useful for L. B.?
A. Oral quinolone
24. B. IV quinolone
C. Oral penicillin
D. IV carbapenem
E. IV vancomycin

29-5. Answers
C. The minimum inhibitory concentration determines the level of anti-infective to which

1.
dosing regimens may be set.

C. Elderly and malnourished patients may not be able to respond with appropriate laboratory
2.
markers of infections because of limited reserves or deletion of inflammatory factors.

B. Coverage of common pathogens associated with the infection increases the probability of
3. curing the infection without increasing anti-infective exposure to other organisms, which
increases the possibility of resistance.

4. B. Synergy is the correct term.

E. Although fungal CNS infections show relatively slight changes in WBCs, protein, and
5.
glucose compared to bacterial infections, the trend is similar.

B. This regimen covers the most likely organisms for meningitis in this age group: Gram-
6.
negative enterics (e.g., Escherichia coli), group B streptococci, and Listeria monocytogenes.

A. Vancomycin covers all Gram-positive organisms associated with endocarditis, with no
7.
cross-sensitivity to penicillin.

A. Because half of bronchitis infections are caused by a viral etiology, antibacterial therapy for
8.
low-risk patients should not be attempted, with the exception of severe presentation.

9. D. Chlamydia pneumoniae is not a pathogen associated with adult pneumonia.

D. Empiric therapy for hospital-acquired pneumonia should have an aminoglycoside and one
10. other Gram-negative agent, such as cefepime. Vancomycin can be added if methicillin-resistant
Staphylococcus aureus is suspected.

B. Latent infections are usually treated with isoniazid alone. In the case of isoniazid-resistant
11. tuberculosis, rifampin and pyrazinamide are effective at treating latent infections. The three-
drug regimens are used to treat active disease.

A. Use of such agents increases the chance of intestinal perforation and increases the length of
12.
symptoms.

A. Most cellulitis infections are associated with Staphylococcus aureus and Streptococcus
13.
pyogenes.

D. Prostate infections are difficult to treat, requiring 4-6 weeks of therapy. Although TMP-
14. SMX is a reasonable choice for treating most prostate infections, ciprofloxacin is preferred
because of its ability to concentrate in prostate fluid.

C. Because of the organism load of tertiary syphilis, high doses of penicillin G are needed for
15.
clinical cure. Responses B and E are congenital syphilis doses for neonates.

B. Voriconazole and caspofungin have activity against Candida but have not yet been tested in
16. a variety of settings. Ketoconazole and itraconazole should not be used for serious Candida
infections. Amphotericin B and fluconazole are currently recommended for Candida.

D. Oseltamivir may be used for either treatment or prophylaxis against both influenza A and
17.
influenza B.

18. C. Foscarnet has activity against acyclovir-resistant herpes.

B. Mycobacterium tuberculosis, although very slow growing, can be grown on culture media.
19. The remaining organisms cannot be grown without the use of cell culture techniques, forcing
the clinician to rely on serum testing and direct staining for identification of the organism.

B. Staphylococcus and Bacillus diarrheas are an intoxication not caused by a living organism.
Both Salmonella and E. coli diarrheas should be treated only if severe or if signs of systemic
20.
infection are present. Vibrio cholerae causes a severe diarrhea requiring anti-infective
treatment.

B. Given the lack of prenatal care, J.B.'s physical signs and symptoms, and the presence of
21.
Gram-negative cocci, J. B. most likely has gonorrhea.

E. Mother, partner, and child should be treated. J. B. and her partner should receive ceftriaxone
125 mg IM × 1 dose and treatment for concurrent chlamydia infection (doxycycline 100 mg bid
22.
× 7 days). The child should receive cefotaxime 25 mg/kg q12h × 7 days. Both mother and child
should be screened for additional sexually transmitted diseases.

D. Given the clinical presentation and laboratory test results, L. B. has a severe urinary tract
23. infection. The presence of systemic symptoms (fever and chills) suggests an upper urinary tract
infection or pyelonephritis.

B. Given the severity of disease, parenteral therapy would be reasonable for initial therapy.
Because the Gram stain of the urine revealed Gram-negative rods, either a quinolone or
24.
extended-spectrum penicillin in combination with an aminoglycoside would be reasonable
empiric therapy until the organism is identified and sensitivities obtained.

29-6. References
Many general references will provide basic information concerning anti-infective therapy. The
Medical Letter (www.medletter.com) publishes a good yearly review of antibacterial and antiviral
therapies in brief. A list of recent practice guidelines in areas of infectious disease follows.
Meningitis
Tunkel AR, Hartman BL, Kaplan SL, et al. Practice guidelines for the management of bacterial
meningitis. Clin Infect Dis. 2004;39:1267-84.
Endocarditis
Baddour LM, Wilson WR, Bayer AS, et al. Complications: A statement for healthcare professionals
from the Committee Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management
of Complications. Circulation. 2005;111: e394-434.
Pneumonia
American Thoracic Society and the Infectious Diseases Society of America. Guidelines for the
management of adults with hospital-acquired, ventilator-associated, and healthcare-associated
pneumonia. Am J Respir Crit Care Med. 2004;171:388-416.
Bartlett JG, Dowell SF, Mandell LA, et al. Practice guidelines for the management of community-
acquired pneumonia in adults: Infectious Diseases Society of America. Clin Infect Dis. 2000;31:
347-82.
Tuberculosis
Horsburgh CR, Feldman S, Ridzon R. Practice guidelines for the treatment of tuberculosis. Clin
Infect Dis. 2000;31:633-39.
Infectious diarrhea
Diagnosis and management of food-borne illnesses: A primer for physicians. MMWR Recomm
Rep. 2001;50(RR-2):1-69.
Guerrant RL, Van Gilder T, Steiner TS, et al. Practice guidelines for the management of infectious
diarrhea. Clin Infect Dis. 2001;32:331-51.
Soft tissue infections
Lipsky BA, Berendt BA, Deery HG, et al. Diagnosis and treatment of diabetic foot infections. Clin
Infect Dis. 2004;39:885-910.
Urinary tract infections
Warren JW, Abrutyn E, Hebel JR, et al. Guidelines for antimicrobial treatment of uncomplicated
acute bacterial cystitis and acute pyelonephritis in women: Infectious Diseases Society of
America (IDSA). Clin Infect Dis. 1999;29:745-58.
Bacterial venereal diseases (gonorrhea and syphilis)
Centers for Disease Control and Prevention. Diseases characterized by genital ulcers: Sexually
transmitted diseases treatment guidelines. MMWR Recomm Rep. 2002;51(RR-6):11-25.
Centers for Disease Control and Prevention. Diseases characterized by urethritis and cervicitis.
Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep. 2002;51(RR-6):30-
42.
Centers for Disease Control and Prevention. Vaccine preventable STDs. Sexually transmitted
diseases treatment guidelines. MMWR Recomm Rep. 2002; 51(RR-6):59-64.
Sepsis
American College of Chest Physicians-Society of Critical Care Medicine Consensus Conference.

Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in
sepsis. Crit Care Med. 1992;20:864-74.
O'Grady NP, Barie PS, Bartlett JG, et al. Practice guidelines for evaluating new fever in critically ill
adult patients. Crit Care Med. 1998;26:1042-59.
Tick-borne systemic febrile syndromes
Wormser GP, Nadelman RB, Dattwyler RJ, et al. Practice guidelines for the treatment of Lyme
disease. Clin Infect Dis. 2000;31(suppl 1):1-14.
Systemic fungal infections
Chapman SW, Bradsher RW, Campbell GD, et al. Practice guidelines for the management of
patients with blastomycosis. Clin Infect Dis. 2000; 30:679-83.
Pappas PG, Rex JH, Sobel JD, et al. Guidelines for the treatment of candidiasis. Clin Infect Dis.
2004; 38:161-89.
Saag MS, Graybill RJ, Larsen RA, et al. Practice guidelines for the management of cryptococcal
disease. Clin Infect Dis. 2000;30:710-18.
Stevens DA, Kan VL, Judson MA, et al. Practice guidelines for diseases caused by Aspergillus.
Clin Infect Dis. 2000;30:696-709.
Viral infections (hepatitis, influenza, and the herpes simplex family)
Association for Genitourinary Medicine, Medical Society for the Study of Venereal Disease. 2002
National Guideline for the Management of Genital Herpes. London: AGUM, MSSVD; 2002.
Association for Genitourinary Medicine, Medical Society for the Study of Venereal Disease. 2002
National Guideline on the Management of the Viral Hepatitides A, B, and C. London: AGUM,
MSSVD; 2002.
Bridges CB, Fukuda K, Uyeki TM, et al. Prevention and control of influenza: Recommendations of
the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2002;51
(RR-03):1-31.
30. Anti-infective Agents - Ronald L. Braden, PharmD, W. Andrew Bell, PharmD
30-1. Aminoglycosides
Introduction
Aminoglycosides are antibiotics active against most aerobic Gram-negative bacteria and select
aerobic Gram-positive bacteria, but they are not effective against most anaerobic bacteria.
Aminoglycosides are primarily used in serious infections because of their significant toxicity. The
most commonly used aminoglycosides include amikacin, gentamicin, kanamycin, neomycin,
netilmicin, streptomycin, and tobramycin.
Mechanism of Action
Aminoglycosides inhibit bacterial protein synthesis through binding to the 30S ribosomal subunit,
thereby irreversibly inhibiting bacterial RNA (ribonucleic acid) synthesis. Aminoglycosides are
bactericidal.
Spectrum of Activity
Amikacin is a semisynthetic parenteral aminoglycoside with the broadest antimicrobial activity of

the class, and it frequently possesses activity against bacteria resistant to other aminoglycosides.
Gentamicin is a parenteral aminoglycoside that is more active against Acinetobacter, Serratia, and
enterococci than is tobramycin.
Kanamycin and neomycin are minimally absorbed oral aminoglycosides used to decrease bacterial
content of the bowel. They have been used for preoperative bowel preparation and as an adjunct in
hepatic encephalopathy.
Netilmicin is a parenteral aminoglycoside that may be the least ototoxic aminoglycoside.
Streptomycin is a parenteral aminoglycoside active against enterococci, streptococci, mycobacteria,

and some Gram-negative anaerobes. It is used as an adjunct agent only because many bacterial
isolates are resistant to streptomycin monotherapy. Streptomycin should be administered only by
intramuscular (IM) injection.
Tobramycin is a parenteral aminoglycoside that is more active against Pseudomonas than is

gentamicin.
Adverse Drug Events
Nephrotoxicity is demonstrated by an increase in blood urea nitrogen (BUN) and serum creatinine.
It usually manifests as nonoliguric renal failure and may cause potassium, calcium, and magnesium
wasting. Nephrotoxicity may occur in 10-25% of patients receiving aminoglycosides and is usually
reversible on discontinuation of the agent. Risk factors include the following:
• Preexisting renal dysfunction
• Prolonged duration of therapy
• Concomitant use of other nephrotoxic agents
• Possibly elevated trough concentrations:
• Gentamicin and tobramycin > 2 mcg/mL
• Amikacin > 8 mcg/mL
Neuromuscular blockade is an uncommon but potentially serious toxicity. Risk factors include the
following:
• Concomitant use of neuromuscular blocking agents
• Myasthenia gravis
• Hypocalcemia
• Elevated peak serum concentrations
Ototoxicity is due to eighth cranial nerve damage demonstrated by auditory and vestibular
symptoms. Auditory symptoms include tinnitus and loss of high-frequency hearing. Vestibular
toxicity is demonstrated by dizziness, nystagmus, vertigo, and ataxia. The incidence of ototoxicity
is not clearly known because profound high-frequency hearing loss can occur prior to detection.
Pharmacokinetics
Aminoglycosides are renally eliminated:
• t1/2 = 2.5-2.7 hours (normal renal function)
• t1/2 = ~69 hours (anephric clearance)
• Vd = 0.27-0.3 L/kg (ideal body weight, or IBW)
Target serum concentrations
Traditional dosing is described in

Table 30-1.
• Amikacin peak = 15-30 mcg/mL
• Amikacin trough 5 mcg/mL
• Gentamicin and tobramycin peak = 4-10 mcg/mL
• Gentamicin and tobramycin trough 2 mcg/mL
Extended interval dosing
• Amikacin trough 3 mcg/mL (< 5 mcg/mL for VAP [ventilator-associated pneumonia] or HCAP
[health care-associated pneumonia])
• Gentamicin and tobramycin 1 mcg/mL
30-2. Penicillins
Mechanism of Action
Penicillin-binding proteins make up the cell wall. When penicillin binds to these proteins, it is able
to inhibit cell wall synthesis in the bacteria, causing cell wall lysis and ultimately cell death.
Penicillins are bactericidal; they inhibit bacterial cell wall synthesis. They are known as ²-lactam
antibiotics because their chemical structure consists of a ²-lactam ring adjoined to a thiazolidine
ring.
Penicillinase-resistant penicillins have substitutions to the ²-lactam ring that sterically inhibit
penicillinase.
Spectrum of Activity and Dosing
See
Tables 30-2 and
30-3 for information about the spectrum of activity and dosing of penicillins.
Adverse Drug Events
Allergic or hypersensitivity reaction occurs in 3-10% of patients. Rash (4-8% of patients) or

anaphylaxis (0.01-0.05% of patients) can occur within 10-20 minutes and is more common in
intravenous (IV) than in oral administration.
Neurologic reactions (seizures) are seen with high doses of penicillin given to patients with renal
insufficiency.
Gastrointestinal (GI) effects, including nausea and vomiting, may occur with oral use.
Hypokalemia and hypernatremia may occur with carboxypenicillins.
Increased transaminases occur with oxacillin and nafcillin.
Cholestatic jaundice may occur with ureidopenicillins.
Hematologic reactions (hemolytic anemia) are possible.
Interstitial nephritis is possible.
Probenecid competitively inhibits tubular secretion of penicillins, thus increasing plasma levels.
This interaction is employed in serious central nervous system (CNS) infections to increase drug
concentrations.
Aminoglycosides are either incompatible or synergistic.
[Table 30-1. Aminoglycosides]
[Table 30-2. Spectrum of Activity of the Penicillins]
Concomitant use with an oral contraceptive may decrease the effectiveness of the oral contraceptive
and increase incidence of breakthrough bleeding.
Other Characteristics
Nafcillin and oxacillin are eliminated primarily by biliary excretion; therefore, there is no need to
adjust dosage for patients with renal dysfunction.
Penicillin G benzathine is a repository drug formulation. When it is given IM, insoluble salt allows
slow drug absorption from the injection site, and therefore, penicillin G has a longer duration of
action (12-24 hours).
30-3. Cephalosporins
Introduction
Cephalosporins are -lactam antibiotics that are structurally and pharmacologically similar to
penicillins.
Mechanism of Action
Cephalosporins are bactericidal agents. Antimicrobial activity is achieved through inhibition of
mucopeptide
[Table 30-3. Dosing of Penicillins]
synthesis in the bacterial cell wall, which results in the formation of defective cell walls and
subsequent cell lysis and cell death.
Cephalosporins are broad-spectrum antimicrobial agents; however, the spectrum of activity varies
greatly among the individual agents. Thus, cephalosporins are grouped into four broad classes, or
generations, according to their antimicrobial coverage (
Table 30-4).
First-generation agents (cefadroxil, cefazolin, cephalexin)
Gram-positive activity is extensive, including many strains of Staphylococcus aureus and

Staphylococcus epidermidis in addition to Streptococcus pyogenes (group A betahemolytic
streptococci), Streptococcus agalactiae (group B streptococci), and Streptococcus pneumoniae.
First-generation agents are inactive against enterococci, methicillin-resistant staphylococci
(methicillin-resistant Staphylococcus aureus [MRSA] and methicillin-resistant Staphylococcus
epidermidis [MRSE]), and Listeria monocytogenes.
[Table 30-4. Cephalosporins]
Gram-negative activity is limited, although some strains of Escherichia coli, Klebsiella

pneumoniae, Proteus mirabilis, and Shigella may display susceptibility. First-generation agents are
inactive against Haemophilus influenzae, Pseudomonas, Enterobacter, Citrobacter, Serratia, other
Proteus spp., and anaerobes such as Bacteroides fragilis.
Second-generation agents (cefaclor, cefotetan, cefoxitin, cefprozil, cefuroxime)
Gram-positive activity is similar to that of first-generation agents.
Gram-negative activity of second-generation agents is generally more extensive than that of first-
generation agents, including some strains of Acinetobacter, Citrobacter, Enterobacter, Neisseria,
Proteus, and Serratia, in addition to Escherichia coli and Klebsiella. Second-generation agents are
active against Haemophilus influenzae, and some (cefotetan and cefoxitin) also have anaerobic
activity. Second-generation agents are inactive against Pseudomonas.
Third-generation agents (cefdinir, cefixime, cefotaxime, cefpodoxime, ceftazidime, ceftibuten,

ceftriaxone)
Gram-positive activity is decreased versus first- and second-generation agents.

Gram-negative activity is extensive, including Enterobacter, Citrobacter, Serratia, Neisseria, and
Haemophilus. Some third-generation agents are active against Pseudomonas (ceftazidime).
Anaerobic coverage varies among individual agents.
Fourth-generation agent (cefepime)
Gram-positive activity is increased versus third-generation agents. Cefepime is inactive against

MRSA, enterococci, and Listeria.
Gram-negative activity is extensive, including enhanced activity against Pseudomonas and

Enterobacteriaceae that produce inducible ²-lactamases.
The extended spectrum of activity of cefepime is attributed to a more rapid penetration of the outer
membrane of Gram-negative bacteria. Cefepime is also more resistant to inactivation by ²-
lactamases.
Adverse Drug Events
• Hypersensitivity, including fever, rash, pruritus, urticaria, anaphylaxis, and hemolytic anemia
• GI effects, such as nausea, vomiting, and diarrhea
• Nephrotoxicity (rare)
• Seizures (potential risk with high doses in patients with renal impairment)
• Clostridium difficile colitis
• Bleeding or hypoprothrombinemia (cefotetan), which is attributable to the presence of an N-

methylthiotetrazole (NMTT) side chain in the structure of these agents (possible prevention or
reversal with administration of vitamin K)
• Blood dyscrasias (rare)
Disulfiram-like reactions have been reported with ingestion of alcohol during treatment with
cephalosporin antibiotics.
Probenecid competitively inhibits tubular secretion of cephalosporins, resulting in higher serum

concentrations.
All cephalosporins (except ceftriaxone) require dosage adjustments in patients with renal
insufficiency.
Monitoring Parameters
Serum concentration monitoring is not necessary. Patients should be monitored for clinical response
and resolution of infection.
Verify that the patient is not allergic to penicillins. Cross-sensitivity with penicillins has been
reported in up to 10% of patients receiving cephalosporins. Obtain a thorough history of any patient
with a previous hypersensitivity reaction to any ²-lactam antibiotic. In general, cephalosporins
should be avoided in these patients.
Other
Bacterial resistance to cephalosporins may result through production of ²-lactamases.
30-4. Carbapenems
Introduction
Carbapenems are -lactam-like antibiotics that are structurally and pharmacologically similar to
penicillins.
Mechanism of Action
Carbapenems bind to penicillin-binding proteins in a manner similar to that of ²-lactams, thereby

inhibiting peptidoglycan synthesis. Carbapenems are bactericidal in susceptible isolates.
Carbapenems are very broad-spectrum antibiotics with activity against most Gram-positive and
Gram-negative aerobes and anaerobes, as well as activity against some Mycobacterium and
Chlamydia spp. Carbapenems other than ertapenem cover Pseudomonas and Acinetobacter and are
the drug of choice for ESBL (extended spectrum ²-lactamases)-producing Entreobactereacea
species.
Adverse Drug Events
GI adverse effects are the most common events reported with imipenem. The effects include
nausea, vomiting, diarrhea (including Clostridium difficile enterocolitis), gastroenteritis, abdominal
pain, glossitis, papillary hypertrophy, staining of the teeth, heartburn, pharyngeal pain, and taste
abnormalities.
Eosinophilia, leukopenia, neutropenia, agranulocytosis, hemolytic anemia, and thrombocytopenia
have been reported.
Seizures have been reported in approximately 0.4% of patients receiving imipenem. Risk factors
• History of seizures or head trauma
• High doses
• Renal dysfunction
Imipenem-Cilastatin
Imipenem is a semisynthetic carbapenem -lactam antibiotic. Cilastatin prevents renal metabolism

of imipenem by dehydropeptidases.
Cilastatin competitively inhibits dehydropeptidase—an enzyme present on the brush border of the
proximal renal tubule—which hydrolyzes imipenem. Cilastatin has no antibacterial activity.
Meropenem and Doripenem
These agents are similar to imipenem with the following differences:
• Decreased CNS toxicity
• No hydrolysis by dehydropeptidases
Ertapenem
Ertapenem is dosed once daily and does not cover Pseudomonas.
30-5. Monobactam
Introduction
Monobactam antibiotics are cell wall-active antibiotics like the ²-lactams, but they do not have a ²-
lactam ring, thereby decreasing cross-reactivity with penicillins and cephalosporins.
Aztreonam
Aztreonam is the only monobactam antibiotic currently available.
Mechanism of action
Aztreonam inhibits synthesis of bacterial cell walls through binding to penicillin-binding protein 3
of susceptible Gram-negative bacteria, thereby inhibiting peptidoglycan synthesis. This action
results in cell wall lyses and cell death.
Spectrum of activity
Aztreonam is active against many aerobic Gram-negative bacteria, but is not active against Gram-
positive or anaerobic bacteria. Though some strains of Pseudomonas are susceptible, resistance is
increasing.
Adverse drug events
• Hypersensitivity: Rash, injection site reactions, and eosinophilia
• GI effects: Nausea, vomiting, and diarrhea
• Rare effects: Hepatotoxicity, neutropenia, and pancytopenia
30-6. Gram-Positive Antibiotics
Linezolid
Linezolid is a synthetic oxazolidine antibiotic (

Table 30-5).
Mechanism of action
Linezolid binds to the 23S ribosomal subunit of the 50S RNA subunit that inhibits bacterial
translation.
Linezolid is bacteriostatic against enterococci and staphylococci and bactericidal against

streptococci. Linezolid is active against Enterococcus faecium isolates, including vancomycin-
resistant Enterococci (VRE), while most Enterococcus faecalis isolates are resistant.
[Table 30-5. Gram-Positive Antibiotics]
Adverse drug events
Hematologic effects, including myelosuppression (anemia, leukopenia, pancytopenia, and

thrombocytopenia), have been reported. Hematologic effects appear to be reversible on
discontinuation of the agent.
Monoamine oxidase (MAO) inhibition may occur. Linezolid is a weak MAO inhibitor and caution
should be exercised in patients receiving vasopressors or serotonergic agents (SSRI [selective
serotonin reuptake inhibitor], TCA [tricyclic antidepressant], meperidine, and triptans).
Quinupristin-Dalfopristin
Quinupristin-dalfopristin is a semisynthetic streptogramin antibiotic. The combination acts

synergistically against Gram-positive bacteria.
Mechanism of action
Quinupristin inhibits late-phase protein synthesis, while dalfopristin inhibits early-phase protein
synthesis through binding to the 50S subunit of bacterial RNA.
Quinupristin-dalfopristin is bactericidal against staphylococci and streptococci and bacteriostatic

against Enterococcus faecium, including VRE. Quinupristin-dalfopristin is not active against
Enterococcus faecalis.
Adverse drug events
Thrombophlebitis and severe injection site reactions are common, and some sources recommend
administration through a central venous catheter only.
Hyperbilirubinemia has been reported in up to 25% of patients receiving the agent.
Arthralgias and myalgias are common, some requiring discontinuation of the agent.
Daptomycin
Daptomycin is a cyclic lipopeptide antibiotic.
Mechanism of action
Daptomycin binds to bacterial cell membranes, causing rapid depolarization, which results in loss
of membrane potential. The loss of membrane potential inhibits protein, DNA (deoxyribonucleic
acid), and RNA synthesis, resulting in cell death.
Daptomycin is bactericidal against Gram-positive bacteria including staphylococci, streptococci,

enterococcus, and Corynebacterium. Daptomycin is active against MRSA, as well as enterococci
that are resistant to vancomycin, linezolid, or quinupristin-dalfopristin.
Adverse drug events
Dermatologic reactions include injection site reaction, rash, and pruritis. Musculoskeletal effects
include increased CPK (creatine phosphokinase), which can progress to rhabdomyolysis (weekly
monitoring recommended). Nephrotoxicity and hepatotoxicity have been reported.
Other
Daptomycin is inactivated by the surfactant in the lung and cannot be used to treat pneumonia.
Daptomycin interacts with some PT (prothrombin time) and INR (international normalized ratio)
assays, resulting in a false elevation.
Vancomycin
Vancomycin is a glycopeptide antibiotic.
Mechanism of action
Vancomycin binds to the bacterial cell wall, inhibiting peptidoglycan synthesis. This binding occurs
at a site different from that of the penicillins. Vancomycin may also inhibit RNA synthesis.
Vancomycin is active against most Gram-positive bacteria, such as staphylococci (including

MRSA), streptococci, enterococci, Corynebacterium, and Clostridium (including Clostridium
difficile). It is bactericidal against all susceptible isolates except enterococci (bacteriostatic).
Vancomycin acts synergistically with aminoglycosides against enterococci.
Adverse drug events
Nephrotoxicity is manifested by an increase in serum creatinine and BUN. The incidence of

nephrotoxicity is not well described, but it appears to be low in the absence of concomitant
nephrotoxic agents. Renal dysfunction is normally reversible on discontinuation of the agent but
may be irreversible.
Ototoxicity is induced by eighth cranial nerve damage and has been reported to cause permanent
hearing loss. Vancomycin rarely causes vestibular toxicity. The incidence of ototoxicity appears to
be low in the absence of concomitant ototoxic agents.
Thrombophlebitis is common and requires frequent IV site rotation.
Histamine release, or "red-man syndrome," is a reaction most commonly associated with rapid IV
infusion. Histamine reactions can be minimized by slow IV infusion, not to exceed 500 mg/30 min.
Vancomycin trough concentrations should be monitored in patients with preexisting renal

dysfunction or patients with increased serum creatinine or BUN during therapy. Monitoring of
vancomycin peak concentrations is not routinely required, except in patients with serious infections,
those with CNS infections, or those not responding to therapy.
Pharmacokinetics
Vancomycin is renally eliminated:
• t1/2 = 6 hours (normal renal function)
• t1/2 = 7-10 days (anephric patients)
• Vd = 0.7 L/kg (total body weight [TBW])
• Dose = 15-20 mg/kg (TBW)
• Interval = q12h to pulse dosing (based on renal function and pharmacokinetic monitoring)
• Peak concentration = 20-40 mcg/mL
• Trough concentration = 10-20 mcg/mL
30-7. Fluoroquinolones
Introduction
Quinolones are broad-spectrum antibacterial agents (

Table 30-6).
Mechanism of Action
Fluoroquinolones are bactericidal agents. The mechanism of action of these agents is not
understood entirely, but antimicrobial activity is known to involve
[Table 30-6. Fluoroquinolones and Nonfluorinated Quinolones]
inhibition of bacterial DNA topoisomerase and subsequent disruption of bacterial DNA replication.
Gram-positive activity includes many strains of staphylococci. Streptococcal activity is variable,

and streptococcal resistance to quinolones is increasingly common. Newer fluoroquinolones
(moxifloxacin and gemifloxacin) generally demonstrate superior Gram-positive coverage versus
older agents (ciprofloxacin, ofloxacin, and levofloxacin). Fluoroquinolones have limited
enterococcal activity and are inactive against MRSA.
Gram-negative activity is extensive, including Escherichia coli, Klebsiella, Enterobacter,

Citrobacter, Proteus, Salmonella, and Shigella, in addition to Moraxella catarrhalis and
Haemophilus influenzae. Activity against Pseudomonas aeruginosa and Stenotrophomonas
maltophilia varies among individual agents.
Anaerobic coverage is poor.
Atypical coverage varies among individual agents. All fluoroquinolones are highly active against
Legionella. Newer agents have more reliable coverage of Mycoplasma pneumoniae and Chlamydia
pneumoniae.
Adverse Drug Events
• GI effects: Nausea and dyspepsia
• CNS effects: Headache, dizziness, and insomnia
• Cardiovascular effects: QT prolongation (avoid use in patients with preexisting QT

prolongation)
• Endocrine effects: Hypoglycemia or hyperglycemia (reason for withdrawal of gatifloxacin from

market)
• Genitourinary effects: Crystalluria (at high doses with alkaline pH)
• Other effects: Tendinitis and photosensitivity
• Rare effects: Rash, urticaria, leukopenia, and hepatotoxicity (reason for withdrawal of
trovafloxacin)
Ciprofloxacin increases theophylline levels. Concomitant use should be avoided, or theophylline

levels should be monitored during treatment. The risk of theophylline toxicity is lower with other
fluoroquinolones.
Antacids, sucralfate, and divalent or trivalent cations (calcium, magnesium, and iron) significantly
decrease the absorption of fluoroquinolones. These agents should not be administered for at least 2
hours after each dose of a fluoroquinolone.
Fluoroquinolones may enhance the effects of oral anticoagulants. Monitor PT and INR if
concomitant therapy cannot be avoided.
Agents that increase the QT interval (cisapride and class IA or III antiarrhythmics) increase the risk
of torsades de pointes. Concomitant use of fluoroquinolones with these agents should be avoided.
Dosage adjustments should be made for renally cleared fluoroquinolones when CrCl (creatinine
clearance) is < 40 mL/min.
Monitoring Parameters
Serum concentrations are not monitored. The patient should be monitored for clinical response and
resolution of infection.
Kinetics
Quinolones display concentration-dependent activity and have a postantibiotic effect against most
susceptible organisms.
Fluoroquinolones have a large volume of distribution and achieve high tissue concentrations in the
lung, gallbladder, kidney, prostate, and genitourinary tract.
• Fluoroquinolones should be avoided in children or pregnant or nursing females because of the risk
of cartilage erosion in tendons and growing bone tissue.
• Do not take antacids; multivitamins; or other calcium, magnesium, or iron supplements for at least
2 hours after each dose.
30-8. Macrolides and Ketolides
Mechanism of Action
Macrolides are bacteriostatic against susceptible organisms (

Table 30-7). The agents bind to the 50S RNA subunit, thereby inhibiting RNA synthesis.
Ketolides are similar to the macrolides. Telithromycin is a derivative of 14-membered ring

macrolides and is the first ketolide antibiotic.
[Table 30-7. Macrolides and Ketolide]
Macrolides, or erythromycins, are active principally against Gram-positive organisms, including
penicillin-resistant streptococci. The macrolides are also effective against Chlamydia, Mycoplasma,
Ureaplasma, spirochetes, and mycobacteria.
Macrolides are the drugs of choice in atypical pneumonia and Chlamydia sexually transmitted
diseases.
Telithromycin possesses greater in vitro activity against multidrug-resistant Gram-positive

organisms and Haemophilus influenzae than do the erythromycins.
Adverse Drug Events
• GI effects: Erythromycins stimulate GI motility, leading to abdominal pain and cramping, nausea,
vomiting, and diarrhea. Clarithromycin appears to be the least stimulating to the GI tract.
• Local effects: Erythromycin lactobionate is reported to cause venous irritation and

thrombophlebitis. The agent should be diluted in at least 250 mL and infused over 30-60 minutes
to decrease the venous irritation.
• Cardiac effects: QT interval prolongation and torsades de pointes have been rarely reported with
erythromycins. Adequate dilution and slow IV infusion appear to decrease this reaction.
• Ototoxicity: Erythromycin has been rarely reported to be ototoxic in doses of 4 g/d or more.
• Hepatotoxicity: Telithromycin appears comparable to the macrolides but carries a black box
warning for hepatotoxicity.
30-9. Tetracyclines and Glycylcyclines
Mechanism of Action
Tetracyclines and glycylcyclines are bacteriostatic. They inhibit bacterial protein synthesis by
reversible binding on the 30S ribosomal subunit and by blocking of the attachment of transfer RNA
to an acceptor site on the messenger RNA ribosomal complex (
Table 30-8).
Glycylcyclines (tigecycline) share the same mechanism of action as tetracyclines but have a
structural modification that increases affinity and binding to the bacterial ribosome and decreases
efflux from the cell. These properties give tigecycline in vitro advantages when compared to
tetracycline.
Tetracyclines are used to treat the following infections:

• Respiratory infections: Atypical pneumonia (Mycoplasma pneumoniae, Chlamydia pneumoniae)
• Genital infections: Chlamydia trachomatis, granuloma inguinale
• Systemic infections: Relapsing fever (Borrelia recurrentis) and Vibrio (V. cholerae, V. vulnificus,
and V. parahaemolyticus)
• Other infections: MRSA and MRSE (minocycline) when vancomycin or other agents are not
considered appropriate; Pasteurella multocida,
[Table 30-8. Tetracyclines and Glycylcyclines]
Mycobacterium marinum, Yersinia pestis, and Helicobacter pylori (in combination with bismuth
subsalicylate and metronidazole or clarithromycin)
• Prophylaxis: Mefloquine-resistant Plasmodium falciparum malaria
Doxycycline is used to treat infections caused by the following organisms:
• Mycobacterium fortuitum and Mycobacterium chelonae
• Streptococcus pneumoniae
Pseudomonas and Proteus organisms are now resistant to tetracyclines.
Tetracyclines are used in the treatment of Propionibacterium acnes.
Administering the drug with food can minimize GI distress.
Adverse Drug Events
Photosensitivity reactions can occur, but may be less frequent with doxycycline and minocycline.
Tetracyclines and glycylcyclines are generally contraindicated during pregnancy and breast-feeding
and in children younger than age 8 because of their association with tooth discoloration and
interference with bone growth.
Hepatotoxicity—specifically acute fatty necrosis—may occur in pregnant women and in patients

with renal impairment.
Minocycline use can cause the following:
• Vestibular side effects (dizziness, ataxia, nausea, and vertigo)

• Skin and mucous membrane pigmentation
• Lupus-like symptoms
GI intolerance includes diarrhea, nausea, vomiting, and anorexia.
Cross-sensitivity within the tetracycline group is common.
IV tetracyclines may cause phlebitis.
Milk, antacids, iron supplements, and probably other substances with calcium, magnesium,
aluminum, and iron decrease tetracycline GI absorption considerably and should be ingested at least
several hours before or after administration of tetracycline.
Although doxycycline and minocycline absorption may be less affected by these divalent and
trivalent cations, avoiding administration within 1 to 2 hours after ingestion of interfering foods is
recommended.
Anticonvulsants (e.g., barbiturates, carbamazepine, and phenytoin) induce hepatic microsomal

metabolism of tetracyclines and therefore decrease tetracycline serum concentrations.
If tetracycline is given with cholestyramine or colestipol, these drugs may bind tetracycline and
reduce GI absorption.
Oral contraceptive efficacy may be decreased with concurrent use of tetracyclines.
Tetracyclines and glycylcyclines may potentiate warfarin-induced anticoagulation; therefore,

monitor PT and INR.
[
Table 30-9. Sulfonamides]
Demeclocycline antagonizes the action of antidiuretic hormones.
30-10. Sulfonamides
Introduction
Sulfonamides are synthetic derivatives of sulfanilamide (Table 30-9). Their usefulness has
decreased over time because of the development of resistance.
Mechanism of Action
Sulfonamides interfere with bacterial folic acid synthesis by competitively inhibiting para
aminobenzoic acid (PABA) utilization. Sulfonamides are bacteriostatic.
• Gram-positive bacteria: Staphylococci (methicillin-sensitive Staphylococcus aureus [MSSA]

and MRSA), streptococci (not enterococci), Bacillus anthracis, Clostridium perfringens, and
Nocardia
• Gram-negative bacteria: Enterobacter, Escherichia coli, Klebsiella, Proteus, Salmonella, and

Shigella
• Other organisms: Chlamydia trachomatis, Toxoplasma gondii, and Plasmodium
Adverse Drug Events
Hypersensitivity reactions appear to be cross-reactive with other sulfonamides, diuretics (including

acetazolamide and thiazides), and sulfonylurea antidiabetic agents.
Dermatologic reactions include rash, urticaria, and Stevens-Johnson syndrome.
30-11. Miscellaneous Antibiotics
Clindamycin
Clindamycin is a semisynthetic antibiotic derived from lincomycin (

Table 30-10).
Mechanism of action
Clindamycin inhibits the 50S subunit, thereby inhibiting RNA synthesis. Clindamycin is either
bacteriostatic or bactericidal, depending on the serum concentration of the agent and the minimum
inhibitory concentration (MIC) of the organism.
Clindamycin is active against most aerobic Gram-positive and most anaerobic Gram-negative
bacteria. It has no activity against aerobic Gram-negative bacteria.
Adverse drug events
Adverse GI effects occur frequently with all forms of clindamycin, and include nausea, vomiting,
diarrhea, abdominal pain, and tenesmus. Clindamycin has induced Clostridium difficile
enterocolitis.
IV administration can lead to thrombophlebitis, erythema, and pain and swelling at the IV site. IM
administration can cause pain, induration, and sterile abscesses.
Clindamycin can cause transient leukopenia, neutropenia, eosinophilia, thrombocytopenia, and

agranulocytosis. These effects are usually reversible on discontinuation of the drug.
Other Miscellaneous Antibiotics
See Table 30-10 for information about other miscellaneous antibiotics.
30-12. Antifungal Agents
Amphotericin B
Amphotericin B is a polyene antifungal agent used in the treatment of potentially life-threatening

systemic fungal infections (
Table 30-11).
[Table 30-10. Miscellaneous Antibiotics]
[Table 30-11. Antifungal Agents]
Amphotericin B lipid formulations
Amphotericin B cholesterol sulfate complex (Amphotec), amphotericin B lipid complex (Abelcet),

and amphotericin B liposomal (AmBisome) formulations are available for the treatment of severe
fungal infections in patients who fail or are intolerant of conventional amphotericin B. The lipid
formulations may decrease toxicity by 20-30%.
Mechanism of action
Amphotericin B binds to ergosterol in the fungal cell wall, leading to increased permeability and
cell death. Amphotericin B is fungistatic.
• Aspergillus, Coccidioides, Cryptococcus, Histoplasma, and Mucor
• Candida, including C. albicans, C. dubliniensis, C. glabrata, C. krusei, C. parapsilosis, and C.

tropicalis (C lusitaniae exhibits variable sensitivity)
Adverse drug events
• Infusion reactions: Fever, chills, hypotension, rigors, pain, thrombophlebitis, and anaphylaxis
can occur.
• Renal and electrolyte effects: Nephrotoxicity is the major dose-limiting toxicity, but
Hypokalemia, hypocalcemia, and hypomagnesemia can occur. Effects are usually reversible on
discontinuation of the agent. Renal tubular acidosis and nephrocalcinosis are possible.
• Hematologic effects: Normocytic and normochromic anemia secondary to decreased

erythropoietin production may occur.
• Hepatic effects: Increased aspartate aminotransferase (AST), alanine aminotransferase (ALT),

alkaline phosphatase, and bilirubin are possible.
Echinocandins
Echinocandins (caspofungin, micafungin, and anidulafungin) are a new class of IV antifungal

agents.
Mechanism of action
Echinocandins inhibit -(1,3) glucan synthase, thereby preventing fungi from forming an essential
component of their cell wall. This loss of cell wall integrity results in cell lysis and death.
Echinocandins are active against most Candida and Aspergillus species, but they lack activity
against other invasive molds. Candida Parapsilosis, C. guilliermondii, and C. famata have increased
MICs to echinocandins, which may result in an inadequate response to treatment.
Caspofungin
Caspofungin is approved for the treatment of aspergillosis in patients refractory to or intolerant of

other therapies and in the treatment of invasive Candida infections. Caspofungin is dose adjusted in
severe liver dysfunction.
Micafungin and Anidulafungin
Micafungin and anidulafungin are approved for the treatment of invasive Candida infections.
Micafungin and anidulafungin do not require dose adjustment for renal or hepatic dysfunction.
Adverse drug events
• Hepatic effects: Increased AST and ALT
• Sensitivity reactions: Histamine-release reactions such as rash, pruritus, and anaphylaxis

• Infusion reactions: Fever, thrombophlebitis, nausea, vomiting, and myalgias
Azole Antifungals
Mechanism of action
The azole antifungals appear to inhibit fungal cytochrome P450 14-²-demethylase, thereby
decreasing ergosterol concentrations in susceptible fungi.
Drug interactions
All azole antifungals are inhibitors of the cytochrome P450 system and have many critical drug
interactions attributable to decreased metabolism and, thus, toxicity.
The azole antifungals have also been shown to prolong the QT interval; thus, coadministration with
other drugs that prolong the QT interval is not advised.
Fluconazole
Fluconazole is a synthetic triazole antifungal and is fungistatic.
Candida krusei, C. glabrata, and C. lusitaniae are commonly resistant.
Adverse drug events
• GI effects: Nausea, vomiting, abdominal pain, and diarrhea
• Hepatic effects: Cholestasis, increased AST, ALT, and GGTP (gamma-glutamyl transpeptidase);
hepatic necrosis; and, rarely, severe hepatic dysfunction
• Hemolytic effects: Eosinophilia, anemia, leukopenia, neutropenia, and thrombocytopenia
• Nervous system effects: Rarely, dizziness, headache, somnolence, coma, and seizures
Itraconazole
Itraconazole is a synthetic triazole antifungal.
Itraconazole is effective in aspergillosis, blastomycosis, histoplasmosis, oropharyngeal and

esophageal candidiasis, sporotrichosis, onychomycosis, coccidioidomycosis, and cryptococcosis.
Adverse drug events
• GI effects: Nausea, vomiting, diarrhea, abdominal pain, dyspepsia, dysphagia, flatulence,

gastritis, and ulcerative stomatitis
• Dermatologic and sensitivity reactions: Rash, pruritus, urticaria, angioedema, and Stevens-
Johnson syndrome
• Nervous system effects: Headache, dizziness, tremor, and neuropathy
• Cardiovascular effects: Congestive heart failure, peripheral edema, pulmonary edema, prolonged
QT interval, ventricular dysrhythmias, and death
• Hepatic effects: Increased AST and ALT
• Electrolyte and metabolic effects: Hypokalemia, adrenal insufficiency, and gynecomastia
Ketoconazole
Ketoconazole is a synthetic imidazole antifungal.
The spectrum of activity includes blastomycosis, candidiasis, coccidioidomycosis, histoplasmosis,

and dermatophytosis.
Adverse drug events
• GI effects: Nausea, vomiting, abdominal pain, and GI bleeding
• Hepatic effects: Increased AST, ALT, and alkaline phosphatase
• Endocrine and metabolic effects: Gynecomastia and decreased cortisol production
• Dermatologic and sensitivity reactions: Pruritus, rash, dermatitis, and purpura
• Nervous system effects: Headache, dizziness, lethargy, photophobia, and abnormal dreams
Voriconazole
Voriconazole is a synthetic triazole antifungal.
The spectrum of activity includes aspergillosis and Candida species (even fluconazole-resistant
isolates).
Adverse drug events
• Hepatic effects such as hepatitis, cholestasis, and fulminant hepatic failure
• Visual disturbances and hallucinations
• Dermatologic and sensitivity reactions, including anaphylactoid reactions, pruritus, rash, Stevens-
Johnson syndrome, and photosensitivity
Posaconazole
Posaconazole is a synthetic triazole antifungal.
Posaconazole is approved for use in aspergillus and invasive Candida infections. It has a broad in
vitro spectrum of activity and has been effective against fungi such as zygomycetes and aspergillus
strains that are highly resistant to other azoles and amphotericin.
Adverse drug events
• GI effects: Nausea, vomiting, diarrhea, and abdominal pain
• Dermatologic and sensitivity reactions: Rash and pruritus
• Nervous system effects: Headache, dizziness, and confusion
• Cardiovascular effects: Hypertension, hypotension, edema, prolonged QT interval, and

ventricular dysrhythmias
• Hepatic effects: Cholestasis and increased AST and ALT
Flucytosine
Mechanism of action
Flucytosine appears to enter fungal cells, where it is converted to 5-fluorouracil. Flucytosine is

either fungistatic or fungicidal, depending on the concentration of the agent.
Flucytosine is active against most strains of Candida and Cryptococcus.

Adverse drug events
• GI effects: GI hemorrhage, ulcerative colitis caused by the antiproliferative effects, anorexia,

abdominal pain, nausea, vomiting, and diarrhea
• Hepatic effects: Increased AST, ALT, and bilirubin
• Renal effects: Increased serum creatinine, BUN, and crystalluria
• Nervous system effects: Confusion, hallucinations, psychosis, headache, parkinsonism,

paresthesias, peripheral neuropathy, hearing loss, and vertigo
• Sensitivity reactions: Erythema, pruritus, urticaria, rash, and toxic epidermal necrolysis
Griseofulvin
Mechanism of action
Griseofulvin disrupts the fungal cell's mitotic spindle structure, thereby inhibiting the metaphase of
cell division. Griseofulvin is fungistatic.
The spectrum of activity includes Trichophyton, Microsporum, and Epidermophyton.
Adverse drug events
• Nervous system effects: Headache, fatigue, dizziness, and paresthesias of the hands and feet after
prolonged therapy
• GI effects: Epigastric pain, nausea, vomiting, flatulence, and diarrhea
• Renal effects: Proteinuria and nephrosis
• Sensitivity reactions: Rash, urticaria, erythema multiforme, angioedema, serum sickness,

photosensitivity, and lupus-like reactions
Nystatin
Mechanism of action
Nystatin binds to fungal sterols. It is fungistatic.
The spectrum of activity includes cutaneous and mucocutaneous candidiasis.
Adverse drug events
Mild nausea and diarrhea may occur.
Terbinafine
Terbinafine is a synthetic allylamine antifungal.
Mechanism of action
Terbinafine interferes with sterol biosynthesis.
The spectrum of activity includes Trichophyton, Microsporum, Epidermophyton, Aspergillus,

blastomycosis, and yeasts.
Adverse drug events
• Hepatic effects: Hepatitis and hepatic failure
• Dermatologic and sensitivity reactions: Anaphylactoid reactions, Stevens-Johnson syndrome,

and erythema multiforme
30-13. Antitubercular Agents
Aminosalicylic Acid
Mechanism of action
Aminosalicylic acid (para aminosalicylate, or PAS) inhibits folic acid synthesis in a manner similar
to that of sulfonamides and is bacteriostatic (
Table 30-12).
Aminosalicylic acid is active against Mycobacterium tuberculosis only.
[Table 30-12. Antitubercular Agents]
Adverse drug events
• GI effects: Nausea, vomiting, abdominal pain, diarrhea, and anorexia can occur.
• Vitamin and mineral absorption: Vitamin B12, folic acid, and iron malabsorption have been
rarely reported.
• Hypersensitivity reactions: Fever, skin eruptions, joint pain, and leukopenia have been reported.
Capreomycin
Mechanism of action
The exact mechanism of action of capreomycin is unknown. The agent is bacteriostatic against
susceptible isolates.
Capreomycin is active against the following Mycobacterium species: M. tuberculosis, M. bovis, M.

kansasii, and M. avium.
Adverse drug events
• Renal effects: Nephrotoxicity is exhibited in up to 30% of patients receiving the agent. It

manifests as acute tubular necrosis, which is usually reversible on discontinuation of the agent.
• Ototoxicity: This problem is experienced by up to 30% of patients and is caused by eighth cranial
nerve damage, which can produce irreversible hearing loss.
• Hepatic effects: Elevated liver function tests have been noted when capreomycin is used in
conjunction with other hepatotoxins.
• Hypersensitivity reactions: Fever, urticaria, and skin eruptions have been noted.
Cycloserine
Mechanism of action
Cycloserine is structurally similar to D-alanine and inhibits cell wall synthesis by competing for
incorporation into the bacterial cell wall.
Cycloserine is active against the following Mycobacterium species: M. tuberculosis, M. bovis, M.

avium, and some M. kansasii isolates.
Adverse drug events

CNS effects may occur, including headache, vertigo, confusion, psychosis, and seizures.
Ethambutol
Mechanism of action
Ethambutol appears to inhibit bacterial cellular metabolism and is bacteriostatic.
Ethambutol is active against the following Mycobacterium species: M. tuberculosis, M. bovis, and
some isolates of M. kansasii and M. avium.
Adverse drug events
Ocular effects may occur. Optic neuritis with decreased visual acuity, central and peripheral
scotomas, and loss of red-green color discrimination have been noted. These effects are usually
reversible on discontinuation of the agent.
Ethionamide
Mechanism of action
Ethionamide appears to inhibit cell wall synthesis by an unidentified mechanism. It is bactericidal

or bacteriostatic, depending on tissue concentrations of the agent.
Ethionamide is active against the following Mycobacterium species: M. tuberculosis, M. bovis, M.

kansasii, and some M. avium isolates.
Adverse drug events
Hepatitis is a rare complication.
Isoniazid
Mechanism of action
Isoniazid (INH) appears to inhibit the bacterial cell wall of susceptible isolates and, therefore, is
active against actively dividing cells only. It is bactericidal or bacteriostatic, depending on tissue
concentrations of the agent.
INH is active against the following Mycobacterium species: M. tuberculosis, M. bovis, and some
strains of M. kansasii.
Adverse drug events
• CNS effects: Peripheral neuritis and rarely seizures, encephalopathy, and psychosis have been
reported.
• Hepatic effects: Increases in bilirubin, AST, and ALT are noted in up to 20% of patients
receiving this agent. INH has led to fulminant hepatitis and death.
• Hematologic effects: Agranulocytosis, eosinophilia, thrombocytopenia, and hemolytic anemia

have been reported.
Pyrazinamide
Mechanism of action
Mycobacterium tuberculosis converts pyrazinamide (PZA) to pyrazinoic acid, which possesses

antitubercular activity.
PZA is active against Mycobacterium tuberculosis only.
Adverse drug events
• Hepatic effects: Increased liver enzymes are common, and fulminant hepatitis has been reported.
• Gout: PZA inhibits renal excretion of uric acid and may induce or worsen gout.
Rifampin
Mechanism of action
Rifampin inhibits RNA synthesis in susceptible isolates.
Rifampin is active against the following Mycobacterium species: M. tuberculosis, M. bovis, M.

kansasii, and some M. avium isolates. Rifampin also has activity against many Gram-positive and
Gram-negative organisms.
Adverse drug events

• GI effects: Nausea, vomiting, diarrhea, and abdominal pain may require discontinuation of the
agent. Clostridium difficile colitis has been reported with rifampin.
• CNS effects: Headache, dizziness, mental confusion, and psychosis have been reported.
• Hepatic effects: Increased bilirubin, AST, and ALT are common. Fulminant hepatitis has been
reported.
• Hematologic effects: Thrombocytopenia, leukopenia, and hemolytic anemia have been reported
rarely.
• Renal effects: Renal insufficiency and interstitial nephritis have been reported.
30-14. Key Points
Aminoglycosides
• Aminoglycoside antibiotics exhibit concentration-dependent bacterial killing.
• Aminoglycoside antibiotics are reserved for severe infections or for use against multidrug-
resistant bacteria.
• Aminoglycoside antibiotic dosing should be pharmacokinetically tailored for each patient to

optimize the therapeutic effect and minimize toxicity.
Antifungal Agents
• Amphotericin B, caspofungin, micafungin, anidulafungin, fluconazole, itraconazole,

posaconazole, and voriconazole are effective against systemic fungal infections.
• Imidazole antifungal antibiotics are potent inhibitors of hepatic metabolism, thereby decreasing
the elimination of numerous agents.
Gram-Positive Antibiotics
• Daptomycin, linezolid, and quinupristin-dalfopristin are clinically effective against MRSA,

MRSE, and VRE.
• Daptomycin cannot be used to treat pneumonia.
• Vancomycin is a broad-spectrum Gram-positive antibiotic that should be pharmacokinetically

tailored for each patient to maximize therapeutic benefit and minimize toxicity.
Miscellaneous Antibiotics
• Clindamycin is an effective anaerobic antibiotic and an effective Gram-positive aerobic antibiotic
with activity against many MRSA isolates.
• The carbapenem antibiotics possess a very broad spectrum of activity and should be restricted to
appropriate indications to minimize development of resistance.
Penicillins
• Penicillin antibiotics exhibit time-above-MIC-dependent bacterial killing.
• All penicillins, except nafcillin and oxacillin, are renally eliminated and require dosage
adjustments in patients with renal dysfunction.
Cephalosporins
• Cephalosporin antibiotics exhibit time-above-MIC-dependent bacterial killing.
• In first-generation cephalosporins, Gram-positive activity is extensive, but Gram-negative activity

is limited.
• In second-generation cephalosporins, Gram-positive activity is similar to that of first-generation

agents, but Gram-negative activity is generally more extensive than that of first-generation
agents.
• In third-generation cephalosporins, Gram-positive activity is decreased compared to that of first-

and second-generation agents, but Gram-negative activity is extensive.
Fluoroquinolones
• Quinolone antibiotics exhibit concentration-dependent bacterial killing similar to that of the

aminoglycosides.
• The later-generation quinolones possess improved Gram-positive activity, including resistant

streptococci.
Sulfonamides
• Sulfonamides are primarily urinary anti-infectives whose usefulness has decreased because of the
development of resistance.
Tetracyclines
• Tetracyclines are drugs of choice for Lyme disease and Rocky Mountain spotted fever.
Macrolides
• Macrolides are primarily active against Gram-positive bacteria, including penicillin-resistant
streptococci.
• Macrolides are the drugs of choice in atypical pneumonia.
• Telithromycin possesses greater in vitro activity against multidrug-resistant Gram-positive

organisms and Haemophilus influenzae than do the macrolides but has a black box warning for
hepatotoxicity.
Antitubercular Agents
• Isoniazid, rifampin, and streptomycin exhibit the lowest incidence of resistance.
• Isoniazid, rifampin, and pyrazinamide are the agents of first choice.
30-15. Questions
Which of the following are true regarding aminoglycoside antibiotics?
I. Aminoglycoside antibiotics are bactericidal against most susceptible isolates.

II. Aminoglycoside antibiotics exhibit concentration-dependent bacterial killing.
III. Aminoglycoside antibiotics should be reserved for serious infections.
1.
A. I only
B. I and II
C. I and III
D. II and III
E. I, II, and III

Which of the following most accurately characterize aminoglycoside toxicity?
I. Ototoxicity because of eighth cranial nerve damage

II. Nephrotoxicity exhibited as acute tubular necrosis
III. Bone marrow suppression
2.
A. I only
B. II only
C. III only
D. I and II
E. II and III

Which of the following best characterize aminoglycoside antimicrobial activity?
I. Active against most aerobic Gram-negative bacteria
II. Active against most anaerobic Gram-negative bacteria
III. Active against most fungal isolates
3.
A. I only
B. II only
C. III only
D. I and II
E. II and III

Which of the following antifungals are effective against systemic infections?
I. Amphotericin B
II. Fluconazole
III. Nystatin
4.
A. I only
B. II only
C. III only
D. I and II
E. I and III

Which of the following are true about amphotericin B-induced nephrotoxicity?
I. Nephrotoxicity is the major dose-limiting toxicity.

II. Nephrotoxicity is usually reversible on discontinuation of the drug.
III. Amphotericin B lipid formulations decrease nephrotoxicity by 20-30%.
5.
A. I only
B. II only
C. I and II
D. II and III
E. I, II, and III

Which of the following best describe the drug interactions noted with the imidazole
antifungals?
I. Increased elimination of warfarin

II. Decreased elimination of warfarin
III. Increased metabolism of the oral contraceptives
6.
A. I only
B. II only
C. III only
D. II and III
E. I, II, and II

Linezolid is best described by which of the following?
I. Linezolid is bacteriostatic against staphylococci.

II. Linezolid is bactericidal against staphylococci.
III. Linezolid is a weak MAO inhibitor.
7.
A. I only
B. II only
C. I and III
D. II and III
E. I, II, and III

Linezolid possesses activity against which of the following bacteria?
I. MRSA
II. Enterococcus faecium
III. Enterococcus faecalis
8.
A. I only
B. II only
C. III only
D. I and II
E. I and III

Quinupristin-dalfopristin is best described by which of the following?
I. Quinupristin-dalfopristin exhibits activity against MSSA.

II. Quinupristin-dalfopristin exhibits activity against MRSA.
III. Quinupristin-dalfopristin exhibits activity against streptococci.
9.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

Vancomycin is best described by which of the following?
I. Vancomycin exhibits activity against MRSA.

II. Vancomycin exhibits activity against Enterobacter.
III. Vancomycin exhibits activity against Clostridium difficile.
10.
A. I only
B. II only
C. III only
D. I and II
E. I and III

Vancomycin toxicity is best described by which of the following?
I. Nephrotoxicity exhibited as acute tubular necrosis that is seldom reversible

II. Ototoxicity that is commonly exhibited as vestibular toxicity
III. Histamine release, or "red-man syndrome," which is associated with rapid IV infusion
11.
A. I only
B. II only
C. III only
D. I and II
E. II and III

Which of the following best describe appropriate vancomycin monitoring?
I. Trough serum concentrations should be routinely monitored in patients with preexisting renal
dysfunction.
II. Peak serum concentrations should be routinely monitored in patients with preexisting renal
dysfunction.
12. III. Serum concentration monitoring is of no benefit in vancomycin monitoring.
A. I only
B. II only
C. III only
D. I and II
E. II and III

Clindamycin exhibits antibacterial activity against which of the following microorganisms?
I. Aerobic Gram-positive bacteria

II. Anaerobic Gram-negative bacteria
III. Aerobic Gram-negative bacteria
13.
A. I only
B. II only
C. III only
D. I and II
E. I and III

Which of the following best describe the carbapenem antibiotics?
I. Carbapenem antibiotics exhibit activity against most Gram-positive and Gram-negative

aerobes and anaerobes.
II. Meropenem induces seizures more commonly than imipenem.
III. Cilastatin exhibits activity against most Gram-positive aerobes.
14.
A. I only
B. II only
C. III only
D. I and II
E. II and III

Which of the following best describe the penicillins?
I. Penicillins exhibit concentration-dependent bacterial killing.

II. Penicillins exhibit time-above-MIC-dependent bacterial killing.
III. Penicillins exhibit excellent MRSA activity.
15.
A. I only
B. II only
C. III only
D. I and II
E. II and III

Which of the following penicillins require dosage adjustment in patients with renal
dysfunction?
I. Ampicillin
II. Nafcillin
III. Oxacillin
16.
A. I only
B. II only
C. III only
D. I and II
E. II and III

Which of the following best describe the cephalosporins?
I. Cephalosporins exhibit concentration-dependent bacterial killing.

II. Cephalosporins exhibit time-above-MIC-dependent bacterial killing.
III. Cephalosporins exhibit excellent MRSA activity.
17.
A. I only
B. II only
C. III only
D. I and II
E. II and III

Which of the following best describe the antibacterial activity of the cephalosporins?
I. In first-generation cephalosporins, Gram-positive activity is extensive, but Gram-negative

activity is limited.
II. In second-generation cephalosporins, Gram-positive activity is similar to that of first-
generation agents, but Gram-negative activity is generally more extensive than that of first-
generation agents.
18. III. In third-generation cephalosporins, Gram-positive activity is decreased compared with that
of first- and second-generation agents, but Gram-negative activity is extensive.
A. I only
B. II only
C. III only
D. All of the above

Which of the following best describe the antibacterial activity of the quinolones?
I. Quinolones exhibit concentration-dependent bacterial killing.

II. Quinolones exhibit time-above-MIC-dependent bacterial killing.
III. Quinolones exhibit extensive anaerobic activity.
19.
A. I only
B. II only
C. III only
D. I and III
E. II and III

Which of the following best describe the important patient counseling points for the
quinolones?
I. Avoid use in children and pregnant or nursing women because of the risk of cartilage erosion
in growing bone tissue.
II. Do not take within 2 hours of taking antacids, multivitamins, calcium, magnesium, or iron
supplements.
20. III. Take with a full glass of water and remain sitting or upright for 2 hours to avoid esophageal
irritation.
A. I only
B. II only
C. III only
D. I and II
E. II and III

Which of the following best describe the sulfonamides?
I. Drugs that interfere with vitamin B12 synthesis by competitively inhibiting PABA utilization
II. Drugs of choice for Clostridium difficile colitis
III. Primarily urinary anti-infectives whose usefulness has decreased because of the
development of resistance
21.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

Which of the following best describe the tetracyclines?
I. Tetracyclines exhibit bacteriostatic activity.

II. Tetracyclines are the drugs of choice for Lyme disease.
III. Tetracyclines are contraindicated in children under age 8.
22.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

Which of the following best describe the macrolides?
I. Primarily effective against Gram-positive aerobic bacteria

II. Effective against penicillin-resistant streptococci
III. Ineffective against penicillin-resistant streptococci
23.
A. I only
B. II only
C. III only
D. I and II
E. I and III

Which antitubercular agents exhibit the lowest incidence of resistance?
I. Isoniazid
II. Rifampin
III. Streptomycin
24.
A. I only
B. II only
C. III only
D. I and II
E. I, II, and III

Which of the following drug combination regimens are considered the agents of first choice for
empiric treatment of TB?
I. Isoniazid, rifampin, and streptomycin

II. Isoniazid, rifampin, and pyrazinamide
III. Isoniazid, ethambutol, and cycloserine
25.
A. I only
B. II only
C. III only
D. All of the above

30-16. Answers
E. Aminoglycoside antibiotics are bactericidal against most susceptible isolates, exhibit

1. concentration-dependent bacterial killing, and are usually reserved for serious infections due to
toxicity.

D. Ototoxicity is due to eighth cranial nerve damage and may be irreversible. Nephrotoxicity is
2. exhibited as an acute tubular necrosis that is usually reversible and seldom requires dialysis.
Neuromuscular blockade is the third most common toxicity noted with the aminoglycosides.

A. Aminoglycosides are active against most aerobic Gram-negative and selected aerobic Gram-
3.
positive bacteria. They have no activity against anaerobic bacteria or fungi.

D. Amphotericin B, caspofungin, fluconazole, itraconazole, and voriconazole are effective
4.
against systemic fungal infections.

E. Acute renal dysfunction is the most common dose-limiting amphotericin B toxicity, the
5. renal dysfunction is usually reversible and seldom requires dialysis, and lipid formulations
decrease toxicity by 20-30%.

B. The imidazole antifungals decrease hepatic clearance of numerous hepatically metabolized
6.
medications, thereby increasing their activity and risk for toxicity.

C. Linezolid is bacteriostatic against staphylococci and enterococci. It is bactericidal against
7.
Streptococcus species only. The agent is a weak MAO inhibitor.

D. Linezolid is active against MSSA, MRSA, and Enterococcus faecium (VRE). Enterococcus
8.
faecalis isolates are resistant.

E. Quinupristin-dalfopristin is active against MSSA, MRSA, streptococci, and VRE.
9.
Enterococcus faecalis isolates are commonly resistant.

E. Vancomycin is active against aerobic Gram-positive bacteria only; it has no clinically
10. significant Gram-negative activity. Vancomycin is the second-line drug of choice for
Clostridium difficile colitis.

C. Vancomycin nephrotoxicity is uncommon and is exhibited as acute tubular necrosis, which
is commonly reversible and seldom requires dialysis. Ototoxicity is due to eighth cranial nerve
11. damage, which manifests as high-frequency hearing loss, seldom affecting the vestibular
system. The histamine, or "red-man syndrome," reaction is most commonly related to the
infusion rate.

A. Vancomycin serum concentration monitoring is not required in patients responding well to
12. therapy and with normal renal function. Vancomycin trough concentrations should be assessed
in patients with preexisting or worsening renal function or those not responding to therapy.

D. Clindamycin exhibits activity against aerobic Gram-positive bacteria and anaerobic Gram-
13. positive and Gram-negative bacteria. It has no clinically significant aerobic Gram-negative
activity.

A. Carbapenems are active against most aerobic and anaerobic Gram-positive and Gram-
14. negative bacteria. Imipenem is more likely to induce seizures, and cilastatin inhibits the
metabolism of imipenem but has no antibacterial activity.

15. B. Penicillins exhibit time-dependent bacterial killing and have no activity against MRSA.

A. All penicillins—with the exception of nafcillin and oxacillin—require dosage adjustment in
16.
patients with renal dysfunction.

17. B. Cephalosporins exhibit time-dependent bacterial killing and have no activity against MRSA.

D. First-generation cephalosporins exhibit extensive Gram-positive activity but limited Gram-
negative activity. Second-generation cephalosporins maintain Gram-positive activity similar to
18. that of the first-generation agents, but their Gram-negative activity is generally improved.
Third-generation cephalosporins exhibit decreased Gram-positive activity, but Gram-negative
activity is significantly improved.

A. Quinolones exhibit concentration-dependent bacterial killing similar to that of the
19. aminoglycosides. They possess good aerobic Gram-positive and Gram-negative activity, but
have limited anaerobic activity.

D. Quinolones have been shown to decrease cartilage formation in beagle pups, but this effect
in humans is somewhat controversial. Their use in children should be reserved for serious
20.
infections to avoid the risk. Quinolones are bound to divalent cations and should not be
coadministered. They do not cause significant esophageal irritation.

C. Sulfonamides interfere with folic acid metabolism by inhibiting PABA utilization. They
21. have no activity against C. difficile colitis and are primarily relegated to urinary anti-infectives
because of resistance.

E. Tetracyclines are bacteriostatic. They are drugs of choice for Lyme disease, and they should
22. not be administered to children under age 8 to avoid permanent tooth staining and potential
deposition into bone.

D. Erythromycins are primarily Gram-positive aerobic antibiotics with good activity against
23.
most penicillin-resistant Streptococcus isolates.

E. Isoniazid, rifampin, and streptomycin exhibit the lowest incidence of Mycobacterium
24.
tuberculosis resistance.

B. Isoniazid, rifampin, and pyrazinamide are considered agents of first choice for empiric
treatment of tuberculosis (TB) because of a low incidence of resistance and acceptable
25.
tolerability profile. Ethambutol is commonly added to the regimen in areas of increased
resistance.

30-17. References
Alvarez-Elcoro S, Enzler MJ. The macrolides: Erythromycin, clarithromycin, and azithromycin.

Mayo Clin Proc. 1999;74:613-34.
Cappelletty D, Eiselstein-McKitrick K. The echinocandins. Pharmacotherapy. (2007) 27: 369-88.
Cunha BA, ed. Antibiotic Therapy, Part I. The Medical Clinics of North America. Philadelphia:
WB Saunders; 2000.
Cunha BA, ed. Antibiotic Therapy, Part II. The Medical Clinics of North America. Philadelphia:
WB Saunders; 2001.
Doribax (doripenem IV injection) [product information]. Raritan, N.J.: Ortho-McNeil; 2009.
Edson RS, Terrell CL. The aminoglycosides. Mayo Clin Proc. 1999;74:519-28.
Factive (gemifloxacin mesylate tablets) [product information]. Waltham, Mass.: Oscient

Pharmaceuticals; 2004.
Hardman JG, Limbird LE, Molinoff PB, et al., eds. Goodman and Gilman's The Pharmacological
Basis of Therapeutics. 9th ed. New York: McGraw-Hill; 1996.
Hellinger WC, Brewer NS. Carbapenems and monobactams: Imipenem, meropenem, and
aztreonam. Mayo Clin Proc. 1999;74:420-34.
Kasten MJ. Clindamycin, metronidazole, and chloramphenicol. Mayo Clin Proc. 1999;74: 825-34.
Kucers A, Bennett NM, eds. Use of Antibiotics: A Comprehensive Review with Clinical Emphasis.
4th ed. Philadelphia: Lippincott Williams & Wilkins; 1998.
Lentino JR, Narita M, Yu VL. New antimicrobial agents as therapy for resistant Gram-positive
cocci. Eur J Clin Microbiol Infect Dis. 2008;27: 3-15.
Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 5th ed.
Philadelphia: Churchill Livingstone; 2000.
Marshall WF, Blair JE. The cephalosporins. Mayo Clin Proc. 1999;74:187-95.
Noxafil (posaconazole) [prescribing information]. Kenilworth, N.J.: Schering; 2006.
Patel R. Antifungal agents: Part I—Amphotericin B preparations and flucytosine. Mayo Clin Proc.
1998;73:1205-25.
Pfaller MA, Boyken L, Hollis RJ, et al. In vitro susceptibility of invasive isolates of Candida spp. to
anidulafungin, caspofungin, and micafungin: Six years of global surveillance. J Clin Microbiol.
2008; 46(1): 150-56.
Reese RE, Betts RF, eds. A Practical Approach to Infectious Diseases. 4th ed. Boston: Little,
Brown; 1996.
Shain CS. Telithromycin: The first of the ketolides. Ann Pharmacother. 2002;36:452-64.
Smilack JD. The tetracyclines. Mayo Clin Proc. 1999;74:727-30.
Smilack, JD. Trimethoprim-sulfamethoxazole. Mayo Clin Proc. 1999;74:730-34.
Terrell CL. Antifungal agents: Part II—The azoles. Mayo Clin Proc. 1999;74:78-100.
Tygacil (tigecycline IV injection) [prescribing information]. Philadelphia: Wyeth Pharmaceuticals;

2009.
Van Scoy RE, Wilkowske CJ. Antimycobacterial therapy. Mayo Clin Proc. 1999;74:1038-48.
Walker RC. The fluoroquinolones. Mayo Clin Proc. 1999;74:1030-37.
Wilhelm MP. Vancomycin. Mayo Clin Proc. 1999; 74: 928-35.
Wright AJ. The penicillins. Mayo Clin Proc. 1999;74: 290-308.

31. Human Immunodeficiency Virus and the Acquired Immune Deficiency Syndrome -
31-1. Overview
Introduction
Human immunodeficiency virus (HIV) is a retrovirus that depletes the helper T-lymphocytes (CD4
cells), resulting in continued destruction of the immune system and subsequent gradual
development of opportunistic infections and malignancies.
Acquired immune deficiency syndrome (AIDS) is HIV with a CD4 count lower than 200 cells/mm3
or a history of opportunistic infection (e.g., unexplained fever for more than 2 weeks, thrush,
Pneumocystis jiroveci pneumonia, toxoplasmosis, cryptococcal meningitis, histoplasmosis,
Mycobacterium avium).
Epidemiology
At the end of 2007, global estimates of children and adults with HIV/AIDS were as follows:
• People living with HIV/AIDS: 33 million
• New HIV infections in 2007: 2.7 million
• Deaths attributable to HIV/AIDS in 2007: 2 million
• Cumulative number of deaths attributable to HIV/AIDS: 33 million
Complete current world epidemiology can be found at www.unaids.org.
At the end of 2006, estimates of children and adults with HIV/AIDS in the United States were as
follows:
• People living with HIV/AIDS: 850,000-950,000
• New HIV infections in 2006: 56,300
• Deaths attributable to HIV/AIDS in 2006: 19,454
• Cumulative number of deaths attributable to HIV/AIDS: 549,594
• People who do not know they are infected with HIV: 180,000-280,000
Complete current U.S. epidemiology can be found at

www.cdc.gov/hiv/topics/surveillance/resources/slides/epidemiology/index.htm.
HIV has two common subtypes:
• HIV-1: most commonly found in the United States
• HIV-2: most commonly found in Africa
• Patient has an opportunistic infection.
• Patient is not ill but has tested positive for HIV.
• Patient has acute retroviral syndrome:
• 50% to 90% of patients acutely infected with HIV experience some of the symptoms.
• Symptoms generally appear 2-4 weeks after virus exposure.
• Duration of the clinical syndrome is about 14 days (the range is a few days to > 10 weeks).
• The disease is not readily recognized in the primary care setting because its symptoms are
similar to those of the flu, mononucleosis, and other common illnesses.
Testing Recommendations
The U.S. Centers for Disease Control and Prevention recommend the following HIV testing in
health care settings:
• Routine, voluntary, opt-out HIV screening for all persons 13-64 years of age in health care
settings. Testing is not based on risk factors.
• HIV screening of pregnant women as part of the routine panel of prenatal screening tests. Testing
is not based on risk factors.
• Repeat HIV screening of persons with known risk at least annually:
• Injection drug users and their sex partners
• Persons who exchange sex for money or drugs
• Sex partners of HIV-infected persons
• Men who have sex with men

• Heterosexual persons who themselves or whose sex partners have had more than one sex
partner since their most recent HIV test
Pathophysiology
HIV is a retrovirus that replicates in and destroys CD4 cells. The result is a chronically deteriorating
immune system leading to opportunistic infections and eventual death. Seroconversion typically
occurs about 3 weeks after the acute infection (the range is from 2 weeks to 6 months). Antibodies
generally appear within 3 months of infection (the range is from 2 weeks to 6 months).
Transmission is through infected blood or hazardous body fluids, which can occur during the
following activities:
• Unprotected sexual contact with an infected person
• Multiple partners increase risk.
• Ongoing or past medical history of sexually transmitted disease increases risk.
• Sharing needles or syringes with an infected person
• Transfusions of infected blood or blood clotting factors (the United States began screening the
blood supply in 1985)
• Vertical transmission (infected mother to infant)
• Breast-feeding
Occupational exposure and household contact are rare.
Diagnostic Criteria
Enzyme-linked immunosorbent assay
Enzyme-linked immunosorbent assay (ELISA) is the initial screening test for detection of anti-HIV
antibodies. False-positive results can occur in patients with
• Collagen vascular diseases
• Chronic hepatitis
• Other chronic diseases
Western blot
All positive ELISA tests must be confirmed by a Western blot. Specificity and sensitivity of the
Western blot is > 99%. The Western blot tests for anti-HIV antibodies.
Other tests
Other diagnostic tests are available. All should be confirmed by a Western blot.
Rapid diagnostic tests can give results from a finger stick or swab of oral fluid in 5-20 minutes.
Monitoring Tools
Viral load
Viral load testing measures the amount of virus in blood. It can assess disease progression and
evaluate efficacy of antiretroviral therapy. Its lower limit of detection is less than 50 copies/mL for
ultrasensitive assays (less than 400 copies/mL for nonultrasensitive assays). A minimally significant
change in viral load is considered to be a threefold or 0.5log10 increase or decrease.
Acute illness and immunizations can cause increases in viral load for 2-4 weeks. Testing should not
be performed during this time.
Baseline viral loads are established by averaging two viral loads (that do not differ by > 0.5log10)
taken 2-4 weeks apart.
Monitoring of viral load in patients not on antiretroviral therapy should occur every 3-4 months.
Monitoring of viral load in patients starting a new regimen should occur 2-8 weeks after treatment
initiation and then every 3-4 months.
CD4 cell count
CD4 cell count indicates the extent of immune system damage and the risk of developing
opportunistic infections. Normal CD4+ cell counts are 800-1,200 cell/mm3.
CD4+ cell counts should be measured every 3-4 months in patients on or off antiretroviral therapy.
A 30% increase or decrease in CD4+ cells from baseline is considered significant.
Goals of therapy
Therapy has the following goals:
• Maximal and durable suppression of viral load

• Restoration or preservation of immunologic function
• Improvement in quality of life
• Reduction of HIV-related morbidity and mortality
Factors involved in achieving goals of therapy are as follows:
• Adherence to the antiretroviral regimen
• Rational sequencing of drugs
• Preservation of future treatment options
• Use of resistance testing in selected clinical settings
See
Table 31-1 for indications for the initiation of antiretroviral therapy in the chronically HIV-1
infected patient.
Guidelines for prevention and treatment and medications used for the treatment of HIV can be
located as a living document at www.aidsinfo.nih.gov, which is updated three or four times a year.
Indications for Consideration of Changing Antiretroviral Therapy
Consider changing antiretroviral therapy (ART) with failure to suppress plasma HIV RNA
(ribonucleic acid) to undetectable levels (< 50 copies/mL) within 4-6 months of initiating a therapy.
Consider changing ART if virus is detected in plasma repeatedly following initial suppression to
undetectable levels.
[Table 31-1. Indications for the Initiation of Antiretroviral Therapy in the Chronically HIV-1
Infected Patient]
Consider genotyping or phenotyping to assist in identifying drugs for the next regimen if
• Adherent to failing regimen for at least the previous 4-6 weeks or within 4 weeks after regimen
discontinuation
• Viral load above 1,000 copies/mL
Consider changing ART if CD4+ T cell numbers persistently decline, as measured on at least two
separate occasions.
Consider changing ART if patient evidences clinical deterioration.

Never change just one medication in a failing regimen (i.e., use at least two new drugs, and
preferably an entirely new regimen).
Change one medication in a successful regimen if a patient is experiencing intolerable side effects
or if the medication has overlapping toxicity with other medications.
Use the treatment history and past and current resistance test results to identify active agents
(preferably two or more) to design a new regimen.
31-2. Drug Therapy
Introduction
See
Table 31-2 for antiretroviral agents recommended by the U.S. Department of Health and Human
Services for initial treatment of established HIV infection.
Nucleoside Reverse Transcriptase Inhibitors
Nucleoside reverse transcriptase inhibitors (NRTIs) are described in

Table 31-3. The mechanism of action of NRTIs is to interfere with HIV viral RNA-dependent DNA
(deoxyribonucleic acid) polymerase, resulting in chain termination and inhibition of viral
replication.
Didanosine, stavudine, and lamivudine are dosed on the basis of weight. Most NRTIs are not
affected by food (except didanosine). NRTIs have a low pill burden as a class and few drug
interactions. All are prodrugs requiring two or three phosphorylations for activation.
Four combination products are available:
• Combivir (zidovudine 300 mg + lamivudine 150 mg) every 12 hours
• Trizivir (zidovudine 300 mg + lamivudine 150 mg + abacavir 300 mg) every 12 hours
• Truvada (tenofovir 300 mg + emtricitabine 200 mg) every 24 hours
• Epzicom (lamivudine 300 mg + abacavir 600 mg) every 24 hours
[Table 31-2. Antiretroviral Regimens for Treatment of HIV Infection in Antiretroviral-Naive

Patients]
No special storage requirements are necessary for drugs in this class.
Usually, two NRTIs are used in combination with one non-nucleoside reverse transcriptase inhibitor
(NNRTI) or one protease inhibitor (PI).
Monitor for signs and symptoms of the following class toxicities:
• Lactic acidosis
• Severe hepatomegaly with steatosis
The following precautions should be kept in mind regarding NRTIs:
• Most patients should be dose-adjusted for renal impairment (exception: abacavir).
• Lamivudine and emtricitabine are chemically similar and should not be used in the same regimen.
• Do not use zidovudine with stavudine because of antagonism (both require thymidine for
activation).
• Do not use didanosine with stavudine during pregnancy because of increased risk of lactic acidosis
and liver damage.
• Tenofovir increases didanosine levels and decreases atazanavir levels. Dosage adjustments are
required.
• Patients should be tested for HLA-B*5701 to determine risk for hypersensitivity reaction to
abacavir. Only negative patients should start abacavir.
• The "D" drugs (ddI [didanosine] and d4T [stavudine]) can cause pancreatitis and peripheral
neuropathy; when used together, this effect can be additive.
• The "D" drugs are more closely associated with lactic acidosis.
Non-nucleoside Reverse Transcriptase Inhibitors
NNRTIs are described in

Table 31-4. Their mechanism of action is to competitively inhibit reverse transcriptase, thereby
resulting in inhibition of HIV replication.
One-step mutation (K103N) confers resistance to all NNRTIs but etravirine. All should be dose-
adjusted for hepatic impairment.
Most are not affected by food (except efavirenz). Efavirenz is contraindicated in pregnancy.
Usually, one NNRTI should be used in combination with two NRTIs.
No special storage requirements are necessary for drugs in this class. Class toxicities include rash
and hepatic toxicity.
Drug interactions can occur (see

Tables 31-5 and
31-6). All are cytochrome P450 (CYP450)-3A4 inducers or inhibitors.
[Table 31-3. Nucleoside Reverse Transcriptase Inhibitors]
[Table 31-4. Non-nucleoside Reverse Transcriptase Inhibitors]
[Table 31-5. Drugs That Should Not Be Used with NNRTIs]
[Table 31-6. Drug Interactions with NNRTIs Requiring Dose Modifications or Cautious Use]
Protease Inhibitors
Protease inhibitors (PIs) are described in

Table 31-7.
Their mechanism of action is to inhibit protease, which then prevents the cleavage of HIV
polyproteins and subsequently induces the formation of immature noninfectious viral particles.
All should be dose-adjusted for hepatic impairment. Most should be taken with food (except
fosamprenavir, tipranavir, lopinavir-ritonavir tablets, and indinavir). Atazanavir and indinavir
require normal acid levels in the stomach for absorption.
Ritonavir is the most potent inhibitor in the class and is primarily used for intensification of other
PIs. Ritonavir and tipranavir should be refrigerated.
Goals of intensification are as follows:
• Decrease pill burden
• Decrease frequency of doses (i.e., decrease from q8h to q12h)
• Increase drug levels, resulting in decreased resistance
[Table 31-7. Protease Inhibitors]
Class toxicities are as follows:
• Fat maldistribution
• Hyperglycemia
• Hyperlipidemia
• Hypertriglyceridemia
• Possible increased bleeding episodes in patients with hemophilia
Baseline PI monitoring is done 4-6 weeks after starting the PI. Monitoring should then take place
every 3-6 months thereafter. The following tests are required:
• Glucose test
• Liver function tests (LFTs)
• Total cholesterol panel (particularly triglycerides)
• Signs and symptoms of gastrointestinal (GI) side effects
• Signs and symptoms of fat redistribution
Usually, one PI (boosted PIs preferred) is used in combination with two NRTIs.
All are CYP450-3A4 inhibitors, and drug interactions are typical of CYP450-3A4 inhibitors. See
Tables 31-8 and
31-9 for more information about drug interactions.
Entry inhibitors
Entry inhibitors include enfuvirtide (T20) and maraviroc. Enfuvirtide is a fusion inhibitor, whereas
maraviroc is a CCR5 (chemokine [C-C motif] receptor 5) antagonist. See
Table 31-10 for information.
Enfuvirtide (T20) (Fuzeon)

Enfuvirtide's mechanism of action is to bind to glycoprotein 41 on the HIV surface, thus inhibiting
HIV binding to the CD4 cell.
The dose is 90 mg subcutaneous every 12 hours. Side effects include injection-site reactions, an
increased rate of bacterial pneumonia, and hypersensitivity.
Enfuvirtide is generally reserved for deep salvage regimens. Preferably, it should be used with at
least two other active drugs. Resistance develops quickly with less potent regimens and in cases of
poor adherence.
No known significant drug interactions have been seen to date. Enfuvirtide can be taken without
regard to meals. It should be stored at room temperature; the reconstituted form should be stored in
the refrigerator, where it will be stable for 24 hours.
Maraviroc (Selzentry)
Maraviroc's mechanism of action is to bind to CCR5 receptors on the CD4 cell surface, which
inhibits HIV binding and entry into the CD4 cell.
Perform Trofile testing before using maraviroc to determine patient's tropism. The patient must be
CCR5 tropic only.
Maraviroc is a CYP450-3A4 substrate. The dose depends on drug reactions:
• Use 150 mg po every 12 hours when giving maraviroc with strong CYP3A4 inhibitors (most PIs).
• Use 300 mg po every 12 hours when giving maraviroc with enfuvirtide, tipranavir-ritonavir,
nevirapine, or weak CYP3A4 inhibitors.
• Use 600 mg po every 12 hours when giving with CYP3A4 inducers (efavirenz, rifampin, etc.).
Side effects include abdominal pain, cough, dizziness, musculoskeletal symptoms, pyrexia, rash,
upper respiratory tract infections, hepatotoxicity, and orthostatic hypotension.
Preferably, use maraviroc with at least two other active drugs. Take it without regard to meals.
Integrase inhibitors
Integrase inhibitors include raltegravir, which is marketed under the trade name Isentress (Table 31-
10). Its mechanism of action is to block activity of the integrase enzyme, thereby preventing HIV
DNA from meshing with the CD4 cell DNA. Metabolism is through UDP-glucuronosyltransferase
1A1 (UGT1A1) mediated glucuronidation
Drug interactions occur with rifampin and other drugs that effect UGT1A1. The dose is 400 mg po
every 12 hours. Side effects include nausea, headache, diarrhea, pyrexia, creatinine phosphokinase
(CPK) elevation. Preferably, raltegravir should be used with at least two other active drugs. Take it
without regard to meals.
Potential Benefits of Early Therapy
• Maintenance of a higher CD4 count and prevention of potentially irreversible damage to the
immune system
• Decreased risk for HIV-associated complications that can sometimes occur at CD4 counts greater
than 350 cells/mm3, including tuberculosis, non-Hodgkin's lymphoma, Kaposi's sarcoma,
peripheral neuropathy, human papillomavirus-
[Table 31-8. Drugs That Should Not Be Used with PIs]

[Table 31-9. Drug Interactions with PIs Requiring Dose Modifications or Cautious Use]
associated malignancies, and HIV-associated cognitive impairment
• Decreased risk of nonopportunistic conditions, including cardiovascular disease, renal disease,

liver disease, and malignancies and infections that are not associated with AIDS
• Decreased risk of HIV transmission to others, which will have positive public health implications
Potential Risks of Early Therapy
• Development of treatment-related side effects and toxicities
• Development of drug resistance because of incomplete viral suppression, resulting in loss of

future treatment options
• Less time for the patient to learn about HIV and its treatment and less time to prepare for the need
for adherence to therapy
• Increased total time on medication, with greater chance of treatment fatigue
• Premature use of therapy before the development of more effective, less toxic, or better-studied
combinations of antiretroviral drugs
• Transmission of drug-resistant virus in patients who do not maintain full virologic suppression
Counseling
All patients should be counseled on the importance of adherence. Greater than 95% adherence is
necessary to decrease the incidence of resistance. Patients should be given tools to facilitate
adherence to complicated regimens (e.g., pillboxes, calendars, pagers, etc).
Patients should be counseled on class side effects, especially any that are unique or potentially
serious.
Antiretroviral Therapy in the HIV-Infected Pregnant Woman
Highly active antiretroviral therapy (HAART) should be offered if the patient is not already
receiving treatment:
• Avoid efavirenz.
• Avoid combining stavudine and didanosine.
• Consider starting treatment after the first trimester.

Continue current combination regimens (preferably with zidovudine) if the patient is already
receiving therapy. Doing so decreases the risk of transmission from 30.0% to 2.5%.
Zidovudine alone can decrease risk of transmission when taken during pregnancy. The mother
should also receive IV zidovudine during labor. The infant should receive 6 weeks of zidovudine (
Table 31-11).
Single-dose nevirapine given at onset of labor in women who have had no prior ART and given
once to the infant between 48 and 72 hours of age has been shown to decrease the transmission rate.
This treatment can also result in resistance to nevirapine, which negatively affects future treatment
options for the mother.
Guidelines for prevention of vertical transmission can be located as a living document at

www.aidsinfo.nih.gov, which is updated three or four times a year.
[Table 31-10. Integrase and Entry Inhibitors]
Postexposure Prophylaxis
General guidelines
Universal precautions should be taken. The most common infectious exposure is needlesticks or
cuts (1 in 300 risk). The risk with mucous membrane exposure is much lower (1 in 1,000 risk).
Postexposure prophylaxis (PEP) can reduce HIV infection by about 80%. Start therapy within 1-2
hours of exposure. The length of therapy is 4 weeks.
Guidelines for PEP can be located as a living document at www.aidsinfo.nih.gov, which is updated
three or four times a year. See also
Tables 31-12 and
31-13.
Nonoccupational PEP
Patients with exposure to HIV from a known positive source, such as sexual exposure or injection
drug use, should receive nonoccupational PEP (nPEP) within 72 hours of the exposure. The length
of therapy is 28 days.
Figure 31-1 provides an algorithm for evaluation and treatment when nonoccupational exposure
occurs.
Table 31-14 describes nPEP antiretroviral regimens.
[Table 31-11. AIDS Clinical Trials Group 076 Guidelines: Dosing of Zidovudine for Prevention of
Vertical Transmission]
Opportunistic Infections
Only two opportunistic infections require primary prophylaxis:
• Pneumocystis jiroveci pneumonia (PCP): Treatment is required when CD4+ cells fall below
200/mm3. The treatment of choice is trimethoprim-sulfamethoxazole (TMP-SMX) DS po qd (see
Table 31-15 for alternatives).
• Mycobacterium avium complex bacteremia (MAC): Treatment is required when CD4+ cells
fall below 50/mm3. Azithromycin 1,200 mg po every week is the treatment of choice.
All other primary prophylaxis occurs only if the patient is antigen-positive or at high risk of
exposure to the causative factor. All other opportunistic infections are treated when the patient is
diagnosed. After treatment, patients receive suppressive therapy.
Some primary and secondary prophylaxis could possibly be discontinued with immune
reconstitution (undetectable viral load and an increase in CD4 cells in response to ART; see Table
31-15).
Immune reconstitution inflammatory syndrome in response to existing or indolent opportunistic

infections can sometimes occur when ART is started.
Guidelines for prophylaxis and treatment of opportunistic infections can be located as a living
document at www.aidsinfo.nih.gov.
31-3. Prevention Guidelines
• Abstain from sex with an infected person.
• Ask about the sexual history of current and future sex partners.
• Reduce the number of sex partners to minimize the risk of HIV infection.
• Always use a latex condom from start to finish during any type of sex (vaginal, anal, or oral).
• Use only water-based lubricants.
• Avoid alcohol, illicit drugs, and sharing of needles (or syringes, cookers, or other drug
paraphernalia).
• Do not share personal items such as toothbrushes, razors, or any devices used during sex. Such
items may be contaminated by blood, semen, or vaginal secretions.
• Do not donate blood, plasma, sperm, body organs, or tissues if you are infected with HIV or have
engaged in sex or needle-sharing behaviors that are risk factors for infection with HIV.
31-4. Hematologic Complications
Anemia can occur in HIV-infected patients. Causes include the following:
• HIV infection of marrow progenitor cells
• Drug-induced marrow suppression (zidovudine, ganciclovir, amphotericin, ribavirin,

pyrimethamine, interferon, TMP-SMX)
Treatment of anemia is described in

Figure 31-2.
31-5. Key Points
• HIV is a virus that destroys the immune system.
• AIDS is caused by HIV and is defined as a CD4+ cell count less than 200/mm3 or the presence of
an opportunistic infection.
• Acute retroviral syndrome occurs in 50-90% of patients within the first 2-4 weeks of infection
with HIV.
• The viral load indicates the amount of virus in the body and is an indication of how well
antiretroviral medications are working.
• The CD4+ cell count refers to the status of the immune system and how much a patient is at risk
for developing an opportunistic infection.
• NRTIs, NNRTIs, PIs, entry inhibitors (fusion inhibitors, CCR5 antagonists), and integrase
inhibitors are the currently available classes of medications used to treat HIV.
[Table 31-12. Recommended HIV PEP Treatment Options]
[Table 31-13. Regimens for PEP]
[Figure 31-1. Algorithm for Evaluation and Treatment of Nonoccupational Exposure]
[Table 31-14. nPEP Antiretroviral Regimens]
[Table 31-15. Opportunistic Infections]
[Figure 31-2. Guidelines for the Treatment of Anemia in the HIV Patient]
• Vertical transmission is prevented by treating the mother with HAART (preferred) or zidovudine
alone.
• Pneumocystis jiroveci pneumonia requires primary prophylaxis at CD4+ cell counts < 200/mm3.
TMP-SMX is the preferred treatment.
• Mycobacterium avium complex requires primary prophylaxis at CD4+ cell counts < 50/mm3.
Azithromycin is the preferred drug.
• All other opportunistic infections require treatment followed by secondary prophylaxis.
31-6. Questions
Use the following case study to answer questions 1-4:
C. T. is a 23-year-old HIV-positive female who presents to the emergency department with

shortness of breath and a fever. Physical exam reveals a temperature of 102°F, heart rate of 100
bpm, and decreased breath sounds in the left lower lobe of lungs. Chest x-ray is positive for
infiltrates in the left lung. She is diagnosed with PCP. She has no previous history of opportunistic
infections and is not on any medications at this time (she has not been seen by a health care
provider in over a year). Her CD4+ count is 13 cells/mm3 and viral load is 170,198 copies/mL.
What is the treatment of choice for C. T.'s PCP?
A. TMP-SMX DS 2 tabs po q8h for 21 days, then 1 tab po daily

1. B. Azithromycin 500 mg po on day 1, then 250 mg po daily indefinitely
C. Doxycycline 100 mg po twice daily for 7 days, then 100 mg po daily
D. Clarithromycin 500 mg po twice daily for 10 days, then 250 mg po daily
E. Vancomycin 1 g IV q12h for 10 days, then TMP-SMX DS po daily

Should C. T. receive any other prophylaxis against opportunistic infections?
A. Yes, against MAC: Zithromax 1,200 mg po weekly

2. B. Yes, against thrush: Diflucan 100 mg po daily
C. Yes, against toxoplasmosis: Bactrim DS 1 tab po every Monday, Wednesday, and Friday
D. Yes, against CMV: Valcyte 450 mg po every Monday, Wednesday, and Friday
E. No

Six weeks later C. T. presents to the HIV clinic for follow-up. Her CD4+ count is 12 cells/mm3
and viral load is 140,202 copies/mL. Should C. T. be started on HIV therapy?
A. Yes; her CD4+ cell count is < 200 cells/mm3 and she has had an opportunistic infection.
3.
B. Yes; her viral load is greater than 100,000 copies/mL.
C. Yes; her Western blot was positive for HIV.
D. Yes; all patients with HIV should be treated as soon as the diagnosis is made.
E. No.

C. T. wishes to be started on HIV therapy. Which of the following would be an appropriate
regimen?
A. Zidovudine + efavirenz + nelfinavir

4.
B. Zidovudine + stavudine + indinavir
C. Stavudine + didanosine + fosamprenavir
D. Tenofovir + emtricitabine + atazanavirritonavir
E. Nelfinavir + indinavir + fosamprenavir

HIV can be transmitted by
A. unprotected sexual contact with an infected person.

5. B. sharing needles or syringes with an infected person.
C. infected mother to infant (vertical transmission).
D. transfusion of blood (before 1985).
E. all of the above.

M. J. is 13 weeks pregnant and just tested positive for HIV. Her viral load is 22,434 copies/mL
and her CD4+ cell count is 425 cells/mm3. M. J. wishes to receive treatment for her HIV.
Which of the following would be an appropriate regimen for M. J.?
6. A. Zidovudine + stavudine + indinavir

B. Zidovudine + lamivudine + lopinavir-ritonavir
C. Zidovudine + lamivudine + efavirenz
D. Stavudine + didanosine + nevirapine
E. No treatment is necessary.

Which of the following antiretroviral medications has shown efficacy as monotherapy in
decreasing the vertical transmission of HIV?
A. Efavirenz
7.
B. Nelfinavir
C. Zidovudine
D. Zalcitabine
E. Stavudine

R. C. is a nurse in the emergency department. She has just been stuck with a needle that was
used for an HIV-positive patient with a known high viral load. Which of the following is true
concerning postexposure prophylaxis?
I. The regimen should be started within 2 hours of exposure.

II. R. C. will need to be treated only with zidovudine.
III. R. C. will need to be treated with a combination of zidovudine + lamivudine + nelfinavir.
8.
IV. Treatment will continue for 4 weeks.
A. I, III, and IV
B. II only
C. II, III, and IV
D. I and IV
E. I, II, and IV

The CD4+ cell count relates to
I. the activity of the virus.

II. the status of the immune system.
III. how much a patient is at risk for acquiring an opportunistic infection.
IV. when the patient was infected.
9. V. time to death in treated patients.
A. IV and V
B. I, II, and III
C. II and III
D. II, III, and IV
E. I, II, and V

The viral load relates to
A. the activity of the virus and efficacy of antiretroviral therapy.

10. B. the status of the immune system.
C. when the patient was infected.
D. how much a patient is at risk for acquiring an opportunistic infection.
E. time to death in a treated patient.

S. J. presents to the emergency department with extreme flank pain with nausea and vomiting.
He is diagnosed with a kidney stone. His past medical history is positive for HIV and diabetes.
His medications include indinavir, lamivudine, didanosine, metformin, and dapsone. Which of
his medications might have caused his kidney stone?
11.
A. Indinavir
B. Lamivudine
C. Didanosine
D. Metformin
E. Dapsone

L. L. comes to the clinic with a chief complaint of burning and tingling in his feet that started
about 1 month ago. His current medications include nelfinavir, stavudine, lamivudine,
sertraline, and gemfibrozil. Which medication might be causing this problem?
12. A. Nelfinavir
B. Stavudine
C. Lamivudine
D. Sertraline
E. Gemfibrozil

S. E. presents to the emergency department with a 2-day history of extreme nausea, vomiting,
and abdominal pain. Labs reveal elevations in amylase and lipase, and a diagnosis of
pancreatitis is made. His medications include nevirapine, tenofovir, didanosine, and
amitriptyline. Which of his medications could have caused his pancreatitis?
13.
A. Nevirapine
B. Tenofovir
C. Didanosine
D. Amitriptyline
E. All of the above

Which HIV medication should not be used until HLA-B*5701 testing has been performed to
assess risk for hypersensitivity?
A. Efavirenz
14.
B. Ritonavir
C. Zidovudine
D. Abacavir
E. Lamivudine

C. J. is starting efavirenz, tenofovir, lamivudine, and TMP-SMX. What should C. J. be
counseled about concerning efavirenz?
A. Anemia
15.
B. CNS side effects
C. Neutropenia
D. Renal toxicity
E. Kidney stones

Which of the following can cause hepatotoxicity and requires monitoring of liver enzymes at
baseline, 2 weeks, 4 weeks, 6 weeks, and then monthly for the first 18 weeks of therapy?
A. Zidovudine
16.
16.
B. Zalcitabine
C. Lopinavir-ritonavir
D. Fosamprenavir
E. Nevirapine

Which of the following can cause hyperglycemia, hyperlipidemia (particularly elevations in
triglycerides), and lipodystrophy?
A. Lopinavir-ritonavir
17.
B. Delavirdine
C. Didanosine
D. Abacavir
E. Lamivudine

Lactic acidosis and hepatic steatosis have been reported with which of these antiretroviral
medications?
A. Nevirapine
18.
B. Efavirenz
C. Stavudine
D. Saquinavir
E. Nelfinavir

The mechanism of action of nucleoside reverse transcriptase inhibitors is to
A. directly inhibit reverse transcriptase.

19. B. prevent entry of the proviral DNA into the nucleus of the CD4+ cell.
C. cause chain termination, resulting in a defective copy of proviral DNA.
D. prevent entry of HIV into the CD4+ cell.
E. prevent cleavage of the newly formed polypeptide chains into a viable HIV.

The mechanism of action of non-nucleoside reverse transcriptase inhibitors is to
A. prevent cleavage of the newly formed polypeptide chains into viable HIV.
20. B. prevent entry of HIV into the CD4+ cell.
C. prevent entry of the proviral DNA into the nucleus of the CD4+ cell.
D. directly inhibit reverse transcriptase.
E. cause chain termination, resulting in a defective copy of proviral DNA.

The mechanism of action of protease inhibitors is to
A. cause a defective copy of proviral DNA to be made.

21. B. prevent entry of the proviral DNA into the nucleus of the CD4+ cell.
C. prevent cleavage of the newly formed polypeptide chains into a viable HIV.
D. prevent entry of HIV into the CD4+ cell.
E. directly inhibit reverse transcriptase.

Which of the following medications if used with atazanavir can result in decreased levels and
effectiveness of atazanavir?
A. Loratadine
22.
B. Tenofovir
C. Esomeprazole
D. Metoclopramide
E. Glipizide

Which of the following opportunistic infections are the only ones requiring primary
prophylaxis?
A. PCP and MAC

23.
B. PCP and toxoplasmosis
C. MAC and histoplasmosis
D. MAC and CMV
E. PCP and thrush

The antifungal of first choice for maintenance therapy after treatment of cryptococcal
meningitis is
A. itraconazole.
24.
B. fluconazole.
C. ketoconazole.
D. amphotericin B.
E. terbinafine.

The first-choice antifungal for treatment of histoplasmosis is
A. itraconazole.
25. B. fluconazole.
C. ketoconazole.
D. caspofungin.
E. terbinafine.

31-7. Answers
A. The treatment of choice for PCP is TMP-SMX in patients who are not allergic to sulfa
medications. Duration of treatment is 21 days. Because this patient's CD4+ cell count is below
1.
200 cells/mm3 and she has had PCP, she will require secondary prophylaxis once treatment is
completed. Preferred prophylaxis is once-daily TMP-SMX DS.

A. This patient's CD4+ cell count is below 50 cells/mm3; therefore, she requires primary
2. prophylaxis against MAC. Zithromax is the drug of choice. Prophylaxis against other
opportunistic infections is generally not required.

A. Current guidelines state that any patient who has had an opportunistic infection or a CD4+
3.
cell count less than 200 cells/mm3 should start treatment for HIV. This patient has had both.

D. Most regimens contain two NRTIs and either one PI or one NNRTI. A includes one NRTI,
one NNRTI, and one PI. E includes three PIs. Zidovudine and stavudine competitively inhibit
4.
each other and would not be used in the same regimen (thus, B is incorrect). Didanosine and
stavudine should not be used together because of increased toxicity (which makes C incorrect).

E. All items are important risk factors for transmission of HIV. Breast-feeding, history of
5. sexually transmitted diseases, occupational exposure to HIV-infected fluids (rare), and
household exposure to HIV-infected fluids (rare) are also risk factors.

B. All HIV-positive pregnant women should receive treatment for HIV to decrease the risk of
transmission to their offspring. Zidovudine and stavudine competitively inhibit each other and
6. should not be used together. Efavirenz is teratogenic and should not be used in pregnancy.
Stavudine and didanosine together are contraindicated in pregnancy because of increased risk
of lactic acidosis and liver damage.

C. Zidovudine and nevirapine are the only HIV medications that can reduce vertical
transmission when used as monotherapy. Most practitioners treat with combination therapy
7.
because of the increased risk of resistance with monotherapy, which affects future choices of
drug regimen.

A. The approved regimens for postexposure prophylaxis are similar to those for treatment of
8.
HIV. Treatment should continue for 4 weeks and should start within 2 hours of exposure.

C. CD4+ cell count describes the status of the immune system (i.e., how much a patient is at
9.
risk for acquiring an opportunistic infection).

A. Viral load relates to the activity of the virus and efficacy of antiretroviral therapy. The goal
10.
of therapy is an undetectable viral load (< 50 copies/mL).

A. Indinavir can cause kidney stones. Patients should drink at least 48 oz of water a day to
11.
decrease the risk of developing a kidney stone.

B. The "D" drugs, d4T (stavudine) and ddI (didanosine), can cause peripheral neuropathy and
12.
pancreatitis.

C. The "D" drugs, d4T (stavudine) and ddI (didanosine), can cause peripheral neuropathy and
13.
pancreatitis.

D. HLAB5701 testing should be performed prior to use of abacavir to assess risk of
14.
hypersensitivity.

B. Efavirenz can cause central nervous system (CNS) side effects such as dizziness, trouble
15. sleeping, drowsiness, trouble concentrating, and unusual dreams during the first 2-4 weeks of
treatment.

E. All NNRTIs can cause hepatotoxicity. There have been rare reports of hepatotoxicity after
16. just one dose of nevirapine. Liver enzymes should be monitored at baseline, 2 weeks, 4 weeks,
6 weeks, and monthly for the first 18 weeks of therapy.

A. Class side effects of PIs include hyperglycemia, hyperlipidemia, fat maldistribution, and
17.
increased bleeding in hemophiliacs.

18. C. Class side effects of NRTIs include lactic acidosis and hepatic steatosis.

C. NRTIs affect reverse transcriptase by causing chain termination, resulting in a defective
19.
copy of proviral DNA.

D. NNRTIs affect reverse transcriptase by directly inhibiting reverse transcriptase, resulting in
20.
less proviral DNA being made.

C. PIs prevent cleavage of the newly formed polypeptide chains into viable HIV, resulting in
21.
an immature virus that is unable to infect other CD4+ cells.

22. C. Atazanavir levels are decreased by proton pump inhibitors, H2 blockers, and antacids.

A. PCP requires primary prophylaxis when the CD4+ cell count falls below 200 cells/mm3.
23. The preferred medication is TMP-SMX. MAC requires primary prophylaxis when the CD4+
cell count falls below 50 cells/mm3. The preferred medication is azithromycin.

B. Generally, cryptococcal meningitis is initially treated with amphotericin B during the
24.
induction phase and then fluconazole for the consolidation phase and maintenance therapy.

A. Histoplasmosis is generally initially treated with amphotericin B or itraconazole for
25.
induction therapy and then itraconazole for maintenance therapy.

31-8. References
Bartlett JG, Gallant JE. 2003 Medical Management of HIV Infection. Baltimore: Johns Hopkins
University Press; 2008:357-60.
Carr A, Miller J, Law M, Cooper DA. A syndrome of lipoatrophy, lactic acidaemia, and liver
dysfunction associated with HIV nucleoside analog therapy: Contribution to protease inhibitor-
related lipodystrophy syndrome. AIDS. 2000; 14:F25-32.
Carr A, Samars K, Thorisdottir A, et al. Diagnosis, prediction, and natural course of HIV-1 protease
inhibitor associated lipodystrophy, hyperlipidaemia, and diabetes mellitus: A cohort study.
Lancet. 1999;353:2093-99.
Centers for Disease Control and Prevention. 1993 revised classification system for HIV infection
and expanded surveillance case definition for AIDS among adolescents and adults. MMWR.
1992;41:1-19.
Centers for Disease Control and Prevention, Perinatal HIV Guidelines Working Group. Public
Health Service Task Force recommendations for the use of antiretroviral drugs in pregnant
women infected with HIV-1 for maternal health and for reducing perinatal HIV-1 transmission in
the United States. MMWR. 1998;47:1-30.
Chaisson RE, Keruly JC, Moore RD. Association of initial CD4 cell count and viral load with
response to highly active antiretroviral therapy. JAMA. 2000;284:3128-9.
Chesney MA. Factors affecting adherence to antiretroviral therapy. Clin Infect Dis. 2000;30(suppl
2): S171-76.
Finzi D, Hermankova M, Pierson T, et al. Identification of a reservoir for HIV-1 in patients on

highly active antiretroviral therapy. Science. 1997; 278:1295-300.
Furret H, Egger M, Opravil M, et al. Discontinuation of primary prophylaxis against Pneumocystis

carinii pneumonia in HIV-1 infected adults treated with combination antiretroviral therapy: Swiss
HIV Cohort Study. N Engl J Med. 1999;340:1301-6.
Hoen B, Dumon B, Harzic M, et al. Highly active antiretroviral treatment initiated early in the
course of symptomatic primary HIV-1 infections: Results of the ANRS 053 trial. J Infect Dis.
1999;180: 1342-46.
Mellors JW, Munoz A, Giorgi JV, et al. Plasma viral load and CD4+ lymphocytes as prognostic
markers of HIV-1 infections. Ann Intern Med. 1997;126: 946-54.
National Institutes of Health. Report of the NIH panel to define principles of therapy of HIV
infection. MMWR. 1998;47(RR-5):1-41.
Sperling RS, Shapiro DE, Coombs RW, et al. Maternal viral load, zidovudine treatment, and the
risk of transmission of human immunodeficiency virus type 1 from mother to infant: Pediatric
AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med. 1996;335:1621-29.
U.S. Food and Drug Administration; Health Resources and Services Administration; National
Institutes of Health; National Center for HIV, STD, and TB Prevention; National Institute for
Occupational Safety and Health; and National Center for Infectious Disease. Notice to readers
update: Provisional Public Health Service recommendations for chemoprophylaxis after
occupational exposure to HIV. MMWR. 1996;45:468-80.
U.S. Public Health Service and Infectious Diseases Society of America. 1999 USPHS/IDSA
guidelines for the prevention of opportunistic infections in persons infected with human
immunodeficiency virus. MMWR. 1999;48(RR-10):1-67.
Vittinghoff E, Scheer S, O'Malley P, et al. Combination antiretroviral therapy and recent declines in
AIDS incidence and mortality. J Infect Dis. 1999;179: 717-20.
Yeni PG, Hammer SM, Hirsch MS, et al. Treatment for adult HIV infection: 2004
recommendations of the International AIDS Society-USA Panel. JAMA. 2004;292:250-65.
32. Immunization - Stephan L. Foster, PharmD
32-1. Introduction
Definitions
• Immunity: A naturally or artificially acquired state resulting in an individual being resistant or

relatively resistant to the occurrence or effects of a foreign substance. Immunity is the mechanism
the body develops for protection from infectious disease. It is usually very specific to a single
organism or to a group of closely related organisms.
• Antigen: A live or inactivated substance capable of evoking antibody production; antigens can be
a live organism, such as bacteria or virus, or an inactivated or killed organism or portion of an
organism. A live organism generally evokes the most effective immune response.
• Antibody: A protein evoked by an antigen that acts to eliminate that antigen.
Mechanisms for Acquiring Immunity
Active immunity
Active immunity is produced by an individual's own immune system. Immunity acquired in this
manner has a delayed onset and is usually permanent. Active immunity may be acquired by having
an active disease or by vaccination. B-lymphocytes (B cells) circulate in the blood and bone marrow
for many years. Reexposure to the antigen causes the cells to replicate and to produce antibody.
These cells are also called memory B cells.
Passive immunity
Passive immunity is produced by an animal or human and transferred to another. Immunity acquired
in this manner has a rapid onset and usually has a brief duration. An infant receives this type of
immunity from his or her mother. All types of blood products contain varying amounts of antibody.
Immune globulins and hyperimmune globulins are also used to induce passive immunity. One
source of passive immunity is antitoxins, which contain antibodies against a known toxin.
32-2. Vaccines
Introduction
Vaccination is the process of producing active immunity through the use of vaccines. The
immunological response is similar to natural infection, with a lower risk than that of the disease
itself.
Classification of Vaccines
Live, attenuated vaccines
Live vaccines are produced by modifying a virus or bacteria to produce immunity. These vaccines
usually do not produce disease, but they may. When disease occurs, it is usually much milder than
the natural disease. These vaccines must replicate to be effective. They require special handling,
such as protection from heat and light, to keep them alive. Circulating antibody from another source
may destroy the vaccine virus and cause vaccine failure.
The following live vaccines are available in the United States in 2009:
• Herpes zoster
• Influenza (live attenuated)
• Measles
• Mumps
• Rotavirus
• Rubella
• Typhoid oral
• Varicella
• Vaccinia (smallpox)
• Yellow fever
Inactivated vaccines
Inactivated vaccines are composed of all or a fraction of a virus or bacterium. These fractions
include subunits (subvirions), bacterial cell wall polysaccharides, conjugated (attached to a protein
carrier) bacteria cell wall polysaccharides, or inactivated toxins (toxoids). The bacteria or virus is
inactivated using heat, chemicals, or both. Inactivated vaccines are not alive and cannot replicate;
therefore, they are unable to induce disease. Inactivated antigens are not affected by circulating
antibody.
The following inactivated vaccines are available in the United States in 2009:
• Anthrax
• Diphtheria
• Haemophilus influenzae type B
• Hepatitis A
• Hepatitis B
• Human papillomavirus
• Influenza
• Japanese encephalitis
• Meningococcal A, C, Y, W-135 polysaccharide
• Meningococcal A, C, Y, W-135 conjugate
• Pertussis, acellular
• Pneumococcal polysaccharide
• Pneumococcal conjugate
• Polio
• Rabies
• Tetanus toxoid
• Typhoid injectable
Vaccination Schedules
Vaccination schedules are available for children, adolescents, and adults from the U.S. Centers for
Disease Control and Prevention (CDC). These schedules are updated yearly and can be found at
www.cdc.gov/vaccines/recs/schedules. The schedules indicate the best times to administer vaccines.
Additional catch-up schedules are available for children and adolescents who are behind in their
vaccinations.
The CDC schedules describe intervals between doses of the same vaccine in a series. The minimum
interval in a series for most vaccines is 4 weeks. Decreasing the interval may interfere with
antibody response and protection. Usually, the last dose in a series is separated from the previous
dose by 4-6 months.
Increasing the interval does not affect vaccine effectiveness. It is never necessary to restart a series
except for oral typhoid vaccine.
Administration of Multiple Vaccines
There are no contraindications to the simultaneous administration of any vaccines. Inactivated and
live vaccines may be given in any combination at the same time.
Live vaccines must be separated from the administration of antibodies, such as blood products and
immune globulins. Inactivated vaccines are not affected by circulating antibody.
If two live vaccines are not given at the same time, a 4-week minimal interval must be observed.
The same is not true for two inactivated vaccines or an inactivated plus a live vaccine.
Vaccine Adverse Reactions
Adverse reactions are any untoward side effects caused by a vaccine.
Local reactions are the most common type of adverse reaction. They include pain, swelling, and
redness at the site of injection. They usually occur within minutes to hours of the injection and are
usually mild and self-limiting. Occasionally, severe local reactions occur that are known as
hypersensitivity reactions.
Systemic adverse reactions include fever, malaise, myalgias, and headache. Systemic adverse
reactions are more common following live vaccines and are similar to a mild case of the disease.
Allergic reactions are reactions to the vaccine antigens or to some component of the vaccine.
Although rare, these reactions may be life threatening.
Another type of problem increasingly seen with vaccination is syncope; therefore, it is important to
monitor patients for at least 15 minutes following vaccination.
The Vaccine Adverse Events Reporting System is a surveillance system monitored by the CDC,
which should be notified within 30 days of an adverse event that requires medical attention.
Contraindications and Precautions
A contraindication is a condition that increases the risk of an adverse reaction or decreases the
effect of a vaccine.
A precaution is a condition that might increase the risk of an adverse event or decrease the effect of
a vaccine.
Contraindications include the following:
• An anaphylactic reaction to any previous dose of vaccine or to any of its components

• Pregnancy for live vaccines and selected inactivated vaccines
• Immunosuppression for live vaccines and selected inactivated vaccines
• Active, untreated tuberculosis for live vaccines
• In the case of the diphtheria, tetanus, and pertussis (DTaP or Tdap), encephalopathy that occurred
within 7 days of a previous DTaP or DTP vaccine
Precautions include the following:
• Acute moderate to severe illness
• Recent administration of antibody-containing blood products and live vaccines
• For the Tdap or DTaP vaccine, unstable or evolving neurological disorder
• For the measles, mumps, and rubella (MMR) vaccine, history of thrombocytopenia or
thrombocytopenic purpura
• High fever, shock, persistent crying, seizure caused by a previous dose of DTP, DTaP, or Tdap
• Guillain-Barre syndrome caused by a previous dose of DTP, TDaP, Tdap, or meningococcal

conjugate vaccine
Vaccine Management
• Maintain cold chain during shipping.
• Follow manufacturers' recommendation for shipping.
• Keep nonfrozen vaccines from freezing during transport.
• Refrigerate or freeze depending on vaccine immediately on arrival.
• Use proper refrigerators.
• Monitor temperatures daily.
• Do not store vaccines in refrigerator door.
• Store in the middle of the refrigerator.
• Keep a temperature log.

• Perform proper inventory management.
• Maintain inventory log.
• Rotate stock.
• Follow manufacturers' guidelines for shelf life.
• Check expiration dates.
• Designate a person to be responsible for vaccines.
• Train all staff members to recognize vaccine shipment arrivals.
• Follow manufacturers' directions for reconstitution.
32-3. Diseases and Vaccines
Pneumococcal Disease
There are 90 known serotypes of Gram-positive Streptococcal pneumonia bacteria with a

polysaccharide capsule. Serious primary diseases associated with Streptococcal pneumonia include
pneumonia, sepsis, and meningitis.
Rates of disease
Highest rates are seen in children less than 2 years of age. Other children at high risk include those
with asplenia, patients with HIV, American Indian and Alaskan Natives, African Americans, and
day care attendees. Patients over the age of 50 have fatality rates of 30-60%.
Pneumococcal disease is one of the leading causes of vaccine-preventable diseases, with 20,000-
40,000 cases of invasive disease every year. Pneumococcal bacteria are common respiratory tract
inhabitants, with estimated asymptomatic carriage rates varying from 5% to 70%. Transmission is
through direct person-to-person droplet contamination or autoinoculation by carriers.
Clinical features include abrupt onset, fever, otitis media, shaking chills, productive cough, pleuritic
chest pain, dyspnea, hypoxia, tachypnea, headaches, lethargy, vomiting, irritability, nuchal rigidity,
seizures, coma, and death.
Resistance to antibiotics is up to 40% in some areas of the United States.
23-valent polysaccharide vaccine (Pneumovax-23 by Merck)
The vaccine is effective against 88% of serotypes causing bacteremic disease; however, it is
ineffective in children less than 2 years old.
Indications
• Adults over the age of 65
• Everyone over 2 years of age with chronic disease
• Smokers 19-64 years of age
Dose
The dosage is 0.5 mL intramuscular (IM) or subcutaneous (SC).
Revaccination (two-dose maximum) is recommended in the following cases:
• Patients at high risk of disease if more than 5 years have passed since the previous dose
• Everyone 65 years and older who received an initial dose under the age of 65 and if more than 5
years have passed since the previous dose
Adverse reactions
Adverse reactions include pain, swelling, and redness at the injection site and slight to moderate
systemic reactions such as fever and myalgias.
7-valent conjugated polysaccharide vaccine (Prevnar by Wyeth)
The vaccine is effective against 86% of serotypes causing bacteremic disease, 83% of serotypes
against meningitis, and 65% of serotypes causing otitis media.
Indications
• All children less than 2 years of age
• Children 24-59 months of age with high-risk medical conditions
Dose
The usual dose is 0.5 mL IM at 2, 4, 6, and 12-15 months of age (see schedules for catch-up
recommendations).
Revaccination is not recommended, but high-risk children should receive 23-valent polysaccharide
vaccine after 2 years of age.
Adverse reactions
Adverse reactions include pain, swelling, and redness at the injection site, difficulty moving the
limb (rare), and slight to moderate systemic reactions such as fever and myalgias.
Influenza
Influenza is an RNA (ribonucleic acid) virus of the orthomyxovirus family.
Antigenic drift, which is frequent minor changes in the antigenic structure of the virus, can reach
epidemic proportions, but not every year. For this reason, yearly adjustments in vaccine
formulations are required. All three types (A, B, and C) can undergo drifts.
Antigenic shift, which is major changes in one or both of the major antigens in influenza A,
resulting in a different subtype, can cause major pandemics in all ages.
Influenza A
Subtypes are based on two surface antigens: hemagglutinin and neuraminidase. Six types of
hemagglutinin (H1, H2, H3, H5, H7, and H9) cause disease in humans and cause virus attachment
to cells. Two types of neuraminidase cause disease in humans (N1 and N2) and have a role in viral
release from cells.
Influenza A causes moderate to severe disease in all ages and can be transmitted in other animals.
Influenza B
Influenza B has no subgroups but has two distinct genetic lineages. It causes milder disease and
affects primarily children. It only affects humans.
Influenza C
Influenza C is rarely reported and many cases are subclinical.
Influenza disease
Major serious complications in all types include pneumonia, Reye's syndrome (progressive
neurological symptoms associated with aspirin use in children), myocarditis, worsening of chronic
bronchitis, and death.
Influenza is one of the leading causes of vaccine-preventable disease, with 20,000-40,000 deaths
during epidemics. Pandemics could result in the deaths of millions of people. Rates of disease are
highest in the elderly (> 65), children less than 2 years of age, and persons of any age with medical
conditions.
Influenza virus penetrates the respiratory epithelial cells and destroys the host. Virus is shed in
respiratory secretions for 5-10 days, and transmission is through direct person-to-person droplet
contamination or contact. The incubation period is approximately 2 days (range, 1-5 days).
Clinical features include abrupt onset, fever, myalgias, sore throat, nonproductive cough, and
headache.
Disease peaks between December and March in the Northern Hemisphere but may occur earlier or
later. Year-round cases may be seen in tropical climates.
Resistance to antivirals is increasing.
Inactive influenza vaccine (Fluvirin by Novartis, Fluzone by Sanofi Pasteur, Fluarix and
FluLavel by GlaxoSmithKline, Afluria by CSL)
All are inactivated, split-virus vaccines. They contain three vaccine components (two type A viruses
and one type B virus).
Vaccines are named according to the virus type/geographic origin/strain sequence number/year of
isolation (hemagglutinin neuraminidase for type A only): for example, A/Bisbane/10/2007(H3N2)
or B/Florida/4/2006.
Vaccines are effective in up to 90% of healthy adults, 50-60% of the elderly, and 30-40% of the
frail elderly.
Indications
• All children 6 months to 18 years of age
• Close contacts of children 0-59 months of age
• Adults 50 years of age or older
• Adults 19 years and older with certain chronic diseases
• Residents of nursing homes or long-term care facilities
• People who may infect others, including contacts of patients with diseases and health care workers
• Pregnant women in all trimesters or women who will become pregnant during the influenza
season
• Patients 6 months to 18 years of age on chronic aspirin therapy
• Patients with neurological or neuromuscular disorders
• Anyone who wishes to decrease the likelihood of influenza disease
Contraindications
Contraindications include severe allergic reactions to previous dose and egg allergy.
Adverse reactions
Adverse reactions include pain, swelling, and redness at the injection site and slight to moderate
systemic reactions such as fever, myalgias, chills, and malaise. Severe neurologic reactions are rare.
Dose
Normal doses are 6-35 months: 0.25 mL IM (repeat in 1 month if first time); 3-8 years: 0.5 mL
(repeat in 1 month if first time); > 8 years: 0.5 mL.
Fluvirin by Novartis is indicated for those e 4 years of age.
Fluarix by GlaxoSmithKline is indicated for those e 3 years of age. FluLaval by GlaxoSmithKline

and Afluria by CSL are indicated for those e 18 years of age.
Revaccination yearly is needed.
Intranasal live attenuated influenza vaccine (FluMist by MedImmune)
Intranasal live attenuated influenza vaccine (LAIV) is an attenuated, cold-adapted live influenza
vaccine. It has the same vaccine antigens as in inactivated influenza vaccine. Its efficacy is 86-93%.
LAIV must be kept refrigerated.
Indications
Indications are similar to those of inactivated vaccine unless contraindications exist:
• Healthy persons 2-49 years of age
• Contacts with high-risk patients, except the severely immunocompromised
Contraindications
With the following contraindications, use inactivated influenza vaccine:
• Children 2-4 years of age with a history of wheezing or asthma
• Persons with chronic medical diseases
• Close contacts of severely immunocompromised persons
• Pregnant women
• Children receiving aspirin therapy
• Persons with a history of Guillain-Barre syndrome

Dose
The dose is 0.1 mL sprayed in each nostril (0.2 mL total). Children age 2-8 who receive influenza
vaccine for the first time need two doses 6-8 weeks apart.
Adverse reactions
Adverse reactions are similar to those of the inactivated vaccine and include nasal congestion,
headache, and vomiting.
Tetanus
Exotoxin is produced by Clostridium tetani, a Gram-positive anaerobic rod that may develop a
highly resistant spore. These spores are widely spread in soil, animal intestines and feces, skin
surfaces, and infected plants.
The disease is characterized by generalized rigidity and convulsive spasms of skeletal muscles. It
usually involves muscles of the face (lockjaw) and neck. Spasms may last 3-4 weeks, and complete
recovery may take months.
The bacteria enter the body through contamination of a wound. Spores germinate in an anaerobic
environment. Toxins are released and transported through the body.
The incubation period is usually 8 days (range, 3-21 days).
Transmission risk factors include puncture wounds, surgery, burns, minor wounds, dental
infections, animal bites, injection drug use, and diabetes. Approximately 10% of cases are of
unknown cause. Tetanus is not contagious person to person.
Tetanus occurs in the United States at a rate of 0.02-0.05 per 100,000 persons per year. The case
fatality rate is approximately 10-20%.
Complications include laryngospasm, fractures, hypertension, nosocomial infections, pulmonary

embolism, aspiration, and death. Wound management recommendations may include tetanus
immune globulin (
Table 32-1).
Tetanus toxoid vaccine
Tetanus toxoid is usually combined with diphtheria toxoid and pertussis vaccine. Toxoid is
formaldehyde-inactivated toxin adsorbed to aluminum. The pediatric version of the vaccine is DT
or DTaP. The adult version is Td or Tdap.
Dose
• Pediatric dose: A 0.5 mL IM dose of DT or DTaP vaccine is given at 2, 4, 6, and 15-18 months
of age. A booster dose should be given at 4-6 years.
• Adolescent dose: A 0.5 mL dose of Tdap vaccine is given at 11-12 years.
• Adult dose: A 0.5 mL dose of Tdap vaccine is required if tetanus-containing vaccine is indicated.
• Revaccination: Every 10 years, revaccination with Td vaccine is required.
[Table 32-1. Guidelines for Tetanus Wound Management]
Adverse reactions
Adverse reactions include pain, swelling (nodule may form), and redness at the injection site;
systemic reactions are uncommon. An exaggerated (Arthus-type) reaction with extensive, painful
swelling from shoulder to elbow can occur at the injection site and is thought to be caused by too-
frequent injections.
Diphtheria
Toxin is produced by Corynebacterium diphtheriae, an aerobic Gram-positive bacterium. This

bacterium must be infected by a virus that carries a genetic code for toxin production.
The most common presentation of diphtheria is characterized by early, nonspecific upper

respiratory infection symptoms that develop into pharyngitis. Two to three days later, a bluish-white
membrane starts to form that can cover the entire soft palate. The membrane can turn dark if
bleeding occurs, and manipulation of the membrane can result in bleeding. Airway obstruction may
occur.
Other sites of infection may include the larynx or the skin.
Other complications may include myocarditis, neuritis with paralysis, respiratory failure, and death.
The overall case fatality rate is 5-10%.
Asymptomatic human carriers are the source of most infections. The incubation period is usually 2-
5 days (range, 1-10 days).
Treatment of acute disease is with antitoxin and antibiotics.
Diphtheria toxoid vaccine
Diphtheria toxoid vaccine is combined with tetanus toxoid and pertussis vaccine. A single-toxoid
antigen is not available. Toxoid is formaldehyde-inactivated toxin adsorbed to aluminum.
The pediatric version of the combination (DT or DTaP) contains three or four times as much
antigen as the adult version (Td or Tdap).
Dose
• Pediatric dose: A 0.5 mL IM dose of DT or DTaP vaccine is given at 2, 4, 6, and 15-18 months
of age. A booster dose should be given at 4-6 years.
• Adolescent dose: A 0.5 mL dose of Tdap is given at 11-12 years.
• Adult dose: A 0.5 mL dose of Tdap vaccine is required if tetanus-containing vaccine is indicated.
• Revaccination: Every 10 years, revaccination with Td vaccine is required.
Adverse reactions
frequent injections of the tetanus antigen component of the combination vaccines.
Pertussis
Pertussis, or whooping cough, is caused by Bordetella pertussis, an aerobic, Gram-negative rod.

The bacteria produce multiple antigenic products, which are responsible for the clinical disease.
The bacteria produce toxin that paralyzes the respiratory cilia and causes inflammation of the
respiratory tract.
The presentation of pertussis is in three stages. The first stage is a catarrhal stage with nonspecific
upper respiratory infection symptoms. After 1-2 weeks, the paroxysmal stage with the characteristic
cough and inspiratory whoop begins and lasts up to 6 weeks. Recovery, the third stage, is gradual,
and the cough usually resolves in 2-3 weeks. The presentation in older children and adults may be
much milder. They may present with a persistent mild cough that lasts up to 7 days. The illness may
appear to be similar to other upper respiratory infections.
Complications may include pneumonia, encephalopathy, seizures, and death. The overall case
fatality rate is 0.2%.
Asymptomatic human carriers are the source of most infections. The incubation period is usually 7-
10 days (range, 4-21 days). Treatment of acute disease includes supportive care, antibiotics, and
prophylaxis of contacts.
Transmission is human to human by the respiratory route. Pertussis is highly contagious, with
attack rates of 80% in susceptible contacts.
Pertussis vaccine
Pertussis vaccine is combined with tetanus toxoid and diphtheria toxoid for children. A single-
toxoid antigen is not available. A whole-cell vaccine was developed in the 1930s but is no longer
available in the United States. Acellular pertussis vaccine was first licensed in 1991 and has fewer
side effects than the whole-cell vaccine.
Dose
• Pediatric dose: A 0.5 mL IM dose of DTaP vaccine is given at 2, 4, 6, and 15-18 months of age.
A booster dose should be given at 4-6 years.
• Adolescent dose: A 0.5 mL dose of Tdap of vaccine is given at 11-12 years.
• Adult dose: A 0.5 mL dose of Tdap is given one time only.
Adverse reactions
frequent injections of the tetanus antigen component of the combination vaccines.
Available vaccines
• Tdap (Adacel by Sanofi Pasteur and Boostrix by GSK), indicated for ages 10-64
• DTaP (Tripedia and Daptacel by Sanofi Pasteur and Infanrix by GSK), indicated for age 2 months
to 7 years
• Td (various manufacturers), recommended over the age of 7 following one dose of Tdap and for
all over the age of 64
Hepatitis B
Hepatitis B is caused by a DNA (deoxyribonucleic acid) virus. It is one of the most common
infections worldwide. An estimated 200 million to 300 million chronic carriers of hepatitis B exist
worldwide.
The clinical course is similar to that of all other types of viral hepatitis, with symptoms of malaise,
weakness, anorexia, nausea, jaundice, abdominal pain, headache, and dark urine. Malaise and
fatigue may last for weeks to months after all other symptoms disappear.
Fulminant hepatitis occurs in 1-2% of all cases, with mortality rates of 60-90%.
Complications are usually related to chronic infections with hepatitis B virus and include chronic
hepatitis, cirrhosis, liver failure, and hepatocellular carcinoma. Twenty-five percent of all carriers
develop chronic, active hepatitis. The risk of becoming a carrier following infection ranges from
6% to 50%.
The incubation period is usually about 90 days (range, 60-150 days). Transmission is human to
human by exposure of body fluids by parenteral or mucosal contact. Hepatitis B is a common
sexually transmitted disease. Perinatal transmission is a significant mode of infection.
Hepatitis B vaccine
The first vaccine was a plasma-derived vaccine released in 1981 and removed from the market in
1992. The current vaccine is hepatitis B surface antigen (HBsAg), produced using recombinant-
DNA technology. It was first released in 1986. Two products are currently marketed: Recombivax
HB (Merck) and Engerix-B (GlaxoSmithKline). Although the antigen contents are different, the
two vaccines are interchangeable.
Combination vaccines are available.
Dose
The usual pediatric dose is 0.5 mL IM given at birth, 2 months, and 6 months. The usual adult dose
is 1.0 mL given at 0, 2, and 6 months. Indications include all infants, all adolescents, and high-risk
adults (e.g., those with multiple sex partners or sexually transmitted diseases, those who use
injection drugs, those on dialysis, and those with hemophilia).
Adolescents 11-15 years of age may be given a two-dose series separated by 4 months. This dose is
approved for only Recombivax HB.
Serological testing may not be accurate after 2 years following vaccination, but immunity continues.
Booster doses should not be given.
Adverse reactions
systemic reactions are uncommon.
Haemophilus Influenzae Type B
Haemophilus influenzae is a Gram-negative cocco-bacillus, whose outer shell consists of a

polyribosylribitol phosphate (PRP) polysaccharide capsule. Six distinctly different types of H.
influenzae exist, labeled a-f; however, H. influenzae type b (Hib) is responsible for 95% of human
disease.
The organism enters through the nasopharynx and may cause disease or may colonize the
nasopharynx, creating an asymptomatic carrier.
The most common clinical infections caused by Hib are meningitis, epiglottitis, pneumonia,
arthritis, and cellulitis. Meningitis accounts for 50-65% of all clinical disease and results in a
mortality rate of 2-5% and neurological sequelae in 15-30% of cases. Other diseases caused by H.
influenzae include otitis, sinusitis, and bronchitis; however, these illnesses are usually caused by
nontypable (unencapsulated) strains.
Hib is primarily a disease of children, with a peak at age 6-7 months. It rarely attacks after the age
of 5 years.
Treatment of acute disease includes hospitalization, intravenous antibiotics, and prophylaxis of

contacts. Transmission is human to human by respiratory droplet spread to susceptible individuals.
Haemophilus influenzae vaccine
The incidence of Hib disease has decreased by more than 99% since the introduction of vaccine.
The first vaccine licensed (1985-88) was a pure polysaccharide vaccine that was ineffective in
children less than 18 months of age. Current vaccines are polysaccharide vaccines conjugated to
protein carriers. The specific carriers vary by manufacturer.
PRP-T (ActHIB by Sanofi Pasteur) and PRP-OMB (PedvaxHIB by Merck) are indicated for infants
6 weeks of age. Doses given before 6 weeks of age may inhibit the production of antibodies to
subsequent doses; therefore, the vaccines are contraindicated in children less than 6 weeks of age.
PRP-T (Hiberix by GlaxoSmithKline) is indicated only for the booster dose at 15 months to 4 years
of age.
Dose
The usual dose for the vaccines approved for infants is 0.5 mL IM given at 2, 4, and 6 months. A
booster dose is recommended for children 12-15 months of age. If PRP-OMB (PedvaxHIB) is used
for the pediatric series, the 6-month dose should be omitted.
The catch-up series for Hib vaccine varies by age and manufacturer. Consult the package insert for
complete dosing information.
Vaccination of children less than 59 months of age is not indicated unless certain medical
indications exist. These include persons with asplenia, those with immunodeficiency conditions,
and those undergoing immunosuppressive therapy.
Combination vaccines of Hib vaccine and hepatitis B vaccine (COMVAX by Merck) and Hib
vaccine and DTaP (TriHIBit by Sanofi Pasteur) are available. TriHIBit is not approved for the
initial pediatric series (2, 4, and 6 months) and can be used for a dose only at e 12 months of age
when a previous dose of Hib was given 2 months earlier, and TriHIBit will be the last dose in the
Hib series. COMVAX must not be administered before 6 weeks of age. DTaP-Hib-IPV (Pentacel by
Sanofi Pasteur) must not be used before the age of 6 weeks.
Adverse reactions
Adverse reactions include pain, swelling, and redness at the injection site; systemic reactions are
uncommon.
Hepatitis A
Hepatitis A is caused by an RNA virus and is the most common hepatitis infection in the United
States. The clinical course is similar to that of all other types of viral hepatitis, with symptoms of
malaise, weakness, anorexia, nausea, jaundice, abdominal pain, headache, and dark urine. Malaise
and fatigue usually last for 2 weeks; however, symptoms may last or recur for up to 6 months.
Fulminant hepatitis A is rare but can occur. The incidence increases with age over 40 years.
Although serious complications are not as common as with hepatitis B, morbidity and its associated
costs (health care costs and lost work days) are significant. There is no risk of the patient becoming
a chronic carrier.
The incubation period averages 28 days (range, 15-50 days). Treatment of acute disease is
supportive. Transmission is human to human by the fecal-oral route of exposure.
Exposure of an unimmunized person to hepatitis A requires the administration of immune globulin

intramuscular (IGIM) as well as beginning the hepatitis A vaccine series, except for healthy persons
1-40 years of age, who may receive the vaccine only.
Hepatitis A vaccine
The available vaccines are Havrix by GlaxoSmithKline and VAQTA by Merck. These are
inactivated whole-virus vaccines. Both vaccines are available in pediatric and adult formulations.
Hepatitis A vaccine is indicated for all high-risk patients and routinely for all children 1-2 years of
age. Consideration of immunization should be given to all children up to 18 years of age. It is not
indicated for children less than 1 year of age. The two vaccines use different potency measurements,
but the volume and schedule of the dose is the same.
Dose
Children and adolescents over 1 year of age are given 0.5 mL, repeated in 6-12 months (Havrix) or
6-18 months (VAQTA), for two doses total.
Adults over 18 years old are given 1.0 mL, repeated in 6-12 months, for two doses total.
Combination vaccine
Twinrix, by GlaxoSmithKline, is a combination product with hepatitis B (adult dose) and hepatitis
A (pediatric dose).
Dose
The usual dose is 1 mL, given at 0, 1, and 6-12 months. An accelerated schedule can be given at 0,
7 days, and 21-30 days, followed by a booster at 1 year, if protection is needed earlier.
The vaccine is indicated for persons 18 years of age and older.
Adverse reactions
Adverse reactions include pain, redness, and swelling at the injection site. Mild systemic reactions
are rare.
Meningococcal Disease
Meningococcal disease is caused by Neisseria meningiditis, a Gram-negative bacteria with a

polysaccharide capsule. The clinical diseases caused by N. meningiditis include meningitis, sepsis,
pneumonia, myocarditis, and urethritis. N. meningiditis is one of the leading causes of meningitis in
the United States. The types of N. meningiditis that cause over 95% of disease are serogroups A, B,
C, W-135, and Y.
Approximately 2,500-3,000 cases occur per year, with an incidence rate of 2 cases per 100,000
people. The incidence in college freshmen who live in dormitories is approximately 4 cases per
100,000. A carrier state exists that increases in incidence during epidemics.
Parts of the world, including parts of Africa and Asia, have a high rate of disease.
Treatment of acute disease is with antibiotics.
Polysaccharide meningococcal vaccine (Menomune by Sanofi Pasteur)
This polysaccharide vaccine is effective against serogroups A, C, W-135, and Y. The vaccine does
not protect against serogroup B, a common cause of infection.
The vaccine is indicated for persons over the age of 2 years. Those who should be vaccinated
include military personnel, freshmen college students living in dormitories, those with anatomic or
functional asplenia, and travelers to the "meningitis belt" of sub-Saharan Africa. Evidence of
immunization is required for religious pilgrimages to Saudi Arabia for the Islamic Hajj. Vaccine
may also be useful during an outbreak.
Dose
The dose is 0.5 mL given subcutaneously. A booster dose may be needed after 3-5 years.
Adverse reactions
Adverse reactions include pain, swelling (nodule may form), and redness at the injection site, as
well as mild systemic reactions, such as fever, headaches, and malaise.
Conjugated polysaccharide meningococcal vaccine (Menactra by Sanofi Pasteur)
This polysaccharide vaccine that conjugated to diphtheria toxoid. It is effective against serogroups
A, C, W-135, and Y. The vaccine does not protect against serogroup B, a common cause of
infection.
Indications
The vaccine is approved for persons 2-55 years of age. The Advisory Committee on Immunization
Practices (ACIP) recommends vaccination for persons age 11-12 (catch-up for ages 13-18) and for
college freshmen living in dormitories.
Indications are the same as for the polysaccharide vaccine; however, revaccination is recommended
for persons who were previously vaccinated and who remain at high risk for the disease. The
interval varies based on age at first dose.
Dose
The dose is 0.5 mL given intramuscularly.
Polio
The three poliovirus types are identified as P1, P2, and P3. The virus enters the mouth and
replicates in the gastrointestinal tract. From the gastrointestinal tract, the virus enters the
bloodstream and infects the cells of the central nervous system.
Up to 95% of all infections are asymptomatic; however, these persons may transmit the infection to
others. Approximately 4-8% of infections are mild with nonspecific upper respiratory infection,
gastroenteritis, and influenza-like symptoms. Some 1-2% of infections present as nonparalytic
aseptic meningitis, which typically resolves in 2-10 days. Flaccid paralysis occurs in less than 1% of
those infected.
The incubation period is usually 6-20 days (range, 3-35 days). Treatment of acute disease includes
supportive care. Transmission is person to person by the fecal-oral route.
Polio vaccine (IPOL by Sanofi Pasteur)
The current vaccine available in the United States is an inactivated, trivalent injectable vaccine
(IPV, or inactivated polio vaccine). Use of oral polio vaccine (OPV) was discontinued in the United
States because of the elimination of wild-type polio disease and because yearly cases of vaccine-
associated paralytic poliomyelitis (VAPP) were reported.
Dose
The pediatric dose is 0.5 mL IM given at 2, 4, 6-18 months, and 4-6 years of age. Routine vaccine
or booster doses for adults are not recommended.
Adverse reactions
Adverse reactions include minor pain, swelling, and redness at the injection site; systemic reactions
are uncommon.
Measles, Mumps, and Rubella
Measles
Measles is a viral infection whose main presentation is a maculopapular rash. The virus is shed
through the nasopharynx. Ten to 12 days after exposure, the prodrome phase begins, with
progressive fever, cough, coryza, and conjunctivitis. Two to 4 days after the prodrome begins, a
maculopapular rash begins on the face and head and gradually spreads throughout the body. The
rash lasts 3-5 days, then gradually fades.
The incubation period is 10-12 days. Transmission is person to person through large respiratory
droplets. Measles is highly contagious.
Complications may include pneumonia, otitis, encephalitis, and death.
Mumps
Mumps is a viral infection with a presentation of parotitis in 30-40% of cases. The virus is shed
through the nasopharynx. Fourteen to 18 days after exposure, the prodrome phase begins, with
headache, malaise, myalgias, and low-grade fever. Two days after the prodrome begins is when the
parotitis begins. Symptoms start to decrease after 1 week and disappear after 10 days.
The incubation period is 14-18 days (range, 14-25 days). Transmission is person to person through
large respiratory droplets.
Complications can include orchitis, oophoritis, pancreatitis, and deafness.
Rubella
Rubella is a viral infection with up to 20-50% of cases subclinical and inapparent. The virus is shed
through the nasopharynx. A 1-5 day prodrome phase begins after incubation, with headache,
malaise, myalgias, lymphadenopathy, low-grade fever, and upper respiratory infection symptoms.
This phase is rare in children. Fourteen to 17 days after exposure, a maculopapular rash appears,
first on the face and then descending to cover the rest of the body. The rash disappears after about 3
days.
The incubation period is 14 days (range, 12-23 days). Transmission is person to person through
large respiratory droplets.
Complications may include arthritis, arthralgias, encephalitis, and hemorrhaging. The major
complication is congenital rubella syndrome (CRS), which occurs in the offspring of a woman who
had rubella during pregnancy. Babies born with CRS have major birth defects that can affect many
organs.
Measles-mumps-rubella vaccine (MMRII by Merck)
The current vaccine available in the United States is a live, attenuated vaccine against all three
diseases.
Dose
The usual pediatric dose is 0.5 mL IM given at 12 months of age. A second dose is recommended at
4-6 years of age to produce immunity in those who did not respond to the first dose.
This vaccine is contraindicated in pregnancy. Pregnancy should be avoided for 4 weeks following
vaccination.
Serologic testing may be necessary to document immunity.
Vaccination with the combination product should be used when one or more of the vaccines are
needed.
Adverse reactions
Adverse reactions include minor pain, swelling, and redness at the injection site and systemic
reactions that mimic a mild case of the diseases.
Varicella (Chicken Pox)
Varicella is a viral infection caused by the herpes zoster virus. The primary infection is called
chicken pox, and the recurrent disease is herpes zoster (called shingles).
The virus enters through the respiratory tract and replicates in the nasopharynx and regional lymph
glands. The incubation period is 14-16 days (range, 10-21 days).
A prodromal phase may precede the rash with a slight fever and malaise. The rash progresses from
a macule to a papule to a vesicle before it crusts over. The rash appears in several waves that last 2-
3 days each. The rash first appears on the face and then the trunk (where most of the rash occurs)
and the extremities.
Recurrent disease (herpes zoster) appears to be related to aging and immunosuppression. Recurrent
disease usually presents as an outbreak of lesions along a dermatome and is usually unilateral.
Neuralgia and intense pain may be present.
Transmission of varicella is person to person by infected respiratory secretions. Transmission by

patients with herpes zoster is by direct contact with a non-immune person.
Complications may include pneumonia, secondary bacterial infections, central nervous system
infections and symptoms, and Reye's syndrome if a child is taking aspirin.
Varicella vaccine (Varivax by Merck)
The current vaccine available in the United States is a live, attenuated vaccine.
Dose
The pediatric dose is 0.5 mL IM, given at 12-18 months of age. A second dose is recommended at
4-6 years of age.
The adult dose (age > 13 years) is two doses of 0.5 mL, each separated by 4-8 weeks.
The vaccine must be stored frozen at +5°F (-15°C) or colder. The diluent used to reconstitute the
vaccine should be stored at room temperature or refrigerated.
Contraindications
This vaccine is contraindicated in pregnancy, and pregnancy should be avoided for 4 weeks
following vaccination. Other contraindications include immunosuppressive disease or patients
receiving immunosuppressive therapy, as well as those receiving antibody-containing blood
products.
Adverse reactions
Adverse reactions include minor pain, swelling, and redness at the injection site, and systemic
reactions that mimic a mild case of the disease, including a mild generalized rash.
Herpes zoster vaccine (Zostavax by Merck)
This vaccine is same strain of virus as in Varivax but 14 times the dose. It is a live, attenuated
vaccine that is 50% effective in preventing herpes zoster.
Indication
It is indicated for all adults over the age of 60 years, regardless of previous zoster outbreak.
Contraindications
Contraindications include immunosuppression, both disease and medically induced.
Dose
The usual dose is 0.65mL subcutaneous (must be reconstituted).
The vaccine must be stored frozen at +5°F (-15°C) or colder. The diluent used to reconstitute the
vaccine should be stored at room temperature or refrigerated.
Adverse reactions
Adverse reactions include pain, redness, and swelling at the injection site and an increased
incidence of headache.
Rotavirus
Rotavirus is the most common cause of severe gastroenteritis in infants and small children.
Symptoms range from mild, watery diarrhea of limited duration to severe diarrhea with vomiting
and fever that can result in dehydration.
In the United States, approximately 27 million episodes, 205,000-272,000 emergency visits,

410,000 outpatient visits, 55,000-70,000 hospitalizations, and 20-60 deaths occur each year because
of rotavirus infection.
Rotavirus is transmitted by fecal-oral route by close person-to-person contacts and through fomites.
Rotavirus vaccines
Two rotavirus vaccines are available:
• Pentavalent human-bovine reassortant rotavirus vaccine (RotaTeq [RV5] by Merck)
• Monovalent human rotavirus vaccine (Rotarix [RV1] by GlaxoSmithKline)
RV5 is a live, oral vaccine that contains five reassortant rotaviruses and is available as a liquid that
requires no reconstitution. RV1 is a live, oral vaccine that contains one human rotavirus strain and
is a lyophilized powder that must be reconstituted prior to injection.
Dose
Both vaccines are administered orally. RV5 contains 2 mL per dose, and RV1 contains 1 mL per
dose.
RV5 is a three-dose series given at 2, 4, and 6 months of age. RV1 is a two-dose series given at 2
and 4 months of age. The rotavirus series should be started no sooner than 6 weeks of age and must
be completed by 8 months, 0 days of age.
Rotavirus vaccine can be administered simultaneously with all other pediatric vaccines indicated at
the same age. It should not be given to infants who had a severe reaction to a previous dose.
Precautions include altered immunocompetence, acute gastroenteritis, moderate or severe acute

illness, preexisting chronic gastrointestinal disease, and a previous history of intussusception.
Adverse effects
There does not appear to be an increase in the incidence of intussusception with the current
vaccines. A previous rotavirus vaccine (Rotashield) was removed from the market in 1999.
Adverse effects may include diarrhea and vomiting.
Human Papillomavirus
Human papillomavirus (HPV) is the most common sexually transmitted disease in the United
States. Although most HPV infections are asymptomatic and self-limiting, persistent infection can
cause cervical cancer and genital warts.
Approximately 100 HPV types exist, with 40 types affecting the genital area and the remainder
associated with skin warts. High-risk viruses can cause low- and high-grade cervical cell
abnormalities and anogenital cancers. Approximately 70% of cervical cancers are caused by HPV
types 16 and 18. HPV types 6 and 11 cause 90% of all genital warts.
HPV vaccines
Two HPV vaccines are available:
• Quadravalent human papillomavirus vaccine (Gardasil by Merck) protects against HPV types 6,
11, 16, and 18.
• Bivalent human papillomavirus vaccine (Cervarix by GlaxoSmithKline) protects against HPV

types 16 and 18.
Indications
Both vaccines are indicated for the prevention of the types of HPV in the specific vaccine, but they
are not used for the treatment of HPV infection.
The HPV vaccines are indicated for all women 9-26 years of age and should be given routinely to
all 11- to 12-year-old girls. The vaccines are also indicated for the prevention of genital warts in
males 9-26 years of age. Vaccination in males is not recommended by the Advisory Committee on
Immunization Practices for routine use, but its use is optional.
Contraindications
HPV vaccine is contraindicated in persons who had a reaction to a previous dose.
Dose
The HPV vaccine is inactivated and administered as a three-dose series given at 0, 2, and 6 months.
The vaccine must be shaken and 0.5mL administered intramuscularly in the deltoid area.
The HPV vaccine may be given simultaneously with other recommended vaccines.
Adverse reactions
Adverse reactions are primarily local and include pain, redness, and swelling at the injection site. A
systemic reaction of fever may occur.
Combination Vaccines
As mentioned in previous sections, several vaccination combinations are on the market:
• Tetanus, diphtheria, and pertussis combinations (various manufacturers): DTaP, DT, Td, Tdap
• Twinrix by GlaxoSmithKline: a combination product with hepatitis B (adult dose) and hepatitis A
(pediatric dose)
• Hib vaccine and hepatitis B vaccine: COMVAX by Merck
• Hib vaccine and DTaP: TriHIBit by Sanofi Pasteur

• Pediarix (GlaxoSmithKline)
• DTaP + hepatitis B + inactivated polio
• Indicated when all vaccine components indicated
• Not approved for < 6 weeks or > 7 years of age
• Efficacy, contraindications, and adverse reactions similar to those of the vaccine components
given separately
• Dose: 0.5 mL IM given at 2, 4, and 6 months of age
• Must be shaken vigorously prior to drawing up in syringe
• Can be given even if infant receives birth dose of hepatitis B vaccine
• Pentacel (Sanofi Pasteur)
• DTaP + Hib + inactivated polio
• Indicated when all vaccine components indicated
• Not approved for < 6 weeks or > 4 years of age
• Efficacy, contraindications, and adverse reactions similar to those of the vaccine components
given separately
• Dose: 0.5 mL IM given at 2, 4, and 6 months of age
• Must be shaken vigorously prior to drawing up in syringe
• Can be given even if infant receives birth dose of hepatitis B vaccine
• ProQuad by Merck: a combination vaccine of measles, mumps, rubella, and varicella vaccine
• Kindrix by GlaxoSmithKline: a combination of DTaP and IPV to be given at 4-6 years
32-4. Key Points
• The two types of vaccine antigens are (1) live viruses and (2) inactivated viruses or bacterial
components.
• There are two types of immunity: active and passive.

• Adverse effects of inactivated vaccines include pain at the injection site and mild systemic
symptoms (mild fever). Adverse effects of live vaccines mimic a mild case of the disease.
• Live vaccines should be avoided during pregnancy.
• Influenza viruses undergo shifts and drifts, which accounts for the need for yearly vaccine
changes.
• Wound management must include evaluation for the need for tetanus toxoid and tetanus immune
globulin.
• Diphtheria toxoid and tetanus toxoid should always be given together, unless a contraindication to
one of the components exists. If there is a need for one, then there is a need for both.
• A combination vaccine of tetanus, diphtheria, and pertussis is available for use in adolescents and
adults (Tdap). It is recommended one time for persons 11-64 years of age. Children under the age
of 7 years receive DTaP or DT (if unable to tolerate pertussis vaccine). All other ages should
receive Td if vaccination is indicated.
• Hepatitis B vaccine is now recommended for all infants, starting at birth, as well as all
adolescents. Other indications include adults with high-risk occupations or behaviors.
• Hepatitis A vaccine is recommended for travel to most parts of the world.
• Inactivated polio vaccine is the only polio vaccine recommended for use in the United States. Oral
polio vaccine is not recommended because of the high incidence of vaccine-associated paralytic
poliomyelitis.
• A second dose of MMR vaccine and varicella vaccine is recommended at 4-6 years of age.
• Combination vaccines are available to decrease the number of injections.
32-5. Questions
A 67-year-old patient presents to your pharmacy for a refill of his insulin. It is October, and he
asks you to review his immunization status with him. About which adult vaccine do you need
to ask his status?
I. Influenza vaccine
II. Pneumococcal vaccine
III. Meningococcal vaccine
1. IV. Hepatitis A vaccine
V. Diphtheria-tetanus (Td) vaccine
A. I only
B. I and II only
C. III and IV only
D. I, III, and V only
E. I, II, and V only

The patient in question 1 states that he received his pneumococcal vaccine 4 years ago. When
should he receive another?
A. Never
2.
B. Every year
C. In 5 years
D. When he reaches the age of 68
E. When he reaches the age of 72

Which of the following describes the current injectable influenza vaccine used in the United
States?
A. Inactivated virus
3.
B. Live attenuated virus
C. Conjugated vaccine
D. Toxoid
E. Toxin

Indications for meningococcal conjugate vaccine include
I. all adolescents 11-12 years of age.

II. travelers to the "meningitis belt" of sub-Saharan Africa.
III. patients with asplenia.
IV. pilgrims to Saudi Arabia for the Islamic hajj.
4. V. college freshmen living in dormitories.
A. I only
B. II, III, and V only
C. I, II, and III only
D. II, III, IV, and V only
E. All of the above

At what age does one switch from DTaP to Td?
A. 2 years
5. B. 5 years
C. 7 years
D. 10 years
E. DTaP can be used in all age groups.

Which of the following vaccines has both a polysaccharide and a conjugated vaccine on the
U.S. market?
I. Influenza
II. Meningococcal vaccine
III. Haemophilus influenzae type B vaccine
IV. Hepatitis vaccine
6.
V. Pneumococcal vaccine
A. IV only
B. II and V only
C. I, II, and III only
D. II, III, and V only
E. All of the above

Which polio vaccine schedule is recommended in the United States?
A. Four doses of IPV

7. B. Four doses of OPV
C. Four doses of IPV plus a booster at 18 years of age
D. Two doses of OPV and 2 doses of IPV
E. Polio vaccine is no longer recommended in the United States.

Hepatitis B vaccine is a
A. polysaccharide vaccine.
8. B. recombinant hepatitis B surface antigen vaccine.
C. live vaccine.
D. conjugate vaccine.
E. a toxoid.

An 18-year-old, healthy student is told that she needs to come to the pharmacy for her routine
vaccinations prior to starting college. She will be living in the dormitory at school. She has not
received any vaccines since grade school. Which of the following vaccines are indicated?
I. MMR if she has not received a second dose

II. Varicella vaccine if she has not received two doses, has no history of varicella infection, or
has negative titers
III. Meningococcal vaccine
9.
IV. Pneumococcal vaccine
V. Tdap if she has not received one for 10 years
A. All of the above

B. I and II only
C. I, II, III, and IV only
D. I, III, and V only
E. I, II, III, and V only

The patient in question 9 is exposed to a patient with hepatitis A 1 month later. She should
receive which of the following vaccines?
A. Hepatitis A vaccine series only

10.
B. Hepatitis B vaccine series only
C. Hepatitis A vaccine series plus IGIM
D. Hepatitis A vaccine plus hepatitis B vaccine series
E. IGIM only

Which of the following is a high-risk group that should be targeted for annual influenza
vaccination?
A. Persons 18-49 years of age

11.
B. Persons with diabetes
C. Patients 21-49 years of age with hypertension
D. Construction workers
E. Healthy patients 21-49 years of age

Which complication of rubella infection is the most significant health problem?
A. Congenital rubella syndrome

12. B. Secondary infection
C. Patent ductus arteriosus
D. Diarrhea
E. Arthritis

Which of the following is a valid contraindication to the receipt of a live-virus vaccine?
A. Taking antibiotics
13. B. Recent administration of antibody-containing blood products
C. Age over 12 months
D. Allergies to penicillin
E. A parent or sibling with a cold who is living in the same household

The most common adverse reaction to an inactivated vaccine is
A. Rash
14. B. Severe headache
C. Injection-site reaction
D. Rhinorrhea
E. Stomach pain

The only vaccine recommended at birth is
A. DTaP.
15. B. IPV.
C. Hib.
D. pneumococcal conjugate vaccine.
E. hepatitis B.

A 32-year-old female is injured in an automobile accident and her spleen is removed. Which of
the following vaccines is not routinely recommended for asplenic adult patients?
A. Pneumococcal vaccine
16.
B. Meningococcal vaccine
C. IPV
D. Haemophilus influenzae type B vaccine
E. Yearly influenza vaccines

If a second dose of a vaccine were given too soon (before the minimal interval time has
passed), the correct course of action would be
A. restarting the entire series.

17. B. not counting that dose and repeating it after the minimal time has passed since the incorrect
dose.
C. not worrying about it and continuing with the next dose as scheduled.
D. drawing antibody titers to confirm immunity.
E. doubling the next dose.

Which of the following groups of children are not at increased risk for pneumococcal disease?
A. Obese children
18. B. Children of Native Alaskan descent
C. Children of African American descent
D. Children with sickle cell disease
E. Children infected with HIV

Which of the following statements are true concerning Haemophilus influenzae type b vaccine
(Hib)?
I. One dose of Hib is recommended for all infants over the age of 15 months if they have not
received a previous dose.
II. Standard dosing for Hib vaccine is 2, 4, 6, and 12-15 months of age.
III. The 6-month dose is omitted if PedvaxHIB is used for the first two doses.
19.
IV. Hib vaccine is not routinely recommended for children 5 years of age and older.
A. I only
B. I, II, and III
C. II, III, and IV
D. II and III
E. All are correct.

Which of the following vaccines available in the United States is a live, attenuated virus
vaccine?
A. Polio (IPV)
20.
B. Haemophilus influenzae vaccine (Hib)
C. DTaP
D. Varicella vaccine
E. Pneumococcal vaccine

32-6. Answers
E. Routine vaccinations in the adult are a yearly influenza vaccine, Td vaccine every 10 years,
1. and a single pneumococcal vaccine for patients with select chronic illnesses (such as diabetes).
Meningococcal and hepatitis vaccines are recommended only for certain indications.

D. Routine revaccination with pneumococcal vaccine is not recommended. Revaccination is
2. recommended for select high-risk groups and everyone 65 years and older who received an
initial dose under the age of 65 and if more than 5 years have elapsed since the previous dose.

A. Injected influenza vaccine is an attenuated, split-virus vaccine. The LAIV is administered
3.
intranasally.

E. With the recent availability of a conjugate meningococcal vaccine, the ACIP recommended
4.
including all adolescents ages 11-12 among the other recommendations.

C. DTaP is indicated for children under the age of 7. Because of adverse effects of DTaP in
5.
children 7 years of age and older, Td or Tdap is used.

B. Polysaccharide pneumococcal vaccine (23-valent) is indicated for those over the age of 2
years and conjugated polysaccharide vaccine (7-valent) is approved for ages 2 months to 7
6.
years. A meningococcal conjugate vaccine has recently been approved, and the polysaccharide
vaccine will be removed from the market once supplies of the conjugate vaccine are adequate.

A. OPV is no longer recommended in the United States, and vaccination with IPV will
7.
continue until poliovirus is eradicated worldwide.

8. B. Hepatitis B vaccine is a recombinant hepatitis B surface antigen vaccine.

9. E. Pneumococcal vaccine is not recommended for a healthy individual until the age of 65.

A. The hepatitis A vaccine alone will protect a healthy individual between 1 and 40 years of
10.
age who has previously been exposed to the virus.

B. High-risk groups targeted for influenza vaccination include persons age 6 months to 18
years and persons > 50 years old. Also included are persons age > 19 years with chronic
pulmonary disease (e.g., emphysema, chronic obstructive pulmonary disease); cardiovascular
disease (e.g., congestive heart failure, post-myocardial infarction, heart anomalies); metabolic
disease (e.g., diabetes); renal dysfunction; hemoglobinopathies (e.g., sickle cell), and
11. immunosuppression (e.g., HIV infection, chemotherapy). Other groups that should receive the
vaccine include residents of long-term care facilities, people 24 months to 18 years old on
aspirin chronically, pregnant women in all trimesters, hospital and outpatient employees,
nursing home employees with patient contact, home health care providers working with high-
risk persons, household members of high-risk persons, and persons desiring to avoid influenza
infection.

A. Complications of rubella may include arthritis, arthralgias, encephalitis, and hemorrhaging;
however, the major complication is congenital rubella syndrome, which occurs in the offspring
12.
of a woman who had rubella during pregnancy. Babies born with CRS have major birth defects
that can affect many organs.

B. Live-virus vaccines will be killed if antibodies have been administered recently. The length
13. of time that must separate these two products depends on the dose and type of antibody-
containing blood product being used.

C. Local reactions are the most common type of adverse reaction, and include pain, swelling,
and redness at the site of injection. These reactions usually occur within minutes to hours of
14.
the injection and are usually mild and self-limiting. Systemic adverse reactions include fever,
malaise, myalgias, and headache and are more common following live vaccines.

E. All the other listed vaccines are first given at 2 months of age. Hepatitis B vaccine is
15. recommended at birth to decrease the incidence of hepatitis B in infants of hepatitis B-infected
mothers.

C. Asplenic patients require protection against the encapsulated bacteria (pneumococcus,
meningococcus, and Haemophilus), as well as common viral infections. Previous series
16.
completions of routine vaccines, such as measles, varicella, and polio, are adequate for
protection. Td vaccines should be repeated every 10 years.

B. The minimal interval in a series for most vaccines is 4 weeks. Decreasing the interval may
interfere with antibody response and protection. Usually the last dose in a series is separated
17.
from the previous dose by 4-6 months. Increasing the interval does not affect vaccine
effectiveness. You never need to restart a series except for oral typhoid vaccine.

A. Rates of pneumococcal disease are highest in children < 2 years of age, those with asplenia,
18. patients with HIV, American Indian and Alaskan Natives, African Americans, and day care
attendees. Obesity is not considered a high-risk disease for pneumococcal infection.

E. Although all the answers are correct, Hib vaccine may be indicated for children over the age
of 5 with certain chronic conditions. This vaccine is relatively complicated to use because
19.
recommendations vary among manufacturers. Please consult package inserts before
administering.

D. Varicella vaccine, LAIV, measles-mumps-rubella vaccines, and rotavirus vaccines are the
only live vaccines routinely administered in the United States. Other nonroutinely administered
20.
live vaccines include oral typhoid vaccine, vaccinia (smallpox) vaccine, and yellow fever
vaccine. The majority of vaccines are inactivated or killed vaccines.

32-7. References
Advisory Committee on Immunization Practices. A comprehensive immunization strategy to

eliminate transmission of hepatitis B virus infection in the United (Part 1). MMWR.
2005;54(RR-16):1-23.
Advisory Committee on Immunization Practices. A comprehensive immunization strategy to

eliminate transmission of hepatitis B virus infection in the United (Part 2). MMWR.
2006;55(RR-16):1-25.
Advisory Committee on Immunization Practices. General recommendations on immunizations.

MMWR. 2006;55(RR-15):1-48.
Advisory Committee on Immunization Practices. Poliomyelitis prevention in the United States:

Updated recommendations. MMWR. 2000;49(RR-5): 1-22.
Advisory Committee on Immunization Practices. Preventing pneumococcal disease among infants

and young children. MMWR. 2000;49(RR-9):1-38.
Advisory Committee on Immunization Practices. Preventing tetanus, diphtheria, and pertussis

among adolescents: Use of tetanus, reduced diphtheria toxoid, and acellular pertussis vaccine
MMWR. 2006; 55(RR-3):1-34.
Advisory Committee on Immunization Practices. Preventing tetanus, diphtheria, and pertussis

among adults: Use of tetanus, reduced diphtheria toxoid, and acellular pertussis vaccine MMWR.
2006;55 (RR-17):1-33.
Advisory Committee on Immunization Practices. Prevention and control of seasonal influenza with
vaccines. MMWR. 2009;58(RR-8):1-52.
Advisory Committee on Immunization Practices. Prevention and control of meningococcal disease.

MMWR. 2005;54(RR-7):1-21.
Advisory Committee on Immunization Practices. Prevention of hepatitis A through active or

passive immunization. MMWR. 2006;55(RR-7):1-23.
Advisory Committee on Immunization Practices. Prevention of pneumococcal disease. MMWR.

1997; 46:1-24.
Advisory Committee on Immunization Practices. Prevention of rotavirus gastroenteritis among

infants and children. MMWR. 2009;58:1-24.
Advisory Committee on Immunization Practices. Prevention of varicella. MMWR. 2007;56 (RR-4):

1-40.
Advisory Committee on Immunization Practices. Quadravalent human papillomavirus vaccine.

MMWR. 2007;56:1-24.
Advisory Committee on Immunization Practices. Revised ACIP recommendation for avoiding

pregnancy after receiving a rubella-containing vaccine. MMWR. 2001;50:1117.
Advisory Committee on Immunization Practices. Revised recommendations of the Advisory

Committee on Immunization Practices to vaccinate all persons aged 11-18 with meningococcal
conjugate vaccine. MMWR. 2007;56794-95.
Advisory Committee on Immunization Practices. Update: Vaccine side effects, adverse reactions,
contraindications, and precautions. MMWR. 1996;45 (RR-12):1-35; errata MMWR.
1997;46:227.
Advisory Committee on Immunization Practices. Use of diphtheria toxoid-tetanus toxoid-acellular

pertussis vaccine as a five dose series. MMWR. 2000;49 (RR-13):1-8; erratum MMWR.
2000;49(47):1074.
Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine: Preventable
Diseases. 11th ed. Atlanta, Ga.: CDC; 2009.
Centers for Disease Control and Prevention. Vaccines and immunizations Web site. Available at:
www.cdc.gov/vaccines/pubs/pinkbook/default.htm.
Grabenstein JD. Immunofacts: Vaccines and Immunologic Drugs. St. Louis, Mo.: Wolters Kluwer
Health; 2007.
Plotkin SA, Orenstein WA, Offitt P, eds. Vaccines. 5th ed. Philadelphia: WB Saunders; 2008.
33. Pediatrics - Catherine M. Crill, PharmD, BCPS, BCNSP
33-1. Special Drug Therapy Considerations in Pediatric Patients
Pediatric Age Definitions
• Preterm: < 36 weeks gestation
• Term: 36 weeks gestation
• Neonate: < 1 month
• Infant: 1 month to < 1 year
• Child: 1-11 years
• Adolescent: 12-16 years
Absorption
Gastric pH
Infants may be considered to be in a relative state of achlorhydria (because of decreased basal acid
secretion and total volume of secretions); however, they are capable of producing sufficient gastric
acid with stimuli (e.g., in response to histamine or pentagastrin challenge, enteral feeding, or stress).
Gastric acid production reaches adult values by approximately age 3.
Implications for drug therapy
• Increased bioavailability of basic drugs
• Decreased bioavailability of acidic drugs
• Increased bioavailability of acid-labile drugs (e.g., penicillin G)
Gastric emptying time in pediatric patients
Gastric emptying time (GET) is longer for pediatric patients than for adults. GET is inversely
related to postconceptional age.
GET is characterized by irregular and unpredictable peristalsis and decreased motility. Premature
neonates have longer GET than term neonates and have a greater incidence of gastroesophageal
reflux. GET is related to the type of feeding. Formula-fed infants exhibit longer transit time than do
breast-fed infants.
Pediatric GET approaches adult function by 7-9 months. Stomach muscles are mature at 7 months.
Stomach muscles are completely innervated at 9 months.

Absorption of sustained-release products (e.g., theophylline) is erratic. The rate of absorption in the
small intestine, where most drugs are absorbed, is slower; peak drug concentrations are lower for
children than for adults.
Pancreatic enzymes and bile salts
• Low levels of amylase and lipase
• Low intraluminal bile acid concentrations and synthesis
• Decreased proteolytic ability
• Erratic absorption of drugs requiring pancreatic enzymes for hydrolysis (e.g., chloramphenicol)
• Decreased absorption of lipid-soluble drugs
• Decreased fat absorption from enteral feedings
• Decreased absorption of fat-soluble vitamins
Gastrointestinal mucosa
• Functional integrity of intestinal mucosa is decreased.
• The surface area of the gastric mucosa is small compared to that of intestinal mucosa (most drugs
are absorbed from the small intestine).
• Changes in splanchnic blood flow in the neonatal period may alter the concentration gradient
across the intestinal mucosa.
Other absorption routes
Skin
Absorption through the skin is inversely related to the thickness of the stratum corneum and directly
related to hydration of the skin. Neonates (particularly premature) have increased skin hydration.
The stratum corneum of preterm infants is immature and ineffective as an epidermal barrier.
Premature neonates may develop drug toxicity if a drug is administered through the dermal route.
Buccal route
The buccal route is not typically used in pediatric patients.
Intramuscular route
Drug delivery is restricted by volume of medication and the pain associated with administration.
Results are variable in premature neonates because of (1) blood flow and vasomotor instabilities
and (2) insufficient muscle mass and tone, contraction, and oxygenation.
Rectal administration
Rectal administration is effective for drug delivery in older infants and children.
Administration through intraosseous route

This vessel-rich marrow (up to age 5) is a great site for drug delivery to the systemic circulation. It
may be an acceptable route in emergency situations for children over age 5 (vessel-rich marrow is
then replaced by yellow marrow).
Distribution
Protein binding
• Decreased albumin and 1-acid glycoprotein concentrations
• Lower binding capacity
• Qualitative differences in neonatal plasma proteins
• Competitive binding by endogenous substances (unconjugated bilirubin, free fatty acids)
• Risk of kernicterus (hypoalbuminemia, unconjugated hyperbilirubinemia, displacement by highly

protein-bound drugs or free fatty acids)
• Exhibition of adult-like binding by 3-6 months of age; adult concentrations of albumin and -acid
glycoprotein at 10-12 months
Differences in body composition
• Vascular and tissue perfusion are altered.
• The brain and liver are the largest organs in children.
• Total body water is greater in neonates and infants.
• Extracellular fluid volume is greater in neonates and infants.

• There is a relative lack of adipose tissue in neonates and infants (adipose level increases into
adulthood).
Implications for drug therapy in neonates and infants
• Increased free fraction of drugs can occur.
• Increased potential of drug displacement by endogenous substances is present.
• Potential risk of kernicterus with physiologic jaundice (unconjugated hyperbilirubinemia) is

present.
• Hydrophilic drugs, which parallel water in the body (e.g., aminoglycosides), exhibit greater
volume of distribution.
• Lipophilic drugs (e.g., diazepam) parallel body fat and will exhibit a smaller volume of
distribution.
Liver Metabolism
Phase I reactions (nonsynthetic): Oxidation, reduction, hydrolysis, and hydroxylation
• The hepatic cytochrome P450 (CYP450) enzyme system is responsible for most phase I reactions.
• The capacity of isoenzymes in the CYP450 system at birth is 20-70% of adult capacity and
increases with postnatal age.
• Full capacity for reduction is present at birth.
• Hydrolysis is most developed at birth, followed by the processes of oxidation and hydroxylation.
• Benzyl alcohol, a preservative present in certain medications, can accumulate in neonates because
of underdeveloped alcohol dehydrogenase. Gasping syndrome (i.e., metabolic acidosis,
respiratory failure, seizures, neurologic deterioration, and cardiovascular collapse) can result.
Phase II reactions (synthetic): Conjugation with glycine or glutathione, glucuronidation,

sulfation, methylation, and acetylation
• The sulfation pathway is the most developed pathway at birth.
• Glucuronidation (i.e., UDP-glucuronosyltransferase [UGT] activity) begins around 2 months of

age. It reaches adult capacity by age 2.
• Assumptions about substances primarily metabolized by glucuronidation (i.e., morphine,

bilirubin, and chloramphenicol) are as follows:
• They are potentially toxic in neonates.
• They may exhibit long half-lives (e.g., toxicity with chloramphenicol).
• They may require greater dosing in infants (e.g., morphine conjugated to its more active
metabolite).
• They may be metabolized by another pathway in infants (e.g., acetaminophen is primarily

metabolized through sulfation in infants).
• Methylation is functional in infants but is not significantly expressed in adults. (Methylation is

responsible for the conversion of theophylline to caffeine.)
• For drugs undergoing phase I and II reactions, the metabolism is reduced and the half-life is
prolonged in infants and neonates.
• Insufficiency of one pathway may lead to metabolism through another.
• Adverse drug reactions are more likely in younger children (i.e., five times more likely in children
under age 1 and three and one-half times more likely in children age 1-4).
• Drug metabolism, which is slower in the neonate, increases between 1 and 5 years of age and is
similar to that in adults after puberty.
Renal Elimination
• Renal blood flow is only 5-6% of cardiac output at birth, compared with 15-25% in adults (12
mL/min versus 140 mL/min).
• Glomerular filtration rate is lower at birth and reaches adult values by 1-5 months of age in term
infants.
• Tubular secretion is low at birth and reaches adult values by 7 months of age in term infants.
• Renal elimination is affected by prematurity and postconceptional age. It increases with maturity.
Estimation of creatinine clearance in pediatric patients
• The estimation of creatinine clearance (CrCl) is altered by differences in renal blood flow,
glomerular filtration, tubular secretion, and muscle mass.
[
Table 33-1. Proportionality Constant for Calculation of Creatinine Clearance Using the Schwartz
Equationa]
• It may be affected by the presence of maternal serum creatinine (SCr) over the first week of life
(i.e., false underestimation of CrCl).
• The Schwartz equation may be used for calculation of CrCl:
CrCl (mL/min/1.73 m2) = k × (length in cm)/SCr
where k = proportionality constant that changes with age and sex (Table 33-1).
Other Pediatric Drug Issues
• Digoxin-like immunoreactive substance (DLIS) is produced in infants. DLIS may interfere with
digoxin assays and falsely elevate concentrations.
• Di(2-ethylhexyl)phthalate (DEHP), a plasticizer contained in intravenous (IV) bags, is shown to

have an effect on the male reproductive system. Pediatric patients at highest risk of DEHP
exposure are neonates on extracorporeal membrane oxygenation, those receiving parenteral and
enteral nutrition, and those receiving plasma exchange transfusions.
• Polyethylene glycol, an additive used to promote stability in certain IV medications, can cause
hyperosmolarity in infants.
33-2. Specific Infections and Disease States in the Pediatric Population
Otitis Media
Otitis media is an inflammatory process of the middle ear.
Classification
• Acute otitis media is an inflammation of the area behind the eardrum (tympanic membrane) in the
chamber called the middle ear. It is accompanied by the presence of fluid in the middle ear
(effusion) and by the rapid onset of signs or symptoms of ear infection (also see the American
Academy of Pediatrics [AAP] and American Academy of Family Physicians [AAFP] definition
in section on diagnostic criteria).
• Recurrent otitis media is the diagnosis of three episodes of acute otitis media within a 6-month
period or four episodes within a year.
• Otitis media with effusion is fluid in the middle ear (effusion) without the associated signs or
symptoms of acute infection.
Signs and symptoms include fever, otalgia (often manifested as ear tugging or pulling), otorrhea
(discharge from the ear), changes in balance or hearing, irritability, difficulty sleeping, lethargy,
anorexia, vomiting, and diarrhea. Associated findings may be runny nose, congestion, or cough.
Pathophysiology
Eustachian tube dysfunction

The infant's eustachian tube is shorter and more horizontal than that of the adult, thus preventing
drainage of middle ear secretions into the nasopharynx and promoting pooling of secretions in the
middle ear. Anatomic abnormalities increase risk (e.g., cleft palate and adenoid hypertrophy). An
immature immune system or altered host defenses also increase risk, as well as viral infections and
allergies increase risk.
Risk factors include male gender; Native American, Canadian Eskimo, or Alaskan descent; family
history of acute otitis media or respiratory tract infection; early age of first episode (earlier age is
associated with greater severity and recurrence); day care environment; parental smoking; lack of
breast-feeding in infancy; and pacifier use.
Complications include mastoiditis, meningitis, subdural empyema, hearing loss, and delayed speech
and language development.
Microbial pathogens
Up to 50% of cases of acute otitis media may be viral in origin. The rest are bacterial:
• Streptococcus pneumoniae is responsible for 40-50% of bacterial otitis media. Resistance is

becoming an increasing problem; bacterial resistance occurs primarily through alteration in
penicillin-binding protein (decreased affinity for binding sites).
• Haemophilus influenzae (primarily nonencapsulated or nontypeable strains) is responsible for 20-

30% of bacterial otitis media cases. Bacterial resistance occurs through ²-lactamase production.
• Moraxella catarrhalis is responsible for 10-15% of bacterial otitis media. Almost all strains are ²-
lactamase producing.
Diagnostic criteria
For diagnosis of otitis media, the clinical presentation must show signs and symptoms consistent
with infection.
In 2004, the AAP and AAFP published a clinical practice guideline on the diagnosis and
management of acute otitis media. The guideline presented a revised definition of acute otitis media
as follows: "diagnosis requires: (1) a history of acute onset of signs and symptoms, (2) the presence
of middle ear fluid (by a bulging tympanic membrane, limited/absent mobility of or air-fluid level
behind the tympanic membrane, or otorrhea), and (3) signs and symptoms of middle ear
inflammation (distinct erythema of the tympanic membrane or distinct otalgia referable to the
middle ear that interferes with normal sleep/activity)."
When middle ear disease is present, otoscopic examination determines color, translucency, and
position. Redness or opacity of membrane, absence of light reflection, or bulging membrane will be
observed.
Pneumatic otoscopic examination determines mobility of the tympanic membrane (i.e., presence or
absence of effusion). The membrane will not move briskly with positive and negative pressure if
effusion is present.
Tympanocentesis (i.e., a needle is inserted through the tympanic membrane to withdraw fluid)
allows for culture and identification of the pathogen.
Treatment principles and goals
• Assess and control pain.
• Eradicate infection.
• Prevent complications.
• Avoid unnecessary antibiotic therapy.
• Improve compliance.
• Eliminate presence of effusion.
• Prevent recurrence.
Drug therapy
Many episodes of otitis media will have spontaneous resolution; however, because there is a risk of
developing complications from untreated otitis media, antimicrobials remain the mainstay of
therapy. Observation therapy may be appropriate in certain patients, depending on age, diagnostic
certainty, and severity of illness and when follow-up can be ensured.
First-line therapy
Amoxicillin is the drug of choice for uncomplicated and nonsevere (mild otalgia and fever < 39°C
or 102.2°F) acute otitis media. Amoxicillin has excellent in vitro activity against Streptococcus
pneumoniae and most Haemophilus influenzae. It has the optimal pharmacodynamic profile of the
available agents and reaches good concentrations in middle ear fluid.
Amoxicillin has an excellent safety and efficacy profile with narrow spectrum of activity. It is
palatable and inexpensive. It may overcome drug-resistant S. pneumoniae with higher doses (i.e.,
achieves greater concentrations in middle ear fluid). It does not eradicate ²-lactamase-producing
organisms.
For penicillin-allergic patients (non-type I hypersensitivity), cefdinir, cefpodoxime, or cefuroxime

may be used. In patients with type I reactions (urticaria or anaphylaxis), azithromycin,
clarithromycin, trimethoprim-sulfamethoxazole (6-10 mg/kg/day of trimethoprim), or
erythromycin-sulfisoxazole (50 mg/kg/day of erythromycin) may be substituted; however,
resistance appears to be increasing with these agents. Depending on the severity of the illness,
ceftriaxone therapy may be initiated. Clindamycin may be used when drug-resistant S. pneumoniae
is suspected.
Amoxicillin-clavulanate should be used as first-line therapy, depending on the severity of illness

(moderate to severe otalgia or fever e 39°C or 102.2°F).
Other effective antimicrobial agents include other cephalosporins (cefprozil, cefaclor, and
ceftibuten). Fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) are thought to be effective,
but they are not approved for use in pediatric patients.
Dosing issues and drug resistance

Treatment options are described in
Table 33-2.
Dosages are as follows:
• Amoxicillin: A high dose is recommended (80-90 mg/kg/day).
• Amoxicillin-clavulanate: A high dose is recommended (90 mg/kg/day of amoxicillin with 6.4

mg/kg/day of clavulanate). Maintain daily
[Table 33-2. Treatment Options for Otitis Media]
clavulanate dose < 10 mg/kg/day to prevent diarrhea.
• Ceftriaxone: An intramuscular (IM) dose of 50 mg/kg/day (single dose versus three daily doses)
is recommended.
Duration of therapy
Two courses of therapy are possible:
• Standard 10-day course
• Shorter course (1-7 days)

Advantages of the shorter course are improved compliance, decreased adverse effects of drug
therapy, decreased risk of bacterial resistance, and lower costs. Disadvantages are delayed or no
cure, increased risk of complications from untreated acute otitis media, and greater risk of
recurrence.
A shorter course is not appropriate for the following:
• Children under age 2 (AAP and AAFP state under age 6)
• Children with severe disease
• Those in day care
• Those with underlying diseases
• Those with a history of recurrent otitis media
Other therapy
Antipyretics (acetaminophen and ibuprofen) or analgesics may be used. Use acetaminophen with
caution in high doses to avoid hepatotoxicity. Use ibuprofen with caution in patients with vomiting,
diarrhea, and poor fluid intake, because dehydration predisposes to ibuprofen-induced renal
insufficiency. Avoid alternating antipyretic therapy. Encourage parents to choose one agent, inform
them of any adverse effects, and educate them about symptoms of these effects (e.g., hepatotoxicity
or renal insufficiency).
Narcotic analgesics may be used for moderate to severe pain not controlled with acetaminophen or
ibuprofen.
Topical analgesics include otic solutions, such as antipyrine-benzocaine (Auralgan and Americaine
Otic) and naturopathic agents (Otikon Otic Solution).
Topical antimicrobials may have a place in therapy, particularly with ruptured membranes
(fluoroquinolone or fluoroquinolone and steroid combination otic suspensions [Floxin, Cipro HC,
and Ciprodex]).
Antihistamines and decongestants are ineffective at eliminating effusion or relieving symptoms.

Use them only if indicated for other signs or symptoms.
• Complete the entire course of prescribed antibiotics.
• Shake bottle well before administering dose. Follow labeling regarding temperature for storage of
medication.
• Contact the physician if patient develops a rash or has difficulty breathing, or if symptoms persist
after 72 hours of initiating therapy.
Adverse drug events
• Gastrointestinal effects: Nausea and diarrhea; discoloration of stools (with cefdinir)
• Hypersensitivity: Rash and anaphylaxis
Drug interactions
Drug interactions may occur with macrolides, particularly erythromycin and clarithromycin.
Nondrug therapy
Local heat or cold therapy may be used (counsel the caregiver on appropriate use and technique to
prevent burn injury).
Tympanostomy tubes decrease recurrent episodes, restore hearing, and relieve discomfort. Risks
include anesthesia and permanent tympanic membrane scarring.
Observation therapy
Observation therapy is appropriate only when follow-up at 48-72 hours can be ensured and
antimicrobials initiated if symptoms persist or worsen. This therapy is not appropriate for the
following:
• Infants < 6 months of age
• Infants and children between 6 months and 2 years of age with a certain diagnosis (nonsevere or
severe illness) or an uncertain diagnosis (severe illness)
• Children 2 years of age with a certain diagnosis and severe illness
A nonsevere illness is mild otalgia and fever < 39°C or 102.2°F. A severe illness is moderate to
severe otalgia or fever e 39°C or 102.2°F.
Immunization and immunoprophylaxis
Pneumococcal conjugate vaccination should provide some protection against strains responsible for
a majority of bacterial otitis media.
Haemophilus influenzae type B vaccination is of no benefit in otitis media. Most strains causing
otitis media are nontypeable and not prevented by vaccination.
Killed and live-attenuated intranasal influenza vaccine may decrease episodes of acute otitis media
during the respiratory season. Most children studied were less than 2 years of age.
Risk reduction
• Alter day care attendance (when possible).
• Adopt exclusive breast-feeding for 6 months.
• Avoid supine bottle feeding.
• Reduce or eliminate pacifier use after 6 months of age.
• Eliminate passive exposure to tobacco smoke.
Recurrent otitis media
Prophylaxis with half therapeutic dosing of amoxicillin or sulfisoxazole has been initiated in high-
risk patients; however, this practice is no longer recommended because of concerns over emergence
of drug-resistant organisms.
Otitis media with effusion
The AAP, AAFP, and the American Academy of Otolaryngology-Head and Neck Surgery
published a clinical practice guideline on otitis media with effusion in 2004. It applies to infants and
children (2 months to 12 years of age) with or without developmental disabilities or underlying
conditions that predispose patients to otitis media with effusion. Recommendations include the
following:
• Use pneumatic otoscopy as the primary diagnostic method.
• Distinguish otitis media with effusion from acute otitis media.
• Determine the risk of speech, language, and learning problems.
• At-risk children: More rapid evaluation and intervention
• Children not at risk: Watchful waiting for 3 months from date of onset or diagnosis
• No role exists for antihistamines, decongestants, antimicrobials, or corticosteroids.
• Hearing testing is recommended with effusion lasting 3 months or when language delay,
learning problems, or hearing loss exists.
• For persistent otitis media with effusion (not at risk), perform evaluations every 3-6 months until
effusion is resolved, hearing loss is identified, structural abnormalities are suspected, or the child
becomes a surgical candidate (tympanostomy tube insertion is preferred).
Otitis Externa
Otitis externa is an inflammation of the outer ear canal, also referred to as swimmer's ear.
Patients present with itching, pain, otic exudate, and hearing impairment
Pathophysiology
Moisture is present in the ear canal and the integrity of the ear canal is disrupted. The most common
organisms are Pseudomonas aeruginosa and Staphylococcus aureus. Other pathogens include fungi
and Bacillus and Proteus species.
Therapy consists of antibiotic or steroid otic preparations such as neomycin, polymyxin, and
hydrocortisone (Cortisporin Otic) or neomycin, colistin, and hydrocortisone (Coly-Mycin S Otic).
Fluoroquinolone otic preparations such as ciprofloxacin (Cipro HC) and ofloxacin (Floxin) can also
be used, as well as acetic acid and hydrocortisone otic preparations (VoSol HC Otic) or oral
analgesics.
Preventive measures include drying ears after exposure to moisture; using drops containing
isopropyl alcohol, with or without acetic acid to reduce pH; and avoiding cotton swabs.
According to a 1994 special report of the American Pharmaceutical Association, otic drops should
be applied as follows:
1. Wash hands before and after administration.

2. Warm otic drops to room temperature by holding bottle in hands for several minutes. Avoid
instilling cold or hot drops into the ear canal.
3. Shake the bottle if indicated on the label.
4. Tilt the child's head to the side or have the child lie down.
5. Pull the child's ear backward and upward and instill the drops in the ear canal. Do not put the
dropper bottle inside the ear canal. To remain free from contamination it should not come into
contact with the ear.
6. Press gently on the small flap over the ear to push the drops into the canal.
7. Have the child remain in the same position for the period of time indicated in the labeling. If this
is not possible, place a cotton ball gently into the ear to prevent the drops from draining out of the
ear canal.
8. Wipe excess medication from the outside of the ear.
Cystic Fibrosis
Cystic fibrosis is an autosomal recessive disease of exocrine gland function resulting in abnormal
mucus production.
Genetic classification
Cystic fibrosis is the result of a gene mutation on the long arm of chromosome 7. The protein
encoded by this gene, the cystic fibrosis transmembrane regulator (CFTR), is a channel involved in
the transport of water and electrolytes.
Defects in processing
The most common genetic mutation involves a 3-base-pair deletion at position 508 (”F508).
Patients homozygous for F508 are pancreatic insufficient.
Prognosis is not as good as that for patients who are pancreatic sufficient. Defects exist in protein
production, regulation, and conduction.
Pulmonary complications
Initial manifestations include chronic cough, wheezing, hyperinflation of lungs, or lower respiratory
tract infections. Patients present with hypoxia, clubbing, labored breathing, and acute respiratory
exacerbations (fever, sputum production, increased oxygen requirements, and dyspnea); changes in
forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and residual volume;
and the development of a chronic obstructive picture as the disease progresses.
Gastrointestinal complications
Gastrointestinal complications include poor digestion of proteins and fats, resulting in foul-smelling
steatorrhea, and distal intestinal obstruction (commonly manifested as vomiting of bilious material,
abdominal distension, and pain).
Infants may have meconium ileus and gastroesophageal reflux.
Other complications
Patients may also have the following complications:
• Cirrhosis and cholelithiasis
• Problems with pancreatic function
• Insulin insufficiency and diabetes mellitus
• Malnutrition
• Nasal polyps and sinusitis, anemia, arthritis, osteopenia, and osteoporosis
Pathophysiology
A defect exists in the chloride transport channel in secretory epithelial cells. Normally, chloride is
transported out of blood followed by sodium and water. However, with cystic fibrosis, decreased
chloride and water secretion and increased sodium absorption lead to thick, dehydrated secretions
and mucus. Exocrine gland involvement includes pancreas, hepatobiliary ducts, gastrointestinal
tract, and the lungs (secretions build up and block airways and pancreatic and hepatobiliary
exocrine flow).
Pulmonary system
Initial obstruction of small airways with mucus plugging results in bronchiolitis and persistence of
bacteria, as follows:
• Early bacterial pathogens: Staphylococcus aureus and Haemophilus influenzae present in

younger patients.
• Later bacterial pathogens: Pseudomonas aeruginosa is the primary pathogen in late childhood.
• Other bacterial pathogens: Proteus and Klebsiella species, Stenotrophomonas maltophilia, and
Burkholderia cepacia can be present.
Viral pathogens can also be present.
Chronic pulmonary infection and inflammation progress to large airway and eventual chronic
obstructive disease.
Pancreatic system
Pancreatic enzyme insufficiency (trypsin, chymotrypsin, lipases, and amylase) and decreased
bicarbonate secretion (necessary for optimal pancreatic enzyme activity) can occur. Thus,
maldigestion of fats and proteins and fat-soluble vitamin deficiency may develop.
Insulin insufficiency (resistance and decreased secretion) leads to glucose intolerance and the
development of diabetes mellitus (occurs later in the disease process and may be associated with
increased morbidity and mortality).
Biliary system
Biliary cirrhosis or fatty infiltration may lead to portal hypertension, development of bleeding
varices, hypersplenism, and cholelithiasis.
Sweat glands
A high concentration of sodium and chloride exists in sweat (representing the failure of sweat
glands to reabsorb sodium and chloride).
Reproductive system
Male infertility is common because of bilateral absence of vas deferens. Female infertility is due to
abnormal cervical mucus.
Diagnostic criteria
Laboratory confirmation of CFTR dysfunction should be obtained through sweat chloride analysis
(i.e., administration of pilocarpine):
• Sweat is collected and electrolytes are measured.
• Chloride of 60 mEq/L or more is diagnostic (values of up to 80 mEq/L have been seen in non-
cystic fibrosis patients).
• Levels of 50-60 mEq/L are indeterminate, and tests may need to be repeated.
Presence of clinical characteristics of cystic fibrosis should also be observed.
Treatment goals
• Halt or decrease disease progression.
• Maintain normal growth and development and nutrition status.
• Maintain pulmonary function.
• Optimize drug therapy for pharmacokinetic differences in cystic fibrosis patients.
Drug therapy
Drug therapy for cystic fibrosis is described in

Table 33-3.
Antibiotic therapy in acute exacerbations

Empiric therapy should be used initially. The patient should then be treated on the basis of sputum
culture and sensitivity. Administer intravenously two antibiotics for 14-21 days in combination with
aggressive therapy for clearance of secretions. Provide coverage for Staphylococcus aureus,
Haemophilus influenzae, and Pseudomonas aeruginosa.
Double coverage of antibiotics is needed when Pseudomonas species are suspected, so typically use
an antipseudomonal penicillin (piperacillin, mezlocillin, piperacillin-tazobactam, ticarcillin-
clavulanate, ticarcillin, aztreonam, meropenem, or imipenem) or a cephalosporin (ceftazidime) plus
an aminoglycoside (tobramycin).
Most S. aureus are -lactamase producers, so use an extended spectrum penicillin— -lactamase
inhibitor combination (e.g., ticarcillin-clavulanate). Use vancomycin for methicillin-resistant S.
aureus.
Burkholderia and Stenotrophomonas species are commonly resistant. Follow culture and sensitivity
results. Antibiotics that may be effective include trimethoprim-sulfamethoxazole, chloramphenicol,
ceftazidime (B. cepacia), doxycycline, and piperacillin (S. maltophilia).
Other agents include ciprofloxacin.
Antibiotic therapy and chronic suppression

Chronic inhaled antibiotic therapy with tobramycin
This therapy results in significant improvement in FEV1, decreased hospitalizations, and decreased
need for IV antibiotics. Decreased systemic concentrations (i.e., less resistance) and high pulmonary
concentrations appear. However, therapy is expensive.
Oral antibiotic therapy

Fluoroquinolones are the only oral antibiotics with good coverage against Pseudomonas.
Compliance with therapeutic regimens is important.
Pancreatic enzyme supplementation
• Give immediately before or during snacks and meals.
• Capsule may be opened and contents sprinkled on applesauce or other acidic carrier.
• Contents should not be crushed or chewed.
Aminoglycosides
• Monitor urine output.
• Use ibuprofen with caution if dehydration, diarrhea, or decreased oral intake is present.
Adverse drug events
• Aminoglycosides: Nephrotoxicity and ototoxicity
• Ibuprofen: Renal insufficiency
• Fluoroquinolones: Arthropathy
[Table 33-3. Drug Therapy for Cystic Fibrosis]
Drug interactions
Pancreatic enzymes and acid suppression therapy may decrease inactivation of enzymes by gastric
acid, thereby reducing dose requirement.
Clinical status should be monitored:
• Fever and activity level
• Pulmonary function (as indicated by FEV1, FVC, residual volume, and chest radiography)
Pharmacokinetic considerations
Aminoglycosides
• Increased clearance and larger Vd, necessitating greater dosing
• Concentration-dependent killing
• Postantibiotic effect against Gram-negative organisms
• Higher doses (10 mg/kg/day tobramycin)
• Peak concentrations from 8-12 mcg/mL
• Trough concentrations of less than 2 mcg/mL
-Lactams
• No change or increased clearance
• No change or increased Vd
• No postantibiotic effect or concentration-dependent killing
Fluoroquinolones
• Concentration-dependent killing
• Postantibiotic effect against Gram-negative organisms

Nondrug therapy
Pulmonary percussion therapy and postural drainage

The purpose of this therapy is to clear mucus and secretions from the pulmonary system. Therapy is
conducted once or twice per day and up to five times daily or more. Percussion is usually conducted
after nebulization therapy with or without bronchodilator or mucolytic. Therapy with handheld
devices or oscillatory vests can be done.
Transplantation
Lung transplantation is an option. Liver-lung transplantation can be done if there is liver
involvement.
Attention-Deficit/Hyperactivity Disorder
According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV), attention-deficit/hyperactivity disorder (ADHD) is a behavioral disorder of
childhood onset (by age 7) characterized by symptoms of inattentiveness and impulsive or
hyperactive behavior.
Classification
DSM-IV makes the following classifications:
• Combined type: Criteria for inattention, hyperactivity, and impulsivity are met.
• Predominantly inattentive type: Criteria for inattention are met, but not for hyperactivity and
impulsivity.
• Predominantly hyperactive and impulsive type: Criteria for inattention are not met, and criteria
for hyperactivity and impulsivity are met.
• ADHD not otherwise specified.
• Inattention: The child has difficulty paying attention, daydreams frequently, is easily distracted
and disorganized, and loses things frequently.
• Hyperactivity: The child has difficulty staying seated and talks too much.
• Impulsivity: The child acts and speaks out without thinking, and the child also interrupts others
frequently.
Pathophysiology
ADHD results from an imbalance in catecholamine neurotransmission (specifically between
dopamine and norepinephrine).
Genetic basis
Genetic studies have primarily evaluated genes involved in neurotransmission. ADHD is likely to
be due to the interaction of many genes. Most evidence currently indicates that dopamine
transmitter (DAT-1) and dopamine D2 and D4 receptors are responsible (dopamine and
norepinephrine are potent agonists of the D4 receptor).
Diagnostic criteria
Diagnostic criteria must be met for accurate diagnosis. Diagnosis is based on DSM-IV criteria that
six or more of the criteria for inattention or hyperactivity and impulsivity are met for at least 6
months "to a degree that is maladaptive and inconsistent with developmental level."
Some impairment should be present before age 7. Impairment should be present in at least two
settings (e.g., home and school). Evidence of clinically significant impairment in functioning should
also be present.
Symptoms must not be related to another illness (e.g., schizophrenia or mood disorder).
Treatment goals
• Educate the patient and family.
• Improve functioning and behavior.
• Achieve effective drug therapy with minimal side effects.
Drug therapy
Table 33-4 describes drug therapy for ADHD.
Patient counseling
Advise patients and caregivers of the need to store medications away from other children or siblings
because of the potential for lethal overdose (tricyclic antidepressants) and for abuse (stimulants).
Adverse drug events

Stimulants cause anorexia, abdominal pain, headache, insomnia, jitteriness, social withdrawal,
transient motor tics, and weight loss (not height dependent).
Methylphenidate is contraindicated in a seizure disorder according to the package insert (i.e., it

lowers the seizure threshold). Canada has suspended marketing of Adderall XR because of concern
over reports of sudden death and stroke in patients taking Adderall or Adderall XR.
Tricyclics carry cardiotoxicity risk (sudden death). Patients should undergo electrocardiogram
(ECG) testing prior to initiation of therapy and periodically throughout therapy.
Bupropion may lower the seizure threshold. Seizures are associated with high doses and a previous
history of seizure disorders. Minimize risk by dividing the daily dose or by using the extended-
release formulation.
Labeling for all the stimulants and for atomoxetine includes warnings for an increased risk of
psychosis or mania, aggression or violent behavior, and anxiety or panic attacks. Atomoxetine
labeling includes warnings for an increased risk of suicidal ideation in children and adolescents and
for the potential for severe liver injury.
Drug interactions
Methylphenidate
• Methylphenidate should not be given with monoamine oxidase (MAO) inhibitors (severe
hypertension).
• Caffeine may enhance stimulant effects.
• Methylphenidate may inhibit metabolism of phenytoin, phenobarbital, warfarin, and tricyclics.
Tricyclics
• Multiple pharmacodynamic and pharmacokinetic drug interactions exist.
• Increased plasma concentrations of tricyclics could result in potential toxicity when certain
antidepressants are added to the regimen (fluoxetine, sertraline, fluvoxamine, paroxetine) as well
as with cimetidine, methylphenidate, diltiazem, quinidine, and verapamil.
• Decreased concentrations of tricyclics may be seen with concomitant administration of

carbamazepine and phenytoin.
• Increased therapeutic effect and potential toxicity may occur with MAO inhibitors.
• Increased central nervous system depressant effects occur with alcohol and sedatives.
Recommendations for therapy and monitoring

The efficacy of therapy should be monitored. Assess behavior changes and evaluate feedback from
teachers and parents.
Stimulants
Begin with a low dose, and titrate upward to optimal functioning ability. The patient may need a
decreased dose if side effects occur or if no further improvement is seen with the larger dose.
No therapeutic drug monitoring or ECG monitoring is needed.
If one stimulant fails, try another stimulant for the patient. For children who fail two stimulants, try
a third type of stimulant.
Tricyclics
Initial and periodic ECGs are needed.
Pharmacokinetic considerations
Methylphenidate does not distribute well into adipose tissue (dose on milligram basis instead of
milligrams per kilogram).
Nondrug therapy
• Behavioral techniques (e.g., positive reinforcement, time out, response cost, and token economy)
• Environmental modifications
• Classroom management
Conjunctivitis
Conjunctivitis is an inflammation of the conjunctiva of the eye.
[Table 33-4. Drug Therapy for Attention-Deficit/Hyperactivity Disorder]
Classification
Conjunctivitis may be bacterial, viral, or allergic.
Conjunctivitis is characterized by redness of the eye, itching, ocular discharge, foreign body
sensation, and crusting of the eye and eyelid. Patient may have altered vision because of the
presence of discharge.
Pathophysiology
Conjunctivitis of the newborn

Inflammation of the conjunctiva often occurs in the first month of life. Causative agents include
topical antimicrobial agents; bacteria (primarily Neisseria gonorrhoeae, Chlamydia trachomatis,
Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, Escherichia coli,
and other Gram-negative bacteria); and viruses (primarily herpes simplex).
Bacterial conjunctivitis (beyond first month of life)

The most common bacteria are Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus
pneumoniae, and Haemophilus influenzae (also gonococcal and chlamydial). Treat bacterial
conjunctivitis with antibiotic therapy.
Viral conjunctivitis
Viral conjunctivitis, also known as pink eye, is contagious. Adenovirus is the most common
causative agent.
This condition is commonly preceded by a cold or sore throat or exposure to another person with
viral conjunctivitis.
Herpes simplex (corneal involvement may yield permanent visual damage) may also be seen.
Allergic conjunctivitis
Allergic conjunctivitis is caused by exposure to dander, pollen, or topical eye preparation. Most
patients will exhibit itching of the eye.
Diagnostic criteria
Diagnosis is based on the patient's symptoms.
Treatment goals
• Eliminate or avoid the allergen (allergic conjunctivitis).
• Treat the underlying infection (bacterial conjunctivitis).
• Decrease severity and provide symptomatic relief (all forms).
Drug therapy
Neonatal
Preventive medicine includes prophylaxis after delivery with antibacterial ophthalmic ointment
(erythromycin, tetracycline, silver nitrate, and povidone-iodine):
• Onset day 1: No treatment (secondary to prophylaxis after delivery)
• Onset days 2-4 (Neisseria gonorrhoeae): Penicillin G or ceftriaxone for 7 days
• Onset days 3-10 (Chlamydia trachomatis): Oral erythromycin + erythromycin ointment for 14
days
• Onset days 2-16 (herpes simplex): Possibly IV acyclovir
Bacterial (beyond first month of life)

Topical antibiotic therapy (bacitracin-polymyxin B, trimethoprim-polymyxin B, erythromycin, or
fluoroquinolone [ciprofloxacin, gentamicin, or tobramycin]) should be used in combination with an
antibiotic ointment (erythromycin or bacitracin) at bedtime for 5-7 days.
Gonococcal
Ceftriaxone should be used for one dose. With corneal ulceration, use systemic IV ceftriaxone
therapy. Also treat for Chlamydia species.
Chlamydial
For adults, oral tetracycline or doxycycline is administered for 2-3 weeks. Administer a single dose
of azithromycin to children.
Viral
Ocular lubricant (artificial tears) should be administered every 3-4 hours while the patient is awake.
Allergic
Remove allergen. Use ocular lubricant (artificial tears); ocular decongestants (phenylephrine,
naphazoline, tetrahydrozoline, and oxymetazoline: ±-adrenergic activity); antihistamines
(olopatadine [Patanol]); antihistamine-decongestant combination products (pheniramine and
naphazoline [Naphcon-A, Opcon-A, and Visine-A]); topical mast cell stabilizer (cromolyn sodium);
combination mast cell stabilizer and antihistamine; or oral antihistamine therapy.
Adverse drug events

Ocular decongestants can cause rebound congestion of the conjunctiva. This reaction is less
common with naphazoline and tetrahydrozoline.
Instilling of eye drops and ointment

Wash hands before and after administration. Tilt head back, grasp lower eyelid and pull away from
eye, place dropper or ointment tube over eye, and have the child look up immediately before
instilling the drop.
For ointment, use a sweeping motion and instill 0.25 to 0.5 inch of ointment inside eyelid. Close
eye after instillation, and wait 1-2 minutes. Blot excess ointment or solution away from around the
eye. Vision may be temporarily blurred with ointment administration.
Wait 5 minutes between drops for multiple drop therapy. For suspension, place that drop in the eye
last. For use of both ointment and drops, instill drops first and wait 10 minutes before applying
ointment.
• Wash hands.
• Do not share towels or linens.

• Store products according to labeling instructions.
Nondrug therapy
Cold compresses are a helpful nondrug therapy.
Recent Pediatric Medication Issues and Labeling Changes
In October 2004, the U.S. Food and Drug Administration (FDA) mandated black box warnings for
all antidepressants regarding the potential for increased suicidal behavior in children.
In January 2005, the FDA sent out a letter warning health care professionals that the use of
promethazine is contraindicated in children under age 2 because of the risk of respiratory
depression and death.
In July 2005, the FDA mandated black box warnings for the use of fentanyl. The FDA mandated
that fentanyl should not be used in children under age 2 and should only be used in children 2 years
of age or older if they are already using other opioid narcotic pain medicines (i.e., they are opioid
tolerant).
In January 2006, the FDA requested the addition of boxed warnings to the labeling for Elidel Cream
(pimecrolimus) and Protopic Ointment (tacrolimus) to notify patients about the possible risk of
cancer. Use of these drugs in children under age 2 is not recommended.
In May 2006, the FDA requested labeling changes for Serevent Diskus (salmeterol xinafoate
inhalation powder), Advair Diskus (fluticasone propionate and salmeterol inhalation powder), and
Foradil Aerolizer (formoterol fumarate inhalation powder) to include a warning that these
medicines may increase the risk of severe asthma attacks and death when these attacks occur.
In August 2007, a letter was sent out warning health care professionals about the concomitant use of
ceftriaxone and IV calcium-containing products and the risk of ceftriaxone and calcium
precipitation. Deaths attributable to intravascular and pulmonary precipitates have occurred in
neonates. Ceftriaxone should not be used in neonates (d 28 days of age) if they are receiving or are
expected to receive calcium-containing IV products.
In October 2007, the FDA recommended that over-the-counter cough and cold medicines not be
used in infants and children under age 2 because of the risk of serious and potentially life-
threatening side effects.
In January 2008, the FDA mandated labeling changes for antiepileptic agents to include a warning
about the risk of suicidal thoughts or actions.
33-3. Key Points
• The pharmacokinetics and pharmacodynamics of medications are altered by developmental

differences in absorption, distribution, metabolism, and elimination in pediatric patients.
• Pharmacotherapy should be adjusted according to the developmental differences to optimize

therapeutic efficacy while minimizing the risk of toxicity.
• Although spontaneous resolution does occur in many cases of acute otitis media, antibiotic
therapy is initiated to prevent complications such as meningitis and mastoiditis. The observation
option is an acceptable initial treatment for select patients depending on age, certainty of
diagnosis, and disease severity.
• The incidence of drug-resistant Streptococcus pneumoniae is increasing. Because of its safety

profile, cost, and excellent pharmacodynamic profile against sensitive and drug-resistant S.
pneumoniae, amoxicillin remains the drug of choice for uncomplicated and nonsevere acute otitis
media. Higher doses should routinely be used.
• Therapy for cystic fibrosis should focus on halting the progression of the disease and maintaining
pulmonary function. Appropriate therapies decrease mucus viscosity and increase clearance of
secretions; manage acute infectious exacerbations; and by using appropriate pancreatic enzyme
supplementation, maintain normal growth and development.
• Pharmacokinetics of medications in cystic fibrosis patients may be altered; therapeutic drug

monitoring and dose alterations should be conducted to ensure efficacy and decrease toxicity.
• An accurate diagnosis of attention-deficit/hyperactivity disorder, a behavioral disorder of

childhood onset characterized by inattentiveness, hyperactivity, and impulsivity, should be
obtained prior to initiating drug therapy.
• Pharmacotherapy for ADHD is with stimulants (first line) and antidepressants (second line).
• ADHD pharmacotherapy should be titrated to the desired functional effect without increasing the
risk of side effects.
• ADHD therapy should include behavioral modification. Monitoring of drug and nondrug therapy
should include input from different environments (i.e., parents and teachers).
• Bacterial and viral conjunctivitis may occur in the first month of life. Antimicrobial ointment
administration should be instituted after delivery for prophylaxis.
• Bacterial, viral, and allergic conjunctivitis should be treated with antimicrobial therapy (bacterial);
symptomatic therapy (bacterial, viral, and allergic); and ocular antihistamines, decongestants,
mast cell stabilizers, or combination products (allergic).
33-4. Questions
J. S., a 4-day-old infant (37 weeks' gestation, birth weight 3.2 kg, length 52 cm), has been
admitted to the hospital secondary to spiking temperatures. J. S. has demonstrated decreased
oral intake and irritability since being discharged home from the newborn nursery 2 days ago.
J. S. is started on IV fluid at maintenance volume and antimicrobial therapy with ampicillin
165 mg IV q6h and gentamicin 8 mg IV q8h. Cultures have been obtained and are pending
from blood, urine, and CSF. Laboratory assessment includes the following: Na 142 mEq/L, K
3.5 mEq/L, Cl 108 mEq/L, HCO3 22 mEq/L, BUN 15 mg/dL, SCr 0.9 mg/dL, and Glc 88
1.
mg/dL. What is J. S.'s estimated creatinine clearance (in milliliters per minute)?
A. 100
B. 80
C. 60
D. 50
E. 25

Which of the following may affect the creatinine clearance estimate in this patient?
I. The presence of maternal serum creatinine

II. Decreased glomerular filtration rate
III. Increased tubular secretion rate
2.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Aminoglycosides are hydrophilic compounds. Which of the following is true regarding
aminoglycoside pharmacokinetic parameters in premature neonates compared with those in
adults?
3. A. Increased clearance
B. Increased Vd
C. Decreased half-life
D. Unchanged elimination
E. Increased liver metabolism

Which of the following may complicate phenytoin therapy in a 2-day-old infant with new-onset
seizures?
I. Hypoalbuminemia
II. Physiologic jaundice
III. IV lipid therapy
4.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

A drug metabolized through which of the following reactions is a concern in the neonatal
population?
A. Hydrolysis
5.
B. Reduction
C. Sulfation
D. Glucuronidation
E. Methylation

M. J., a 7-month-old female, is brought to your pharmacy by her mother, who describes the
infant as having new onset of fever (102.5°F) and increased irritability in the past 24 hours.
The mother states that she stayed home with M. J. today instead of sending her to day care. M.
J. has been bottle-fed since birth. Family history is significant for an older sibling with a recent
upper respiratory tract infection. Examination of her ear canal using a pneumatic otoscope
reveals a bulging, red tympanic membrane with no mobility on negative or positive pressure.
Computer records reveal she has been treated for acute otitis media twice since birth (at 3 and
6. 5 months of age). Decisions for antimicrobial therapy in this patient should be based on
coverage for which of the following pathogens?
A. Staphylococcus epidermidis, Streptococcus pneumoniae, and Pseudomonas aeruginosa

B. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis
C. Haemophilus influenzae, Streptococcus pyogenes, and Pseudomonas aeruginosa
D. Streptococcus pneumoniae, Staphylococcus aureus, and Moraxella catarrhalis
E. Staphylococcus epidermidis, Pseudomonas aeruginosa, and Burkholderia cepacia

The drug of choice for M. J.'s current episode of acute otitis media is
A. amoxicillin.
7. B. amoxicillin-clavulanate.
C. IM ceftriaxone.
D. cefixime.
E. trimethoprim-sulfamethoxazole.

When the pharmacist is counseling M. J.'s mother about the antibiotic suspension prescribed by
M. J.'s physician, which of the following should be discussed?
I. Risk factors for otitis media

II. Whether the suspension should be refrigerated
III. The need to shake the suspension vigorously prior to administration
8.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Which of the following is a common side effect of amoxicillin-clavulanate therapy?
A. Hemolytic anemia
9. B. Liver function test abnormalities
C. Pancreatitis
D. Diarrhea
E. Headache

Which of the following is a side effect that should be a concern in a child with acute otitis
media and nausea and vomiting who is receiving ibuprofen for fever?
A. Stevens-Johnson syndrome
10.
B. Renal insufficiency
C. Hyponatremia
D. Oral candidiasis
E. Liver failure

How is otitis externa, or swimmer's ear, best treated?
A. Instill an antimicrobial and steroid solution into the ear canal.

11. B. Apply antimicrobial ointment into the ear canal with a cotton swab.
C. Instill an antihistamine solution into the ear canal.
D. Increase pH of the ear canal with administration of Burow's solution.
E. Decrease pH of ear canal with administration of dilute HCl solution.

R. E., age 15, weighs 40 kg and has cystic fibrosis. R. E. is admitted to the hospital secondary
to an acute pulmonary exacerbation. Home medications include Ultrase as directed, TOBI
nebulization, ADEK qd, and dornase alfa (qd nebulization). She is started on ceftazidime 2 g
IV q8h and tobramycin 130 mg IV q8h. Which of the following should be ordered in this
patient?
12.
A. Serum tobramycin peak concentration
B. Serum tobramycin trough concentration
C. Serum tobramycin peak and trough concentrations
D. Sputum ceftazidime concentration
E. Sputum ceftazidime and tobramycin concentrations

Sputum cultures taken from R. E. shortly after hospital admission are positive for
Staphylococcus aureus (non-methicillin sensitive). Which of the following agents should be
initiated at this time?
13. A. Oxacillin
B. Ticarcillin
C. Piperacillin
D. Vancomycin
E. Amikacin

Which of the following is a pancreatic enzyme supplement?
A. Actigall
14. B. Beractant
C. Creon
D. Diabinese
E. Pulmozyme

Which of the following can be used to decrease the viscosity of pulmonary secretions?
A. Exosurf
15. B. Mucomyst
C. Protilase
D. Liquaemin
E. Serevent

Counseling a patient on the use of pancreatic enzyme supplementation should include which of
the following?
A. Capsules may be opened and sprinkled over any food.

16.
B. Capsule contents should not be crushed or chewed.
C. The total daily dose may be given at one time in the evening.
D. Adequate supplementation will increase bowel movement frequency.
E. The supplementation dose should not change with diet changes.

N. G., age 8, has newly diagnosed attention-deficit/hyperactivity disorder. Which of the
following is not considered first-line therapy for N. G.?
A. Ritalin
17.
B. Dexedrine
C. Wellbutrin
D. Adderall
E. Methylin

Atomoxetine is associated with which of the following serious adverse effects?
A. Hepatic injury
18. B. Renal failure
C. Cardiovascular collapse
D. Anaphylaxis
E. Toxic epidermal necrolysis

T. S., age 9, is being started on imipramine therapy after failing therapy for ADHD with
several different stimulants. T. S. has two other siblings, a 15-year-old brother and a 3-year-old
sister. The pharmacist instructs T. S.'s parents to keep the medicine away from siblings and in a
safe place. What is the most likely reason for the pharmacist's concern?
I. Toxicity of imipramine with overdose

II. Abuse potential of imipramine
19.
III. Stability of imipramine product
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

A decrease in seizure threshold is a side effect of which of the following agents used for
ADHD?
I. Methylphenidate
II. Bupropion
III. Clonidine
20.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Every spring, M. S. develops itchy, red eyes, which are often swollen and draining. Which of
the following is the most likely cause of this ocular disorder?
A. Viral conjunctivitis
21.
21.
B. Bacterial conjunctivitis
C. Allergic conjunctivitis
D. Blepharitis
E. Episcleritis

Which of the following therapies is not an appropriate recommendation for M. S.'s symptoms?
A. Ocular lubricant
22. B. Ocular decongestant
C. Ocular antihistamine
D. Ocular mast cell stabilizer
E. Ocular antimicrobial

Which of the following is not commonly associated with conjunctivitis?
A. Chlamydia
23. B. Neisseria
C. Staphylococcus
D. Streptococcus
E. Clostridium

Which of the following is a side effect of the prolonged use of ocular decongestants?
A. Peripheral vasodilation
24. B. Rebound conjunctival congestion
C. Development of arrhythmias
D. Development of tolerance
E. Development of allergy to product

33-5. Answers
E. Using the Schwartz equation, J. S.'s estimated creatinine clearance is 26 mL/min (CrCl =
1.
0.45 × 52/0.9).

C. The presence of maternal serum creatinine that decreases in neonates over the first week of
life may cause a false underestimate of creatinine clearance to be calculated during this time. If
one assumes that by the end of the first week of life, J. S.'s SCr has decreased to within the
2.
normal infant range to 0.4 mg/dL, the estimated CrCl would be 59 mL/min (CrCl = 0.45 ×
52/0.4). Other factors that affect creatinine clearance in the neonate and infant include a
decreased glomerular filtration rate and a decreased tubular secretion rate.

B. Aminoglycosides are hydrophilic compounds; they will exhibit larger volumes of
3. distribution in patients with greater total body water. Neonates and infants have greater total
body water, greater extracellular fluid volume, and a relative lack of adipose tissue.

E. Phenytoin is a highly plasma protein-bound drug. The total and free concentrations of highly
protein-bound drugs may be altered because of developmental differences in protein binding
(decreased protein concentrations and altered binding capacity) and displacement by
endogenous substances (e.g., free fatty acids and unconjugated bilirubin). Physiologic jaundice,
as exhibited by increasing total and unconjugated bilirubin concentrations, may occur in the
4. neonatal period. Unconjugated bilirubin may displace drugs from albumin binding sites.
Additionally, one of the by-products of lipid metabolism, free fatty acids, may also displace
drugs from albumin binding sites (thereby increasing the free drug concentration). Kernicterus
(also known as yellow brain) may occur when unconjugated bilirubin displaced by drugs or
other endogenous substances (i.e., free fatty acids) crosses the blood-brain barrier, where it can
deposit in the brain and cause neurologic complications.

D. UDPG (uridinediphosphoglucose)-glucuronyl transferase is responsible for conjugation of
endogenous substances (bilirubin) and medications (morphine and chloramphenicol). The
capacity for glucuronidation metabolism does not begin until around 2 months of age and
reaches adult capacity by 2 years of age. Medications metabolized through this system are
5.
potential toxins in the neonatal population. An example would be the use of chloramphenicol
in neonates and the development of "gray-baby syndrome" because of drug accumulation.
Hydrolysis, reduction, sulfation, and methylation are functional in the neonatal period and
should not pose drug therapy complications in this population.

B. The most common pathogens in acute otitis media are Streptococcus pneumoniae (40-50%),
6.
Haemophilus influenzae (20-30%), and Moraxella catarrhalis (10-15%).

B. Despite the emergence of drug-resistant Streptococcus pneumoniae, amoxicillin—because
of its excellent pharmacodynamic profile, side effect profile, and cost—remains the drug of
choice in uncomplicated and nonsevere acute otitis media. However, amoxicillin-clavulanate is
now considered first-line therapy in patients with severe illness. This patient is considered to
7. be in the high-risk group (age < 2 years, day care attendance, and recurrent otitis media) and
should be treated with antibiotics. High-dose therapy with amoxicillin-clavulanate (90
mg/kg/day amoxicillin and 6.4 mg/kg/day clavulanate) should be used first line in this patient
because of symptoms consistent with severe illness (moderate or severe otalgia or fever of
39°C or 102.2°F or greater).

E. Counseling should include specific information about the antibiotic, its side effect profile,
storage information, information about administering the medicine, dosage instructions, the
8. importance of taking the full course, and the need to shake the bottle prior to administering the
dose. In addition, a discussion of risk factors for acute otitis media and preventive measures
(pneumococcal and flu immunization) is appropriate in a counseling session.

D. The most common side effects with amoxicillin-clavulanate therapy include rash, urticaria,
9. nausea, vomiting, and diarrhea. Although the other listed side effects may be seen with other
antibiotic therapies, they do not typically occur with amoxicillin-clavulanate therapy.

B. Dehydration, which may develop in a child who is vomiting, is a risk factor for ibuprofen-
induced renal insufficiency. If ibuprofen is used as an antipyretic or analgesic in pediatric
10. patients, the parents or caregivers should be counseled regarding this risk and the need to
follow intakes and outputs during the period of acute illness (i.e., gastroenteritis) when the
child may be receiving ibuprofen therapy.

A. The treatment of otitis externa includes the instillation of an antibiotic and steroid otic
solution into the ear canal. Cotton swabs should be avoided to prevent otitis externa.
Antihistamine solutions are not indicated in the treatment of otitis externa. Otic solutions
11.
containing acetic acid may also be of benefit in otitis externa by decreasing (not increasing) the
pH of the ear canal and lowering its bacteria-harboring potential. Hydrochloric acid in any
form should not be used in the ear canal.

C. Therapeutic drug monitoring is a critical part of the overall therapeutic plan in patients with
cystic fibrosis. Patients with cystic fibrosis exhibit altered pharmacokinetic parameters of
aminoglycosides, primarily increased clearance and greater volumes of distribution.
12. Tobramycin peak concentrations should be obtained to make sure the dose being given is
sufficient to reach concentrations of 8-12 mcg/mL, and trough concentrations should be
obtained to ensure adequate renal clearance (cystic fibrosis patients receive higher
milligram/kilogram doses).

D. S. aureus is a common pathogen in cystic fibrosis patients. Methicillin-sensitive S. aureus
13. may be treated with a number of agents (e.g., oxacillin); however, methicillin-resistant S.
aureus should be treated with vancomycin.

C. Creon is the brand name for a pancreatic enzyme supplement. Creon is available as a
14.
microencapsulated formulation.

B. Mucomyst is the brand name for N-acetylcysteine, which lowers mucus viscosity (the
15.
sulfhydryl group opens the disulfide bond in mucoproteins).

B. Pancreatic enzyme products are available in powder, tablet, and microencapsulated
formulations. The microencapsulated formulations may be opened and the contents sprinkled
over acidic foods (e.g., applesauce). Contents should not be crushed or chewed. Additionally,
16.
the dose should be based on the amount and type of food (i.e., full doses with meals or half-
doses with snacks and light meals). Adequate replacement will actually decrease bowel
movements and improve stool consistency (i.e., decrease steatorrhea).

C. All of the listed products are stimulants, with the exception of Wellbutrin. Stimulants are
17.
considered first-line therapy for ADHD; antidepressants may be considered second-line agents.

A. Atomoxetine's labeling has a warning about the potential for severe liver injury.
18. Atomoxetine should be discontinued in any patient who develops jaundice or laboratory
evidence of liver injury.

A. Overdose of tricyclic antidepressants may be fatal because of the development of
arrhythmias. Because T. S. has a younger sibling in the house, there is a potential for the child
19. to get into her older brother's medicine. Stimulants may have the potential for abuse in patients
who do not have ADHD (i.e., the 15-year-old brother), but tricyclic antidepressants are not
associated with a high abuse potential. There are no stability issues with imipramine.

C. Both bupropion and methylphenidate may lower the seizure threshold. Clonidine is not
20.
associated with seizure occurrence.

C. Allergic conjunctivitis occurs after exposure to allergens, primarily dander or pollen.
21.
Patients suffering from allergic conjunctivitis will typically complain of eye itching.

E. Antimicrobial therapy has no place in therapy for allergic conjunctivitis. Ocular lubricants,
22. decongestants, antihistamines, mast cell stabilizers, or combinations of these products are
appropriate options for allergic conjunctivitis.

E. The most common pathogens in neonatal bacterial conjunctivitis are Neisseria gonorrhoeae,
Chlamydia trachomatis, Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus
pneumoniae, and Escherichia coli. Bacterial conjunctivitis beyond the first month of life is
23.
most commonly caused by Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus
pneumoniae, and Haemophilus influenzae. Clostridium, an anaerobe, is not a common
bacterial pathogen in conjunctivitis.

B. Not unlike reactions from prolonged use of nasal decongestants, prolonged use of ocular
24. decongestants may cause rebound congestion of the conjunctiva. This effect is less pronounced
with naphazoline and tetrahydrozoline.

33-6. References
American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of stimulant
medication in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc
Psychiatry. 2002;41(suppl 2):26S-49S.
American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck

Surgery, American Academy of Pediatrics Subcommittee on Otitis Media with Effusion. Otitis
media with effusion. Pediatrics. 2004;113: 1412-29.
American Academy of Pediatrics, Committee on Quality Improvement and Subcommittee on

Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline: Treatment of the school-
aged child with attention-deficit/hyperactivity disorder. Pediatrics. 2001;108:1033-44.
American Academy of Pediatrics, Committee on Quality Improvement and Subcommittee on

Attention-Deficit/Hyperactivity Disorder. Diagnosis and evaluation of the child with attention-
deficit/hyperactivity disorder. Pediatrics. 2000; 105:1158-70.
American Academy of Pediatrics, Subcommittee on Management of Acute Otitis Media. Diagnosis

and management of acute otitis media. Pediatrics. 2004;113:1451-65.
American Pharmaceutical Association. Special Report: Medication Administration Problem-

Solving in Ambulatory Care. Washington, D.C.: American Pharmaceutical Association; 1994:9.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-
IV), 4th ed. Washington, D.C.: American Psychiatric Association; 1994:78-85.
Beringer P. Cystic fibrosis. In: Herfindal ET, Gourley DR, eds. Textbook of Therapeutics: Drug and
Disease Management. 7th ed. Baltimore: Lippincott Williams & Wilkins; 2000:781-94.
Clinical Practice Guidelines for Cystic Fibrosis Committee. Clinical Practice Guidelines for Cystic
Fibrosis. Bethesda, Md.: Cystic Fibrosis Foundation; 1997.
Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media: Management and surveillance in an
era of pneumococcal resistance—A report from the Drug-Resistant Streptococcus pneumoniae
Therapeutic Working Group. Pediatr Infect Dis J. 1999; 18:1-9.
Dowell SF, Marcy SM, Phillips WR, et al. Otitis media—Principles of judicious use of
antimicrobial agents. Pediatrics. 1998;101:165-71.
Faden H, Duffy L, Boeve M. Otitis media: Back to basics. Pediatr Infect Dis J. 1998;17:1105-13.
Fiscella RG, Jensen MK. Ophthalmic disorders. In: Berardi RR, Ferreri SP, Hume AL, et al., eds.
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34. Geriatrics and Gerontology - William Nathan Rawls, PharmD
34-1. Overview
Introduction
Gerontology is the study of the problems of aging and all its aspects. Geriatrics focuses on the
diseases associated with aging and the treatments for those conditions. Geriatrics is of particular
concern for pharmacists.
More than 12% of the U.S. population is older than 65 years of age. By 2050, the percentage is
expected to increase to over 20%.
Persons over 65 years of age have more chronic illnesses and take more prescription and
nonprescription drugs than persons in younger age groups. The use of herbal or dietary supplements
by older adults has increased significantly in the last 10 years, with the increased risk of adverse
events and drug interactions.
Age-related physiologic changes and increased medication use contribute to a greater risk of
adverse drug events. Changes in vision, hearing, and mental functioning can result in increased
problems with medication compliance.
Adverse Drug Events in the Older Adult
Drug-related hospitalizations occur four times more often for older adults than for younger adults.
Older adults receiving multiple medications are at risk of a "prescribing cascade" that occurs when
an unrecognized adverse effect of a medication is treated as a new illness and additional
medications are prescribed.
Older adults are at increased risk of drug-drug interactions when taking multiple medications, and
this potential is decreased by medication simplification.
The possibility that a newly developed medical condition or worsening of an existing illness is
related to an older adult's medication or herbal use should be considered when a pharmacist is
making medication recommendations.
Changes in Pharmacokinetics Associated with Aging
Decreased absorption of various drugs occurs secondary to decreased stomach acidity and changes
in blood flow to the stomach (the least altered by aging).
Altered drug distribution is caused by a decrease in total body water, increased lipid storage, and
decreased serum albumin in malnourished elderly persons. These factors can contribute to increased
serum levels of drugs.
Decreased hepatic blood flow and reduced hepatic enzyme activity cause slower drug metabolism.
Increased levels of drugs require increased metabolism by the liver.
Elimination of drugs by the kidneys is slowed because of decreased renal blood flow and lowered
glomerular filtration. Thus, drug accumulation develops.
The Cockcroft-Gault formula for estimating creatinine clearance can be used to predict renal
function in the elderly:
Note: Use ideal body weight. The equation above is for males. For females, multiply the result by
0.85.
In dosing the elderly, the general rule is to start with lower doses than those used in younger
patients and to increase doses at a slower rate.
34-2. Drugs of Concern
The following drugs can cause psychiatric symptoms:
• Anticholinergics
• Narcotics
• Central nervous system stimulants
• Antiparkinson drugs
The following drugs can produce anxiety symptoms:
• Theophylline
• Nasal decongestants
• -agonists
• Antiparkinson drugs
• Appetite suppressants
The following drugs can contribute to nutritional deficiencies:
• Diuretics
• Digoxin, digitalis
• Laxatives (overuse)
• Sedatives (overuse)
These specific drugs pose a risk to geriatric patients:
• Long-acting benzodiazepines (e.g., chlordiazepoxide [Librium] and diazepam [Valium]) should be

avoided because of the risk of prolonged sedation and increased risks of falls and fractures.
• Amitriptyline (Elavil) has potent anticholinergic and sedating effects with risk to older patients.
• Digoxin (Lanoxin) at higher doses (> 0.125 mg daily) has an increased risk of toxicity without
greater benefits.
• Meperidine (Demerol) taken orally has an increased risk of respiratory and circulatory depression.
• Antipsychotic use may result in the increased risk of heart events and infections.
34-3. Medication Compliance and the Older Adult
Types of noncompliant behavior in the elderly include the following:
• Failure to take medications
• Premature discontinuation of a medication
• Excessive consumption of a medication
• Use of medications not currently prescribed
Several strategies can improve patient medication compliance:
• Limit the number of different medications and decrease the dose frequency.
• Simplify dosage instructions.
• Tailor the regimen to the patient's schedule.

• Use compliance aids and telephone reminders.
• Enlist the assistance of family members and friends.
34-4. Basic Components of Evaluating Drug Therapy in Older Adults
These questions should be answered in an evaluation of drug therapy:
• Why is the drug being used? A diagnosis or reason should be given
• Is the drug being given correctly? The dosage, form, and schedule of administration should be
analyzed.
• Are any symptoms or complaints related to drug therapy?
• Is monitoring of treatment ongoing?
• What is the endpoint of therapy?
34-5. Alzheimer's Disease and Related Dementias
Introduction
Dementia is the decline in intellectual abilities (e.g., impairment of memory, judgment, and abstract
thinking) coupled with changes in personality. Dementia patients tend to be described as cognitively
impaired.
Cognition is the mental process by which people become aware of objects of thought and
perception, including all aspects of thinking and remembering. Impairment of cognition
significantly affects the life of the dementia patient, his or her family members, and the community
in general.
Types of Dementia
Alzheimer's disease accounts for approximately 70% of dementias. Vascular dementias account for
approximately 15% of dementias. Patients may have both Alzheimer's disease and vascular
dementia.
Other Causes of Dementia
• Vascular disease, cerebrovascular accidents (strokes)
• Neurologic disorders such as Parkinson's disease, frontotemporal dementia, dementia with Lewy
bodies, and Huntington's chorea
• Metabolic disorders such as hypothyroidism, alcoholism, and anemia
• Infectious diseases such as meningitis, syphilis, AIDS (acquired immune deficiency syndrome)
Alzheimer's disease is a progressive neurologic disease that results in impaired memory and
intellectual functioning and altered behavior. Alzheimer's disease is characterized by the slow onset
of symptoms leading to loss of ability to function independently. Symptoms may include psychoses
with hallucinations, illusions, and delusional thinking. As Alzheimer's disease progresses, the brain
continues to deteriorate.
Depression can cause cognitive impairment similar to that of Alzheimer's disease and should be
identified and treated.
Pathophysiology
Hallmark pathologic changes in the brain are linked to Alzheimer's disease (i.e., neuritic plaques
and neurofibrillary tangles increase). Neuritic plaques are composed of amyloid proteins deposited
on neurons. Neurofibrillary tangles exist within neurons and disrupt normal function.
Neurotransmitters are also altered in Alzheimer's disease. Acetylcholine concentrations decrease

significantly.
Diagnostic Criteria
Diagnosis of Alzheimer's disease requires the presence of memory impairment and one or more of
the following:
• Aphasia (language disturbance)
• Apraxia (impaired motor abilities)
• Agnosia (failure to recognize objects)
• Disturbance of executive function (e.g., planning, organizing)
When evaluating a patient for treatment of dementia and Alzheimer's disease, review the patient's
medications and consider any that might cause mental confusion or worsen underlying disease
states. Drugs that block activity of acetylcholine can worsen dementia and decrease the
effectiveness of medications used to treat Alzheimer's disease.
Anticholinergic drugs are used for a variety of conditions, ranging from depression to incontinence.
Indications should be identified before treating Alzheimer's disease. Anticholinergic effects can be
additive (i.e., a combination of anticholinergic drugs can result in toxicity even when each is given
at low doses; see
Table 34-1).
Provide support to caregivers, and treat the patient's behavioral and mood symptoms.
[Table 34-1. Anticholinergic Drugs That Can Worsen Alzheimer's Disease]
Consider a trial of a cholinesterase inhibitor and monitor for benefits to memory and cognitive
functioning.
Monitoring
Monitor memory and cognitive functions every 6-12 months.
Routinely assess behaviors and ability to perform activities of daily living (e.g., bathing, feeding,
toileting, dressing).
Monitor for focal neurologic signs and symptoms that may suggest other causes of changes in
cognitive function.
Drug Therapy
The pharmacologic approach to treatment falls into two categories:
• Medications used to control behavioral and emotional symptoms
• Medications used to slow or reverse the disease process
Symptomatic therapy
Medications used to control behavioral and emotional symptoms are used to provide symptomatic
improvement and do not affect the outcome of the disease.
Anxiolytics are used to decrease anxiety and possibly agitation, motor restlessness, and insomnia.
Such medications include lorazepam (Ativan), oxazepam (Serax), and buspirone (Buspar). The
benzodiazepines can increase the risk of falls and injury.
Antidepressants improve depression, which can worsen the cognitive functioning of a patient with
Alzheimer's disease. Antidepressants include sertraline (Zoloft) and citalopram (Celexa).
Antipsychotics are used to decrease psychotic symptoms such as hallucinations and delusions.
Antipsychotics such as haloperidol (Haldol), risperidone (Risperdal), and aripiprazole (Abilify) may
reduce agitation and aggressiveness in dementia patients. A U.S. Food and Drug Administration
(FDA) black box warning concerning the risk of increased mortality (cardiac events and infections)
is associated with the use of antipsychotics in demented elderly patients.
Sedative-hypnotics are used for short-term treatment of insomnia but can increase confusion and
memory impairment. These medications include trazodone (Desyrel), zolpidem (Ambien), and
temazepam (Restoril).
Cholinesterase inhibitors
Medications used to slow or reverse the symptoms of Alzheimer's (see

Table 34-2) affect acetylcholine activity in the brain. Acetylcholine levels may be decreased by as
much as 90% in Alzheimer's disease. These levels can be increased by inhibiting the enzyme
acetylcholinesterase.
Acetylcholinesterase inhibitors increase acetylcholine but do not replace lost cholinergic neurons or
change the underlying pathology. This class of medications is used to prevent or slow deterioration
in cognitive functioning.
The first cholinesterase inhibitor approved to treat Alzheimer's disease was tacrine (Cognex), which
proved beneficial but may cause hepatotoxicity (damage to the liver). Thus, tacrine requires regular
liver function testing and is rarely prescribed.
[Table 34-2. Drugs Used to Treat Alzheimer's Disease]
Safer cholinesterase inhibitors include the following:
• Donepezil (Aricept) is selective for acetylcholinesterase in the brain (i.e., not in peripheral tissues)
and is approved for mild to moderate and moderate to severe dementia.
• Rivastigmine (Exelon), a nonselective cholinesterase inhibitor, decreases both

acetylcholinesterase and butyrylcholinesterase. It is approved for mild to moderate Alzheimer's
disease and dementia associated with Parkinson's disease.
• Galantamine (Razadyne) is a selective acetylcholinesterase inhibitor that activates nicotinic

receptors, which may increase acetylcholine. It is approved for mild to moderate Alzheimer's
disease dementia.

Donepezil
Give orally, 5 mg daily for 4-6 weeks. Increase dosage to 10 mg daily at bedtime. Take with or
without food.
Rivastigmine
Oral doses are given with a gradual dosage increase. Begin at 1.5 mg twice daily and then 3.0 mg
twice daily, 4.5 mg twice daily, and 6.0 mg twice daily, with a minimum of 2 weeks between dose
increases. If rivastigmine is discontinued because of adverse effects, restart at beginning dose. Take
with meals in divided doses. Transdermal patch dosing begins with 4.6 mg every 24 hours, once
daily for 4 weeks. It then increases to 9.5 mg every 24 hours, once daily.
Galantamine
Doses begin with 4 mg twice daily for 4 weeks, 8 mg twice daily for 4 weeks, and then 12 mg twice
daily. If galantamine is discontinued for more than a few days, restart at the beginning dose. In
hepatic or renal dysfunction, doses should not exceed 16 mg per day. Do not use in instances of
severe dysfunction. Take with meals in divided doses. Initiate therapy with extended-release
capsules at 8 mg daily with a morning meal for 4 weeks. Increase the dose to 16 mg daily for 4
weeks and then 24 mg daily.
Adverse drug events
• Donepezil: Side effects include nausea, vomiting, and gastrointestinal (GI) symptoms. These side
effects may be minimized by increasing the dose at 6 weeks.
• Rivastigmine: Side effects include nausea, vomiting, GI upset, and possibly significant weight
loss. Adverse effects are dose related and may be lessened by increasing the dose at a slower rate.
• Galantamine: Adverse effects include nausea, vomiting, and GI upset. Slow dose titration will
decrease side effects.
NMDA-receptor antagonists
Blocking the excitotoxicity effects of the neurotransmitter glutamate at N-methyl-D-aspartate

(NMDA) receptors has been reported to be beneficial in Alzheimer's disease. Memantine
(Namenda) is an NMDA-receptor antagonist used for moderate to severe Alzheimer's disease
dementia. Doses begin with 5 mg daily for 1 week, increasing to 5 mg twice daily, with weekly
increases to 10 mg twice daily.
The dose should be reduced to 5 mg twice daily in patients with renal impairment (creatinine
clearance less than 30mL/min).
Side effects include drowsiness, dizziness, headache, blood pressure elevations, and motor
restlessness.
Anticholinergic drugs will reduce the effectiveness of cholinesterase inhibitors and cause dry
mouth, blurred vision, constipation, and mental confusion (i.e., conditions that are more
problematic in the elderly).
Cytochrome P450 enzyme inhibitors of 2D6 and 3A4 increase levels of galantamine and donepezil
by inhibiting their metabolism.
Dextromethorphan (Robitussin DM), a potent NMDA-receptor antagonist, should be used
cautiously with memantine. Smoking and nicotine products may alter levels of memantine.
Concurrent use of amantadine increases the potential for adverse effects.
• Monitor cognitive function (e.g., poor results on mini-mental state exam, decline in performance
of activities of daily living, incidence of behaviors that indicate cognitive decline).
• Watch for signs and symptoms of toxicity.
• Discontinue treatment with active peptic ulcer disease, severe bradycardia, and acute medical
illness.
• Perform periodic complete blood cell count and basic chemistries.
• Look for expected benefits with the use of cholinesterase inhibitors and NMDA-receptor
antagonists. Such benefits include improvement in memory, some stabilization of behaviors or
mood, and possible slowing of the progression of the disease.
Nonprescription agents
High-dose vitamin E (2,000 units daily) has been recommended as an antioxidant to slow
progression of Alzheimer's disease. Vitamin E may interfere with vitamin K absorption and result
in increased risk of bleeding. Increased mortality has been reported with high-dose vitamin E. The
potential toxicity of high-dose vitamin E may outweigh the benefits.
Ginkgo biloba, an herb, has been used to treat symptoms of Alzheimer's disease with reports of
modest benefits. Ginkgo biloba is associated with increased risk of bleeding and hemorrhage,
especially when combined with daily aspirin use, and is not recommended.
Nondrug Therapy
The treatment of Alzheimer's disease includes nonpharmacologic and pharmacologic therapies.

Patients need to live in an environment that permits safe activities while minimizing risk.
Caregivers need training and support to deal with the behavioral and functional issues associated
with this disease. Caregivers are at risk for depression and stress-related medical illnesses.
Caregivers may also neglect their own health care needs and should be encouraged to maintain a
healthy lifestyle.
34-6. Parkinson's Disease
Introduction
Parkinson's disease (PD) is a chronic progressive neurologic disorder with symptoms that present as
a variable combination of rigidity, tremor, bradykinesia, and changes in posture and ambulation. An
estimated 1 million persons in the United States suffer from PD. Approximately 60,000 new cases
are diagnosed each year.
The risk of developing PD increases with age, and a substantial increase in the U.S. population of
persons over 60 years of age is predicted.
Because medications are the primary treatment for PD, pharmacists play an important role in the
care of these patients.
Classification
The two classes of PD are primary parkinsonism and secondary parkinsonism. Primary
parkinsonism has no identified cause. Secondary parkinsonism can be the result of drug use (e.g.,
reserpine, metoclopramide, antipsychotics); infections; trauma; or toxins.
Clinical signs and symptoms of PD develop insidiously, progress slowly, may fluctuate, and worsen
with time despite pharmacologic therapy.
Symptoms
Tremors at rest may begin unilaterally and are present in 70% of PD patients. Tremors that do not
occur during sleep may worsen with stress.
Rigidity of limbs and trunk may develop. The face may have a masklike expression. Patients may
have difficulty dressing or standing from a seated position.
Akinesia (the absence of movement) and bradykinesia (slowed movements) can occur. Postural
instability with abnormal gait and an increased risk of falls are often experienced.
Depression and possibly dementia are possible nonmotor symptoms of PD.
Other symptoms include micrographia (small writing), drooling, decreased blinking, constipation,
and incontinence.
Pathophysiology
PD involves a progressive degeneration of the substantia nigra in the brain with a decrease in
dopaminergic cells (more than the typical decrease that accompanies normal aging). The most
significant neurotransmitter in PD is dopamine, but other neurotransmitters may play a role (e.g.,
acetylcholine, glutamate, GABA, serotonin, norepinephrine).
The etiology is unknown, but genetic susceptibility is possible. Environmental toxins combined
with aging may also be responsible for the development of PD.
Diagnostic Criteria
Clinical diagnosis is based on the presence of bradykinesia and either rest tremor or rigidity. The
stages of the disease are described in
Table 34-3.
The goal for treating PD is to relieve symptoms and maintain or improve quality of life for the
patient. Treatment should be initiated when functional impairment and discomfort for the patient or
caregiver occurs.
[Table 34-3. The Stages of Parkinson's Disease]
A safe environment and caregiver support programs in addition to medications will often allow
patients to remain in the community.
Drug Therapy
Mechanism of action
Medications increase dopamine or dopamine activity by directly stimulating dopamine receptors or

by blocking acetylcholine activity, which results in increased dopamine effects (
Table 34-4).
Selection of an initial medication to treat PD may vary with the prescriber. Some choose to begin
[Table 34-4. Drugs for Treating Parkinson's Disease]
therapy with selegiline (Eldepryl), which offers possible neuroprotection; others prescribe
carbidopa-levodopa (Sinemet), which has proven benefits. Some experts will initiate therapy with a
dopamine agonist in patients younger than 60 years of age.
Levodopa
Levodopa is the most effective drug in the treatment of PD and is converted to dopamine in the
body. It is given with carbidopa, a decarboxylase inhibitor that prevents the peripheral conversion
of levodopa to dopamine, thereby reducing nausea and vomiting while allowing more drug to pass
through the blood-brain barrier.
Generally, doses are increased gradually to minimize the risk of side effects. Doses are given before
meals to facilitate absorption. Carbidopa effectively inhibits peripheral conversion of levodopa at
doses of 100 mg per day.
Levodopa provides benefits to all stages of PD, but chronic use is associated with adverse effects.
Patients may have periods of good mobility alternating with periods of impaired motor function.
Dopamine agonists
Dopamine agonists work directly on dopamine receptors and do not require metabolic conversion.
They may be used as monotherapy or as adjunctive therapy, allowing lower doses of carbidopa-
levodopa.
Selective monoamine oxidase type B inhibitors
Monamine oxidase (MAO)-B inhibitors may be used as initial therapy in early PD and as adjunct
treatment for more advanced disease. They may have neuroprotective properties.
With doses used for PD, adverse effects from consuming tyramine-containing foods would not be
expected.
Catechol-O-methyl transferase inhibitors
Catechol-O-methyl transferase (COMT) inhibitors are ineffective when given alone and should
always be given with carbidopa-levodopa. They are most often used to treat patients during end-of-
dose wearing-off periods and patients experiencing motor fluctuations.
Treatment complications and strategies for improving patient response
• No initial response: If the patient does not initially respond to levodopa (carbidopa-levodopa
combination), gradually increase the dose to at least 1,000-1,500 mg of levodopa.
• Suboptimal response: After increasing levodopa, add another drug (e.g., a dopamine agonist,
selegiline, or a COMT inhibitor).
• "On and off" phenomenon: This type of response is associated with advancing disease and loss
of benefits from a dose of medication. Use more frequent doses or sustained-release levodopa.
• Acute intermittent hypomobility "off" episodes: Such episodes are seen in advanced disease.
They can be treated with subcutaneous injections of apomorphine, a direct-acting dopamine
agonist.
• End-of-dose or "wearing-off" period: A decreased duration of benefit after a dose is

experienced during a wearing-off period. Levodopa wanes after less than 4 hours; therefore, use
combination therapy (two or more drugs), give levodopa more frequently, or use sustained-
release levodopa (Sinemet CR).
• Usually take medications on an empty stomach. Eat shortly afterward to avoid upset stomach.
• Take a missed dose as soon as possible. Skip the missed dose if the next scheduled dose is within
2 hours.
• Dizziness, drowsiness, and stomach upset may occur and make operating equipment dangerous.
• Report any confusion, mood changes, and uncontrolled movements to the prescriber as soon as
possible.
• If taking a sustained-release product, do not crush.
Adverse effects and drug-drug interactions
Adverse effects of medications used to treat PD are described in

Table 34-5. See
Table 34-6 for information concerning drug-drug interactions.
• Liver function, complete blood count, basic chemistries (periodically)
• Blood pressure, pulse, ECG (periodically)
• Reduction of rigidity, tremor, slowed movements
• Examination for mental confusion, mood changes, psychotic thinking
Nondrug Therapy for Parkinson's Disease
Educate the patient and caregiver about the benefits and side effects of PD medications. Provide
aids for
[Table 34-5. Adverse Effects of Medications Used to Treat Parkinson's Disease]
compliance to enable the patient to participate in medication use as long as he or she is physically
capable.
Physical therapy or occupational therapy may be important in maintaining physical activity and
improving safety of working and living quarters. As PD progresses, speech therapy may be
necessary to maintain communication ability.
Dietary consultation may assist the patient in nutritional concerns related to swallowing difficulties
and food selections.
34-7. Glaucoma
Introduction
Glaucoma is a group of eye diseases characterized by an increase in intraocular pressure (IOP),

which causes pathologic changes in the optic nerve and typical visual-field defects. Glaucoma
affects over 4 million Americans, and as many as 15 million more people may have increased IOP
but no clinical signs and symptoms of glaucoma.
The prevalence of glaucoma increases with age and is most often seen in those 65 years of age or
older. The number of persons with glaucoma is expected to increase with the aging of the American
population. With improved screening programs to identify those with increased IOP, an increase in
the number of those diagnosed with glaucoma is expected.
Classification
Open-angle glaucoma is a form of primary glaucoma. The angle of the anterior chamber remains
open in an eye, but filtration of aqueous humor is gradually diminished because of the tissues of the
angle. Open-angle glaucoma accounts for approximately 80-90% of cases.
Angle-closure (narrow-angle) glaucoma is a form of primary glaucoma in an eye characterized by a

shallow anterior chamber and a narrow angle. The filtration of aqueous humor is compromised
because of the iris blocking the angle.
[Table 34-6. Drug-Drug Interactions with Medications Used to Treat Parkinson's Disease]
Congenital glaucoma results from defective development of the structures in and around the
anterior chamber of the eye and results in impairment of aqueous humor.
Clinical signs and symptoms of open-angle glaucoma develop slowly and may present with only
minor symptoms, such as headache and mild eye pain. Optic nerve damage results from chronic
elevations in IOP. Hence, early and consistent treatment is important to prevent loss of vision.
Acute angle-closure glaucoma presents with blurred vision, severe ocular pain, and possible nausea
and vomiting. It should be considered a medical emergency, and immediate care should be
recommended.
Chronic angle-closure glaucoma may have symptoms similar to those of open-angle glaucoma.
Tonometry is used to screen for IOP, but direct ophthalmoscopy (slit-lamp examination) is
necessary to accurately evaluate the eye for changes in the optic nerve.
Pathophysiology
The pathogenesis of glaucoma results from changes in aqueous humor (the fluid filling the eye and
in front of the lens) outflow that result in increased IOP. This increase in pressure leads to optic
nerve atrophy and progressive loss of vision.
Increased IOP can result from decreased elimination or increased production of aqueous humor.
Aqueous humor is secreted by the ciliary processes into the posterior chamber of the eye. It then
flows through the trabecular meshwork and the canal of Schlemm.
Open-angle glaucoma is the result of decreased elimination of aqueous humor as it passes through
the trabecular meshwork, thereby resulting in elevated IOP.
Angle-closure glaucoma is caused by papillary blockage of aqueous humor outflow. This blockage
can result when a patient has a narrow anterior chamber in the eye or a dilated pupil where the iris
comes into greater contact with the lens. With the blocking of outflow, aqueous humor accumulates
in the posterior chamber, presses the lens forward, and further decreases drainage, with possible
complete blockage as the outcome.
Diagnostic Criteria
• Elevated IOP as determined by tonometry
• Funduscopic assessment to identify characteristic changes in the optic disc and retina
Figure 34-1 illustrates the treatment of open-angle glaucoma. Treatment principles of glaucoma are
as follows:
• Reduce IOP to prevent optic nerve damage and visual field loss.
• Use topical medications as first-line treatment.
• Consider acute angle-closure glaucoma as a medical emergency.
Monitoring
Periodic screening for increased IOP should be done, with yearly examinations for those over 65
years of age and as part of a routine eye examination.
Drug Therapy
Mechanism of action
Medications are considered the mainstay of therapy for the treatment of glaucoma (
Table 34-7). -adrenergic
[Figure 34-1. Algorithm for the Treatment of Open-Angle Glaucoma]
[Table 34-7. Medications for the Treatment of Glaucoma]
blocking drugs ( -blockers) are considered first-line treatment for open-angle glaucoma. -
adrenergic antagonists can be nonselective (i.e., they block both ²1 and ²2 receptors) or selective
(i.e., they block only 1 receptors). Drugs that block only 1 receptors are considered
cardioselective and cause less decrease in blood pressure and heart rate.
-adrenergic antagonists
Nonselective antagonists include timolol, carteolol, levobunolol, and metipranolol. 1-selective

antagonists include betaxolol and levobetaxolol.
Therapy is initiated with a single topical ophthalmic solution, and additional agents are added if
decrease in IOP is less than acceptable. The effects of therapy on IOP should be apparent after a
week of treatment.
Prostaglandin analogues are also used as first-line treatment (or in combination with ²-blockers).
Topical carbonic anhydrase inhibitors and ±2 agonists may be used in treatment.
Medications such as epinephrine, pilocarpine, and oral carbonic anhydrase inhibitors are prescribed
less often, but they are considered to be effective adjunctive drugs.
Multiple factors present obstacles that can interfere with good compliance. Patients are often
asymptomatic and do not feel treatment is necessary. Because decreased vision is associated with
glaucoma, patients may have difficulty with written instructions.
Adequate glaucoma therapy often requires two or more types of eye drops that may have to be given
more than once daily. Correct administration of eye drops requires coordination and reasonable
cognitive functioning.
Glaucoma is more common in the elderly, who may have more difficulty complying with prescribed
medications.
Patient guidelines concerning the use of eye drops to treat glaucoma follow:
• Wash hands before administering eye drops, and avoid touching the dropper tip.
• Confirm that the medication is not outdated and has been stored properly.
• Looking upward, pull the lower lid down and instill the correct number of drops.
• Close the eye to allow the medication to have maximal effect.
• In most cases, wait 5 or more minutes between different medications.
Adverse drug events
Table 34-8 describes the adverse effects that may be seen with glaucoma medications.
Drug interactions between topical medications and systemic drugs are unlikely.
Acetazolamide interacts with the following:
• Aspirin to cause increased aspirin levels and possible toxicity
• Cyclosporine to cause increased cyclosporine levels
• Lithium to cause either increased or decreased lithium levels
• Phenytoin to cause an increased risk of osteomalacia
Medication use is critical to the successful treatment of glaucoma and should be monitored by the
health professional.
[Table 34-8. Classification, Mechanism of Action, and Adverse Effects of Glaucoma Medications]
Other aspects
A combination is available of timolol 0.5% and dorzolamide 2% (Cosopt). This combination

effectively lowers IOP and requires only twice-daily doses. This simplified dosing should improve
compliance with treatment. This combination (i.e., using two drugs from different categories)
represents a sound treatment approach. Poor response to therapy may result in the prescribing of
multiple medications, which may negatively affect the patient's ability to successfully use the more
complex regimen.
Nondrug Therapy
Laser surgery
Argon laser trabeculoplasty has proven effective as adjunctive therapy that increases the flow of
aqueous humor.
Surgery
A surgical procedure involves creating new means of drainage for aqueous humor to leave the
anterior chamber.
34-8. Key Points
Alzheimer's Disease
• Alzheimer's disease is a progressive neurologic disease that results in impaired memory,

intellectual functioning, and behavior.
• Alzheimer's disease has no cure, but therapies exist to decrease memory impairment as well as
improve behavior and patient functioning.
• Other forms of dementia that are potentially reversible should be identified and treated
accordingly.
• New drug therapies may slow the progression of Alzheimer's disease and allow patients to remain
in the least restrictive environment possible.
• Caregiver support and education are important measures to ensure patient safety and well-being.
Parkinson's Disease
• Parkinson's disease is a chronic, progressive neurologic disease for which no cure exists;
medications are available to slow the progression of symptoms.
• The etiology of Parkinson's disease is unknown but may involve genetic susceptibility combined
with environmental toxins and age-related changes in the brain.
• Dopamine, the central neurotransmitter, is decreased in Parkinson's disease, and current drug
therapy is primarily directed at increasing dopamine levels.
• Drug therapy monitoring in Parkinson's disease requires an understanding of a variety of different

medications that may cause significant adverse effects.
• Physical therapy, occupational therapy, dietary considerations, and support counseling for
caregivers are necessary components of treating Parkinson's disease.
Glaucoma
• Glaucoma, a group of eye diseases, is characterized by increased intraocular pressure resulting in

damage to the optic nerve and possible blindness.
• Open-angle glaucoma is the most common form of this disease; angle-closure glaucoma can be a
medical emergency.
• The goal of therapy is to reduce intraocular pressure with the simplest medication regimen
possible.
• Drug therapy for glaucoma usually begins with a topical -adrenergic antagonist; patients often
require combination therapy.
• Medication compliance is essential in the control of glaucoma. Education of the patient and
caregiver is required to overcome treatment barriers.
34-9. Questions
Of the following pharmacokinetic processes, which is the least altered by aging?
A. Absorption
1. B. Distribution
C. Metabolism
D. Elimination
E. Excretion

Which of the following is given as a once-daily oral dose?
A. Buspirone
2. B. Donepezil
C. Memantine
D. Rivastigmine
E. Tacrine

Galantamine increases levels of which neurotransmitter?
A. Acetylcholine
3. B. Dopamine
C. Melatonin
D. Norepinephrine
E. Serotonin

Weight loss is most often associated with which of the following?
A. Donepezil
4. B. Galantamine
C. Mirtazapine
D. Rivastigmine
E. Tacrine

Which of the following statements concerning donepezil are correct?
I. It inhibits acetylcholinesterase but not butyrylcholinesterase.

II. It should be taken with meals in divided doses.
III. Side effects include tachycardia and blood pressure alterations.
5.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Of the following medications used to treat behavioral and emotional symptoms in Alzheimer's
patients, which has an FDA black box warning of increased mortality?
A. Buspirone
6.
B. Citalopram
C. Lorazepam
D. Risperidone
E. Zolpidem

The maximum daily dose of galantamine in patients with renal impairment is
A. 8 mg/d.
7. B. 12 mg/d.
C. 16 mg/d.
D. 24 mg/d.
E. 32 mg/d.

All of the following could worsen cognition in Alzheimer's disease patients except
A. dicyclomine.
8. B. dimenhydrinate.
C. meclizine.
D. trazodone.
E. trihexyphenidyl.

Memantine's reported benefit in treating the symptoms of Alzheimer's disease is thought to be
the result of
A. increasing serotonin receptor activity.

9.
B. blocking the effect of glutamate on receptors.
C. direct blocking of acetylcholine receptors.
D. decreasing intracellular dopamine activity.
E. decreasing amyloid deposits in the brain.

Which works by direct stimulation of dopamine receptors?
A. Amantadine
10. B. Benztropine
C. Entacapone
D. Ropinirole
E. Selegiline

Which of the following has a risk of causing a significant drug interaction if taken with
ondansetron?
A. Amantadine
11.
B. Apomorphine
C. Carbidopa-levodopa
D. Pramipexole
E. Entacapone

What would be the most likely outcome if a Parkinson's patient on levodopa were also
prescribed haloperidol?
A. Excessive nausea and vomiting

12.
B. Hypertensive crisis
C. Tachycardia and possible chest pain
D. Worsening symptoms of Parkinson's disease
E. Excessive somnolence

Which inhibits monoamine oxidase (MAO)?
A. Benztropine
13. B. Bromocriptine
C. Pramipexole
D. Rasagiline
E. Tolcapone

How does carbidopa affect levodopa?
A. It slows the release from presynaptic neurons.

14. B. It prevents the excretion of dopamine.
C. It increases stimulation of dopamine receptors.
D. It decreases tolerance to normal doses.
E. It inhibits the peripheral conversion to dopamine.

A patient with Parkinson's disease currently taking selegiline has been prescribed mirtazapine
(Remeron). What would be the most likely outcome of this combination?
A. Inhibition of benefits with worsening parkinsonism

15.
B. No significant drug interaction
C. Risk of serotonin syndrome
D. Increased benefits with improved parkinsonism
E. Hypertensive episode

Which of the following statements are true concerning the treatment of Parkinson's disease?
I. Entacapone is not used as monotherapy except for patients with end-of-dose wearing-off
periods and for those experiencing motor fluctuations.
II. Pramipexole has been reported to cause "sleep attacks."
III. Food-drug interactions would not be expected with selegiline when given at doses of 10 mg
16. daily.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

Timolol ophthalmic drops would be more likely to cause which adverse effect as compared to
levobetaxolol ophthalmic drops?
A. Agitation and restlessness

17.
B. Nausea and vomiting
C. Confusion
D. Change in heart rate and blood pressure
E. Altered intraocular pressure

Which of the following would not be considered for monotherapy of glaucoma?
A. Latanoprost
18. B. Dorzolamide
C. Carteolol
D. Methazolamide
E. Brimonidine

Which of the following can cause iris pigmentation changes?
A. Acetazolamide
19. B. Betaxolol
C. Brimonidine
D. Latanoprost
E. Pilocarpine

Which of the following is available as a fixed combination product?
A. Dorzolamide and timolol

20. B. Betaxolol and bimatoprost
C. Bimatoprost and levobunolol
D. Latanoprost and timolol
E. Methazolamide and latanoprost

All of the following are available as an ophthalmic solution except
A. brimonidine.
21. B. dipivefrin.
C. dorzolamide.
D. methazolamide.
E. metipranolol.

Which should not be used if a patient has a sulfa allergy?
A. Betaxolol
22. B. Bimatoprost
C. Brimonidine
D. Brinzolamide
E. Unoprostone

Which of the following is true about ±2-adrenergic agonists?
A. They cause an increase in aqueous humor synthesis.

23. B. They cause a decrease in aqueous humor formation.
C. They cause an increase in uveoscleral outflow.
D. They cause an increase in aqueous humor outflow.
E. They cause a decrease in uveoscleral outflow.

Which of the following statements concerning glaucoma therapy is correct?
I. Carteolol is available as an ophthalmic solution and as a gel-forming solution.

II. Latanoprost and metipranolol ophthalmic solutions should be stored in the refrigerator.
III. Prostaglandin analogues, -adrenergic antagonists, and -adrenergic agonists can be used
as monotherapy.
24.
A. I only
B. III only
C. I and II only
D. II and III only
E. I, II, and III

34-10. Answers
A. Of all the age-related changes of the pharmacokinetic process, absorption is the least
1.
altered, perhaps because most drugs are passively absorbed.

B. All of these drugs except donepezil require at least twice-daily dosing. Donepezil has a long
half-life, which allows once-daily doses. None of these agents is available in sustained-release
2.
forms, although rivastigmine has a once-daily patch. Buspirone is an antianxiety drug that is
dosed twice or three times daily.

A. Galantamine is a cholinesterase inhibitor, and all cholinesterase inhibitors increase levels of
3.
acetylcholine, the neurotransmitter that appears to be involved with memory function.

D. Weight loss, probably because of nausea and vomiting, is a warning for rivastigmine. In
4. controlled trials, approximately 26% of women on doses of 9 mg/d or greater had weight loss
of equal to or greater than 7% of their baseline weight.

A. Donepezil is selective for acetylcholinesterase and does not inhibit butyrylcholinesterase.
Donepezil does not have to be taken with meals and is given once daily. Donepezil does not
5.
increase heart rate, and this class of medications that increase acetylcholine should be used
with caution in patients with bradycardia.

D. Risperidone, as well as other atypical antipsychotics, increases mortality risk when given to
6. dementia patients with agitation or aggressive behaviors. This is probably a class effect, and
any antipsychotic should be used only if no alternative medication is effective.

C. With renal or hepatic dysfunction, galantamine doses should not exceed 16 mg/d. With
7.
severe renal or hepatic dysfunction, galantamine should not be used.

D. All of the drugs listed—with the exception of trazodone—have anticholinergic activity.
Decreasing the activity of acetylcholine could worsen dementia and block benefits of
8. cholinesterase inhibitors. Trazodone is an antidepressant with sedating properties but little
anticholinergic activity. It may be given at bedtime to help with sleep. Trazodone does have a
side effect of orthostatic hypotension.

B. Glutamate is the main excitatory neurotransmitter in the central nervous system, and one
9. theory states that blocking the effects of glutamate on NMDA receptors will decrease
symptoms of Alzheimer's disease.

D. Ropinirole directly stimulates dopamine receptors; the other drugs increase dopamine
10.
activity by different mechanisms.

B. Apomorphine can cause severe hypotension and loss of consciousness when taken with
11.
ondansetron and other serotonin-receptor antagonists.

D. Haloperidol and other antipsychotics block dopamine activity and can worsen PD. They can
12.
also block the benefits of PD medications, which increase dopamine activity.

D. Rasagiline is an MAO inhibitor that is selective for MAO-B, which decreases the potential
13.
for drug-drug and drug-food interactions. At higher doses, this selectivity lessens.

E. Carbidopa inhibits the peripheral conversion of levodopa to dopamine, thus allowing more
14.
levodopa to cross the blood-brain barrier, and decreases adverse effects from dopamine.

C. The combination of two drugs that increase serotonin levels can result in serotonin
15.
syndrome, which can cause confusion, agitation, tremor, seizures and coma.

D. Entacapone should always be given with carbidopa-levodopa because benefits depend on
16.
carbidopa inhibiting the peripheral conversion of levodopa.

D. Timolol is a nonselective -adrenergic antagonist that causes a reduction in heart rate and
17.
blood pressure. There is enough absorption from eye drops to produce these cardiac effects.

D. All of the other choices could be considered as monotherapy for glaucoma. Methazolamide
18.
is an oral carbonic anhydrase inhibitor and is used in conjunction with ophthalmic drops.

D. Latanoprost, a prostaglandin analogue, is known to change iris pigmentation and to darken
19.
eyelashes.

A. Dorzolamide plus timolol (Cosopt) is the only combination ophthalmic solution for treating
20.
glaucoma. An advantage for using a combination product would be increased compliance.

D. Methazolamide and acetazolamide are both available only as oral tablets or capsules.
21.
Topical carbonic anhydrase inhibitors are brinzolamide and dorzolamide.

22. D. Patients with sulfa allergy should not be given a carbonic anhydrase inhibitor.

23. B. Brimonidine and other ±2-adrenergic agonists cause a decrease in aqueous humor formation.

B. All of these drugs can be used as monotherapy in glaucoma. Timolol and pilocarpine are
24. available as gel forms. Latanoprost (but not metipranolol) should be stored in a refrigerator
before dispensing.

34-11. References
Chen JJ, Shimomua SK. Parkinsonism. In: Herfindal ET, Gourley DR, eds. Textbook of
Therapeutics. 8th ed. Philadelphia: WB Saunders; 2006:839-54.
Grutzendler J, Morris JC. Cholinesterase inhibitors for Alzheimer's disease. Drugs. 2001;61:41-52.
Khaw P, Shah P, Elkington A. Glaucoma-1 treatment. BMJ. 2004;328(7432):156-8.
Olanow CW, Watts RL, Koller WC. An algorithm for the management of Parkinson's disease.
Neurology. 2001;56:872-91.
Rawls WN. Alzheimer's disease. In: Herfindal ET, Gourley DR, eds. Textbook of Therapeutics. 8th
ed. Philadelphia: WB Saunders; 2006:1811-28.
Scarpini E, Scheltens P, Felman H. Treatment of Alzheimer's disease: Current status and new
perspectives. Lancet Neurol. 2003;2:539-47.
Steinman MA, Landefeld C, Rosenthal GE, et al. Polypharmacy and prescribing quality in older
people. J Am Geriatr Soc. 2006;54:1516.
35. Toxicology and Chem-Bioterrorism - Peter A. Chyka, PharmD, FAACT, DABAT
35-1. Overview of Poisoning and Toxicology
Poisoning in America
Poisoning exposures and overdoses affect more than 2.5 million people annually, and more than
37,000 deaths occur yearly. A large number of poisonings occur in young children (< 1% of deaths
are in preschool-age children), but most fatalities occur in adults.
Any chemical can become toxic if the exposure is too great in relation to body weight and tolerance.
Medications are the most common cause of poisoning morbidity and mortality (
Table 35-1).
Most poisonings in preschool-age children are unintentional or accidental. Unintentional poisonings

can also occur in adolescents and adults; however, intentional (suicide and drug abuse) poisonings
and overdoses are common.
Toxicology is the study of the adverse effects of chemicals and other xenobiotics on living
organisms. There are several specialized areas of toxicology, including basic science, clinical,
analytical, forensic, regulatory, and occupational settings, that have a unique focus and purpose.
In general, toxicity occurs when too much of a substance is taken in relation to a normally tolerable
dose. Different mechanisms by which a chemical can produce toxicity include the following:
• Exaggeration of pharmacologic effects
• Formation of reactive toxic metabolites
• Formation of intracellular free radicals
• Interference with enzyme action
• Interference with DNA (deoxyribonucleic acid) or RNA (ribonucleic acid) synthesis
• Inactivation of biochemical cofactors
• Initiation of premature cell aging (apoptosis)
• Tissue destruction on contact
The contributions of Adrianne Y. Butler, PharmD; Billie J. Holliman, PharmD; and C. Renee
Adams-McDowell, PharmD, to the first edition of this chapter are acknowledged.
Poison Prevention Approaches and Pharmacy
Poison Prevention Packaging Act of 1970: Safety caps
This act was issued to prevent preschool-age children from opening and ingesting harmful
substances or to delay the opening of packaging containing such substances (to limit the amount of
harmful substance that may be ingested within a reasonable amount of time).
Drugs requiring safety caps include aspirin, ibuprofen, acetaminophen, and oral prescription drugs
with certain exceptions (e.g., birth control pills and nitroglycerin).
Use of poison control centers
A poison control center determines if a true poisoning exists, recommends first aid, refers poisoning
victims to health care facilities for further evaluation and treatment, monitors the progress and
outcome of each poisoning case, and documents poisoning experiences. Programs and materials on
poison prevention are also available.
Nationwide access is available by calling 1-800-222-1222 for 24-hour poison center services for the
area from which the call is placed in the United States.
[Table 35-1. Ranking of Most Frequent Poisonings from U.S. Poison Centers and Emergency
Departments, 2006]
Poison prevention tips for consumers
• Store all drugs and chemicals out of the reach of children.
• Never put chemicals in food containers.
• Choose products with safety caps when there is a choice, and use them properly.
• Read and follow all label directions carefully.
• Never call medicine "candy."
• Use safety latches.
Pharmacy Requirements of the Joint Commission on Accreditation of Healthcare

Organizations
• Maintain and keep available the medical staff-approved stock of antidotes and other emergency
drugs in both the pharmacy and patient care areas.
• Maintain authoritative and current antidote information.

• Keep the phone number of the poison control center readily available in areas outside of the
pharmacy where drugs are stored.
Emergency Actions
First aid should be administered, if applicable.

Table 35-2 describes first-aid techniques.
Other considerations
• Avoid wasting time looking for an "antidote" at home.
• Do not use home remedies such as saltwater, mustard powder, raw eggs, hydrogen peroxide,
cooking grease, or gagging.
• Immediately call 911 or an ambulance if the person is not breathing, has had a seizure, or is
unresponsive.
• For other situations, contact a poison center immediately to determine whether first aid should be
used or whether a poisoning emergency exists.
Decontamination of the Gastrointestinal Tract
The practice of using drugs to decrease the absorption of other drugs from the gastrointestinal tract
is in a state of change. For example, ipecac syrup is being
[Table 35-2. First Aid for Poisoning Emergencies]
abandoned by many as a home- or hospital-based therapy, and its use is primarily at the preference
of the consulting poison center or health care professional. Current recommendations are described
in this section, as well as basic information about the drugs in case they are encountered.
Current recommendations
Ipecac syrup has questionable effectiveness, and its use is generally now avoided.
Gastric lavage involves placing a tube into the stomach through a nostril or the mouth and
repetitively washing out the stomach contents with water or a saline solution. This method of
gastric decontamination is of questionable effectiveness, particularly if it is performed more than 1
hour after ingestion of toxin.
Cathartics such as magnesium citrate are not routinely used any more.
Activated charcoal given orally is often the only treatment necessary if the toxin is adsorbed and the
activated charcoal is used within 1-2 hours of ingestion of the toxin.
Whole bowel irrigation can be considered if the toxin is poorly or slowly adsorbed and its presence
in the gastrointestinal tract is likely.
Ipecac syrup
Indications and dosage

Ipecac syrup was previously used for general prophylaxis of selected poisonings of expected minor
or moderate severity in alert patients. Many clinicians have abandoned it as a prehospital or hospital
treatment. In 2003, the American Academy of Pediatrics recommended that ipecac syrup no longer
be used routinely as a home treatment for poisoning.
Contraindications
• The patient is experiencing pronounced sleepiness, coma, or seizures.
• The patient has ingested caustics, aliphatic hydrocarbons, and fast-acting agents that produce
coma or seizures (e.g., tricyclic antidepressants, clonidine, calcium channel blockers, beta
blockers, and hypoglycemic agents).
• Time since ingestion is believed to be 1 hour or more.
Adverse effects
• Common: Diarrhea, sleepiness, and protracted vomiting
• Uncommon: Mallory-Weiss tears and tracheal aspiration into the lungs.
Disadvantage
A disadvantage of ipecac syrup is that emesis and the drug's relative lack of efficacy complicate
administration of other oral therapies.
Activated charcoal
Indications and dosage

This agent is occasionally used to adsorb poisons in an alert or comatose patient. Administer as a
slurry by mouth or through a lavage tube:
• Children: 25-50 g
• Adults: 25-100 g
Contraindications
• Ingestions of aliphatic hydrocarbons and caustics
• Absence of patient's bowel sounds
• Ingestions of heavy metals (sodium, lithium, iron, or lead) or simple alcohols
Adverse effects
• Uncommon: Tracheal aspiration and pneumonitis
• Common: Emesis and soiling of clothes and furnishings
Advantages and disadvantages
• Advantages: Rapid onset of action, nonspecific action for a wide variety of chemicals, and
reasonable effectiveness within 1 hour of ingestion
• Disadvantages: Messy and difficult administration and possible removal of beneficial drugs
together with the toxin
Cathartics
Cathartics were previously used as an adjunct to activated charcoal administration to decrease

gastrointestinal transit time. Their efficacy is unproved. Fluid and electrolyte disturbances are
possible with repeated doses.
Cathartics may contribute to emesis following activated charcoal use.
Agents previously used include magnesium citrate, magnesium sulfate, sodium sulfate, and sorbitol.
Some activated charcoal products contain sorbitol mixed in the preparation. The sorbitol
concentration varies from brand to brand.
Whole bowel irrigation
Indications and technique

Whole bowel irrigation is generally used to wash out the gastrointestinal tract when using charcoal
may be inappropriate (e.g., if iron or lithium was ingested) and the toxin is suspected to be present
in the gastrointestinal tract (e.g., when drugs are sustained-release formulations or when the patient
ingested illicit drugs packed in condoms).
Use larger volumes of polyethylene glycol electrolyte solutions (e.g., Colyte, GoLYTELY) than the
amounts conventionally used for bowel preparation. Administer by mouth or through a gastric or
duodenal tube for treatment of poisoning:
• Children: 25 mL/kg/h (approximately 500 mL/h) up to 2-5 L

• Adults: 2 L/h up to 5-10 L
Contraindications
• Ingestion of caustics or aliphatic hydrocarbons
• Patients with absent bowel sounds or gastrointestinal tract obstruction
Adverse effects
Few adverse effects have been reported, but limited results are available from which to draw
conclusions. Some nausea and vomiting have been reported.
Advantages and disadvantages
• Advantages: Prompt whole-bowel evacuation within 2 hours
• Disadvantages: Messy procedure because of rectal effluent
Other hospital-based therapies
These therapies include supportive and symptomatic care, multiple doses of activated charcoal (to
enhance systemic elimination when appropriate), hemodialysis (to enhance systemic elimination
when appropriate), and use of antidotes (to antagonize or reverse toxic effects when indicated).
35-2. Substance Abuse and Toxicology
Substance abuse often leads to acute and chronic toxicity.

Table 35-3 shows selected drugs of abuse.
During 2007, 35.7 million Americans age 12 and older (14.4% of the population) admitted using an
illicit drug in the past year, and 9.9 million (4.0%) reported driving under the influence of an illicit
drug during the past year.
Approximately 1.4 million adults are treated in emergency departments annually for abuse and
misuse of drugs not including alcohol, with one-third involving alcohol in combination with other
drugs.
Management of the acute condition generally follows the same guidelines as those for management
of poisonings and overdoses. A challenge in treating patients during acute drug overdose is
determining the possible agents taken and possible adulterants (e.g., talc, strychnine, other drugs) or
contaminants.
Chronic abuse can foster dependence, which often leads to withdrawal symptoms when the patient
stops using the drugs. Detoxification programs, long-term behavioral counseling, and drugs to
produce aversion or substitution to drug-taking behaviors are often needed.
35-3. Antidotes
Role of Antidotes
An antidote counteracts or changes the nature of a poison. Few antidotes are available relative to the
large number of potential poisons.
Table 35-4 lists antidotes that are commonly used in the treatment of a patient with a poisoning or
an overdose.
Many hospitals have an insufficient stock of antidotes. The pharmacy and therapeutics committee
of a hospital should regularly review the inventory of antidotes.
Selected Antidotes
Acetylcysteine
Acetylcysteine is available under the trade names Mucomyst (10%, 20% oral solution) and
Acetadote (20% for injection).
Uses
Acetylcysteine is used to treat acute acetaminophen overdose. An unapproved indication is to treat
adverse reactions to drugs that may produce free radicals as part of the adverse reaction; the dosage
regimen is unique to the application.
Mechanism of action
Acetylcysteine protects the liver from the toxic effects of an acetaminophen metabolite by
supplying glutathione to aid in metabolism of the reactive metabolite. Other mechanisms are also
proposed, which include providing sulfate for acetaminophen metabolism and minimizing the
formation of free radicals.
This agent may be useful in minimizing hepatotoxic injury once it has begun. It also may aid in
cases of fulminant hepatic failure.
[Table 35-3. Selected Drugs of Abuse and Addictive Substances]
[Table 35-4. Commonly Used Antidotes]
Indications
Acute overdoses of acetaminophen produce a reactive metabolite that leads to hepatotoxicity
(jaundice, coagulopathy, hypoglycemia, hepatic failure, hepatic encephalopathy, hepatorenal
failure). Symptoms become evident 1-2 days after ingestion.
Acetylcysteine can prevent or minimize hepatic injury if given early. For best results, administer
within 10 hours of ingestion of acetaminophen overdose. It is minimally effective when started 24
hours after ingestion.
The need for therapy is determined by obtaining a serum concentration of acetaminophen at least 4
hours after ingestion (and within 24 hours) and plotting it on the acetaminophen nomogram to
determine whether there is a risk for hepatotoxicity.
Contraindications
Use of acetylcysteine is contraindicated if there is a known hypersensitivity to the drug.
Adverse effects
With oral administration, nausea and vomiting are common.
With intravenous (IV) administration, anaphylactoid reactions (rash, hypotension, wheezing, and
dyspnea) have been reported. Acute flushing and erythema may occur during the first hour of
infusion and typically resolve spontaneously.
Dosage
Table 35-4 gives dosage information on drug products for oral or IV administration available in the
United States.
Atropine
Indications
Atropine is used in cases of organophosphate (including chem-bioterrorism nerve agents) and
carbamate anticholinesterase insecticide poisoning:
• For control of pulmonary hypersecretion, atropine is given in repeated doses intravenously until
secretions have dried. Atropinization may have to be maintained for hours to days.
• For control of bradycardia, atropine is given until the heart rate increases or until a need for
alternatives is indicated.
Nontoxicologic indications include atropine use for premedication to anesthesia induction (for
antisecretory effects) and ophthalmic mydriasis and cycloplegia.
Mechanism of action
Atropine is an anticholinergic agent that competitively inhibits acetylcholine at muscarinic
receptors. It has little effect on nicotinic receptors.
Contraindications
There are no contraindications in cases of insecticide poisoning. Contraindications for other
indications are as follows:
• Hypersensitivity to atropine or anticholinergics

• Narrow-angle glaucoma
• Reflux esophagitis
• Obstructive gastrointestinal disease
• Ulcerative colitis or toxic megacolon
• Obstructive uropathy
• Unstable cardiovascular status in acute hemorrhage or thyrotoxicosis
• Paralytic ileus or intestinal atony
• Myasthenia gravis
Adverse effects
Exaggeration of anticholinergic effects (e.g., tachycardia, hypertension, sedation, hallucinations,
mydriasis, changes in intraocular pressure, warm red skin, dry mouth, urinary retention, ileus,
dysrhythmias, and seizures) can occur.
When large doses of atropine are used, the agent should be free of preservatives, because agents
such as benzyl alcohol or chlorobutanol can produce their own toxicity.
Dosage
For bronchorrhea and bronchospasm from organophosphates or carbamates, the adult dose is 2-5
mg (pediatric dose is 0.05 mg/kg) slowly administered intravenously. This dose is repeated at 10- to
30-minute intervals until bronchial hypersecretion is resolved. Severe poisonings may require up to
100 mg over a few hours to several grams over several weeks. If atropinization is required for
several days, continuous atropine infusion may be used (rates of 0.02-0.08 mg/kg/h are
recommended).
For symptomatic bradycardia (for mild poisonings), the adult dose is 1 mg (pediatric dose is 0.01
mg/kg) intravenously. For moderate to severe poisonings, adult doses increase to 2-5 mg (pediatric
doses are 0.02-0.05 mg/kg) and should be repeated every few minutes until heart rate increases.
Digoxin immune Fab (Digibind and DigiFab)
Uses
Digoxin immune Fab is used to treat life-threatening acute or chronic digoxin poisoning.
Some cross-reactivity with digitoxin and other digoxin-like compounds (digitalis, foxglove, lily of
the valley, and bufadienolide from cane frogs) can occur.
Mechanism of action
Digoxin immune Fab binds digoxin in plasma, promotes redistribution from tissues, and enhances
elimination in the urine. The digoxin bound to digoxin immune Fab is inactive. Each 40 mg (1 vial)
binds 0.6 mg of digoxin.
Digoxin immune Fab is a monovalent, digoxin-specific, antigen-binding fragment (Fab) that is

produced in healthy sheep.
Indications
Chronic digoxin toxicity typically begins with nausea, vomiting, diarrhea, fatigue, confusion,
blurred vision, diplopia, and the observation of white borders or halos around dark objects.
Deterioration of renal function, hypokalemia, or drug interactions often lead to toxicity.
Acute digoxin poisoning has early symptoms similar to those of chronic poisoning, but the onset is
more abrupt. Nausea and vomiting are common, and the serum potassium concentration is typically
normal or elevated.
A wide variety of arrhythmias occur with acute or chronic digoxin poisoning.
Digoxin immune Fab is reserved for life-threatening symptoms such as bradycardia, second- and
third-degree heart block that is unresponsive to atropine, ventricular arrhythmias, and hyperkalemia
(typically in excess of 5 mEq/L).
Contraindications
Digoxin immune Fab is contraindicated in patients with hypersensitivity to sheep.
Adverse effects
Common adverse effects include hypokalemia, allergic reactions (1% of patients), and hypotension.
For patients on maintenance digoxin therapy, the abrupt binding of digoxin will lead to loss of
therapeutic effect and a prompt decrease in potassium concentrations.
Dosage
Digoxin immune Fab is administered by IV infusion or rapid IV bolus (Table 35-4).
Dosage is determined by one of several approaches, depending on available information, as follows:

empiric dosage of 10-20 vials (Table 35-4), dosing based on the dose of digoxin ingested, or dosing
based on the serum digoxin concentration.
Flumazenil (Romazicon)
Uses
Flumazenil is used in cases of benzodiazepine overdose and in reversal of conscious sedation and
general anesthesia from benzodiazepines.
Mechanism of action
Flumazenil is a competitive antagonist of the benzodiazepine receptor in the central nervous system
(CNS).
Indications
Flumazenil should be used adjunctively with supportive care. Sedation can recur following
ingestion of a benzodiazepine with a long half-life, requiring additional doses of flumazenil. In a
suicidal overdose, it is rarely used because of the risk of potential co-ingestants. If no response
occurs to a 5 mg cumulative dose, the sedation is probably not related to a benzodiazepine.
Contraindications
Flumazenil is contraindicated in patients with known hypersensitivity to it.
Co-ingestion of tricyclic antidepressants may precipitate ventricular dysrhythmias or seizures. Other

mixed overdoses can decrease the seizure threshold (i.e., haloperidol, bupropion, lithium).
Abrupt withdrawal of flumazenil in patients on maintenance therapy, such as for treatment of

epilepsy, can precipitate seizures.
Flumazenil is contraindicated in patients with increased intracranial pressure, because the antidote
may potentially alter cerebral blood flow.
It can produce withdrawal in the benzodiazepine-dependent patient.
Adverse effects
Flumazenil has a wide margin of safety when not contraindicated.
Side effects include agitation, sweating, headache, abnormal vision, dizziness, and pain at the
administration site. Rarely reported side effects include bradycardia, tachycardia, hypotension, and
hypertension.
Dosage
Table 35-4 gives dosage information for IV administration.
Naloxone (Narcan)
Uses
Naloxone is used in the following cases:
• Reversal of opioid anesthesia
• Respiratory or CNS depression related to opioid toxicity
• Empiric administration in patients with altered mental status of unknown etiology
Mechanism of action
Naloxone is an opioid antagonist. It competes at three CNS opioid receptors (mu, kappa, and delta)
and leads to reversal of the depressive opioid effects.
Indications
Opioids cause sedation, respiratory depression, hypotension, miosis, and analgesia. Because it has
no agonist activity, naloxone will not worsen respiratory depression. The goal of therapy is to
restore adequate spontaneous respirations.
When being administered naloxone, a patient should be monitored for respiratory rate changes and
for opiate withdrawal symptoms (anxiety, hypertension, tachycardia, diarrhea, and seizure). To
avoid withdrawal, use the lowest possible dose that maintains proper ventilation. The patient should
be observed for respiratory depression once naloxone therapy is discontinued because the half-life
of naloxone may be shorter than that of the opioid. If a patient is not responsive to 10 mg of
naloxone, it is doubtful that an opioid is causing the respiratory depression.
Contraindications
• Avoid in patients with a known hypersensitivity to it.
• Use with caution in the opiate-dependent patient.
• Use with caution in patients with preexisting cardiovascular disease or those receiving cardiotoxic
drugs.
Adverse effects
Use in an opiate-dependent patient can precipitate withdrawal. Withdrawal convulsions in a neonate
can be life threatening.
Hypertension and dysrhythmias occur more often with opioid reversal in postoperative patients who
have underlying cardiac and pulmonary complications.
Dosage
The IV route is preferred in emergency situations because of the rapid onset of action within 1-2
minutes (Table 35-4).
Naloxone has poor oral bioavailability.
The intramuscular and subcutaneous routes have erratic absorption.
Pralidoxime (Protopam)
Uses
Pralidoxime is used in cases of severe poisoning by an organophosphate anticholinesterase
insecticide or chem-bioterrorism nerve agent.
Mechanism of action
Pralidoxime dephosphorylates acetylcholinesterase and regenerates acetylcholinesterase activity.
Indications
Pralidoxime is indicated in severe organophosphate or nerve agent poisoning, in combination with
atropine, to resolve nicotinic (muscle and diaphragmatic weakness, fasciculations, muscle cramps)
and central (coma, seizures) cholinergic manifestations. It is ineffective for organophosphates
without anticholinesterase activity.
Its use in cases of carbamate poisoning is controversial, but some sources do recommend it for
severe cases.
Contraindications
Pralidoxime should not be used in patients who are hypersensitive to the drug.
Adverse effects
• Tachycardia, dizziness, hyperventilation, and laryngospasm associated with rapid IV infusion
• Nausea, vomiting, diarrhea, bitter aftertaste, and rash after oral doses
• Blurred vision and diplopia
• Possible neuromuscular blockade (weakness) with high levels or in patients with myasthenia
gravis
Dosage
See Table 35-4 for IV doses.
35-4. Terrorism and Disaster Preparedness
Introduction
The world faces the growing threat of attacks with biological, chemical, explosive, and radiological
weapons. Health care professionals should have an awareness of the potential for biological
terrorism, an appreciation for epidemiologic clues of a chem-bioterrorist event, and a basic
understanding of the classes of agents that can be weaponized and their effects.
Biological Threats
Bioterrorism is the deliberate use of infectious biological agents to cause illness and is categorized
for risk by the Centers for Disease Control and Prevention (CDC) as follows:
• Category A agents are high-priority agents that can be easily transmitted, can result in high
mortality rates, and have the potential for major public health impact. They include smallpox,
anthrax, plague, botulism, tularemia, and viral hemorrhagic fevers (filoviruses [e.g., Ebola and
Marburg] and arenaviruses [e.g., Lassa and Machupo]).
• Category B agents include brucellosis; epsilon toxin of Clostridium perfringens; food safety
threats (e.g., Salmonella species, Escherichia coli O157:H7, Shigella); glanders (Burkholderia
mallei); melioidosis (B pseudomallei); psittacosis (Chlamydia psittaci); Q fever (Coxiella
burnetii); ricin; staphylococcal enterotoxin B; typhus fever; viral encephalitis (alphaviruses such
as Venezuelan equine encephalitis, eastern equine encephalitis, and western equine encephalitis),
and water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum).
• Category C agents include emerging infectious disease threats such as Nipah virus and hantavirus.
See
Table 35-5 for clinical features and suggested treatment for likely forms of category A diseases and
for ricin, a category B agent that has been weaponized and used in terrorism.
The mode of transmission for biological agents is essentially the same as that of all other infectious
diseases:
• Aerosol (most common form for biological weapons)
• Dermal contact
• Injection
• Food
• Water
Chemical Threats
Toxic chemicals that may be used in warfare and in a chemical terrorism attack include nerve,
vesicant or blister, blood, choking or pulmonary, incapacitating, and tear- and vomit-inducing (riot
control) agents. See
Table 35-6 for descriptions, symptoms, and treatment of chemicals most likely to be used.
Normally, toxic chemicals used for these purposes are liquids or solids. Often they are dispersed in
the air in aerosols.
The CDC also considers several commonly available agents to be threats, including hydrofluoric
acid; benzene; ethylene glycol (antifreeze); and various metals such as arsenic, mercury, and
thallium. These agents are not detailed in Table 35-6.
Radiological Threats
Radiological weapons involve nuclear radiation or radioactive materials with various
radionucleotides. Radionucleotides can produce topical and systemic effects that may be immediate
or delayed, depending on the agent, route of exposure, and extent of exposure.
Medical management of radiological emergencies and terrorist attacks is specific for

radionucleotides. Guidance on treatment is available from the Radiation Emergency Assistance
Center/Training Site (REAC/TS) at the Oak Ridge Institute for Science and Education (Oak Ridge,
Tennessee). The emergency response phone number is 1-865-576-1005; ask for REAC/TS. For
program information, visit www.orise.orau.gov/reacts.
The early use of stable iodine, taken as potassium iodide or sodium iodide tablets, can reduce the
uptake of radioiodine by the thyroid. Many individuals near nuclear reactors will maintain a stock
of stable iodine tablets in the event of a radioactive accident. Ingestion of stable iodine is of little
value for other radionucleotide exposures unless the radioactive constituents are unknown, as in a
"dirty bomb."
Prussian blue 500-mg capsules are approved for the treatment of patients with exposures to
radioactive cesium (Cs-137) and thallium (Tl-201). Prussian blue absorbs the radioactivity that is
recirculated in the intestines and thereby enhances its elimination in the stool. The drug is available
from the CDC.
Calcium and zinc salts of diethylene triamine pentaacetic acid for IV infusion and aerosol
nebulization are approved to treat patients who have been exposed to radionucleotides that may be
found in a "dirty bomb" such as plutonium, americium, and curium. The drugs form chelates with
the radionucleotides that are excreted in the urine. The drugs are available from the CDC.
Emergency Preparedness
Pharmacists are in a unique position to quickly recognize communitywide patterns of symptoms,

illness, and mortality in humans and animals that can be important clues to terrorist events.
The CDC advises that if citizens believe that they have been exposed to a biological or chemical
agent, or if they believe an intentional biological threat will occur or is occurring, they should
contact their local health or police department or another law enforcement agency (e.g., the Federal
Bureau of Investigation). These agencies will notify the state health department and other response
partners, through a preestablished notification list that channels to the CDC.
The CDC maintains the Strategic National Stockpile (SNS) to ensure the availability and rapid
deployment of life-saving pharmaceuticals, antidotes, and other medical supplies and equipment
necessary to counter nerve agents, biological pathogens, and chemical agents. The SNS program
stands ready for immediate deployment to any U.S. location in the event of a terrorist attack using a
biological toxin or chemical agent
[Table 35-5. Biological Agents That May Be Used in a Terrorist Attack]

directed against a civilian population. A limited stock of drugs to treat nerve agents (CHEMPACK)
has been deployed to emergency medical services and hospital sites throughout the United States
and is maintained by the CDC. For further information, visit the CDC Web site at www.cdc.gov.
Pharmacists should consider volunteering in their communities to assist with emergency

preparedness. Roles in mass dispensing and vaccination clinics, SNS deployment, and general
disaster medical relief are possible opportunities. Contact the local health department or emergency
medical services agency.
Essential steps to volunteering for emergency preparedness include reaching an understanding with
one's family and employer, registering as a volunteer and identifying skills to contribute, obtaining
security credentials, participating in training, and doing whatever it takes when needed.
35-5. Key Points
• Medications are the most common cause of poisoning morbidity and mortality. Any chemical can
become toxic if too much is taken in relation to body weight and tolerance. A large number of
poisonings occur in young children, but most fatalities occur in adults.
• Several approaches can minimize the risk of unintentional childhood poisonings (e.g., use of
safety latches, proper storage of poisonous substances, and adherence to label instructions), but
the proper use of child-resistant containers (safety caps) is one of the most effective means.
• As part of the Poison Prevention Packaging Act of 1970, pharmacists are required to dispense oral
prescription drugs (with certain exceptions such as nitroglycerin and oral contraceptives) in
[Table 35-6. Chemical Agents That May Be Used in a Terrorist Attack]
child-resistant containers unless the patient or prescriber indicates the desire for a nonsafety cap.
• Immediate first aid for a poison exposure can minimize potential toxic effects and involves water
and fresh air, depending on the route of exposure. Contact a poison center immediately through
the nationwide access number (1-800-222-1222) to determine whether first aid should be
administered or whether a poisoning emergency exists.
• The use of drugs to decrease the absorption of drugs from the gastrointestinal tract after a
poisoning or overdose is in a state of change.
• Ipecac syrup—an orally administered emetic—has questionable effectiveness, and its use is now
generally avoided. It should not be used when (1) the person exhibits sleepiness, coma, or
seizures; (2) agents such as caustics and aliphatic hydrocarbons and fast-acting agents that
produce coma or seizures (e.g., tricyclic antidepressants, clonidine, strychnine, hypoglycemic
agents) have been ingested; (3) the ingestion was greater than 1 hour ago; or (4) there is an
obvious need for hospital referral.
• Cathartics such as magnesium citrate are not routinely used.
• Activated charcoal—an orally administered adsorbent—is often the only treatment necessary if
the toxin can be adsorbed and it is used within 1-2 hours of ingestion. It should be avoided in
ingestions of aliphatic hydrocarbons and caustics and in patients with absent bowel sounds, and it
is not useful with ingestion of heavy metals (sodium, lithium, iron, or lead) or simple alcohols.
• Whole-bowel irrigation, with products such as CoLyte and GoLYTELY, can be considered if the
toxin is poorly adsorbed and its presence in the gastrointestinal tract is likely.
• Other hospital-based therapies include supportive and symptomatic care, multiple doses of
activated charcoal (to enhance systemic elimination when appropriate), hemodialysis (to enhance
systemic elimination when appropriate), and use of antidotes (to antagonize or reverse toxic
effects when indicated).
• Substance abuse often leads to acute and chronic toxicity from a variety of medications,
commercial products, and illicit agents. The management of acute toxicity from substance abuse
typically follows the same general approaches as those for poisoning and overdose. A challenge
faced in many acute drug overdose episodes is determining the agents taken and possible
adulterants or contaminants. Chronic abuse can lead to dependence and withdrawal symptoms
when use is stopped.
• Few antidotes are available relative to the large number of potential poisons. The use of an
antidote is usually an adjunct to conventional and supportive therapies. Many hospitals have an
insufficient stock of antidotes.
• Acetylcysteine is a glutathione substitute in the metabolism of the acetaminophen-toxic reactive

metabolite. It is most effective in preventing hepatotoxicity if given orally within 10 hours of an
acetaminophen overdose, and it may also help later to minimize hepatic injury once it has begun.
Oral (Mucomyst) and IV (Acetadote) preparations are available.
• Atropine is used to treat the muscarinic effects (bronchorrhea, bradycardia, etc.) produced by
organophosphate and carbamate insecticides and anticholinesterase nerve gas agents by
competing with acetylcholine for binding at muscarinic receptors in the nervous system.
• Pralidoxime (Protopam) reactivates the enzyme acetylcholinesterase by dephosphorylation and

allows metabolism of accumulated amounts of acetylcholine produced by enzyme inhibition from
exposures to anticholinesterase nerve gas agents and organophosphate and carbamate
insecticides.
• Digoxin immune Fab (Digibind, DigiFab) is a specific antibody for digoxin, but it exhibits some
cross-reactivity with other digoxin-like compounds. It is an ovine-derived antigen-binding
fragment reserved for the treatment of life-threatening symptoms of digoxin overdose (e.g.,
bradycardia, ventricular arrhythmias, second- and third-degree heart block, hyperkalemia).
• Flumazenil (Romazicon) is a competitive antagonist of benzodiazepines at the benzodiazepine
receptor in the CNS. It is used in the treatment of severe CNS and respiratory depression that
may occur when benzodiazepines are used as an anesthetic or taken as an overdose. Seizures may
occur when flumazenil is administered to patients with co-ingestants of tricyclic
antidepressants—drugs that lower the seizure threshold—and to patients requiring
benzodiazepines for seizure control.
• Administration of naloxone (Narcan), a competitive antagonist of opiate binding at the opioid

receptors in the CNS, reverses the CNS and respiratory depression of opiate toxicity. Naloxone
may precipitate withdrawal symptoms in opiate-dependent patients.
• Bioterrorism is the deliberate use of infectious biological agents to cause illness. High-priority
agents can be easily transmitted, result in high mortality rates, and have the potential for major
public health impact. They include smallpox (Variola virus), anthrax (Bacillus anthracis), plague
(Yersinia pestis), botulism (Clostridium botulinum), tularemia (Francisela tularensis), and viral
hemorrhagic fevers (e.g., Ebola, Marburg, Lassa, Machupo).
• These chemicals can be used in warfare and may be used in a terrorist attack:
• Substances that act on nerves (e.g., anticholinesterase agents such as sarin)
• Substances that are blistering or vesicant agents (e.g., mustard agents, lewisites)
• Substances that act on blood (e.g., arsine, cyanide)
• Substances that act on the pulmonary system (e.g., phosgene, chlorine, ammonia)
• Substances that are incapacitating (e.g., fast-acting CNS depressants or hallucinogens)
• Substances that can also be used in riot control (e.g., various lacrimating agents such as
chloroacetophenone and vomiting agents such as adamsite).
• Health care providers must have an awareness of the potential for terrorism, an appreciation for
epidemiologic clues of a chem-bioterrorist event, and a basic understanding of the classes of
agents that can be weaponized and their effects. The CDC maintains the Strategic National
Stockpile. The SNS can be rapidly deployed to communities to ensure the availability of life-
saving pharmaceuticals, antidotes, other medical supplies, and equipment necessary to counter
nerve agents, biological pathogens, and chemical agents.
35-6. Questions
Flumazenil is contraindicated in which of the following?
I. A patient with QRS widening with a known ingestion of Elavil

II. A patient who was previously given flumazenil and who now complains of abnormal vision
and dizziness
III. A patient with known use of cocaine
1.
A. I only
B. II only
C. III only
D. I and III
E. I and II

A patient is brought to the emergency department. She is experiencing CNS and respiratory
depression, which are suspected to be related to ingestion of her sister's MS Contin. You
recommend supportive care and the administration of which of the following?
2. A. Flumazenil
B. Naloxone
C. Lorazepam
D. Flumazenil and Narcan
E. Pyridoxine

A police officer presents to the emergency room with a rash. He fears that he was exposed to a
biological weapon several days before the rash appeared. You notice the rash is forming
pustules and is most prominent on the face and extremities. The patient says the rash developed
all at once. He has possibly contracted which of the following?
3.
A. Smallpox
B. Chickenpox
C. Anthrax
D. Tularemia

What is the recommended treatment for the likely disease?
I. Supportive, as there is no specific treatment

II. Ciprofloxacin
III. Doxycycline
4.
A. II or III
B. II and III
C. I only
D. II only
E. III only

Which of the following is the currently available prevention for smallpox?
I. Dryvax
II. A live-virus preparation of the vaccinia virus
III. Avoidance of direct contact with infected persons and their body fluids
5.
A. I only
B. I and II only
C. II and III only
D. I, II, and III
E. No vaccine is currently available.

A patient presents with a black, necrotic, painless skin lesion on her arm. She also complains
of fever, malaise, headache, and swelling of her underarm lymph nodes. Which of the
following is the possible biological agent responsible for these symptoms?
6. A. Hemorrhagic fever virus

B. Anthrax
C. Botulism
D. Tularemia
E. Arsine

The recommended antibiotic treatment of the infection in question 6 may include which of the
following?
A. Ciprofloxacin
7.
B. Doxycycline
C. Amoxicillin
D. All of the above
E. Supportive therapy, as there is no specific treatment

Inhalation exposure to the agent in question 6 requires which of the following?
A. Postexposure prophylaxis with ciprofloxacin, doxycycline, or levofloxacin for 60 days

8. B. Immediate vaccination of civilian personnel
C. Early treatment with streptomycin or gentamicin
D. Early treatment with ribavirin

A cab driver presents to the emergency department with vomiting, diarrhea, sweating,
salivation, moist rales, bradycardia, muscle tremor, and weakness. He reports inhaling a mist
dropped from a low-flying plane several hours earlier. You also note that he has miosis and his
respiratory difficulty is increasing rapidly. Which of the following is the likely mechanism of
toxicity of the poison?
9.
A. Inhibition of protein synthesis
B. Binding of the agent to cytochrome oxidase
C. Inhibition of acetylcholinesterase
D. An alkylating agent that cross-links DNA strands

The recommended initial management of the symptoms in question 9 includes all except which
of the following?
A. Immediate decontamination of skin and eyes

10.
B. Disposal of contaminated clothes
C. British antilewisite
D. Atropine
E. Pralidoxime

The patient in question 9 deteriorates and develops seizures. Which of the following do you
recommend?
A. Phenytoin
11.
B. Diazepam
C. Lithium
D. Dryvax
E. All of the above

Which of the following conditions or situations is not a contraindication to the use of ipecac
syrup?
A. High blood pressure controlled with drug therapy

12.
B. Seizures shortly before administration
C. Unresponsiveness to verbal commands
D. Ingestion of a corrosive agent
E. A and C

Which of the following is an effect of activated charcoal?
A. Promotes dissolution of tablets

13. B. Minimizes drug absorption from the gastrointestinal tract
C. Increases urinary flow
D. Enhances systemic elimination of certain drugs
E. B and D

Which of the following is useful in the treatment of acetaminophen poisoning?
A. Acetylcysteine
14. B. Dimercaprol
C. Pralidoxime
D. Atropine
E. Dryvax

Digoxin immune Fab is used to treat which of the following signs or symptoms of digoxin
poisoning?
A. Hypokalemia
15.
B. Diplopia
C. Ventricular tachycardia
D. Second-degree heart block unresponsive to atropine
E. C and D

How does crack cocaine differ from pharmaceutical cocaine?
A. Crack cocaine is more stable under heat and can be smoked.

16. B. Pharmaceutical cocaine is the hydrochloride salt.
C. Crack cocaine is the free-base form of cocaine.
D. Crack cocaine may be contaminated with other substances.

Which of the following mechanisms is associated with the production of hepatic injury from an
acute overdose of acetaminophen?
A. Interference with RNA (ribonucleic acid) synthesis

17.
B. Interference with transaminase enzyme activity
C. Direct toxicity of acetaminophen
D. Formation of a toxic metabolite
E. Exaggeration of its pharmacologic effects

Which of the following signs or symptoms is characteristic of an acute exposure to an
organophosphate as an insecticide or terrorist weapon?
A. Dry mouth and mucous membranes

18.
B. Excessive bronchial secretions
C. Muscle rigidity
D. Urinary retention
E. All of the above

35-7. Answers
D. Flumazenil is contraindicated in all patients who have ingested a tricyclic antidepressant

and have cardiac symptoms because its use could cause ventricular dysrhythmias. It is not
1. recommended in mixed overdose where the co-ingested drug can cause a seizure (i.e., cocaine).
Statement II describes associated adverse effects with that may occur with the administration
of flumazenil; they are not contraindications.

2. B. Naloxone is an opioid antagonist.

A. See Table 35-5. Smallpox is the most likely agent. The agent causes formation of a pustular
rash that is typically most prominent on the face and extremities. Lesions form at the same
3. time. Chickenpox rash is most prominent on the trunk and develops in successive groups of
lesions over several days. Anthrax forms painless necrotic lesions. Tularemia causes a
nonspecific febrile illness that rapidly develops into pneumonia.

C. See Table 35-5. Smallpox has no specific treatment, but the live-vaccine (Dryvax) may
4. lessen the disease if given within 4 days of the exposure. Ciprofloxacin and doxycycline are
used in the management of anthrax, plague, and tularemia.

5. D. See Table 35-5. All options are correct.

B. See Tables 35-5 and 35-6. Anthrax forms a painless, necrotic ulcer. Hemorrhagic fever
viruses cause a rash that develops into petechiae, ecchymosis, hemorrhages, and other bleeding
symptoms. Botulism causes a symmetric descending paralysis. Tularemia causes a nonspecific
febrile illness that rapidly develops into pneumonia. Arsine is a chemical agent that causes
6. nausea, vomiting, hemolysis, and secondary renal failure. Arsine is produced when water
comes into contact with metallic arsenide or when acids come into contact with metallic
arsenic or arsenical compounds. The mechanism of hemolysis is not specifically known, but
the most recent mechanism postulated involves a direct arsine-hemoglobin interaction that
forms arsenic metabolites, causing direct alteration of the erythrocyte cell membrane.

D. See Table 35-5. Ciprofloxacin, levofloxacin, and doxycycline are approved by the U.S.
Food and Drug Administration (FDA) for treatment of anthrax, while amoxicillin can be used
when the other drugs are not tolerated or pose patient-specific risks. These agents can be used
7.
separately or in combination, depending on the symptoms and the patient's sensitivity to the
agents. Antimicrobial resistance to ciprofloxacin has been growing rapidly because of
widespread overuse after the anthrax-contaminated mail episodes in 2002.

A. See Table 35-5. Persons at risk for inhalational anthrax need 60 days of prophylactic
antibiotics. Ciprofloxacin and doxycycline are FDA-approved for postexposure prophylaxis
(PEP) in adults and children; levofloxacin is used in adults 18 years of age and older. If these
drugs are not tolerated, amoxicillin can be used. In 2009, a vaccine (BioThraxT) became
8.
available that can be given postexposure in conjunction with antibiotics or as a vaccination for
high-risk personnel (e.g., military or lab personnel likely to be in contact with the bacteria).
Streptomycin and gentamicin are among the suggested treatments for pneumonic plague.
Ribavirin is a potential treatment for some hemorrhagic fever viruses.

C. See Table 35-6. The symptoms exhibited are classically cholinergic, and the likely chemical
agents causing these symptoms are organophosphates such as nerve agents or possibly
organophosphate pesticides. Both can be spread by low-flying planes. Inhibition of protein
9. synthesis is the mechanism of toxicity of ricin or abrin. Cyanides bind to cytochrome oxidase,
thereby interrupting normal cellular respiration and causing rapid convulsions. Blister agents
such as sulfur and nitrogen mustards are thought to be alkylating agents that cross-link DNA
strands, thereby separating dermal layers in the skin and causing fluid-filled blisters to form.

C. British antilewisite is a specific antidote for lewisite. See Table 35-6. It also is used as a
chelator for treatment of acute arsenic, inorganic or elemental mercury, gold, and other heavy
metal poisonings. See Table 35-4. The other measures are treatments for organophosphate
agents. Good decontamination and disposal of contaminated clothes (especially leather) are
needed, because organophosphates are well absorbed across the skin, through the lungs, and
10. through ingestion—essentially all possible routes of exposure. Atropine is used for muscarinic
symptoms (miosis; nausea and vomiting; diarrhea; urination; bradycardia; and excessive
bronchial, lacrimal, dermal, nasal, and salivary secretions). Pralidoxime is used with atropine
to resolve severe organophosphate symptoms (such as those from exposure to nerve agents),
including nicotinic symptoms of muscle weakness and cramps, fasciculations, and tachycardia,
and CNS symptoms such as coma and seizures.

B. See Table 35-6. Recommended treatment for seizures attributable to organophosphate
agents is either diazepam or lorazepam. Phenytoin is a seizure medication, but benzodiazepines
11. (then barbiturates if benzodiazepines fail) are generally preferred over phenytoin for the control
of overdose- or withdrawal-related seizures. Lithium is not a seizure medicine and, in fact, may
cause seizures with elevated blood concentrations. Dryvax is a vaccine for smallpox.

A. Controlled high blood pressure is not a problem with the use of ipecac syrup, but the other
12. situations are clear contraindications because of potential aspiration (seizures and
unresponsiveness) and additional esophageal burns on vomiting up gastric contents (corrosive).

E. Activated charcoal adsorbs chemicals on contact and prevents their absorption into the
bloodstream. For certain drugs (e.g., phenobarbital, theophylline), multiple doses of activated
13. charcoal can promote the back diffusion of drugs across the intestinal capillary bed into the
lumen of the gut, trap it there, and promote its elimination. The elimination half-life can be
decreased by as much as one-half.

A. Acetylcysteine prevents the development of liver injury from acetaminophen if given early
14. after ingestion and, in some cases, may help minimize the effects of hepatotoxicity after it has
occurred.

E. Digoxin immune Fab is reserved for life-threatening symptoms because of its profound
effects, scarcity, and high cost. Most serious cases of digoxin poisoning have normal or high
15.
potassium concentrations because of the digoxin's interference with the sodium-potassium
ATPase pump.

16. E. All are differences between the two forms of cocaine.

D. Acetaminophen forms a toxic metabolite that has a direct toxic effect within the hepatocyte.
17. It has other proposed mechanisms, but this mechanism is thought to be the inciting event. See
the description for acetylcysteine in Section 35-3.

B. Excessive bronchial secretions are one of the principal causes of death from exposure to
18. organophosphates. The other symptoms are not observed. See the description for atropine and
pralidoxime in Section 35-3.

35-8. References
General Toxicology
American College of Emergency Physicians. Clinical policy for the initial approach to patients
presenting with acute toxic ingestion or dermal or inhalation exposure. Ann Emerg Med.
1999;33:735-61.
Bronstein AC, Spyker DA, Cantelina LR, et al. 2006 annual report of the American Association of
Poison Control Centers' National Poison Data System (NCDS). Clin Toxicol. 2007;45:815-917.
Chyka PA. Clinical toxicology. In: Dipiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A
Dart RC, ed. Medical Toxicology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2004.
Diversion Control Program, Drug Enforcement Administration, U.S. Department of Justice. Drugs
and chemicals of concern. Available at: www.deadiversion.usdoj.gov/drugs_concern/index.html.
Flomenbaum NE, Goldfrank LR, Hoffman RS, et al., eds. Goldfrank's Toxicologic Emergencies.
8th ed. New York: McGraw-Hill; 2006.
Ford MD, Delaney KA, Ling LJ, Erickson T. Clinical Toxicology. Philadelphia: WB Saunders;
2001.
Klaassen CD. Principles of toxicology and treatment of poisoning. In: Brunton LL, Lazo JS, Parker
KL, eds. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 11th ed. New
National Institute on Drug Abuse, National Institutes of Health. NIDA InfoFacts: Science-based
facts on drug abuse and addiction. Available at: www.nida.nih.gov/Infofacts/Infofaxindex.html.
Office of Applied Studies, Substance Abuse and Mental Health Services Administration. Drug
Abuse Warning Network, 2006. DHHS publication SMA 08-4339. Rockville, Md.: Substance
Abuse and Mental Health Services Administration; 2008.
Olson KR, ed. Poisoning and Drug Overdose. 5th ed. New York: Lange/McGraw-Hill; 2007.
Terrorist Threats
Abramowicz M, ed. Prevention and treatment of injury from chemical warfare agents. Med Letter.
2002;44:1-4.
Kales SN, Christiani DC. Acute chemical emergencies. N Engl J Med. 2004;350:800-8.
Oak Ridge Institute for Science and Education. Managing radiation emergencies: Guidance for
hospital medical management. Available at: www.orise.orau.gov/reacts/.
Setlak P. Bioterrorism preparedness and response: Emerging role for health-system pharmacists.
Am J Health-Syst Pharm. 2004;61:1167-75.
Shepherd G, Schwartz RB. Emergency preparedness: Identification and management of chemical

and radiological exposures. In: Dipiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A
Pathophysiologic Approach. 7th ed. New York: McGraw-Hill; 2008:93.
Terriff CM, Brouillard JE, Costanigro LT, Gruber JS. Emergency preparedness: Identification and
management of biological exposures. In: Dipiro JT, Talbert RL, Yee GC, et al., eds.
Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-Hill; 2008:91.
U.S. Centers for Disease Control and Prevention. Emergency preparedness and response. Available
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www.hhs.gov/aspr/opeo/ndms/.
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www.fda.gov/Drugs/EmergencyPreparedness/BioterrorismandDrugPreparedness/default.htm.
36. Anemias - Trevor McKibbin, PharmD, MS, BCPS
36-1. Disease Overview
Introduction
Anemia is a reduction in red cell mass that decreases the oxygen-carrying capacity of the blood.
This chapter will focus on iron deficiency anemia (IDA), megaloblastic anemias, and anemia of
renal failure.
Epidemiology
Approximately 3.4 million Americans have anemia. Anemia is more common in women than men.
Seventy-five percent of anemias result from iron deficiency, anemia of chronic disease, and acute
bleeding. The remaining 25% of anemia cases result from bone marrow damage, decreased
erythropoiesis, and hemolysis. IDA is the single most common form of anemia, accounting for 25%
of all cases.
Kinetic Approach to Anemia
Anemia may be caused by one or more of three mechanisms: decreased red blood cell (RBC)
production, increased RBC destruction, and blood loss.
Classification by Morphology
The most common way to classify an anemia is by the morphology (shape and structure) of the
RBCs.
Macrocytic (large cell) morphology
Anemias in this class include the following:
• Megaloblastic anemia
• Folic acid deficiency (decreased red blood cell production)
• Vitamin B12 deficiency (decreased red blood cell production)
• Pernicious anemia
Normochromic, normocytic morphology
Anemias in this class may result from following:

• Acute blood loss
• Bone marrow failure (decreased RBC production)
• Hemolysis (increased RBC destruction)
• Immunologic destruction, such as occurs in autoimmune diseases and endocrine disorders
In aplastic anemia, marrow fails to produce all three types of blood cells, which results in anemia,
neutropenia (decreased white blood cells), and thrombocytopenia (decreased platelets). About half
of aplastic anemia cases are believed to be caused by drugs or chemicals. Drugs that cause aplastic
anemia include chloramphenicol, felbamate, carbamazepine, and phenytoin.
Genetically inherited enzyme deficiencies such as glucose-6-phosphate dehydrogenase (G6PD)

deficiency can lead to hemolysis, because RBCs deficient in G6PD are susceptible to hemolysis
when exposed to certain oxidant drugs (e.g., dapsone, sulfamethoxazole, and nitrofurantoin).
RBC membrane abnormalities, such as those caused by hereditary spherocytosis, can cause
increased RBC destruction.
Hypochromic (low hemoglobin content) or microcytic (small cell) morphology
Anemias in this class include the following:
• Iron deficiency anemia (decreased red blood cell production)
• Certain genetic anomalies, such as sickle cell anemia and thalassemia
The signs and symptoms of anemia depend on the amount of time during which the anemia has
developed and the severity of RBC depletion. An anemia that has developed over a long period of
time may be asymptomatic in the beginning stages and then progress to fatigue, malaise, headache,
exertional dyspnea, angina, pallor, or loss of skin tone. A patient with acute anemia, such as from
recent blood loss, may present with tachycardia, shortness of breath, or lightheadedness.
Many of the signs and symptoms of anemia are secondary to tissue hypoxia. In the case of hypoxia,
blood supply is shunted to life-sustaining organs (brain, heart, and kidney) and away from nonvital
organs (e.g., extremities or nail beds), which results in pallor of the skin.
The various types of anemia have additional signs and symptoms that will be discussed in further
detail in elsewhere in the chapter.
Pathophysiology
Iron deficiency anemia
IDA is the most common anemia, accounting for one-fourth of all anemia cases. It is caused by iron
store depletion resulting from
• Inadequate oral intake of iron (especially animal protein)
• Increased iron demands, such as those found in
• Pregnant or lactating women
• Infants and adolescents, who experience periods of rapid growth
• The elderly
• Blood loss as a result of
• Menstruation or postpartum blood loss
• Trauma
• Gastrointestinal (GI) ulcers
• Inadequate absorption as a result of
• Medications (e.g., tetracyclines)
• Gastrectomy
• Enteritis
• Persistent diarrhea
• Disease states, such as
• Carcinomas
Hemoglobin is composed of iron (heme) and proteins (globin). Lack of iron results in reduced
hemoglobin synthesis. The RBCs produced under those conditions are
• Hypochromic (decreased concentration of hemoglobin)

• Microcytic (smaller cells)
Megaloblastic anemias
Megaloblastic anemias either are caused by a deficiency in or an inability to use vitamin B12
(cobalamin) or folic acid.
Vitamin B12 deficiency can result from
• Decreased intake: This problem may occur with patients who are strict vegetarians.
• Decreased absorption: Vitamin B12 requires gastric intrinsic factor to be absorbed. The lack of
intrinsic factor results in pernicious anemia, which can be inherited or acquired by gastrectomy.
• Achlorhydria: Vitamin B12 requires an acidic environment to be absorbed. Chronic therapy with
proton pump inhibitors and H2 antagonists may contribute to vitamin B12 deficiency.
• Inadequate utilization of vitamin B12: This problem can be a result of protein deficiencies.
Folic acid deficiency can result from
• Decreased intake: This problem is especially found in patients who are alcoholic, indigent, or
elderly.
• Decreased absorption: This problem occurs in patients with Crohn's disease or celiac disease. It
can also be drug induced.
• Increased demands: For example, deficiencies may occur during pregnancy or growth spurts or
could accompany malignancy or long-term hemodialysis.
• Use of certain drugs: Such drugs include methotrexate and phenytoin.
Both vitamin B12 and folic acid are necessary for the RNA (ribonucleic acid) and DNA
(deoxyribonucleic acid) required for cell division during the development of RBCs. Because RNA
and DNA synthesis is impeded when vitamin B12 and folic acid levels are deficient, cell divisions
are skipped, resulting in abnormally large cells (macrocytic anemia).
Anemia of renal failure
The primary reason that patients with renal failure are anemic is because of the lack of
erythropoietin (EPO) production. EPO is a hormone produced primarily (90%) in the kidneys that
stimulates the synthesis and differentiation of erythroid progenitor cells (precursors to RBCs).
The uremic environment in patients with chronic renal failure decreases the lifespan of RBCs.
Folic acid deficiency also can develop as a result of increased folic acid demands during synthesis
of RBCs. Additionally, folic acid can be removed during hemodialysis.
Patients with chronic renal failure can become iron deficient as a result of iron and blood loss
during dialysis.
Diagnostic Criteria
If anemia is suspected, the following blood tests should be performed:
• Complete blood cell count (CBC), which includes
• Hemoglobin (Hgb)
• Hematocrit (Hct)
• RBC count
• Red cell indices:
• Mean corpuscular volume (MCV), which is a measure of the size of RBCs
• Mean corpuscular hemoglobin (MCH), which is a measure of the weight of hemoglobin in a

RBC (MCH will be low in the case of microcytosis or hypochromia)
• Mean corpuscular hemoglobin concentration (MCHC), which is a measure of the weight of

hemoglobin, but is more useful than MCH because it can distinguish between low
hemoglobin (hypochromia) and a small cell (MCHC will be low only in the case of
hypochromia)
• Platelets
• Reticulocyte count (pre-RBCs)
• Red cell morphology
• Serum iron, total iron binding capacity (TIBC), transferrin saturation, and ferritin
• Bilirubin, which is a by-product of RBC destruction
Other tests include the following:
• Stool test for presence of blood
• Peripheral blood smear

• Thorough history and physical examination
Blood work
The first level to decrease will be ferritin (storage form of iron). However, ferritin may be increased
in inflammatory diseases. The iron level will be low. TIBC, which is a measure of the amount of
binding space left on transferrin (transport protein of iron), will be increased. (Less iron in the blood
means that more space will be available on the transferrin molecule.)
As the iron deficiency progresses, hemoglobin will decrease, because iron is a component of
hemoglobin. Decreased hemoglobin indicates a hypochromic anemia. The hematocrit also will
eventually fall.
MCV will be decreased, which indicates microcytosis. MCH and MCHC will be decreased, which
indicates decreased hemoglobin. The blood smear will show a microcytic, hypochromic cell.
Specific signs and symptoms

In addition to the general signs and symptoms listed previously for anemia, the following additional
symptoms may be present in severe IDA:
• Koilonychias (spoon-shaped nails)
• Angular stomatitis or glossitis
• Pica (appetite for nonfood substances such as chalk, soil, or clay)
Blood work
Blood work should show the following:
• Decreased Hct and Hgb
• Decreased RBC count
• Elevated MCH, which indicates a macrocytosis
• Normal iron level, TIBC, and reticulocyte count
Vitamin B12 deficiency

If the problem is vitamin B12, the serum B12 level will be decreased. A positive Schilling test will
indicate pernicious anemia. (The Schilling test determines absorption of vitamin B12 by measuring
the amount of radioactive B12 excreted in urine.)
Additional signs and symptoms include the following:
• Loss of vibratory sensation in lower extremities
• Ataxia or vertigo
• Glossitis
• Muscle weakness
• Neuropsychiatric abnormalities (e.g., irritability or emotional instability, dementia, psychosis)
Folic acid deficiency

In a case of folic acid deficiency, the folate level will be decreased. Overall, folic acid deficiency
anemia is very similar to vitamin B12 deficiency anemia, except that the neurological symptoms that
may be present with vitamin B12 deficiency anemia are absent.
As the name implies, this anemia occurs in patients with chronic renal failure. Before diagnosis,
other causes must be ruled out (e.g., blood loss). CBC will reveal a normochromic, normocytic
anemia.
In IDA treatment, the goal is to normalize Hgb and Hct:
• Hgb should increase 2 g/dL in 3 weeks.
• Hct should increase 6% in 3 weeks.
• Reticulocytosis usually will occur within 1 week.
If those indices do not improve within their respective time frames, the diagnosis should be
reevaluated, and compliance with therapy should be confirmed.
A second goal is to replenish iron stores. Although Hgb and Hct will return to normal within 1-2
months, iron therapy should be continued for 3-6 months after Hgb is normalized to replenish total
body iron stores.
Goals of vitamin B12 replacement
Hgb should increase within 1 week.
If neurologic symptoms were present, they should improve within 24 hours. However, if vitamin
B12 deficiency is long-standing, symptoms may not be relieved completely for several months.
Maintenance administration of vitamin B12 should continue for as long as nutritional intake is a
problem.
Goals of folic acid replacement

RBC morphology will correct within 1-2 days. Hgb will start to normalize within 10 days. Hct will
return to normal levels within 2 months.
Maintenance administration of folic acid should continue for as long as nutritional intake of folic
acid is a problem.
The initial therapy goal is to reach a target Hgb of 11-12 g/dL through a slow, steady increase
(usually within 2-4 months). Medication doses of erythropoiesis-stimulating agents should be
titrated to maintain a Hgb level between 11-12 g/dL, not to exceed a Hgb of 13 g/dL.
Because laboratory variability in the measurement of hematocrit is greater than that of hemoglobin,
reliance on the Hct measurement alone is not the optimal method for assessing the patient's
response to treatment.
36-2. Drug Therapy
Iron Deficiency Anemia
Treatment consists of iron supplementation through therapeutic iron preparations (200 mg of

elemental iron per day in 2-3 divided doses) (
Table 36-1). Iron is best absorbed in the reduced (ferrous) form. Ferrous sulfate salt, which is 20%
elemental iron, is the most common form. Therefore, ferrous sulfate 325 mg tid will treat iron
deficiency adequately.
Intravenous (IV) iron preparations should be used only in cases of
• Iron malabsorption
• Oral noncompliance
• Refusal of blood transfusion
IV iron formulations often are used in patients with chronic renal failure who require dialysis along
with human recombinant erythropoietin therapy. Four IV iron products are available in the United
States:
• Iron dextran (InFeD and Dexferrum)
• Ferric gluconate (Ferrlecit)
[Table 36-1. Drugs Used to Treat Iron Deficiency Anemia]
• Iron sucrose (Venofer)
• Feraheme (ferumoxytol)
Ferumoxytol was recently approved for iron-deficiency anemia in adult patients with chronic kidney
disease.
Mechanism of action
Iron supplementation corrects the iron deficiency and enables Hgb to be synthesized at normal
levels.
Patient instructions (for oral supplementation)
• Take iron supplementation 1-2 hours prior to a meal (on an empty stomach).
• If iron is intolerable on an empty stomach, take it with a small snack, but try to avoid dairy
products or tea. (Food can decrease the absorption of iron by 50%.) Take it with orange juice if
possible (orange juice may increase absorption).
• Keep out of reach of children. Iron is a major cause of ingestion deaths in children.
• Take iron 1 hour before or 3 hours after any antacids.
• Some medications interact with iron. Please ask your physician or pharmacist before taking any
new medications in combination with iron.
• If constipation occurs, you may take over-the-counter docusate.
The oral formulation primarily has GI effects:
• Dark-colored stools
• Constipation or diarrhea
• Nausea or vomiting
The IV formulations may have the following effects:
• Injection site reactions
• GI effects (e.g., diarrhea, nausea)
• Hypotension
• Allergic reactions, including anaphylaxis
The risk of anaphylaxis is greatest with iron dextran. Clinicians commonly administer a test dose
before infusing the entire dose of this agent. Premedication with antihistamines and corticosteroids
also may prevent anaphylaxis.
Drug interactions
• Antibiotics (tetracycline and quinolones): Iron binds to these antibiotics, preventing absorption.
• Antacids: Iron needs an acidic environment for optimal absorption.
• Have reticulocytes, Hgb, and Hct increased?
• Is the iron tolerable? (Tolerance will influence compliance.)
• Is the patient improving symptomatically?
Kinetics
Bioavailability is increased in an acidic environment and is decreased by food.
Megaloblastic Anemias
Vitamin B12 should be administered orally if absorption is not an issue. The recommended daily
intake is 2 mcg. A solution for nasal administration of vitamin B12 is also available.
A vitamin B12 deficiency that leads to pernicious anemia is usually corrected through intramuscular
(IM) vitaminB12 (cyanocobalamin) injection as follows:
• Initially 1,000 mcg IM every day for 1 week

• Then 100-1,000 mcg IM every week for 4 weeks
• Then 100-1,000 mcg IM every month thereafter for maintenance
Although IM vitamin B12 is used more often, patients with deficiency states may be supplemented
orally in very high doses (e.g., 1,000-2,000 mcg per day).
People choosing vegan diets should supplement with vitamin B12 daily and may require lower
maintenance doses than those with absorption abnormalities. Pregnant women and breast-feeding
mothers may have higher daily requirements.
Mechanism of action
Vitamin B12 supplementation allows for normal synthesis of the RNA and DNA involved in the
synthesis of RBCs.
If injections are given at home, the patient or family members should be counseled on sterile
injection techniques and proper needle disposal.
Vitamin B12 supplementation can cause the following adverse effects:
• Hyperuricemia or hypokalemia caused by increased synthesis of reticulocytes
• Sodium retention
• An expansion of the intravascular volume as a result of increased RBC synthesis, which can
increase cardiac output and cause angina or dyspnea
• Itching in 1-10% of patients
• Diarrhea in 1-10% of patients
• Anaphylaxis in < 1% of patients
• Monitor CBC. Is there an increase in Hgb?
• Is the patient improving symptomatically (especially neurologic symptoms, if present)?
• Is the potassium level normal?

Kinetics
Intrinsic factor is necessary for vitamin B12 absorption. It must be present for vitamin B12 to be
transported across the GI mucosa.
Vitamin B12 is bound in blood to transcobalamin II and converted in tissues to active coenzymes
methylcobalamin and deoxyadenosylcobalamin.
Folic Acid Deficiency Anemia
Folic acid deficiency anemia is corrected by supplementing folic acid 1 mg daily for 4 months.
Once the underlying cause of the deficiency is corrected, folic acid supplementation may be
discontinued. Long-term folate administration is necessary if the cause is not corrected, such as in
hemodialysis or alcoholism.
Mechanism of action
Folic acid supplementation allows for normal RNA and DNA synthesis, both of which are involved
in the synthesis of RBCs.
• Stress the importance of compliance with regimen.
• Women of childbearing age should be counseled to take a multivitamin containing folic acid,
regardless of whether an anemia is present, to prevent neural tube birth defects.
Fewer than 1% of patients have allergic reactions to folic acid.
Drug interactions
Folic acid may increase phenytoin metabolism.
Phenytoin, primidone, sulfasalazine, para-aminosalicylic acid, and oral contraceptives may decrease
folic acid concentrations.
Chloramphenicol may blunt response to folic acid.
• Is the RBC morphology normalizing?

• Are the Hgb and Hct normalizing?
• Is the patient complying?
Kinetics
Folic acid is a water-soluble B vitamin absorbed in the small intestine with Cmax at 30 minutes to 1
hour.
Anemia of Renal Failure
Recombinant human erythropoietin
The primary cause of anemia in renal failure is decreased EPO synthesis; therefore, the optimal
drug for this type of anemia is an erythropoiesis stimulating agent (ESA). Epoetin alfa (Procrit,
Epogen) and darbepoetin alfa (Aranesp) are ESAs with similar mechanisms of action, but
darbepoetin alfa has a longer half-life.
An ESA is indicated in the treatment of anemia associated with chronic renal failure, including
dialysis and nondialysis patients. ESAs are indicated to elevate or maintain the RBCs and to
decrease the need for transfusions in these patients. (Nondialysis patients with symptomatic anemia
considered for therapy should have an Hct < 30%.) The National Kidney Foundation-Kidney
Disease Outcomes Quality Initiative (NKF-K/DOQI) guidelines recommend that epoetin be
administered subcutaneously, because that route of administration is as effective (or more effective)
than IV administration. However, epoetin often is administered intravenously in patients on
dialysis, because the dialysis port offers easy IV access.
Mechanism of action
Human recombinant erythropoietin stimulates erythropoiesis (increased RBC production).
Patient instructions (Epoetin alfa)
• Do not shake the vial because the epoetin may break down, thus decreasing the medication's
effectiveness.
• Store the medication in the refrigerator, but do not freeze. Keep it out of direct sunlight.
• Make sure that the solution in the vial is clear and free of particulate matter. Do not use if the
solution is cloudy or frothy.
• Monitor your blood pressure at home and alert your physician of any significant increases in blood
pressure.
• Single-use vials are intended to be used only once. Discard any remaining solution and vial. If the
label is marked with an "M," the vial is a multidose vial, and it may be stored in the refrigerator
for 21 days.
• Take your blood pressure medications exactly as prescribed while on this medication, and
maintain a sodium-restricted diet.
• Avoid hazardous activity in the first 90 days of therapy (e.g., operating heavy machinery).
• As with all medications, watch for signs of possible allergic reaction. Tell your doctor if you
experience a local reaction (swelling, itching, redness).
• A very small number of patients may experience an anaphylactic reaction (shortness of breath,
wheezing, low blood pressure, rapid heart rate, sweating). If any of those reactions occur,
discontinue using the medication immediately and call 911.
• Follow the instructions for correct sterile injection technique and needle disposal (Box 36-1).
Box 36-1. Instructions for Self-Administering Epotein Alfa
Preparing the dose
1. Wash your hands thoroughly with soap and water before preparing the medication.
2. Check the date on the epoetin alfa vial to be sure that the drug has not expired.
3. Remove the vial of epoetin alfa from the refrigerator and allow it to reach room temperature.
Each epoetin alfa vial is designed to be used only once: do not re-enter the vial. It is not
necessary to shake epoetin alfa. Prolonged vigorous shaking may damage the product. Assemble
the other supplies you will need for your injection.
4. Hemodialysis patients should wipe off the venous port of the hemodialysis tubing with an
antiseptic swab. Peritoneal dialysis patients should cleanse the skin with an antiseptic swab
where the injection is to be made.
5. Flip off the red protective cap but do not remove the gray rubber stopper. Wipe the top of the
gray rubber stopper with an antiseptic swab.
6. Using a syringe and needle designed for subcutaneous injection, draw air into the syringe by
pulling back on the plunger. The amount of air should be equal to your epoetin alfa dose.
7. Carefully remove the needle cover. Put the needle through the gray rubber stopper of the epoetin
alfa vial.
8. Push the plunger in to discharge air into the vial. The air injected into the vial will allow epoetin
alfa to be easily withdrawn into the syringe.
9. Turn the vial and syringe upside down in one hand. Be sure the tip of the needle is in the
epoetin alfa solution. Your other hand will be free to move the plunger. Draw back on the
plunger slowly to draw the correct dose of epoetin alfa into the syringe.
10. Check for air bubbles. The air is harmless, but too large an air bubble will reduce the epoetin
alfa dose. To remove air bubbles, gently tap the syringe to move the air bubbles to the top of the
syringe, then use the plunger to push the solution and the air back into the vial. Then re-measure
your correct dose of epoetin alfa.
11. Double-check your dose. Remove the needle from the vial. Do not lay the syringe down or
allow the needle to touch anything.
Injecting the dose
Patients on home hemodialysis using the intravenous injection route:
1. Insert the needle of the syringe into the previously cleansed venous port and inject the epoetin
alfa.
2. Remove the syringe and dispose of the whole unit. Use the disposable syringe only once.
Dispose of syringes and needles as directed by your doctor, by following these simple steps:
• Place all used needles and syringes in a hard plastic container with a screw-on cap, or a metal
container with a plastic lid, such as a coffee can properly labeled as to contents. If a metal
container is used, cut a small hole in the plastic lid and tape the lid to the metal container. If a
hard plastic container is used, always screw the cap on tightly after each use. When the
container is full, tape around the cap or lid, and dispose of it according to your doctor's
instructions.
• Do not use glass or clear plastic containers, or any container that will be recycled or returned
to a store.
• Always store the container out of the reach of children.
• Please check with your doctor, nurse, or pharmacist for other suggestions. There may be
special state and local laws that they will discuss with you.
Patients on home peritoneal dialysis or home hemodialysis using the subcutaneous route:
1. With one hand, stabilize the previously cleansed skin by spreading it or by pinching up a large
area with your free hand.
2. Hold the syringe with the other hand, as you would a pencil. Double check that the correct
amount of epoetin alfa is in the syringe. Insert the needle straight into the skin at a 90° angle.
Pull the plunger back slightly. If blood comes into the syringe, do not inject epoetin alfa, as the
needle has entered a blood vessel; withdraw the syringe and inject at a different site. Inject the
epoetin alfa by pushing the plunger all the way down.
3. Hold an antiseptic swab near the needle and pull the needle straight out of the skin. Press the
antiseptic swab over the injection site for several seconds. Use the disposable syringe only once.
4. Use the disposable syringe only once. Dispose of syringes and needles as directed in the
instructions at left, under step 2.
5. Always change the site for each injection as directed. Occasionally a problem may develop at
the injection site. If you notice a lump, swelling, or bruising that does not go away, contact your
doctor. You may wish to record the site you just used so you can keep track.
Reproduced with permission from Procrit® package insert. Raritan, NJ: Ortho Biotech Products,
LP; 2000.

Table 36-2 shows adverse effects of epoetin alfa and the percentage of patients reporting them. The
most common adverse effect is elevated blood pressure. ESAs are contraindicated in patients with
uncontrolled hypertension.
Pure red cell aplasia (PRCA), in association with neutralizing antibodies to native erythropoietin,
has been reported rarely in the literature. If PRCA is suspected, discontinue epoetin immediately.
Drug interactions
No drug interactions have been reported.
Prior to initiation of therapy, the patient's iron stores should be evaluated. Transferrin saturation
should be at least 20% and ferritin at least 100 ng/mL. Patients on ESA therapy often require iron
supplementation for efficacy of the ESA.
[Table 36-2. Percentage of Patients Reporting Adverse Effects of Epoetin Alfa]
Monitor Hgb very closely. Once Hct approaches 12 g/dL, the dose of epoetin should be decreased.
If Hgb increases more than 1 g/dL within 2 weeks, the dose should be decreased. The dose should
be increased if Hgb has not increased 1 g/dL in 8 weeks and Hgb is not in the target Hct range of
11-12 g/dL.
Blood pressure should be adequately controlled prior to initiation of ESA therapy. Blood pressure
must be closely monitored and controlled during therapy.
Monitor serum chemistries.
Kinetics
The half-life of epoetin is approximately 4-13 hours. The half-life of epoetin in patients not on
dialysis with serum creatinine > 3 is no different than in patients requiring dialysis.
Other aspects
Epoetin alfa is also available in predrawn syringes.
Darbepoetin
Mechanism of action
Darbepoetin has the same mechanism of action as epoetin.
Counseling points are very similar for both darbepoetin and epoetin, except that all darbepoetin
vials are single-use only; therefore, the patient should dispose of the vial as instructed after each
dose. Both darbepoetin and epoetin are available in predrawn syringes.

The most common adverse effects are:
• Cardiovascular: Hypertension, hypotension, edema, arrhythmia
• GI: Nausea, vomiting, diarrhea, constipation
• Central nervous system: Fatigue, fever, headache
• Neuromuscular or skeletal: Myalgia, arthralgia, limb pain
• Respiratory: Infection, dyspnea, cough
Drug interactions
No drug interactions have been reported.
• Monitor patient's iron stores prior to and during therapy.
• Monitor patient's blood pressure.
• Adjust dose by closely monitoring Hgb every week until maintenance dose is established. Target
Hgb is 12g/dL. Increase dose if Hgb increases more than 1 g/dL over a 4-week period. Decrease
dose by 25% if Hgb increases more than 1 g/dL over 2-week period.
Kinetics
Darbepoetin's half-life is 21 hours when administered intravenously and 49 hours when
administered subcutaneously. Its half-life is approximately three times longer than epoetin's.
Because of its longer half-life, less frequent dosing options are available with darbepoetin.
Iron Deficiency Anemia
Dietary supplementation plays an important role in IDA treatment:
• Increase intake of iron-rich foods, such as meat, fish, and poultry.
• Drink orange juice with meals when possible.
• Limit tea or milk with meals. Only use in moderation between meals.
Folic Acid Deficiency Anemia
Dietary supplementation also is important in treating folic acid deficiency:

• To get as much dietary folate as possible, do not overcook vegetables. Eat them raw or steamed.
• Eat a wide variety of properly prepared vegetables, fruits, and mushrooms.
36-4. Key Points
• Anemia is a reduction in red cell mass, which decreases the blood's oxygen-carrying capacity.
• Iron deficiency anemia is the most common anemia, accounting for 25% of all cases. IDA presents
as a microcytic, hypochromic anemia.
• Iron preparations are best absorbed on an empty stomach.
• Iron preparations are hard to tolerate as a result of their numerous GI effects, which may
necessitate administration with a small snack.
• Megaloblastic anemias are macrocytic and are the result of a folic acid or vitamin B12 deficiency.
• Vitamin B12 requires intrinsic factor to be absorbed. Patients deficient in intrinsic factor develop
pernicious anemia.
• Because many patients experience difficulties absorbing vitamin B12, it often is administered via
an IM injection.
• The primary reason that patients with renal failure are anemic is because of the lack of
erythropoietin production.
• Anemia of renal failure is treated with subcutaneous or (SC) IV epoetin.
• Patients receiving epoetin must have their hematocrit and blood pressures monitored routinely.
• Darbepoetin has the same mechanism of action as epoetin, but it is longer acting and can be
administered less frequently.
36-5. Questions

Patient Profile 1—SuperPrice Drug Store

Patient name: George M. McBeavy Address: 1040 Dauberson Ave.
DOB: 7/11/52 Allergies: NKDA

Weight: 193 pounds
Problem list
Gastroesophageal reflux disease OTC recommendations
Iron deficiency anemia Maalox 1 tbsp q2h prn for "indigestion"
Hypertension Acetaminophen 325 mg q4-6h prn for headache
Medication record Ranitidine 75 mg daily prn for "heartburn"
Ferrous sulfate 325 mg tid Docusate 100 mg daily for constipation
Hydrochlorothiazide 25 mg daily
Which medication could present a problem with Mr. McBeavy's iron supplement?
A. Acetaminophen
1. B. Ranitidine
C. Maalox
D. Docusate
E. Ranitidine and Maalox

Mr. McBeavy admits to you that he is not able to take his iron tablet because it makes him
nauseated. What advice can you give him?
A. Take your iron with some crackers and milk.

2.
B. Take your iron with some crackers and water.
C. Don't worry about it. It's only a vitamin.
D. Start taking iron with the largest meal of the day.
E. Take iron after breakfast.

If Mr. McBeavy's anemia progresses to severe stages, what effects may he experience?
A. Koilonychia (spooning of the nails)

3. B. Pica (e.g., craving ice, clay, chalk)
C. Glossitis (sore, beefy red tongue)
D. Extreme fatigue
E. All of the above

If you were to examine Mr. McBeavy's blood smear, you would find cells that are
A. microcytic and hypochromic.

4.
B. macrocytic and hypochromic.
C. macrocytic and normochromic.
D. microcytic and normochromic.

When one is examining Mr. McBeavy's iron study results, which of the following would be
consistent with iron deficiency anemia?
A. Elevated TIBC
5.
B. Elevated ferritin
C. Elevated MCV
D. Elevated hemoglobin
E. Elevated hematocrit

Which iron preparation is most likely to cause an anaphylactic reaction?
A. IV iron dextran
6. B. IV iron sucrose
C. IV sodium ferric gluconate
D. Extended-release ferrous sulfate po
E. Immediate-release ferrous sulfate po

Why are sustained-release (SR) preparations of iron not the ideal formulation?
A. The incidence of nausea is higher with SR formulations.

B. They are dosed only once daily, and goal Hgb levels are not attained.
7. C. Because SR preparations are dissolved in the small intestines, the alkaline environment
results in a lower bioavailability than the acidic environment of the stomach.
D. Dissolution in the small intestines is not bioavailable, because intrinsic factor is not present
in the small intestines.
E. SR preparations require dosing with food.

Which of the following options would you advise a patient to drink with meals to optimize iron
absorption from meals?
8. A. Orange juice
B. Coffee
C. Tea
D. Milk

The most likely regimen to supplement vitamin B12 is
A. 1,000 mcg po every month.

9. B. 1,000 mcg IV every month.
C. 1,000 mcg IM every month.
D. 1,000 mcg IM every day.
E. Any one of the above is a reasonable regimen.

To be absorbed, vitamin B12 requires which of the following?
A. Pernicious factor
10. B. Transcobalamin II
C. Intrinsic factor
D. Vitamin B12 absorption factor
E. All of the above

Folic acid deficiency could be found in all of the following patients except
A. strict vegetarians.
11. B. alcoholics.
C. the indigent.
D. people who routinely overcook their vegetables.
E. a college student whose diet consists only of burgers and potato chips.

Folic acid may interact with which of the following medications?
A. Propranolol
12. B. Propoxyphene
C. Piroxicam
D. Phenytoin
E. Prednisone

The two macrocytic anemias are
A. vitamin B12 deficiency and iron deficiency anemias.

13. B. vitamin B12 deficiency and folic acid deficiency anemias.
C. iron deficiency and folic acid deficiency anemias.
D. sickle cell anemia and anemia of renal failure.
E. iron deficiency and pernicious anemias.

The best regimen to replace folic acid is
A. folic acid 1 mg po every day for 3-4 months.
14. B. folic acid 10 mg po every day for 3-4 months.
C. folic acid 10 mg IV for 2 weeks, then 1 mg po every day for 2 months.
D. folic acid 1 mg po three times weekly for 3-4 months.
E. folic acid 1 mg po once monthly for 6 months.

The most common medication given to treat anemia of renal failure is
A. vitamin B12.
15. B. a solution of citric acid in combination with sodium acetate.
C. epoetin alfa.
D. ferrous sulfate po.
E. folic acid po.

What advantage does darbepoetin have over epoetin?
A. Lower incidence of hypertension

16. B. Fewer drug interactions
C. Lower cost
D. Longer half-life and less frequent administration
E. Improved tolerability

The most common side effect of epoetin is
A. anaphylaxis.
17. B. hypertension.
C. pure red cell aplasia.
D. injection site reaction.
E. weight gain.

Prior to initiation of epoetin therapy, which of the following should be evaluated?
A. Folic acid and vitamin B12 levels

18. B. Transferrin and ferritin levels
C. Erythropoietin receptor level
D. Presence or absence of intrinsic factor
E. All of the above

In which of the following patients would it be possible to teach self-administration of epoetin
at home?
I. A patient on home hemodialysis taking epoetin via IV administration

II. A patient on home peritoneal dialysis taking epoetin via SC administration
III. A patient on home hemodialysis taking epoetin via SC administration
19.
A. II only
B. II and III only
C. III only
D. I, II, and III
E. I only

Patient Profile 2—Central Dialysis Center

Patient name: Rebecca S. Wiley
Weight: 148 pounds
Diagnosis: Address: 1460 Sawyer Brown Rd.
Hypertension Allergies: Penicillin (rash)
Diabetes mellitus Dialysis schedule: Monday, Wednesday, Friday
End-stage renal disease Medications:
Hyperlipidemia Insulin NPH 30 U bid
Labs: Simvastatin 20 mg qhs
Ferritin: 80 ng/mL (normal) Atenolol 25 mg after dialysis
Transferrin saturation: 15% (low) Nephrocaps 1 capsule daily
Hct: 32% (low)
Hemoglobin: 8.6 g/dL (low)

Which of the following will be monitored when Mrs. Wiley starts epoetin therapy?
A. Blood pressure
20. B. Hematocrit
C. Serum chemistries
D. Iron profile
E. All of the above

The target Hgb range for Mrs. Wiley is
A. 11-12 g/dL.
21. B. 9-11 g/dL.
C. 11-13 g/dL.
D. 12-13 g/dL.
E. 9-14 g/dL.

Which of Mrs. Wiley's medications will interact with epoetin?
A. Insulin
22. B. Simvastatin
C. Atenolol
D. None of the above
E. All of the above

What medication should be added to Mrs. Wiley's regimen?
A. Oral propranolol
23. B. IV iron
C. Oral levothyroxine
D. IM vitamin B12
E. No additional medications are required at this time.

36-6. Answers
E. Iron is best absorbed in an acidic environment. Therefore, antacids dramatically decrease the
1.
absorption of iron. Iron supplements should be taken 1 hour before or 3 hours after antacids.

B. Many patients are not able to tolerate iron on an empty stomach. Those patients should take
2. iron with a small snack. Milk would not be acceptable in this case, because dairy products
decrease the absorption of iron.

E. Koilonychia, pica, extreme fatigue, and glossitis all are symptoms of severe iron deficiency
3.
anemia.

A. Iron deficiency produces a hypochromic (low-hemoglobin) anemia, given that iron is a
component of the hemoglobin molecule. The cells are also microcytic (meaning "small cell"),
4.
because they spend longer in the marrow awaiting proper hemoglobin synthesis and therefore
divide more.

A. Total iron-binding capacity is elevated in IDA. TIBC is a measure of the amount of binding
5. space left on transferrin (the transport protein of iron). Less iron in the blood means that more
space is available on the transferrin molecule.

A. IV iron dextran has the highest incidence of anaphylaxis among the four IV iron
6.
preparations available.

C. SR preparations are left intact in the stomach and are dissolved in the small intestine. The
7. alkaline environment of the small intestine tends to form insoluble iron complexes that cannot
be absorbed.

A. Tea and milk can decrease the absorption of iron from a meal by more than 50%. Orange
8.
juice, however, can double the absorption of iron from food.

C. The most common IM dose of vitamin B12 is 1,000 mcg per month. However, vitamin B12
9. may be supplemented by the oral route if absorption is not impaired. Additionally, it may be
supplemented in very high doses, such as 1,000-2,000 mcg per day in pernicious anemia.

10. C. Vitamin B12 requires intrinsic factor for absorption.

A. Folic acid deficiency is found in alcoholics, the indigent, and—rarely—in people who
11. overcook their vegetables routinely. Strict vegetarians do not develop folic acid deficiency
because a folate-rich diet includes various types of vegetables.

D. Phenytoin increases the metabolism of folate, thereby decreasing the effectiveness of folic
12.
acid.

B. Vitamin B12 deficiency and folic acid anemias are both macrocytic (large cell) anemias. Iron
13.
deficiency anemia and sickle cell anemia are both microcytic and hypochromic anemias.

A. Folic acid is administered po because it is absorbed easily. The proper dose is 1 mg folic
14.
acid po every day, and the deficiency should be corrected after 3-4 months.

C. Epoetin is the most common medication used to treat anemia of renal failure, because it
15. stimulates erythropoiesis. The lack of erythropoietin production is the primary cause of anemia
of renal failure.

D. Darbepoetin is very similar to epoetin because it has the same mechanism of action and
16.
similar side effects. However, it has a longer half-life and can be administered less frequently.

17. B. Hypertension is the most common adverse drug effect from epoetin.

B. Transferrin and ferritin levels should be evaluated prior to epoetin therapy. IDA is a
18. common problem in patients with end-stage renal disease. The patient's transferrin should be at
least 20% and ferritin should be at least 100 ng/mL before epoetin therapy is initiated.

D. Patients on home peritoneal dialysis or hemodialysis can be taught to self-administer SC
19. injections. Additionally, if patients are receiving home hemodialysis, they can be taught to take
their epoetin intravenously through the dialysis venous port.

E. Iron profiles need to be monitored prior to starting epoetin and periodically during therapy
because IDA is very common in dialysis patients. Blood pressure needs to be monitored
because increased blood pressure is the most common adverse effect of epoetin. Hematocrit
20.
levels need to be checked as a measure of response to epoetin, and levels should be maintained
at 30-36%. Serum chemistries need to be monitored regularly in any patient with end-stage
renal disease, because most electrolytes are regulated by the kidney.

21. A. The target range of Hgb for patients receiving epoetin is 11-12 g/dL.

22. D. No drugs are known to interact with epoetin.

B. Mrs. Wiley's ferritin is less than 100 ng/mL, and her transferring saturation is less than 20%.
23. Most hemodialysis patients receiving epoetin will need iron therapy at some point during their
treatment.

36-7. References
Agarwal AK. Practical approach to the diagnosis and treatment of anemia associated with CKD in
elderly. J Am Med Dir Assoc. 2006;7(suppl 1):S7-12.
Alleyne M, Horne MK, Miller JL. Individualized treatment for iron-deficiency anemia in adults.
Am J Med. 2008;121:943.
Fishbane S. Safety in iron management. Am J Kid Dis. 2003;41:S18-26.
Ineck B, Mason BJ, Lyons W. Anemias. In: Dipiro JT, Talbert RL, Yee GC, et al., eds.
64.
National Kidney Foundation: K/DOQI clinical practice guidelines for anemia of chronic kidney
disease, 2000. Am J Kidney Dis. 2001;37(suppl 1): S182-238.
Parker KP, Mitch WE, Stivelman JC, et al. Safety and efficacy of low-dose subcutaneous
erythropoietin in hemodialysis patients. J Am Soc Nephrol. 1999; 8:288.
Procrit [package insert]. Raritan, N.J.: Ortho Biotech Products; 2000.

37. Thromboembolic Disease - Gale Hamann, PharmD, BCPS, CDE
37-1. Venous Thromboembolic Disease
Definition and Epidemiology
Venous thromboembolism (VTE) is a disease process that involves the development of a deep
venous thrombosis (DVT), a pulmonary embolism (PE), or both.
A pulmonary embolism is a thrombus or foreign substance from the systemic circulation that lodges
in the pulmonary artery or its branches and causes a complete or partial occlusion of pulmonary
blood flow.
A deep venous thrombosis is a thrombus that forms most commonly in the popliteal or femoral
veins, the veins of the calf, or the iliac veins of the upper leg. Veins of the upper extremities are less
commonly involved.
Approximately 2 million Americans develop VTE each year; 600,000 people in this group have
VTE manifested as a PE, and of these, 200,000 die. It is estimated that 1 million Americans will
develop a clinically silent PE that goes undiagnosed.
Complications of VTE are postthrombotic syndrome and pulmonary hypertension. Postthrombotic

syndrome is characterized as swelling in the affected lower extremity after a DVT. Pulmonary
hypertension is a complication that can occur after a PE and is characterized by elevated arterial
pressures in the pulmonary vasculature.
The incidence of VTE increases with age and doubles in each decade of life after age 50. VTE costs
an estimated $1.5 billion annually.
The most common symptoms of a PE are dyspnea, cough, hemoptysis, tachypnea, tachycardia,
pleuritic chest pain, diaphoresis, and overwhelming anxiety. The patient may be cyanotic and
hypoxemic secondary to having a reduced ability to oxygenate the blood. Patients with a massive
PE may present with syncope. The mortality rate of a PE ranges from 2.3% to 17%.
The most common symptoms of a DVT are pain, tenderness, edema, and erythema of the affected
extremity. Other symptoms may include dilation of the superficial veins, a palpable cord, and a
positive Homans' sign.
Pathophysiology
Venous thrombi generally form in areas of the veins where blood flow is slowed or disrupted. Often
they begin as small thrombi in the large venous sinuses of a valve cusp pocket in the veins of the
calf or thigh. Trauma to the vessel causes the release of tissue factor. Tissue factor, in turn, activates
the coagulation cascade. This activity results in the formation of thrombin and ultimately the
formation of fibrin to form clots. Other common factors that can precipitate the development of a
thrombus include disrupted blood flow from immobility or hypercoagulability.
Risk factors for VTE include the following:
• Age over 40 years
• Prolonged immobility
• Major surgery involving the abdomen, pelvis, and lower extremities
• Trauma, especially fractures of the hips, pelvis, and lower extremities
• Malignancy
• Pregnancy
• Previous VTE
• Congestive heart failure or cardiomyopathy
• Stroke
• Acute myocardial infarction
• Indwelling central venous catheter
• Hypercoagulability
• Estrogen therapy
• Varicose veins
• Obesity
• Inflammatory bowel disease
• Nephrotic syndrome
• Myeloproliferative disease
A PE is the result of a dislodged thrombus that is embolized from a thrombus in the deep venous
structures of the legs, pelvis, or arms. The embolus travels to the lungs, where it is trapped in the
pulmonary arterial microvasculature. Blood flow is obstructed from the PE, which leads to lung
edema and reduced pulmonary compliance. This condition results in inadequate oxygen exchange,
leading to hypoxemia. Blood flow in the pulmonary artery increases right ventricular afterload,
which may lead to right ventricular dilation, dysfunction, and ischemia.
Diagnosis
A DVT is diagnosed on the basis of a detailed history and clinical symptoms. A duplex ultrasound,
which measures both blood flow and compressibility of the affected vessel, confirms the diagnosis.
A PE is diagnosed based on a detailed history and clinical symptoms. A spiral CT (computed

tomography) scan or a ventilation-perfusion scan confirms the diagnosis.
VTE Prophylaxis
Table 37-1 shows recommendations for VTE prophylaxis.
VTE Treatment
VTE treatment success with unfractionated heparin (UFH) is related to obtaining therapeutic
activated partial thromboplastin time (aPTT) levels as rapidly as possible (
Table 37-2). Studies have indicated that the VTE recurrence risk is 20-25% higher if aPTT levels
are not within the therapeutic range at 24 hours. The therapeutic range for an aPTT is determined by
an antifactor Xa chromogenic assay of 0.3-0.7 IU/mL.
The use of low molecular weight heparin (LMWH) has enabled treatment of a DVT to move from a
hospitalization of 5-7 days to either a hospital stay of 1-2 days or outpatient management (
Table 37-3).
[Table 37-1. Recommendations for VTE Prophylaxis]
[Table 37-2. Guidelines for Anticoagulation: IV Unfractionated Heparin]
[Table 37-3. Guidelines for Anticoagulation: LMWH or Fondaparinux]
With outpatient DVT treatment, the diagnosis may take place in either a physician's office or the
emergency department. After a Doppler ultrasound confirms the diagnosis of a DVT, the patient is
educated on administration of LMWH and receives the first dose of LMWH at that time. After
those steps, LMWH and warfarin are administered on an outpatient basis. Warfarin is monitored
with an international normalized ratio (INR) at 1- or 2-day intervals. After two therapeutic INRs,
the LMWH may be discontinued; warfarin is continued for at least 3 months, and the patient is
evaluated for long-term anticoagulation or as indicated (
Table 37-4).
Drug Therapy
Unfractionated heparin
Mechanism of action
UFH binds to antithrombin (AT) and converts it from a slow progressive thrombin inhibitor to a
rapid thrombin inhibitor. This, in turn, catalyzes inactivation of factors XIIa, XIa, IXa, Xa, and IIa
(thrombin).
[Table 37-4. Duration of Anticoagulation Therapy]
Patient counseling
Patients need to monitor for signs and symptoms of bleeding or bruising, especially at surgical sites.
Therapeutic use
• Prevention and treatment of VTE
• Prevention of VTE in patients with a previous VTE or a known hypercoagulability
• Prophylaxis for VTE in high-risk populations
• Prevention of a mural thrombosis after myocardial infarction (MI)
• Treatment of patients with unstable angina and MI
• Prevention of acute thrombosis after coronary thrombolysis
Heparin is monitored by an aPTT, which is sensitive to the inhibitory effects of heparin on factors
IIa (thrombin), Xa, and IXa.
The College of American Pathologists and the American College of Chest Physicians (ACCP)
recommend against the use of a fixed aPTT therapeutic range of 1.5-2.5 times a control aPTT. They
do recommend that a therapeutic aPTT range be established on the basis of an antifactor Xa
concentration of 0.3-0.7 units/mL.
An aPTT should be measured 6 hours after a bolus dose of heparin or after any dosage change and
then every 6 hours until a therapeutic aPTT is reached. Once a therapeutic aPTT is achieved, an
aPTT may be evaluated every 24 hours.
Platelet count and hematocrit should be evaluated at baseline and every 1-3 days.
Pharmacokinetics
The pharmacokinetics of heparin differs depending on whether an intravenous (IV) or subcutaneous
(SC) route of administration is used.
Heparin is cleared from the body by a rapid saturable mechanism that occurs at therapeutic doses. A
second, slower unsaturable first-order clearance that is largely by renal means occurs at high doses.
The half-life of heparin varies from approximately 30 minutes after an IV bolus of 25 international
units (IU)/kg to 60 minutes after an IV bolus at 100 IU/kg.
Dosing
Heparin should be dosed using a weight-based nomogram. A therapeutic range for heparin is
determined by an antifactor Xa chromogenic assay of 0.3-0.7 IU/mL. Weight-based dosing
nomograms are effective in achieving a therapeutic aPTT, although they are not universally
transferable to every hospital. Published nomograms are specific only for the reagent and
instrument used to validate that nomogram.
Determining a therapeutic range by using the calculation of 1.5-2.5 times the mean control aPTT
may be erroneous. Previous weight-based nomograms, which use a therapeutic range based on the
calculation of 1.5-2.5 times the control aPTT, have been recognized to be accurate only for that
aPTT reagent used.
Table 37-5 is an example of a weight-based dosing nomogram. Each hospital should develop its
own nomogram based on its therapeutic range.
[Table 37-5. Body Weight-Based Dosing of IV Heparin]
Another approach to heparin therapy is to administer an IV bolus of 5,000 IU followed by a

continuous infusion of at least 30,000-35,000 IU over 24 hours. The infusion rate is adjusted to
maintain a therapeutic aPTT.
UFH may be administered subcutaneously every 12 hours. The patient should receive an initial dose
of 17,500 IU or 250 IU/kg SC q12h. The dose should be adjusted to an aPTT that corresponds to a
plasma heparin level of antifactor Xa chromogenic assay of 0.3-0.7 IU/mL. This level should be
measured 6 hours after the injection.
Alternatively, UFH may be administered as a fixed dose that is unmonitored. An initial dose of 333
IU/kg is administered, followed by 250 IU/kg SC every 12 hours.
Adverse effects
The most common adverse effects are minor bleeding in the form of gingival bleeding, epistaxis,
and ecchymosis. The most common serious adverse effects of heparin are gastrointestinal or
urogenital bleeding.
Fatal or life-threatening adverse effects often result from intracranial or retroperitoneal bleeding.
Transient thrombocytopenia may occur within the first 2-4 days of therapy, which will resolve with
continued therapy. Heparin-induced thrombocytopenia may also occur, which requires
discontinuation of the heparin.
Osteoporosis is a risk with chronic use.
Contraindications
Contraindications include the following:
• Active bleeding
• Severe uncontrolled hypertension
• History of heparin-induced thrombocytopenia
Use epidural or spinal anesthesia with caution because patients are at risk of developing an epidural
or spinal hematoma, which can result in long-term or permanent paralysis.
LMWHs and pentasaccharides
Table 37-6 describes LMWH and pentasaccharide dosage forms. The pharmacokinetics of LMWHs
and pentasaccharides are described in
Table 37-7.
Mechanism of action
LMWHs inhibit factor Xa and, to a much lesser extent, factor IIa.
[Table 37-6. LMWH and Pentasaccharide Dosage Forms]
Fondaparinux is a pentasaccharide. It binds selectively to AT, which potentiates the inactivation of

factor Xa in the coagulation cascades, thus inhibiting the formation of thrombin.
Advantages of LMWH and fondaparinux over UFH
• LMWHs and fondaparinux have fewer interactions with plasma proteins; thus, they have a more
predictable response at lower doses.
• LMWHs have a much longer half-life, which allows them to be administered subcutaneously
every 12-24 hours.
• Fondaparinux has a half-life of 17-21 hours, which allows dosing every 24 hours.
• LMWHs have a lower incidence of osteoporosis and heparin-induced thrombocytopenia.

Fondaparinux does not cause heparin-induced thrombocytopenia and can be used as an
anticoagulant to treat heparin-induced thrombocytopenia.
Therapeutic use
• Arterial embolism prevention in patients with mechanical or tissue prosthetic heart valve
replacement
• Arterial embolism prevention in patients with atrial fibrillation or atrial flutter
• Arterial embolism prevention in patients with an acute cardioembolic stroke
[Table 37-7. Pharmacokinetics of LMWHs and Pentasaccharides]
Monitor platelet counts, hematocrit and hemoglobin, and signs and symptoms of bleeding.
Bone mineral density should be monitored with long-term use.
Anti-Xa heparin levels can be monitored in obese patients or in patients receiving LMWH who
have significant renal impairment. Anti-Xa levels should be drawn 4 hours after a dose. Therapeutic
levels are 0.6-1.0 IU/mL for twice-daily dosing and 1-2 IU/mL for once-daily dosing. The
therapeutic range for daltaparin is 0.5-1.5 IU/mL 4-6 hours after receiving 3-4 doses.
Prothrombin time (PT)/INR and aPTT are not useful in monitoring LMWH.
Currently, fondaparinux has no direct monitoring parameters.
Dosing LMWH and fondaparinux

See
Tables 37-8 and
37-9 for dosage requirements.
Patient counseling
• Strict compliance is necessary to ensure a consistent level of anticoagulation.
• Notify a health care provider if an increase occurs in bruising, hematuria, melena, hemoptysis,
epistaxis, or gingival bleeding or if any other abnormal bleeding happens.
• Consult a health care provider or pharmacist before taking any over-the-counter medications.
• Avoid aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).

• The air bubble in the LMWH or fondaparinux syringe should be near the plunger prior to
injection. This method ensures that all of the drug is expelled from the syringe and helps
minimize the amount of bleeding, bruising, and hematoma formation from the injection site.
Adverse effects
and ecchymosis. The most common serious adverse effects of heparin are gastrointestinal or
[Table 37-8. Indications and Recommended Doses of LMWH and Fondaparinux]
Heparin-induced thrombocytopenia can occur with LMWH, but its incidence is greater with UFH.
Osteoporosis can occur with chronic use.
Direct thrombin inhibitors
Direct thrombin inhibitors are as follows:
• Lepirudin (Refludan)
• Argatroban
Mechanism of action
Lepirudin is a recombinant DNA-derived polypeptide nearly identical to hirudin. It produces an
anticoagulant effect by binding directly to thrombin and does not require AT to yield its effect.
Lepirudin does not bind to other plasma proteins as heparin does.
Argatroban is a synthetic molecule that reversibly binds to thrombin.
Therapeutic use
Lepirudin is used for the treatment of DVT and heparin-induced thrombocytopenia.
Argatroban is used for treatment of heparin-induced thrombocytopenia and percutaneous coronary

intervention.
Pharmacokinetics
Lepirudin has a half-life of 1-2 hours. Approximately 45% of lepirudin is eliminated by the kidneys.
Argatroban is metabolized in the liver to inactive metabolites. The half-life is 0.5-1 hour.
Lepirudin
Monitor complete blood count (CBC) and signs and symptoms of bleeding.
Monitor the therapeutic effect by measuring the aPTT 4 hours after beginning therapy and after a
dosage change. After the aPTT is stable within the therapeutic range, daily monitoring is sufficient.
[Table 37-9. Enoxaparin Dosage Regimens for Patients with Severe Renal Impairment (Creatinine
Clearance < 30 mL/min)]
Argatroban
Monitor CBC and signs and symptoms of bleeding. The aPTT is used to monitor and adjust
argatroban therapy. The aPTT should be drawn 2 hours after an infusion is started and after each
dosage change.
Argatroban will also elevate a PT/INR. For patients on concomitant warfarin therapy, this effect
may impede monitoring and make proper assessment of the INR difficult. For combination therapy,
argatroban may be discontinued after an INR is greater than 4. An INR should be drawn after 4-6
hours. If the INR is in the therapeutic range, continue with warfarin only. If the INR is below the
therapeutic range, restart argatroban and increase the dose of warfarin. Repeat this procedure until
the INR is within the therapeutic range.
Dosing
Lepirudin
Administer a bolus dose of 0.4 mg/kg IV over 15-20 seconds with an infusion of 0.15 mg/kg/h.
Measure an aPTT 4 hours after the infusion. Titrate the infusion to a therapeutic range. The
therapeutic range is a target range aPTT ratio of 1.5 to 2.5. If the aPTT is below the therapeutic
range, increase the infusion by 20%. If the aPTT is above the therapeutic range, hold the infusion
for 2 hours, and then decrease the infusion by 50%. Four hours after a dosage change, aPTTs should
be measured.
Argatroban
Administer a continuous IV infusion at the rate of 2 mcg/kg/min. Adjust infusion rate to maintain
an aPTT ratio of 1.5 to 2.5. The usual dose is 2-10 mcg/kg/min.
The dose should be reduced in moderate hepatic insufficiency. A continuous IV infusion should
begin at a rate of 0.5 mcg/kg/min. Because of the prolonged elimination half-life, measure an aPTT
4 hours after initiation or a dosage change.
Patient counseling
Monitor symptoms of bruising and bleeding, and report them to a health care provider immediately.
Adverse effects
and ecchymosis. The most common serious adverse effects are gastrointestinal or urogenital
bleeding.
There is no known antidote for lepirudin or argatroban. The anticoagulant effect declines rapidly
after discontinuation of the drug.
Nonhemorrhagic effects such as fever, nausea, vomiting, and allergic reactions rarely occur.
Warfarin (Coumadin)
Dosage forms
• Tablets: 1 mg (pink), 2 mg (lavender), 2.5 mg (green), 3 mg (tan), 4 mg (blue), 5 mg (peach), 6

mg (teal), 7.5 mg (yellow), and 10 mg (white)
• Injections (IV): 5 mg powder for reconstitution (2 mg/mL)
Mechanism of action
Warfarin is a vitamin K antagonist that produces its pharmacologic effect by interfering with the
intercon-version of vitamin K and its 2,3-epoxide (vitamin K epoxide). Warfarin leads to the
depletion or reduction in activity of vitamin K-dependent coagulation proteins (factors II, VII, IX,
and X) produced in the liver. The level and activity of the vitamin K-dependent clotting factors
decline over 6-96 hours. At least 4-5 days of warfarin therapy are necessary before a patient is
completely anticoagulated.
Therapeutic use
• Prevention of arterial embolism in patients with mechanical or tissue prosthetic heart valve
replacement
• Prevention of arterial embolism in patients with atrial fibrillation or atrial flutter
• Prevention of arterial embolism in patients with a previous cardioembolic stroke
• Prevention of acute MI in patients with peripheral arterial disease
Patient counseling
• Warfarin should be taken at the same time every day.

• Strict compliance is necessary to ensure a consistent level of anticoagulation.
• Strict compliance with a consistent vitamin K diet is necessary to ensure a consistent level of
anticoagulation.
• Notify the health care provider in the event of hematuria, melena, epistaxis, hemoptysis, increased
bruising, or any abnormal bleeding.
• Notify all health care providers, including dentists, of warfarin therapy.
• Blood monitoring to determine an adequate level of anticoagulation and compliance is necessary

at regular intervals.
• Consult the health care provider or pharmacist before taking any new prescription or over-the-
counter medications.
• Avoid aspirin or NSAIDs unless instructed otherwise by a physician.
• Women of childbearing age should use an effective form of birth control because warfarin has
teratogenic effects.
Warfarin therapy is monitored by a prothrombin time. The PT responds to a reduction in factors II,
VII, and X. The INR is used to standardize the responsiveness of thromboplastin to the
anticoagulant effects of warfarin. The INR is calculated by the following equation:
INR = (observed PT/mean normal PT)ISI
ISI is the International Sensitivity Index, which is a measure of thromboplastin sensitivity. The
lower the ISI is, the more responsive the thromboplastin is to the anticoagulant effects of warfarin.
The ACCP Evidenced-Based Clinical Practice Guidelines (8th edition) recommends two intensities
of anticoagulation: a less intense level with a target INR of 2.5 and a range of 2.0-3.0, and a high-
intensity level of anticoagulation with a target INR of 3.0 and a range of 2.5-3.5 (
Table 37-10).
Upon initiation of warfarin therapy, the INR should be evaluated daily if the patient is in the
hospital and every 2-3 days if the patient is not hospitalized.
Pharmacokinetics
Warfarin is a racemic mixture of two optically active isomers, warfarin S and warfarin R, in roughly
equal amounts. The S isomer is five times more potent than the R isomer.
Warfarin is rapidly and completely absorbed from the gastrointestinal tract with peak concentration
in approximately 90 minutes. Warfarin is 99% protein-bound with a half-life of 36-42 hours.
The onset of anticoagulation occurs after 4-5 days of therapy and is caused by the depletion of the
clotting factors rather than steady-state concentrations of warfarin. Thus, the onset of action is
based on the half-life of the clotting factors II, VII, IX, and X.
Dosing
Time in the therapeutic range and intensity of anticoagulation are critical for optimizing the
therapeutic efficacy of warfarin and minimizing the risk of hemorrhage.
Warfarin initiation does not require loading. Loading doses can result in an inappropriate increase
in the INR, which is not reflective of an anticoagulant effect.
Initiating warfarin at 5 mg daily should result in an INR around 2.0 in 4-5 days for most patients.
An alternative method is to administer between 5 and 10 mg for the first 1 or 2 days and then adjust
the dose depending on the INR response.
Initiating warfarin at a dose of 5 mg daily may be appropriate in the elderly; in patients with liver
disease, heart failure, or malnutrition; in patients taking drugs known to increase the responsiveness
to warfarin; or in patients with a high risk of bleeding.
Initiating warfarin at a dose of 7.5-10 mg daily may be appropriate for young, healthy, or obese
patients.
If a rapid anticoagulant effect is indicated, IV heparin, LMWH, or fondaparinux should be

administered along with warfarin for at least 4-5 days until a therapeutic INR is reached. Heparin,
LMWH, or
[Table 37-10. Recommended Therapeutic Ranges for Oral Anticoagulation]
fondaparinux may be discontinued when the INR is within the therapeutic range on two consecutive
occasions.
Disease state interaction

Disease states that can increase the response to warfarin are hyperthyroidism, congestive heart
failure, liver disease, fever, and genetic warfarin increased sensitivity.
Disease states that can decrease the response to warfarin are hypothyroidism and genetic warfarin
resistance. Patient nonadherence can also result in a reduced warfarin response.
Warfarin is a drug with a narrow therapeutic index. Numerous drugs interact with warfarin to
potentiate or reduce its anticoagulant effect. Because the S isomer is five times more active than the
R isomer, drugs that inhibit or induce the S isomer will have a more significant effect on warfarin
than drugs that inhibit or induce the R isomer (
Table 37-11).
Drug-food interactions
Foods that contain high amounts of vitamin K can reduce the anticoagulant effect of warfarin
(Table 37-11). It is important that patients be consistent in their consumption of these foods and
that they evenly space their consumption over a 7-day period. If a patient suddenly stops eating
these foods, the INR may dramatically increase.
Adverse effects
The most common adverse effect is minor bleeding in the form of gingival bleeding, epistaxis, and
ecchymosis. The most common serious adverse effects of warfarin are either gastrointestinal or
Warfarin-induced skin necrosis is a rare, but serious adverse effect. Skin necrosis begins within 10
days of warfarin initiation. It is characterized by painful, erythematous lesions on breast, thighs, and
buttocks, which may progress to hemorrhagic lesions. It may be associated with protein C
deficiency and, to a lesser effect, protein S deficiency. The concomitant use of
[Table 37-11. Drugs and Foods That Can Interact with Warfarin]
UFH, LMWH, or fondaparinux with initiation of warfarin can prevent its occurrence.
Purple toe syndrome is a dark blue-tinged discoloration of the feet that occurs rarely 3-8 weeks after
warfarin initiation.
Fatal or life-threatening adverse effects are related to intracranial or retroperitoneal bleeding. Box
37-1 outlines the treatment guidelines for the management of elevated INRs or bleeding.
Special precautions must be taken for patients undergoing invasive procedures.

Table 37-12 outlines the risk stratifications for perioperative arterial or venous thromboembolism.
Box 37-2 outlines the recommendations for managing anticoagulation in these patients.
37-2. Atrial Fibrillation
Atrial fibrillation (AF) is a supraventricular tachyarrhythmia characterized by uncoordinated atrial

activity up to 300-500 beats per minute that is associated with an irregular ventricular response.
Uncontrolled AF can result in a rapid ventricular response, which can affect blood circulation. AF
may be chronic or paroxysmal in nature.
Box 37-1. Management of Elevated INRs or Bleeding in Patients Receiving Vitamin K
Antagonists
INR Above Therapeutic Range But < 5.0; No Significant Bleeding
Lower dose or omit dose, monitor more frequently, and resume at lower dose when INR is
therapeutic. If INR is only minimally above therapeutic range, no dose reduction may be required.
INR 5.0 But < 9.0; No Significant Bleeding
Omit the next one or two doses, monitor more frequently, and resume at an appropriately adjusted
dose when the INR is in the therapeutic range.
Alternatively, omit the dose and give vitamin K (1.0-2.5 mg orally), particularly if the patient is at
increased risk of bleeding. If more rapid reversal is necessary because the patient requires urgent
surgery, vitamin K ( 5 mg orally) can be given with the expectation that a reduction of the INR
will occur in 24 hours. If the INR is still high, additional vitamin K (1-2 mg orally) can be given.
INR 9.0; No Significant Bleeding
Hold warfarin therapy and give higher dose of vitamin K (2.5-5.0 mg orally) with the expectation
that the INR will be reduced substantially in 24-48 hours. Monitor more frequently and use
additional vitamin K if necessary. Resume therapy at an appropriately adjusted dose when the INR
is therapeutic.
Serious Bleeding at Any Elevation of INR
Hold warfarin therapy and give vitamin K (10 mg by slow IV infusion), supplemented with fresh
frozen plasma, prothrombin complex concentrate, or recombinant factor VIIa, depending on the
urgency of the situation. Vitamin K can be repeated every 12 hours.
Life-threatening Bleeding
Hold warfarin therapy and give fresh-frozen plasma, prothrombin complex concentrate, or
recombinant factor VIIa supplement with vitamin K (10 mg by slow IV infusion). Repeat, if
necessary, depending on INR.
Reprinted with permission from Ansell J, Hirsh J, Dalen JE, et al. Pharmacology and management
of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical
Practice Guidelines (8th edition). Chest. 2008;133(suppl 6):160S-98S.
Over 2.2 million Americans have AF, which increases in prevalence after age 45 and greatly
accelerates after age 65. An estimated 10% of Americans over the age of 80 have AF.
AF is a risk factor for the development of a stroke. It is estimated that 4.5% of patients with
nonvalvular
[Table 37-12. Suggested Patient Risk Stratification for Perioperative Arterial or Venous
Thromboembolism]
AF, if untreated, would experience a stroke. If transient ischemic attack and silent stroke are
included, the incidence is around 7%.
Box 37-2. Recommendations for Managing Anticoagulation Therapy in Patients Requiring

Invasive Procedures
Patients with Low Risk of Thromboembolism
• Discontinue warfarin 5 days prior to procedure.
• Consider bridging with low-dose SC LMWH.
• Suggest therapeutic-dose SC LMWH over other management options.
Patients with Moderate Risk of Thromboembolism
• Consider bridging with therapeutic-dose SC LMWH or IV UFH or with low-dose SC LMWH

over not bridging during interruption of warfarin therapy.
• Suggest therapeutic-dose SC LMWH over other management options.
Patients with High Risk of Thromboembolism
• Bridge with therapeutic-dose SC LMWH or IV UFH during interruption of warfarin therapy.
• In patients whose INR is still elevated (> 1.5) 1 to 2 days before surgery, administer 1 to 2 mg
oral vitamin K to normalize INR.
• Discontinue therapeutic-dose LMWH 24 hours prior to procedure and administer half the total
daily dose as the last preoperative dose.
• Discontinue UFH approximately 4 hours before a procedure.
• Suggest LMWH over IV UFH.

• Restart warfarin 12-24 hours after procedure or when hemostasis is adequate.
• Resume therapeutic-dose LMWH approximately 24 hours after the procedure or when

hemostasis is adequate.
• In patients at high bleeding risk, delay therapeutic-dose LMWH or UFH for 48-72 hours or
administer low-dose LMWH or UFH when hemostasis is secured, or completely avoid LMWH
or UFH.
• Individualize treatment plans based on postoperative hemostasis and bleeding risk.
Patients Undergoing Minor Dental or Dermatologic Procedure or Cataract Removal
• Continue warfarin therapy around the time of the procedure.
• Coadminister an oral prohemostatic agent such as tranexamic acid or epsilon amino caproic acid
mouthwash for dental procedures.
Adapted with permission from Douketis JD, Berger PB, Dunn AS, et al. The perioperative
management of antithrombotic therapy: Antithrombotic and thrombolytic therapy: American
College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest.
2008;133(suppl 6):299S-339S.
The Framingham Heart Study demonstrated that patients with rheumatic heart disease and AF had a
17-fold increase in the incidence of stroke compared to age-matched controls.
AF is characterized by an "irregularly irregular" heartbeat, with the possibility of a rapid ventricular

response. Common symptoms are palpitations and fatigue. Patients may complain of their heart
"fluttering" and feeling weak.
Drug Therapy
Warfarin therapy has demonstrated approximately a 68% (50-70%) relative risk reduction in stroke
in patients with AF, whereas aspirin therapy has demonstrated only a 21% (0-38%) relative risk
reduction. A meta-analysis of five studies reported a 36% relative risk reduction in all strokes and a
46% reduction in ischemic strokes with warfarin compared to aspirin. Randomized controlled
studies have demonstrated that anticoagulation with warfarin, INR 2-3, is highly effective in
reducing the risk of stroke. Warfarin therapy with an INR 1.2-1.5 has not been shown to be
effective in stroke prevention; in addition, an INR > 4 was associated with a higher rate of
intracranial hemorrhage. Conversely, the risk of bleeding and intracranial hemorrhage is higher with
warfarin therapy than with aspirin.
Risk stratification for stroke in AF has been developed (

Tables 37-13 and
37-14).
Table 37-15 gives treatment guidelines for stroke prevention based on risk stratifications.
[Table 37-13. Risk Stratification in AF Based on CHADS 2 Score]
[Table 37-14. Stroke Rate Based on CHADS 2 Score]
Other Therapy
Cardioversion, described in Box 37-3, is an elective procedure for AF patients.
37-3. Stroke
Stroke is defined as a sudden onset of focal neurologic deficit lasting longer than 24 hours.
[Table 37-15. Recommendations for Antithrombotic Therapy in AF]
Box 37-3. Anticoagulation for Elective Cardioversion in Patients with AF
Patients with AF of 48 hours, or unknown duration, who are scheduled for elective
cardioversion should be anticoagulated with warfarin to a target INR of 2.5 with a range of 2.0-3.0
for 3 weeks prior to direct current or pharmacologic cardioversion and for 4 weeks after successful
cardioversion. If AF returns, then continue chronic anticoagulation with warfarin at a target INR of
2.5 (range of 2.0-3.0).
Alternatively, such patients should be anticoagulated with IV UFH with a target aPTT of 60
seconds (range of 50-70 seconds), full dose LMWH, or at least 5 days of warfarin with a target
INR of 2.5 (range of 2.0-3.0) at the time of cardioversion. Then undergo transesophageal
echocardiography (TEE). If no thrombus is seen on TEE and cardioversion is successful,
anticoagulation should be continued with a target INR of 2.5 (range of 2.0-3.0) for at least 4
weeks. If a thrombus is seen on TEE, then cardioversion should be postponed and anticoagulation
should be continued indefinitely. The TEE should be repeated before attempting cardioversion
later.
For patients with AF for < 48 hours in duration, cardioversion may be performed without
anticoagulation. However, in patients without a contraindication to anticoagulation, begin IV UFH
(target aPTT of 60 seconds; range of 50-70 seconds) or use full-dose LMWH at presentation. If the
patient has risk factors for stroke, then a TEE-guided approach is a reasonable alternative strategy.
For emergency cardioversion in hemodynamically unstable patients, IV UFH (target aPTT of 50

seconds; range of 50-70 seconds) should be started as soon as possible, followed by 4 weeks of
anticoagulation with warfarin (target INR of 2.5; range of 2.0-3.0).
Oral anticoagulation at the time of cardioversion in patients with atrial flutter is recommended in a
manner similar to that used for AF.
Adapted with permission from Singer DE, Alberts GW, Dalen JE, et al. Antithrombotic therapy in
atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (8th edition). Chest. 2008(suppl 6);133:546S-92S.
Transient ischemic attack (TIA) is defined as a focal ischemic neurologic deficit usually lasting 2-5
minutes, which resolves completely in less than 24 hours.
After heart disease and cancer, stroke is the third-leading cause of death in America. Approximately
700,000 Americans suffer a stroke each year; 500,000 of these individuals experience their first
stroke, and 200,000 experience a recurrent stroke. The incidence of stroke increases with age, and
the rate doubles for each decade after age 55.
Hypertension is a factor in 70% of patients who suffer a stroke.
Risk factors for stroke are as follows:
• Hypertension
• Smoking
• Heart disease (coronary heart disease, heart failure, left ventricular hypertrophy, and atrial
fibrillation)
• Elevated pulse pressure
• Previous TIA or stroke
• Diabetes
• Hyperlipidemia
• Obesity
Cigarette smoking increases the risk of stroke two to three times compared with the risk in
nonsmokers. Atrial fibrillation increases the risk of a stroke six times.
Symptoms of a stroke depend on where the stroke occurred in the brain and the rapidity with which
the symptoms develop. One or more TIAs commonly precede a stroke. Symptoms range from focal
deficits to more significant deficits, such as hemiplegia or hemiparesthesia, blindness in one eye, or
speech difficulties.
Pathophysiology
Fifteen percent of strokes are hemorrhagic in nature. The remaining 85% of strokes are ischemic in
nature. In the case of ischemic strokes,
• 20% are cardioembolic.
• 20% are due to atherosclerotic cerebrovascular disease.
• 25% are due to penetrating artery disease or lacunar infarctions.
• 30% are cryptogenic.
• 5% are due to other causes.
Atherosclerosis and plaque formation result in arterial narrowing, which leads to stenosis with
reduced blood flow. This condition may enhance platelet aggregation, which can lead to an arterial
occlusion. An occlusive clot is present in up to 80% of ischemic strokes.
The Framingham Heart Study indicates that a strong relationship exists between hypertension and
the risk of both hemorrhagic and nonhemorrhagic stroke. Atherothrombotic infarctions occur four
times more often in patients with hypertension (blood pressure > 165/95 mm Hg) than in patients
without hypertension. The treatment of hypertension reduces the incidence of stroke by 35-40%.
Cardioembolic etiology accounts for one-fifth of all ischemic strokes. The most common cause of a
cardiac embolism is AF; other factors include valvular heart disease, coronary heart disease,
prosthetic heart valves, and dilated cardiomyopathy. A cardioembolic stroke often has an abrupt
onset and more commonly involves the middle cerebral artery.
Diagnosis and Prevention
Diagnosis is based on physical examination, medical history, and diagnostic imaging such as CT
scan, magnetic resonance imaging (MRI) scan, magnetic resonance angiography (MRA), or cerebral
arteriography.
Preventive measures are as follows:
• Maintain blood pressure < 140/90 mm Hg or < 130/90 mm Hg for patients with diabetes or
coronary artery disease.
• Control hyperlipidemia with statin therapy (low-density lipoprotein < 100 mg/dL).
• Maintain glycemic control (hemoglobin A1c < 7%).

• Stop smoking.
• Reduce weight if overweight.
• Exercise (i.e., 30 minutes of moderate exercise daily).
• Implement the DASH (Dietary Approaches to Stop Hypertension) diet (low in sodium and
saturated fat; high in fruits, vegetables, whole grains, and fiber).
Drug Therapy
Tissue plasminogen activator
Mechanism of action
Because most strokes are caused by a thromboembolic occlusion in an intracranial artery,
thrombolytic therapy is key to restoring or improving perfusion. Tissue plasma activator (t-PA) is a
plasminogen activator (serine protease) that enhances the conversion of plasminogen to plasmin in
the presence of fibrin. t-PA binds to fibrin in a thrombus and converts bound plasminogen to
plasmin. Plasmin, an enzyme responsible for clot dissolution, initiates local fibrinolysis.
Indications
Criteria for use in acute treatment of stroke are as follows:
• Onset of symptoms < 3-4.5 hours
• No indication of intracranial hemorrhage from baseline CT scan of the head
• Blood pressure < 185/110 mm Hg
• Platelets > 100,000/mm3
• No conditions present that would increase the patient's likelihood of bleeding
• No heparin therapy within 48 hours with an elevated aPTT
• No oral anticoagulants or an INR > 1.7
• No suspicion of subarachnoid hemorrhage on pretreatment evaluation
• No gastrointestinal or urinary tract hemorrhage within 21 days
• No stroke or serious head injury within 3 months
• No recent (within 3 months) intracranial or intraspinal surgery

• No seizure at the onset of stroke
• No active internal bleeding
• No intracranial neoplasm, arteriovenous malformation, or aneurysm
• No major surgery or serious trauma within 2 weeks
• No clinical symptoms suggesting post-MI or pericarditis
• Not currently pregnant or lactating
Specific treatment guidelines are available to evaluate patient characteristics for the use of t-PA in
acute stroke.
Dose
t-PA is administered at a dose of 0.9 mg/kg (maximum dose 90 mg) IV, with 10% of the dose given
as an initial bolus over 1 minute and the balance infused over 60 minutes.
Monitor hematocrit, mental status, and signs and symptoms of bleeding.

Bleeding is the most common adverse effect with t-PA. The most common sites of bleeding are
gastrointestinal, urogenital, retroperitoneal, and intracranial.
Contraindications
Contraindications include intracranial hemorrhage, recent stroke, blood pressure > 185/100 mm Hg,
active internal hemorrhage, platelets < 100,000/mm3, anticoagulant therapy within 24 hours of t-
PA, intracranial neoplasm, arteriovenous malformation, and aneurysm.
Antiplatelet drugs
Aspirin
Mechanism of action
Aspirin produces its antiplatelet effect by irreversibly inactivating the enzyme cyclooxygenase,
which prevents the conversion of arachidonic acid to thromboxane A2. Thromboxane A2 stimulates
platelet aggregation. The effects of aspirin on platelets occur for the life of the platelet (i.e.,
approximately 5-7 days). Aspirin has demonstrated a 27-30% risk reduction of stroke.
Patient counseling
• Notify physician if melena, persistent stomach pain or discomfort, breathing difficulties, increased
bleeding or bruising, or skin rashes develop.
• Avoid NSAIDs or warfarin unless instructed otherwise by a physician.
• Avoid over-the-counter medications that contain aspirin.
• Do not crush or chew enteric-coated aspirin.
Dose
Within 24-48 hours of an acute ischemic stroke, patients should receive aspirin 325 mg daily.
Aspirin is effective for stroke prevention at a dose of 50-325 mg daily.
Signs and symptoms of bleeding should be monitored.

Adverse drug reactions include nausea, vomiting, dyspepsia, gastrointestinal ulceration, gastric
erosion, duodenal ulcers, gastrointestinal hemorrhage, rash, urticaria, angioedema, bronchospasm,
and asthma exacerbation.
Warfarin, UFH, LMWH, NSAIDs, fondaparinux, and clopidogrel may increase the risk of bleeding
if used in combination with aspirin.
Use enteric-coated aspirin after an acute episode of peptic or gastric ulcer disease.
Avoid aspirin use if there is a risk of aspirin-induced asthma.
Clopidogrel (Plavix)
Mechanism of action
Clopidogrel is a selective and irreversible inhibitor of adenosine diphosphate-induced platelet
aggregation that does not affect arachidonic acid metabolism. The effects of clopidogrel on platelets
occur for the life of the platelet, approximately 5-7 days.
The CAPRIE (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Event) trial demonstrated
an 8.7% relative risk reduction of composite outcomes of ischemic stroke, MI, or vascular death
with the use of clopidogrel versus aspirin in patients with a recent stroke or MI or in patients with
symptomatic peripheral arterial disease. Clopidogrel was most beneficial for patients with
peripheral artery disease and showed a 23.8% relative risk reduction over aspirin.
Dose
Clopidogrel is effective in stroke prevention at a dose of 75 mg daily.
Patient counseling
• Notify physician of melena, persistent stomach pain or discomfort, increased bleeding or bruising,
or development of a skin rash.

Nausea, dyspepsia, diarrhea, abdominal pain, increased bruising, and bleeding may occur.
Drug-drug interaction
Warfarin, aspirin, NSAIDs, UFH, fondaparinux, and LMWH can increase the risk of bleeding if
combined with clopidogrel.
Clopidogrel may inhibit cytochrome isoenzyme CYP450-2C9 substrates, thus creating the potential
to inhibit the metabolism of fluvastatin, tolbutamide, and torsemide. Close monitoring may be
advisable.
Proton pump inhibitors may inhibit the activation of clopidogrel, thus reducing its effectiveness.
Use clopidogrel with caution in peptic or gastric ulcer disease.
It may require dosage reduction in moderate to severe hepatic dysfunction.
Extended-release dipyridamole plus immediate-release aspirin (Aggrenox)

Mechanism of action
Dipyridamole is a phosphodiesterase inhibitor that increases cyclic adenosine monophosphate in the
platelet, which potentiates the deaggregating effects of prostacyclin on platelets.
The Second European Stroke Prevention Study demonstrated that a combination of dipyridamole
200 mg and aspirin 25 mg bid showed a 37% stroke risk reduction compared to placebo and
reduced the risk of nonfatal and fatal stroke by 23% compared to aspirin.
Patient counseling
• Notify physician of melena, persistent stomach pain or discomfort, breathing difficulties,

increased bleeding or bruising, or development of a skin rash.

• Take this medication on an empty stomach, 1 hour before or 2 hours after meals. If stomach upset
occurs, take it with food or milk.
• Do not crush or chew.
Dose
A combination of extended-release dipyridamole 200 mg with immediate-release aspirin 25 mg in a
capsule is taken twice daily.

Adverse reactions include headache, nausea, vomiting, dyspepsia, gastrointestinal ulceration, gastric
erosion, duodenal ulcers, gastrointestinal hemorrhage, rash, urticaria, angioedema, hypotension,
dizziness, flushing, epistaxis, bronchospasm, and asthma exacerbation.
Warfarin, UFH, LMWH, NSAIDs, fondaparinux, aspirin, and clopidogrel may increase the risk of
bleeding if used in combination with this product.
Drug-disease interaction
Use dipyridamole-aspirin with caution in the presence of peptic or gastric ulcer disease.
37-4. Key Points
• Appropriate VTE prophylaxis should be used with all patients who have risk factors for its
development. ACCP Evidenced-Based Clinical Practice Guidelines (8th edition) has guidelines
for VTE prophylaxis specific for at-risk patient populations.
• UFH should be administered as a bolus of 80 IU/kg IV, then a maintenance infusion of 18 IU/kg
per hour. Heparin is monitored by aPTT levels. A therapeutic aPTT range should be determined
for each hospital or laboratory that corresponds to an antifactor Xa concentration of 0.3-0.7
IU/mL.
• LMWH offers a more predictable response at lower doses without the need to monitor levels,
except in patients with severe renal impairment or in obesity. It has a lower incidence of
osteoporosis and heparin-induced thrombocytopenia. It can also be administered once or twice
daily by SC injection, which allows care to shift from the hospital to the outpatient arena.
• An acute VTE should be treated with IV UFH, LMWH, or fondaparinux to provide immediate
anticoagulation, followed by the initiation of warfarin therapy. Warfarin should be initiated at
5.0-7.5 mg daily for most patients. Patients with malnutrition, liver disease, or heart failure;
patients who are taking drugs known to increase the responsiveness to warfarin; patients who
have a high risk for bleeding; or elderly patients may be started at a lower dose. UFH, LMWH, or
fondaparinux should be overlapped with warfarin for at least 4-5 days or until two consecutive
INRs are within the therapeutic range.
• Patients with a single VTE with reversible, time-limited risk factors should be anticoagulated for 3
months. Patients with a single idiopathic VTE should be anticoagulated for at least 3 months, but
consider long-term therapy depending on the risk-benefit ratio. Patients with a recurrent VTE
should be anticoagulated long term.
• Atrial fibrillation is a condition that predisposes a patient to the development of a stroke. Warfarin
titrated to a target INR of 2.5 with a range of 2.0-3.0 reduces the risk for stroke by approximately
68% (50-70%). Aspirin is not as effective as warfarin in high-risk patients with AF, with an
approximately 21% (0-38%) relative risk reduction.
• Patients with a thromboembolic occlusion in an intracranial artery should receive t-PA, provided
that the following conditions are met:
• Onset of symptoms is less than 3-4.5 hours.
• CT scan of the head does not indicate an intracranial hemorrhage.
• Blood pressure < 185/100 mm Hg.
• Conditions are not present that would increase the patient's likelihood of bleeding.
• t-PA is administered at a dose of 0.9 mg/kg (maximum dose 90 mg) IV with 10% of the dose
given as an initial bolus over 1 minute and the balance infused over 60 minutes.
• The drugs of choice for a noncardioembolic stroke are
• Aspirin 50-325 mg daily
• Clopidogrel 75 mg daily
• Aspirin 25 mg/dipyridamole 200 mg bid
37-5. Questions
A 24-year-old female presents to the emergency department with complaints of severe

shortness of breath, dyspnea, and chest pain. She is also experiencing tachycardia and
tachypnea. Two days prior she noticed pain and swelling in her left lower extremity. Her past
medical history is negative for thrombosis. Her current medications include Tri-Levlen daily
and ibuprofen 600 mg q6h prn for pain. A duplex ultrasound of the left lower extremity
revealed a DVT. Her vital signs are T, 98.4°; P, 124/min; R, 36/min; BP, 162/100 mm Hg; Wt,
100 kg; Ht, 165 cm. The most likely cause of her shortness of breath, dyspnea, and chest pain
1.
is
A. bronchitis.
B. asthma exacerbation.
C. pulmonary embolism.
D. heart failure exacerbation.
E. atrial fibrillation.

This patient is started on heparin therapy. Which dosage regimen is most appropriate?
A. IV heparin 20,000 IU bolus, then 5,000 IU/h

2. B. IV heparin 8,000 IU bolus, then 1,800 IU/h
C. IV heparin 5,000 IU bolus, then 500 IU/h
D. IV heparin 5,000 IU q12h
E. SC heparin 5,000 IU q12h

All of the following are risk factors for a DVT except
A. hip replacement surgery.

3. B. knee replacement surgery.
C. hernia repair surgery.
D. hip fracture surgery.
E. abdominal surgery.

Which diagnostic test would be most helpful with the diagnosis of a pulmonary embolism?
A. Chest x-ray
4. B. Electrocardiogram
C. Spiral CT of the chest
D. Bronchoscopy
E. Echocardiogram

A patient is started on warfarin for atrial fibrillation. What is an appropriate starting dose of
warfarin?
A. 1 mg daily
5.
B. 5 mg daily
C. 15 mg daily
D. 20 mg daily
E. 25 mg daily

What laboratory test is used to monitor heparin therapy?
A. aPTT
6. B. PT
C. INR
D. Clotting time
E. Factor XIa

A 47-year-old patient is diagnosed with a lower-extremity DVT. The patient's height is 6 feet
and weight is 220 lb (100 kg). The physician would like to treat this patient on an outpatient
basis with warfarin and low molecular weight heparin. Which dose below would be the most
appropriate?
7.
A. Enoxaparin 30 mg SC q12h
B. Enoxaparin 40 mg SC q24h
C. Enoxaparin 100 mg SC q12h
D. Enoxaparin 200 mg SC q12h
E. Enoxaparin 220 mg SC q12h

How long should enoxaparin be continued in a patient with an acute DVT?
A. At least 4-5 days until the INR is > 2.0 for 24 hours
8. B. At least 42 days until the INR is > 3.0 for 24 hours
C. At least 24 hours until the INR is > 4.0 for 24 hours
D. At least 48 hours until the INR is > 4.0 for 24 hours
E. At least 7-10 days until the INR is > 3.5 for 24 hours

All of the following statements are important information to communicate to a patient on
warfarin therapy except
A. Take warfarin every day without missing any doses.

9.
B. Eat a consistent amount of vitamin K-rich foods per week.
C. Report any symptoms of bleeding to your physician.
D. Take warfarin with meals and remain standing for 30 minutes.
E. Do not take aspirin-containing products unless directed to do so by your physician.

Vitamin K-rich foods can affect the anticoagulant effect of warfarin. Which of the following
foods can decrease the anticoagulant effects of warfarin?
I. Lima beans
II. Spinach
III. Broccoli
10.
A. Only I is correct.
B. Only III is correct.

Drugs can affect the anticoagulant effect of warfarin. Which of the following drugs can
increase the effects of warfarin?
I. Ciprofloxacin
II. Trimethoprim-sulfamethoxazole
III. Fluconazole
11.

What is the most appropriate therapy for a patient with atrial fibrillation, cerebrovascular
accident, hypertension, and diabetes?
A. Aspirin 325 mg daily

12.
B. Warfarin 5 mg daily
C. Clopidogrel 75 mg daily
D. t-PA 90 mg daily
E. Aspirin 25 mg/dipyridamole 200 bid

A patient presented to the emergency department with symptoms of aphasia and dysarthria,
which resolved over the course of 3 days. The patient has a history of hyperlipidemia, type 2
diabetes mellitus, and hypertension.
An echocardiogram showed an ejection fraction of 55%, normal valve function, and normal
chamber size. An electrocardiogram showed normal sinus rhythm. Carotid ultrasound indicated
moderate stenosis. A CT of the head showed no hemorrhages. Blood pressure was 178/102 mm
Hg. Hemoglobin A1c was 10.2%. A lipid profile was as follows: total cholesterol: 294 mg/dL;
13.
HDL: 32 mg/dL; LDL: 218 mg/dL; triglycerides: 200 mg/dL. Medications include glipizide 10
mg daily and hydrochlorothiazide 25 mg daily. Which therapy is indicated in this patient?
A. Aspirin 325 mg po daily

B. Clopidogrel 75 mg po bid
C. Aspirin 25 mg/dipyridamole 200 mg po daily
D. Warfarin 5 mg po daily
E. t-PA 90 mg po daily

All of the following are other treatment goals for this patient except
A. hemoglobin A1c < 7%.

14. B. blood pressure < 130/80 mm Hg.
C. LDL < 100 mg/dL.
D. aPTT 70-100 seconds.
E. smoking cessation.

Fondaparinux is an anticoagulant that inhibits which clotting factor?
A. IIa
15. B. IXa
C. Xa
D. XIa
E. VIIa

A 58-year-old male is scheduled for a total knee replacement tomorrow. He has a medical
history of hypertension, for which he is treated with amlodipine 5 mg daily. His height is 6 feet
2 inches and his weight is 176 lb (80 kg). What form of DVT prophylaxis is indicated in this
patient?
I. Enoxaparin 30 mg SC q12h
II. Fondaparinux 2.5 mg SC q24h
16.
III. Aspirin 325 mg daily
C. Either I or II are correct.
D. Either II or III are correct.

A 68-year-old male presents to the emergency department with complaints of epistaxis as well
as bruising on his arms and legs. He has been taking warfarin 8 mg daily. His INR is 10.2.
What is the most appropriate therapy to reverse his warfarin toxicity?
A. Hold warfarin for 4 days; restart warfarin at a lower dose when his INR is < 3.0.
B. Hold warfarin and administer vitamin K 0.5 mg IV; restart warfarin at a lower dose when
17. his INR is < 3.0.
C. Hold warfarin and administer tranexamic acid 10 mg IV; restart warfarin at a lower dose
when his INR is < 3.0.
D. Hold warfarin and administer vitamin K 5 mg po; restart warfarin at a lower dose when his
INR is < 3.0.
E. Hold warfarin and administer prothrombin complex 5 mg po; restart warfarin at a lower
dose when his INR is < 3.0.

A 63-year-old is receiving warfarin 7.5 mg daily for atrial fibrillation. What therapeutic INR
range is indicated for this patient?
A. 1.0-2.0
18.
B. 1.5-2.5
C. 2.0-3.0
D. 2.0-3.5
E. 2.5-3.5

A 56-year-old female presents to the emergency department with complaints of flank pain,
dysuria, and increased urinary frequency. She is diagnosed with a urinary tract infection. Her
past medical history includes type 2 diabetes mellitus, hypertension, and atrial fibrillation. Her
medications include metformin 1 g bid, quinapril 40 mg daily, and warfarin 5 mg daily. What
would be the most appropriate antibiotic to treat this patient's UTI?
19.
A. Septra DS bid
B. Ciprofloxacin 500 mg bid
C. Rifampin 300 mg qid
D. Doxycycline 100 mg bid
E. Erythromycin 500 mg qid

Which of the following drugs produce action by inhibiting platelet activity?
I. Clopidogrel
II. Dipyridamole
III. t-PA
20.

What color is warfarin 7.5 mg?
A. White
21. B. Blue
C. Yellow
D. Pink
E. Green

Which of the following is a common side effect associated with unfractionated heparin?
A. Hypokalemia
22. B. Hypoglycemia
C. Ecchymosis
D. Nausea
E. Hyponatremia

What is the length of anticoagulation therapy for atrial fibrillation?
A. 3 months
23. B. 6 months
C. 9 months
D. 12 months
E. Long term

Advantages of LMWH over UFH include all of the following except
A. SC administration.
24. B. no dosage adjustment needed with renal insufficiency.
C. once- or twice-daily dosing.
D. predictable response at lower doses.
E. lower incidence of heparin-induced thrombocytopenia.

37-6. Answers
C. Symptoms of shortness of breath, dyspnea, chest pain, tachycardia, and tachypnea, along
1. with a recent history of a DVT, are indications of a pulmonary embolism. A ventilation-
perfusion scan or a spiral CT of the chest would confirm the diagnosis.

B. Several studies have indicated that weight-based dosing of heparin is more effective in
obtaining therapeutic aPTT than standard heparin titration. A weight-based protocol with an 80
2.
IU/kg IV bolus followed by an infusion of 18 IU/kg per hour should produce aPTTs close to
the therapeutic range. The other doses are not appropriate.

C. High-risk surgeries involve the abdomen and lower extremities; thus, hip and knee
replacement as well as hip fracture surgery are major risk factors for the development of a
3.
VTE. Hernia repair surgery is considered minor surgery and, unless the patient has other risk
factors, would not require DVT prophylaxis other than early ambulation.

C. A spiral CT of the chest or a ventilation-perfusion scan would be necessary to confirm the
4. diagnosis of a PE. Chest x-ray, electrocardiogram, echocardiogram, or bronchoscopy would not
assist with the diagnosis.

B. Warfarin 5 mg daily should result in an INR around 2.0 within 4-5 days. The other doses are
either extremely low or high for the majority of patients. Higher doses of warfarin may elevate
5. an INR, but this increase may not be associated with a level of anticoagulation. A rapid
increase in INR is due to depletion of factor VII rather than the anticoagulant effect that is
associated with depletion of factors II and X.

A. An aPTT is the laboratory test used to monitor heparin therapy. An aPTT should be checked
6. 6 hours after a dosage change and every 24 hours if it is within the therapeutic range. A
PT/INR is used to monitor warfarin therapy.

C. Enoxaparin 100 mg SC q12h or 1 mg/kg SC q12h is the dose for treatment of an acute
7. DVT. Enoxaparin 30 mg SC q12h and 40 mg SC q24h are doses used for DVT prophylaxis.
Enoxaparin 200 mg SC q12h and 220 mg SC q12h are extremely high doses.

A. For the treatment of an active DVT or PE, at least 4-5 days of heparin or LMWH overlap
8. with warfarin is needed before an anticoagulant effect is produced by warfarin. Heparin or
LMWH should be discontinued after an INR is > 2.0 for 24 hours.

D. Statements A, B, C, and E are important to discuss with patients on warfarin. Patients
9. should follow strict compliance with warfarin. They should eat vitamin K-rich foods
consistently over the course of a week and report any symptoms of bleeding to their physician.

D. Green, leafy vegetables contain higher amounts of vitamin K; thus, spinach and broccoli
10.
can reduce an INR. Lima beans, although green, do not have a large amount of vitamin K.

E. All of these drugs have the potential to produce a major rise in INR. These drugs should not
11.
be combined with warfarin if possible.

B. In a patient with AF with multiple risk factors for a stroke (hypertension, prior
cerebrovascular accident, and diabetes), warfarin is the drug of choice if the patient is a good
12. warfarin candidate. Aspirin and clopidogrel are antiplatelet agents and are not as effective as
warfarin in stroke risk reduction. t-PA is used for acute stroke treatment and administered
intravenously.

A. Aspirin 325 mg daily is correct. Clopidogrel is dosed at 75 mg daily rather than bid. Aspirin
25 mg/dipyridamole 200 mg is dosed bid rather than daily. Warfarin is not appropriate in this
patient because there is no indication that this was a cardioembolic stroke (the echocardiogram
13.
and electrocardiogram were normal). t-PA is not used orally and is used only for acute
treatment of stroke to restore perfusion. Moderate stenosis of the carotid artery indicates
atherosclerotic disease is present, and antiplatelet therapy is indicated.

D. All of the goals are correct except aPTT range. Because antiplatelet therapy is indicated in
14.
this patient, aPTT monitoring is not indicated.

15. C. Fondaparinux inhibits factor Xa.

C. Enoxaparin 30 mg SC q12h or fondaparinux 2.5 mg SC q24h are correct. Aspirin is not
16.
effective for DVT prophylaxis in knee replacement surgery.

D. Warfarin toxicity with an INR of 10.2 can be effectively reversed by holding the dose of
warfarin and administering vitamin K 5 mg orally. Warfarin should be restarted when the INR
17.
is < 3.0. The IV route is used only in emergent situations because anaphylactic reactions are
possible. Prothrombin complex is administered IV only for severe bleeding situations.

C. The therapeutic range for oral anticoagulation is an INR of 2.0-3.0, with a target of 2.5.
18. Increased bleeding is associated with an INR > 4.0, and embolic events are more common with
an INR < 1.5.

D. Doxycycline 100 mg bid would be the most appropriate therapy for a UTI. Septra DS,
19.
erythromycin, and ciprofloxacin will interact with warfarin to elevate the INR.

C. Clopidogrel and dipyridamole both inhibit antiplatelet activity, and t-PA is a thrombolytic
20.
agent.

21. C. Warfarin 7.5 mg is yellow, 1 mg is pink, 10 mg is white, and 4 mg is blue.

C. Minor bleeding and bruising are common side effects of heparin therapy. Other common
22.
areas for bleeding are the urogenital and gastrointestinal tracts.

E. The duration of anticoagulation therapy for patients with AF is lifelong. The risk for stroke
is present as long as AF is present. Patients who undergo direct current cardioversion to normal
23.
sinus rhythm require anticoagulation therapy for 4 weeks after conversion because the risk of
stroke remains high during this period.

B. Because LMWHs are renally eliminated, they must be dose-adjusted for creatinine clearance
< 30 mL/min. Guidelines have recently been released for enoxaparin dosing in renal
24. impairment. For DVT prophylaxis, enoxaparin should be administered 30 mg SC q24h rather
than q12h. For DVT treatment, enoxaparin should be administered 1 mg/kg SC q24h rather
than q12h.

37-7. References
Adams HP, Albers G, Albers MJ, et al. Update to the AHA/ASA recommendations for the
prevention of stroke in patients with stroke and transient ischemic attaches. Stroke.
2008;39:1647-52.
Adams HP, del Zoppo G, Albert MJ, et al. AHA/ASA scientific statement, guidelines for early
management of adults with ischemic stroke. Stroke. 2007; 38:1655-711.
Albers GW, Amarenco P, Easton JD, et al. Antithrombotic and thrombolytic therapy for ischemic
stroke: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th
edition). Chest. 2008;133(suppl 6):630S-69S.
Ansell J, Hirsh J, Dalen JE, et al. Pharmacology and management of the vitamin K antagonists:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th
Deeb SN, O'Gara PT, Madias C, et al. Valvular and structural heart disease: American College of
Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest.
2008;133(suppl 6): 593S-629S.
del Zoppo GJ, Saver JL, Jauch EC, et al. Expansion of the time window for treatment of acute
ischemic stroke with intravenous tissue plasminogen activator: A science advisory from the
American Heart Association/American Stroke Association. Stroke. 2009;40;2945-48.
Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy:
Antithrombotic and thrombolytic therapy: American College of Chest Physicians Evidence-
Based Clinical Practice Guidelines (8th edition). Chest. 2008;133(suppl 6):299S-339S.
Fagan SC, Hess DC. Stroke. In: Dipiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A
Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC 2006 guidelines for the management of
atrial fibrillation: Executive summary. Circulation. 2006; 114:e257-354.
Gage BF, Waterman AD, Shannon W, et al. Validation of clinical classification schemes for
predicting stroke: Results from the National Registry of Atrial Fibrillation. JAMA
2001;285:2864-70.
Geerts WH, Bergquist D, Pineo GF, et al. Prevention of venous thromboembolism: American
College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest.
2008;133(suppl 6):381S-453S.
Goldstein LB, Adams R, Becker K, et al. Primary prevention of ischemic stroke: A statement for
healthcare professionals from the Stroke Council of the American Heart Association. Circulation.
2001; 103:163-83.
Haines S, Witt DM, Nutescu EA. Venous thromboembolism. In: Dipiro JT, Talbert RL, Yee GC, et
2008: 331-72.
Hirsh J, Anand SS, Halperin JL, et al. Guide to anticoagulant therapy: Heparin—a statement for
healthcare professionals from the American Heart Association. Circulation. 2001;103:2994-3018.
Hirsh J, Bauer KA, Donati MB, et al. Parenteral anticoagulants: American College of Chest
Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest. 2008;133(suppl
6):141S-59S.
Hirsh J, Fuster V, Ansell J, et al. American Heart Association/American College of Cardiology

Foundation guide to warfarin therapy. Circulation. 2003;107:1692-711.
Hirsh J, Guyatt G, Albers, GW, et al. Executive summary: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines (8th edition). Chest. 2008;133(suppl 6):71S-105S.
Kearon C, Kahn SR, Agnelli G, et al. Antithrombotic therapy for venous thromboembolic disease:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th
Raschke RA, Gollihare B, Peirce JC. The effectiveness of implementing the weight-based heparin
nomogram as a practice guideline. Arch Intern Med. 1996;156:1645-49.
Singer DE, Alberts GW, Dalen JE, et al. Antithrombotic therapy in atrial fibrillation: American
College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest.
2008; 133(suppl 6):546S-92S.
Appendix A: Normal Laboratory Values
Test Conventional units SI units

Albumin 3.5-5 g/dL 35-50 g/L
Alkaline phosphatase
Adults 30-120 units/L 0.5-2 nkat/L
Children < 350 units/L < 350 units/L
Adolescent males < 500 units/L < 500 units/L
Adolescent females 25-100 units/L 25-100 units/L
Amylase 0.58-1.97 mckat/L 35-118 IU/L
Anion gap 7-16 mEq/L 7-16 mmol/L
Arterial blood gases (ABG)
HCO3 21-28 mEq/L 21-28 mmol/L
O2 saturation 94-100% 0.94-1
pH 7.35-7.45 7.35-7.45
PO2 80-105 mmHg 10.6-14 kPa
PCO2 35-45 mmHg 4.7-6 kPa
Basal metabolic panel (BMP)
Bicarbonate 22-29 mEq/L 22-29 mmol/L
Blood urea nitrogen (BUN)
Adults 8-25 mg/dL 2.9-8.9 mmol/L
Children 5-18 mg/dL 1.8-6.4 mmol/L
Chloride 97-110 mEq/L 97-110 mmol/L
Creatinine
Males 0.7-1.3 mg/dL 62-115 ¼mol/L
Females 0.6-1.1 mg/dL 53-97 ¼mol/L
Glucose (fasting, plasma) 65-109 mg/dL 3.6-6 mmol/L
Potassium 3.5-5 mEq/L 3.5-5 mmol/L
Sodium 136-145 mEq/L 136-145 mmol/L
Blood pressure (mm Hg)
Normal < 120/< 80 < 120/< 80
Prehypertension 120-139/80-89 120-139/80-89
Hypertension
Stage 1 140-159/90-99 140-159/90-99
Stage 2 160/100 160/100
Hypertensive crisis > 180/> 120 > 180/> 120
Isolated systolic > 140/< 90 > 140/< 90
Calcitonin < 100 pg/mL < 100 ng/L
Calcium 8.6-10.3 mg/dL 2.15-2.58 mmol/L
Carbon dioxide 21-30 mEq/L 21-30 mmol/L
Coagulation screen
Activated partial thromboplastin time (aPTT) 22-37 seconds 22-37 seconds
Antithrombin III (antigenic) 22-39 mg/dL 220-390 mg/L
Antithrombin III (functional) 80-130% 0.8-1.3 units/L
Bleeding time 3-9.5 min 180-570 seconds
Protein C 0.7-1.4 ¼/mL 700-1,400 units/mL
Protein S 0.7-1.4 ¼/mL 700-1,400 units/mL
Prothrombin time (PT) 10-13 seconds 10-13 seconds
Complete blood count (CBC)
Hemoglobin (Hb)
Males 13.8-17.5 g/dL 138-175 g/L
Females 12.1-15.3 g/dL 121-153 g/L
Hematocrit (Hct)
Males 40.7-50.3% 0.407-0.503
Females 36-46% 0.36--0.46
Mean corpuscular volume (MCV) 80-100 mcm3 80-100 fL
Mean corpuscular hemoglobin (MCH) 27-33 pg/cell 1.66-2.09 fmol/cell
Mean corpuscular hemoglobin concentrate
33-36 g/dL 20.3-22 mmol/L
(MCHC)
Platelet count 150-350 × 103/mm3 150-350 × 109/L
Red blood cells (RBC)
Males 4.5-5.9 × 106/mm3 4.5-5.9 × 1012/L
Females 4-5.2 × 106/mm3 4-5-2 × 1012/L
White blood cells (WBC) 4.5-11 × 103 cells/mm3 4.5-11 × 109 cells/L
White blood cell differential
Basophils 0-0.19 × 103 cells/microL 0-0.19 × 109 cells/L
Eosinophils 0-0.45 × 103 cells/microL 0-0.45 × 109 cells/L
Lymphocytes 1.5-4 × 103 cells/microL 1.5-4 × 109 cells/L
0.2-0.95 × 103 0.2-0.95 × 109
Monocytes
cells/microL cells/L
Neutrophils (absolute) 1.8-7.7 × 103 cells/microL 1.8-7.7 × 109 cells/L
Corticotropin (ACTH) 08:00h < 60 pg/mL < 13.2 pmol/L
Cortisol 08:00h 5-30 mcg/dL 138-810 nmol/L
Creatinine kinase
Males 30-220 IU/L 0.5-3.67 mckat/L
Females 20-170 IU/L 0.33-2.83 mckat/L
Glucose tolerance test
Baseline fasting blood glucose 70-105 mg/dL 3.9-5.8 mmol/L
60-minute fasting blood glucose 120-170 mg/dL 6.7-9.4 mmol/L
Hematologic tests
Erythrocyte sedimentation rate (ESR)
Adult males 0-17 mm/h 0-17 mm/h
Adult females 1-25 mm/h 1-25 mm/h
Children 0-10 mm/h 0-10 mm/h
Ferritin
Males 30-300 ng/mL 30-300 mcg/L
Females 10-200 ng/mL 10-200 mcg/L
Fibrinogen 150-400 mg/dL 1.5-4 g/L
Hemoglobin A1c 5.3-7.5% 0.053-0.075
Iron
Males 45-160 mcg/dL 8.1-31.3 mcmol/L
Females 30-160 mcg/dL 5.4-31.3 mcmol/L
Reticulocytes 0.5-1.5% 0.005-0.015
Total iron binding capacity (TIBC) 220-420 mcg/dL 39.4-75.2 mcmol/L
Transferrin saturation
Males 20-50% 0.20-0.50
Females 15-50% 0.15-0.5
Vitamin B12 223-1,132 pg/mL 165-835 pmol/L
Isoenzymes
Creatine phosphokinase (MB) 0-7 IU/L 0-0.12 ¼kat/L
Lipase 10-150 units/L 10-150 units/L
Lipids
Total cholesterol
Desirable < 200 mg/dL < 5.2 mmol/L
Borderline-high 200-239 mg/dL < 5.2-6.2 mmol/L
High > 239 mg/dL > 6.2 mmol/L
Low-density lipoprotein (LDL)
Borderline-high 130-159 mg/dL 3.36-4.11 mmol/L
High > 159 mg/dL > 4.11 mmol/L
High-density lipoprotein (HDL)
Low < 40 mg/dL < 1.03 mmol/L
Desirable > 60 mg/dL 1.55 mmol/L
Triglycerides
Borderline-high 150-199 mg/dL 1.7-2.25 mmol/L
High 200-499 mg/dL 2.26-5.64 mmol/L
Very high > 500 mg/dL > 5.65 mmol/L
Liver function tests (LFTs)
Alanine aminotransferase (ALT, SGPT) 7-53 IU/L 0.12-0.88 mckat/L
Ammonia (NH4+) 15-45 ¼g/dL 11-32 ¼mol/L
Aspartate aminotransferase (AST, SGOT) 11-47 IU/L 0.18-0.78 mckat/L
Bilirubin (adults) (F)
Conjugated 0.2 mg/dL 4 mcmol/L
Total 0.1-1 mg/dL 2-18 mcmol/L
Lactate dehydrogenase (LDH) 100-250 IU/L 1.67-4.17 mckat/L
Magnesium 1.3-2.2 mEq/L 0.65-1.1 mmol/L
Phosphate 2.5-5 mg/dL 0.8-1.6 mmol/L
Prolactin
Males 0-15 ng/mL 0-15 mcg/L
Females 0-20 ng/mL 0-20 mcg/L
Protein, total 5.5-8 g/dL 55-80 g/L
Thyroid hormone function tests
Free thyroxine (Free T4) 0.8-2.7 ng/dL 10-35 pmol/L
Thyroid-stimulating hormone (TSH) 0.35-6.2 mcU/mL 0.35-6.2 mU/L
Thyroxine-binding globulin capacity 10-26 mcg/dL 100-260 mcg/L
Total triiodothyronine (T3) 60-181 ng/dL 0.92-2.78 nmol/L
Total thyroxine by RIA (T4) 4.5-10.9 mcg/dL 58-140 nmol/L
Uric acid 3-8 mg/dL 179-476 mcmol/L
References
Dipiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 7th
ed. New York: McGraw-Hill; 2008.
Facts and Comparisons 4.0. St. Louis, Mo.: Wolters Kluwer Health. Available at:
www.factsandcomparisons.com. Updated periodically.
Micromedex Healthcare Series. Greenwood Village, Colo.: Thomson Healthcare. Available at:
www.thomsonhc.com. Updated periodically.
Appendix B: Drugs in Renal Failure
Dose adjustment for renal failure

Dose for
Trade normal renal CrCl > 50 CrCl = 10- CrCl < 10 Supplement for
Generic name name function mL/min 50 mL/min mL/min hemodialysis
Analgesics
FeverAll,
Acetaminophen Genapap, 650 mg po q4h q4h q6h q8h None
Tylenol
Ascriptin,
Aspergum,
Aspirtab,
Bayer, Dose after
Aspirin 650 mg po q4h q4h q4-6h Avoid
Easprin, dialysis
Ecotrin,
Ecpirin,
Entercote
75% of
50% of normal
Butorphanol 2 mg q3-4h Same normal No data
dose
dose
75% of
30-60 mg po 50% of normal
Codeine Same normal No data
q4-6h dose
dose
Anesthetic 75% of
50% of normal
Fentanyl Sublimaze induction Same normal Not applicable
dose
(individualized) dose
1-2 mg IV q4-
Hydromorphone Dilaudid Same Same Same Same
6h
37.5-75 mg
50-100 mg IV 25-50 mg IV or
Meperidine Demerol Same IV or po Avoid
or po q3-4h po q3-4h
q3-4h
2.5-10 mg q6- 50-75% of
Methadone Same Same Same
8h normal dose
20-25 mg po 15-18.75 10-12.5 mg po
Morphine Same Same
q4h mg po q4h q4h
75% of
50% of normal
Pentazocine 50 mg q4h Same normal Same
dose
dose
Propoxyphene Darvon 65 mg po q6-8h Same Same Avoid Avoid
Antiarrhythmics
N-acetyl- 50% q8-
500 mg q6-8h Same 25% q12-18h Same
procainamide 12h
3-6 mg IV
Adenosine Adenocard Same Same Same Same
bolus
0.5-1 mg IV
push q3-5 min,
Atropine Same Same Same Same
max 0.04
mg/kg
Class I
200-300 mg po
Moricizine Ethmozine Same Same Same Same
q8h
150-300 mg po
Propafenone Rythmol Same Same Same Same
q8h
Class Ia
100-200
100-200 mg 100-200 100-200 mg
Disopyramide Norpace mg q12- Same
q6h mg q8h q24-48h
24h
1,000- 1,000-
Procan, 1,000-2,500 mg 1,000-2,500 mg Maintenance
Procainamide 2,500 mg 2,500 mg
Pronestyl q12h q8-24h dose post-HD
q4h q6-12h
Quinidex, 300-600 mg po 150-300 mg po
Quinidine Same Same Dose post-HD
Quinaglute q8-12h q4-6h
Class Ib
50-100 mg IV
over 1-2 min
Lidocaine Xylocaine Same Same Same Same
bolus, then 1-4
mg/min IV
200-400 mg po
Mexiletine Mexitil Same Same Same Same
q8-12h
400-600 mg po
Tocainide Tonocard Same Same Same Dose post-HD
q8h
Class Ic
25-50 mg po 25-50 mg 25 mg po
Encainide Enkaid 25 mg po q24h Same
q8-12h po q12-24h q24h
50-100 mg po 25-50 mg 25-50 mg po
Flecainide Tambocor Same Same
q12h po q12h q12h
Class II (see ²-
blockers in
antihypertensives)
Class III
800-2,000 mg
Amiodarone Cordarone load, then 200- Same Same Same Same
600 mg q24h
5-30mg/kg 25-50% of
25% of normal
Bretylium Bretyol load, then 5-10 Same normal Same
dose
mg IV q6h dose
Class IV (see calcium
channel blockers in
antihypertensives)
Antibiotics
Aminoglycosides
30-70% of
60-90% of 20-30% of
7.5 mg/kg IV normal 50% of full dose
Amikacin Amikin normal normal dose
q12h dose q12- post-HD
dose q12h q24-48h
18h
1.7 mg/kg 1.7 mg/kg IV
1.7 mg/kg 50% of full dose
Gentamicin Garamycin 1.7 mg/kg q8h q12-48h by q48-72h by
q8-24h post-HD
levels levels
1.7 mg/kg 1.7 mg/kg IV
1.7 mg/kg 50% of full dose
Tobramycin Nebcin 1.7 mg/kg q8h q24-48h by q48-72h by
q8-24h post-HD
levels levels
Cephalosporins
250-500 mg po 250-500 mg po
Cefaclor Ceclor Same Same Same
q8h post-HD
500 mg po 500 mg po 500 mg po q24- 0.5-1 g po post-
Cefadroxil Duricef 0.5-1 g po q12h
q12h q12-24h 48h HD
Ancef, 0.25-2g 0.25-2g 50% of normal 15-20 mg/kg
Cefazolin 0.25-2g q6h
Kexol q8h q12h dose q24-48h post-HD
25-50% of 25-50% of
250-2,000 mg 125-2,000
Cefepime Maxipime Same normal dose normal dose
q8-12h mg q24h
q24h q24h post-HD
150-200
200 mg po 150 mg po 300 mg po post-
Cefixime Suprax mg po 100 mg po q12h
q12h q12h HD
q12h
1-2 g IV q6- 1-2 g IV 0.5-2 g IV q24h
Cefotaxime Claforan Same 1-2 g IV q24h
12h q8-12h post-HD
50% of
25% of normal
Cefotetan Cefotan 1-2 g IV q12h Same normal 1g post-HD
dose
dose
1-2 g IV 1-2 g IV 1-2 g IV q24-
Cefoxitin Mefoxin 1-2 g IV q6-8h 1g post-HD
q8h q8-12h 48h
100-400 mg 100-400 mg
Cefpodoxime Vantin Same Same Dose post-HD
q12h q24h
250-500 mg po 250 mg po post-
Cefprozil Cefzil Same 50% q12h 50% q12h
q12h HD
Ceptaz,
Fortaz, 1 g IV 0.5-1 g IV 500 mg q24-
Ceftazidime 1 g IV q8-12h 1g post-HD
Tazicef, q12h q12-24h 48h
Tazidime
0.5-1.5 g 0.25-1 g
Ceftizoxime Cefizox 1-2 g IV q8h 0.5-1 g q24-48h 1 g post-HD
q8h q12h
0.25-2 g IV
Ceftriaxone Rocephin Same Same Same Same
q12-24h
Ceftin,
250-500 mg
Cefuroxime Kefurox, Same Same Same Dose post-HD
q12h
Zinacef
250-500 250-500
250-500 mg po 250-500 mg po
Cephalexin Keflex mg po q6- mg po Dose post-HD
q6h q12h
8h q12h
Fluoroquinolones
250-500
500-750 mg po mg po 250-500 mg po
250 mg q12h
Ciprofloxacin Cipro q12h; 400 mg Same q18h; 400 q18h; 400 mg
(200 mg if IV)
IV q12h mg IV IV q24h
q24h
400 mg po
400 mg IV or 400 mg po or IV
or IV × 1,
400 mg po or po × 1, then 200 × 1, then 200
Gatifloxacin Tequin Same then 200
IV q24h mg po or IV mg po or IV
mg po or
q24h q24h post-HD
IV q24h
500 mg po
500 mg po or 500 mg po or IV
or IV × 1,
250-500 mg po IV × 1, then × 1, then 250
Levofloxacin Levaquin Same then 250
or IV q24h 250 mg po or mg po or IV
mg po or
IV q48h q48h post-HD
IV q48h
Miscellaneous
1-2 g IV loading
500 mg-2 g q8- 250 mg-1 g 125-500 mg q8- dose, then 0.5 g
Aztreonam Azactam Same
12h q8-12h 12h IV q6-8h post-
HD
250-500 mg po
Erythromycin E-Mycin Same Same Same Same
q6h
500 mg IV 250 mg IV 250 mg IV q12h
Imipenem Primaxin 0.25-1 g IV q6h Same
q12h q12h post-HD
600 mg IV
Linezolid Zyvox Same Same Same Dose post-HD
q12h
50-100%
50% normal 500 mg IV q24h
Meropenem Merrem 1-2 g IV q8h Same normal
dose q24h post-HD
dose q12h
Quinupristin- 7.5 mg/kg IV
Synercid Same Same Same Same
dalfopristin q8h
300-600
600 mg po 300-600 mg po
Rifampin Rifadin Same mg po q24- Same
q24h q48h
48h
8-20 mg/kg/d 4-10 2-5 mg/kg/d po
Trimethoprim- Bactrim,
po q6-12h or Same mg/kg/d po Avoid or IV q24h post-
sulfamethoxazole Septra
IV q12h or IV q12h HD
500 mg IV q6h 1 g IV q12- 1 g IV q24-
Vancomycin Vancocin 1 g IV q4-7d 1 g IV q4-7d
or 1 g q12h 24h 96h
Penicillins
250-500 mg po
q24h;
250-500 mg po 250-500
Amoxicillin- 250-500 mg po supplemental
Augmentin q8h; 875 mg po Same mg po
clavulanic acid q24h dose during and
bid q12h
at the end of
dialysis
Principen, 250-500 mg 250-500 250-500 250-500 mg
Ampicillin dose post-HD
Omnipen q6h mg q6h mg q6-12h q12-24h
Ampicillin- 1.5-3 g
Unasyn 1.5-3 g q6h 1.5-3 g q8h 1.5-3 g q24h dose post-HD
sulbactam q12h
1-2 g IV
Methicillin Staphcillin 1-2 g IV q4-6h Same 1-2 g IV q8-12h Same
q6-8h
Nafcin,
Nafcillin 1-2 g IV q4-6h Same Same Same Same
Unipen
Oxacillin Bactocil 1-2 g IV q4-6h Same Same Same Same
1-4 million 1-4 million 1-4 million 1-4 million
1-4 million
Penicillin G units IV units IV units IV q12- units IV q12-
units IV q4-6h
q6-8h q8-12h 18h 18h
3-4 g IV 2 g IV q8h plus
Piperacillin Pipracil 3-4 g IV q6h Same 3-4 g IV q8h
q6-8h 1 g post-HD
2.25 g IV
Piperacillin- 3.375-4.5 g IV q6h (q8h if 2.25 g IV q8h
Zosyn 3.375 g 2.25 g q8h
tazobactam q6-8h CrCl < 20 post-HD
mL/min)
2 g IV q12h; 3 g
1-2 g IV
Ticarcillin Ticar 3 g IV q4h 1-2 g IV 8h 1-2 g IV q12h supplement
q4-8h
post-HD
2 g IV q4h
Ticarcillin- 2 g IV q4- 2 g IV q12h
Timentin 3.1 g IV q4h or 3.1 g IV 2 g IV q12h
clavulanic acid 8h post-HD
q4-8h
Anticoagulants
30 mg SC
Enoxaparin Lovenox 30 mg SC q12h Same 30 mg SC qd Limited data
qd
30 mg SC
40 mg SC qd Same 30 mg SC qd
qd
1 mg/kg SC 1 mg/kg
Same 1 mg/kg SC qd
q12h SC qd
Anticonvulsants
200 mg po bid;
second dose: 75% of normal 75% of normal
Carbamazepine Tegretol Same Same
1,200 mg po dose dose
q24h
2-10 mg po q6-
Diazepam Valium Same Same Same Same
24h
500-1,500 mg 75% of normal
Ethosuximide Zarontin Same Same Same
po q24h dose
300 mg load,
300-600 mg po 400 mg po 300 mg po
Gabapentin Neurontin 300 mg po qod then 200-300
tid tid q12-24h
mg post-HD
50 mg po q12-
75% of
24h initially, 100 mg
Lamotrigine Lamictal Same normal 100 mg qod
then 100-500 postdialysis
dose
mg po q24h
Lorazepam Ativan 1-2 mg q8-12h Same Same Same Same
75-100%
50% of normal 50% of normal
Oxcarbazepine Trileptal 300-600 mg bid Same of normal
dose dose post-HD
dose
Dosage
Luminal, 50-100 mg q8- 50-100 mg q12- supplementation
Phenobarbital Same Same
Solfoton 12h 16h is required post-
HD
Phenytoin Dilantin 100 mg tid Same Same Same Same
250 mg tid or 250 mg 250 mg q8- 250 mg q12- 30% of normal
Primidone Mysoline
qid q8h 12h 24h dose post-HD
No dose
Depakene, 15-60 mg/kg
Sodium valproate Same Same Same adjustment
Depakote q24h
necessary
50% of
200 mg po 25% of normal
Topiramate Topamax Same normal Same
q12h dose
dose
Antiemetics
10-15 mg IV 7.5-15 mg 5-7.5 mg IV
Metoclopramide Reglan Same Same
qid IV q6h q6h
Antifungals
Amphotericin B 0.25-1 mg/kg 0.25-1 mg/kg
Fungizone Same Same Same
nonlipid IV q24h IV q24-36h
Consider Consider
Consider
dosage dosage
dosage
adjustment; adjustment; Supplemental
Amphotericin B lipid 5 mg/kg IV adjustment;
Abelcet specific specific dose is not
complex q24h specific
guidelines guidelines necessary
guidelines not
not not
available
available available
Amphotericin B
3-6 mg/kg/d IV 3-6 mg/kg/d IV 3-6 mg/kg/d IV
cholesteryl sulfate Amphotec Same Same
q24h q48h q48h
complex
Amphotericin B 3-5 mg/kg IV 3-5 mg/kg IV 3-5 mg/kg IV
AmBisome Same Same
liposome q24h q48h q48h
50-200 mg
100-400 mg po 50-200 mg po
Fluconazole Diflucan Same po or IV Same
or IV q24h or IV q24h
q24h
100-200 mg po
100-200 mg po 100 mg po q12-
Itraconazole Sponanox Same Same q24h (IV
or IV q12h 24h (oral only)
contraindicated)
200-400 mg po
Ketoconazole Nizoral Same Same Same Same
q24h
Antihistamines
400 mg po bid
200 mg po
Cimetidine Tagamet or 400-800 mg Same 300 mg q8-12h Dose post-HD
bid
qhs
Supplemental
20-40 mg po 5-20 mg po 2-10 mg po doses are not
Famotidine Pepcid 2-4 mg po qhs
qhs qhs qhs required post-
HD
150 mg po
150 mg po 150 mg po 150 mg po q48-
Nizatidine Axid q12h or 300 mg 150 mg po q48h
q24h q24-48h 72h
po qhs
150-300 mg po
75-150 mg 150 mg po 50% of po dose
qhs; 50 mg IV 75-150 mg po
po qhs; 50 q12-24h; post-HD; 50 mg
Ranitidine Zantac q6h; 6.25 mg/h q24h; 50 mg IV
mg IV 50 mg IV IV q24h post-
continuous q24h
q12h q18-24h HD
infusion
Antihypertensives
Angiotensin-
converting enzyme
(ACE) inhibitors
10-40 mg po 10-40 mg 5-20 mg po 5-20 mg po 5-20 mg po
Benazepril Lotensin
q12-24h po q24h q24h q24h q24h
Administer dose
post-HD or
18.75-75
25-150 mg po 25-150 mg 12.5-50 mg po administer 25-
Captopril Capoten mg po q12-
q8h po q8-12h q24h 35%
18h
supplemental
dose
5 mg po qd
titrated
5-10 mg po 2.5-10 mg 2.5-5 mg po
Enalapril Vasotec upwards to 2.5-7.5 po q12h
q12h po q12h q12h
maximum
of 40 mg
0.625 mg
IV × 1, 0.625 mg IV ×
then up to 1, then up to
1.25-5 mg IV 1.25-2.5 0.625 mg IV
Enalaprilat Vasotec 1.25 mg 1.25 mg q6h if
q6h mg IV q6h q6h
q6h if response is
response is inadequate
inadequate
10-40 mg po 10-40 mg 10-40 mg 7.5-30 mg po
Fosinopril Monopril Same
q12-24h po q24h po q24h q24h
2.5 mg initially,
then 20% of
10-40 mg po 2.5-7.5 mg 1.25-2.5 mg po patient's dose
Lisinopril Zestril Same
q24h po q24h q24h post-HD if
patient is on a
dosing regimen
2.5 mg initially,
then 25% of
10-80 mg po 10 mg po 7.5-60 mg 7.5-60 mg po patient's dose
Quinapril Accupril
q24h qd initially po q24h q24h post-HD if
patient is on a
dosing regimen
Supplement
2.5-20 mg po 1.25-15 mg 1.25-10 mg po
Ramipril Altace Same 20% of patient's
q24h po q24h q24h
dose post-HD
-blockers
1-16 mg po
Doxazosin Cardura Same Same Same Same
q24h
1-15 mg po
Prazosin Minipress Same Same Same Same
q12h
1-20 mg po
Terazosin Hytrin Same Same Same Same
q24h
Angiotensin-receptor

blockers
8-32 mg po
Candesartan Atacand Same Same Same Same
q24h
150-300 mg po 75 mg initial
Irbesartan Avapro Same Same Same
q24h dose
25-100 mg po
Losartan Cozaar Same Same Same Same
q12-24h
80-320 mg po
Valsartan Diovan Same Same Same Same
q24h
² -blockers
Administer dose
post-HD or
50-100 mg po 25-50 mg administer 25-
Atenolol Ternormin Same 25 mg po q96h
q24h po q24h 50 mg
supplemental
dose
6.25-50 mg po
Carvedilol Coreg Same Same Same Same
q12h
200-400 mg po
Labetalol Normodyne Same Same Same Same
bid
50-400 mg po Supplement 50
Metoprolol Lopressor Same Same Same
q24h mg po post-HD
40-320 mg/d po 40-320 40-320
40-320 mg/d po Supplemental
Nadolol Corgard single or mg/d po mg/d po
q40-60h dose post-HD
divided doses q24h q24-48h
10-40 mg po
Pindolol Visken Same Same Same Same
q12h
80-160 mg po
Propranolol Inderal Same Same Same Same
bid
Same;
80-160 mg po 80-160 mg 80-160 mg 80-160 mg po
Sotalol Betapace supplement 80
q12h po q12-24h po q24-48h q4-72h
mg post-HD
Calcium channel

blockers
2.5-10 mg po
Amlodipine Norvasc Same Same Same Same
q24h
Dilacor,
180-480 mg po
Diltiazem Cardizem, Same Same Same Same
q24h
Tiazac
2.5-10 mg po
Felodipine Plendil Same Same Same Same
q24h
2.5-5 mg po
Isradipine Dynacirc Same Same Same Same
q12-24h
20-40 mg po
Nicardipine Cardene Same Same Same Same
tid
Adalat, 10-30 mg/d po
Nifedipine Same Same Same Same
Procardia tid
Nimodipine Nimotop 30 mg po q8h Same Same Same Same
Calan,
80-120 mg po
Verapamil Isoptin, Same Same Same Same
q8h
Verelan
Diuretics
1-2 mg IV q8-
Bumetanide Bumex Same Same Same Same
12h
40-80 mg IV
Furosemide Lasix Same Same Same Same
q12h
25-200 mg po
Hydrochlorothiazide Hydrodiuril Same Same Not effective Not applicable
qd tid
25 mg q6- 25 mg q12-
Spironolactone Aldactone 25 mg tid-qid Avoid Not applicable
12h 24h
25-150 mg 25-150 mg
Triamterene Dyrenium Avoid Avoid Not applicable
q12-24h q12h
Antivirals
5-10 mg/kg 2.5-5 mg/kg po
5-10 mg/kg po 2.5-5 mg/kg po
Acyclovir Zovirax Same po or IV or IV q24h post-
or IV q8h or IV q24h
q12-24h HD
100 mg po 100 mg po
Amantadine Symmetrel Same 200 mg po q7d 200 mg po q7d
q12h q24-48h
Dose per CrCl <
200 mg po
10 mL/min; no
q12h; second 200 mg po 200 mg po
Didanosine Videx 100 mg po q24h supplemental
dose: 250-400 q12h q24h
dosing
mg q24h
necessary
Dose post-HD:
0.05 mg po qd
for treatment-
naive patients
0.25-0.5 0.15-0.3
Entecavir Baraclude 0.5-1 mg po qd 0.05-0.1 mg qd and 0.1 mg po
mg qd mg qd
qd for
lamivudine-
refractory
patients
125 mg po
125 mg po 62.5 mg po 250 mg
500 mg q8- q12-24h or
Famciclovir Famvir q12h or 500 mg q24h or 250 mg following each
12h 500 mg po
po q8h po q24h dialysis session
12-24h
2.5-5 1.25-2.5 1.25 mg/kg 3
5 mg/kg IV 1.25 mg/kg 3
Ganciclovir Cytovene mg/kg mg/kg times/week
q12h times/week
q12h q24h post-HD
No data: No data: No adjustment
Indinavir Crixan 800 mg po q8h No data: same
same same necessary
Supplemental
150-300 mg po 100-300 50-150 mg 25-50 mg po
Lamivudine Epivir dosing is not
q12-24h mg po qd po q24h q24h
required
750 mg po q8h;
Nelfinavir Viracept second dose: Same Same Same Same
1,250 mg bid
An additional
200 mg po 200 mg dose is
Nevirapine Viramune q24h × 14 d, Same Same Same recommended
then q12h following
dialysis
Additional dose
recommended
after each
1,000-1,200 mg
Ribavirin Rebetol
1,000-1,200 mg
Ribavirin Rebetol Same Avoid Avoid dialysis session
q24h
in HIV patients
with CrCl < 10
mL/min
600 mg po
Ritonavir Norvir Same Same Same Same
q12h
Fortovase, 600-1,200 mg
Saquinavir Same Same Same Same
Invirase po q8h
30-40 mg po 15-20 mg 15-20 mg po 15-20 mg po
Stavudine Zerit Same
q12h po q12-24h q24h q24h
500 mg po 500-1,000
Valacyclovir Valtrex q12h to 1,000 Same mg po q12- 500 mg q24h Dose post-HD
mg po q8h 24h
0.75 mg po 0.75 mg po
Zalcitabine Hivid 0.75 mg po q8h Same No data
q12h q24h
200 mg po q8h;
second dose:
Zidovudine Retrovir Same Same 100 mg po q8h 100 mg po q8h
300 mg po
q12h
Bisphosphonates
3-3.3 mg
Zoledronic acid Zometa 4 mg IV 3.5 mg IV Avoid No data
IV
Gout agents
150-200 150 mg
300 mg po 150 mg po
Allopurinol Zyloprim mg po 100 mg po q48h supplemental
q24h q24h
q24h dose
Acute: 2 mg, Decrease
then 0.5 mg po normal Decrease
Acetycol,
Colchicine q6h; chronic: Same dose by normal dose by Same
Colsalide
0.5-1 mg po 50% to no 25%
q24h change
Not Not
Probenecid Benemid 500 mg po bid Not effective Not effective
effective effective
Hypoglycemic

agents
50-200 mg po 25-200 mg
Acarbose Precose Avoid Avoid No data
tid po tid
250-1,500 mg
Acetohexamide Dymelor Avoid Avoid Avoid No data
po q24h
100-500 mg po 50-250 mg
Chlorpropamide Diabinese Avoid Avoid Avoid
q24h po q24h
5-10 mcg SC
Exenatide Byetta Same Avoid Avoid Avoid
bid
2.5-15 mg po 1.25-7.5
Glipizide Glucotrol Same 1.25-7.5 mg po Same
q24h mg po
Diabeta,
Glynase, 1.25-20 mg po
Glyburide No data No data Avoid Avoid
Micronase, q24h
PresTab
100% of 75% of
50% of normal No supplement
Insulin Variable normal normal
dose necessary
dose dose
500-850 mg po 250-425 125-212
Metformin Glucophage Avoid No data
bid mg po bid mg po bid
100-250 mg po
Tolazamide Tolinase Same Same Same No data
q24h
No supplement
Tolbutamide Orinase 1-2 g q24h Same Same Same
necessary
Nonsteroidal anti-
inflammatory
agents
25-75 mg po 12.5-37.5 6.25-37.5 6.25-18.75 mg No supplement
Diclofenac Voltaren
bid mg po bid mg po bid po bid necessary
Etodolac Lodine 200 mg bid Same Same Same Same
Advil,
Ibuprofen 800 mg po tid Same Same Same Same
Motrin
25-50 mg po
Indomethacin Indocin Same Same Same Same
tid
60 mg IM
loading dose,
Ketorolac Toradol 50% of 15 mg IM or IV
then 15-30 mg 25-50% of
Same normal q6h (no bolus
q6h; 30 mg IV normal dose
Nabumetone Relafen dose dose)
loading dose,
then 15 mg q6h
0.5-1 g po No supplement
Naproxen Naprosyn 1-2 g po q24h Same 0.5-1 g po q24h
q24h necessary
Oxaprozin Daypro
Tolmetin Tolectin 500 mg bid Same Same Same Same
Proton pump 1,200 mg po
Same Same Same Same
inhibitors q24h
Esomeprazole Nexium 400 mg po tid Same Same Same Same
Lansoprazole Prevacid
20-40 mg po
Omeprazole Prilosec Same Same Same Same
q24h
15-60 mg po
Pantoprazole Protonix Same Same Same Same
q24h
20-60 mg po
Same Same Same Same
q24h
20-80 mg po
q24h; 80 mg IV Same Same Same Same
q12h
References
Aronoff GR, Bennett WM, Berns JS, et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults
and Children . 5th ed. Philadelphia, Pa.: American College of Physicians; 2007.
www.thomsonhc.com . Updated periodically.
UpToDate. Waltham, Mass.: Wolters Kluwer Health. Available at: www.uptodate.com . Updated periodically.
Appendix C: Drugs in Hepatic Failure
Drug Trade name Dose

For mild impairment, use 200 mg bid;
Abacavir Ziagen abacavir is contraindicated in patients
with moderate to severe impairment.
Cetafen, FeverAll, Silapap, Use with caution; avoid chronic use in
Acetaminophen
Tylenol patients with impairment.
Dose adjustment may be necessary in
Amiodarone Cordarone, Pacerone
patients with hepatic dysfunction.
Begin with low initial doses, and
Amitriptyline Elavil
increase dose as tolerated and needed.
Amlodipine Norvasc Start dose at 2.5 mg po daily.
Use with caution in patients with
Amoxicillin-clavulanic
Augmentin impairment, and monitor hepatic
acid
function with prolonged use.
Avoid in patients with severe hepatic
Aspirin
dysfunction.
Decrease dose by 50% in patients with
moderate hepatic dysfunction; give
Atomoxetine Strattera
25% of normal dose if hepatic
dysfunction is severe.
Monitor hepatic transaminases every 2
Azathioprine Imuran weeks for 4 weeks, then monthly
thereafter.
Azithromycin Zithromax impairment because of potential for
hepatotoxicity.
Azole antifungals:
Fluconazole Diflucan No adjustments are necessary.
Adjustments may be necessary, but no
Itraconazole Sporanox
guidelines are available.
Dose reduction should be considered in
Ketoconazole Nizoral
patients with severe liver disease.
Posaconazole Noxafil Use with caution.
For patients with mild to moderate
hepatic dysfunction, use standard
loading dose; reduce maintenance
Voriconazole VFEND dosage by 50% for patients with severe
hepatic impairment; use only when
benefit outweighs risk; monitor closely
for toxicity.
Benzodiazepines:
Reduce by 50-60% or avoid in patients
Alprazolam Xanax
with cirrhosis.
Avoid or decrease dose in patients with
Chlordiazepoxide Librium
cirrhosis or hepatitis (5 mg po bid-qid).
Diazepam Valium
liver disease.
Lorazepam Ativan Use with caution.
Dose reduction of 50% may be
Midazolam Versed
necessary.
Oxazepam Serax No dose adjustments are necessary.
Temazepam Restoril No dose adjustments are necessary.
Dose reduction of 50% may be
Triazolam Halcion
necessary (0.125 mg po at night).
No adjustment is needed; use with
caution in patients with moderate to
Bicalutamide Casodex severe hepatic dysfunction; discontinue
if alanine transaminase > 2 times upper
limit of normal or jaundice develops.
Decrease initial dose to 2.5 mg in
Bisoprolol Zebeta patients with hepatic insufficiency; do
not exceed a dose of 10 mg daily.
Liver function should be tested
Bosentan Tracleer monthly; adjust or discontinue
accordingly.
Avoid in patients with severe hepatic
dysfunction; use lower initial doses,
Buspirone Buspar
and increase gradually as needed and
tolerated.
Dose adjustment is recommended in
Bupivacaine Marcaine, Sensorcaine patients with severe disease; use with
caution.
Carbamazepine Tegretol Avoid in patients with hepatic disease.
moderate hepatic dysfunction; avoid in
Celecoxib Celebrex
patients with severe hepatic
dysfunction.
Adjustment may be necessary in
Chlorambucil Leukeran
patients with impairment.
Use with caution; monitor serum
Chloramphenicol concentrations; dose may be decreased
in patients with hepatic impairment.
Use doses in the lower ranges with
Chlorpromazine Thorazine frequent monitoring and gradual dose
adjustment.
Cimetidine Tagamet
severe hepatic dysfunction.
Decrease dose in patients with severe
Clindamycin Cleocin
hepatic dysfunction.
Clomiphene is contraindicated in
Clomiphene Clomid, Serophene
Dose adjustment may be necessary; use
Codeine with caution in patients with severe
impairment.
Gengraf, Neoral, Restasis, Dose adjustment may be necessary;
Cyclosporin
Sandimmune monitor levels closely.
Dose reduction may be necessary; use
Cytarabine Cytosar with caution in patients with hepatic
impairment.
Dacarbazine may cause hepatotoxicity;
Dacarbazine DTIC
monitor closely for signs.
No dose adjustment is needed for
patients with mild to moderate hepatic
impairment; avoid in patients with
Darunavir Prezista
severe impairment; monitor liver
function tests at baseline, then
If bilirubin is 1.2-3 mg/dL, reduce dose
Daunorubicin Cerubidine by 25%; if > 3 mg/dL, reduce dose by
50%.
Delavirdine Rescriptor
hepatic impairment.
Consider dose adjustment; monitor for
Didanosine Videx
toxicity.
Cardizem, Cartia, Dilacor, Use with caution because diltiazem is
Diltiazem
Tiazac extensively metabolized by the liver.
hepatic cirrhosis or hepatic
Disulfiram Antabuse
insufficiency; avoid in patients with
advanced or severe hepatic disease.
If bilirubin is 1.2-3 mg/dL, reduce dose
Doxorubicin Adriamycin, Rubex by 50%; if bilirubin is 3.1-5 mg/dL,
reduce dose by 75%.
Efavirenz Sustiva
hepatic impairment.
Dose reduction may be necessary in
Erythromycin E-Mycin
Do not exceed a dose of 20 mg in
Esomeprazole Nexium patients with severe hepatic
dysfunction.
Estrogens
impaired liver function.
Initial dose is 2.5 mg/day; monitor
Felodipine Plendil
blood pressure.
Flecainide has an increased half-life in
patients with hepatic impairment;
Flecainide Tambocor
monitor plasma levels; avoid use in
patients with significant impairment.
Use caution with initial and repeated
Flumazenil Romazicon
doses in patients with liver disease.
Adrucil, Carac, Efudex,
Fluorouracil Use with extreme caution.
Fluoroplex
Fluphenazine Prolixin Use with caution.
Furosemide has a diminished
natriuretic effect with increased
sensitivity to hypokalemia and volume
Furosemide Lasix
depletion in patients with cirrhosis;
monitor effects, especially with high
doses.
Griseofulvin is contraindicated in
Griseofulvin Grifulvin, Gris-PEG
patients with severe liver disease.
Haloperidol Haldol
hepatic impairment.
3-hydroxy-3-methyl-
glutaryl-coenzyme A Avoid in patients with elevated serum

(HMG-CoA) reductase transaminases.
inhibitors
Addaprin, Advil, Genpril, I-
Prin, Midol, Motrin,
Ibuprofen hepatic impairment; avoid in patients
NeoProfin, Proprinal,
with severe impairment.
Ultraprin
Decrease dose to 600 mg q8h in
Indinavir Crixivan patients with mild to moderate hepatic
dysfunction.
Consider a dose reduction if serum
glutamic pyruvic transaminase > 5
Interferon beta-1a Avonex times upper limit of normal;
discontinue if jaundice or other
symptoms of liver disease develop.
Test liver function at months 1, 3, and
Interferon beta-1b Betaseron
6, then periodically thereafter.
Lower doses may be necessary; defer
therapy for treatment of latent
Isoniazid Laniazid, Nydrazid
tuberculosis infection in patients with
acute hepatic disease.
Empiric dose reductions are
recommended in patients with
hepatitis; monitor liver function tests at
Isotretinoin Accutane
baseline, then at weekly or biweekly
intervals until a response to the
treatment is established.
Fixed-dose combinations should not be
used in patients with impaired hepatic
Lamivudine-zidovudine Combivir function; lamivudine-zidovudine is
contraindicated in patients with hepatic
impairment.
Reduce initial, escalation, and
maintenance doses by 25% in patients
with moderate to severe hepatic
Lamotrigine Lamictal
impairment without ascites; decrease
doses by 50% in patients with severe
hepatic dysfunction with ascites.
Lansoprazole Prevacid
hepatic dysfunction.
Avoid in patients with moderate to
severe hepatic dysfunction; decrease
dose to 10 mg/d if liver enzymes are
Leflunomide Arava elevated to 2 times the upper limit of
normal; discontinue if liver enzymes
are elevated to 3 times the upper limit
of normal.
Levonorgestrel is contraindicated in
Levonorgestrel Mirena, Plan B
patients with acute liver disease.
Lidocaine Xylocaine Dose adjustments may be required.
Initiation of therapy at a reduced
Losartan Cozaar dosage may be advisable in patients
with hepatic impairment.
Medroxyprogesterone is
Medroxyprogesterone Depo-Provera, Provera contraindicated in patients with severe
hepatic impairment.
Mefloquine may have increased half-
Mefloquine Lariam
life and plasma levels.
Mercaptopurine Purinethol
patients with hepatic impairment.
Avoid; liver disease is a risk factor for
Metformin Glucophage developing lactic acidosis during
therapy.
Adjust dose in patients with
impairment because of risk of
Methadone Dolophine
accumulation; avoid in patients with
severe disease.
Decrease dose by 25% when bilirubin
is 3.1-5 mg/dL or aspartate
Methotrexate Folex, Rheumatrex
transaminase is > 180 IU; avoid if
bilirubin is > 5 mg/dL.
Methyldopa is contraindicated in
Methyldopa Aldomet
Dose adjustment may be necessary in
Metoprolol Lopressor patients with hepatic insufficiency; no
recommendations are available.
Metronidazole Flagyl disease; no recommendations are
available.
Decrease dose to 25-30% of normal
Mexiletine Mexitil
dose.
Avinza, DepoDur,
Duramorph, Infumorph, Decrease dose in patients with
Morphine
Kadian, MS Contin, cirrhosis.
Oramorph SR, Roxanol
Nabumetone Relafen severe hepatic insufficiency; reduce
dose if necessary.
Avoid in patients with elevated
Nefazodone Serzone
transaminases.
No adjustment is necessary for patients
with mild impairment; use is not
Nelfinavir Viracept
recommended in patients with
moderate to severe impairment.
Nevirapine is contraindicated in
Nevirapine Viramune patients with moderate to severe
impairment.
Decrease dose by 50-60% in patients
Nifedipine Adalat, Procardia
with cirrhosis.
Starting dose is not to exceed 8.5 mg/d
Nisoldipine Sular
in patients with liver impairment.
Do not exceed 400 mg/d in patients
Ofloxacin Floxin
with severe liver dysfunction.
Decrease dose in patients with hepatic
Omeprazole Prilosec
dysfunction.
Do not exceed 8 mg/d in patients with
Ondansetron Zofran
severe hepatic insufficiency.
Dose should be decreased in patients
Oxycodone Oxycontin
with severe liver disease.
Pantoprazole Protonix Adjustment is not required.
For alanine aminotransferase < 2.5
upper limit of normal, use caution; for
Pioglitazone Actos active liver disease (alanine
aminotransferase > 2.5 upper limit of
normal), avoid use.
Phenobarbital Barbita, Luminal, Solfoton
Monitor levels frequently because dose
reduction may be necessary in patients
Phenytoin Dilantin
with hepatic insufficiency; increased
unbound concentrations may occur.
Prednisolone is contraindicated in
Econopred, Orapred,
patients with cirrhosis; use with caution
Prednisolone Pediapred, Pred Forte, Pred
in patients with severe hepatic
Mild, Prelone
impairment.
Lower doses or longer dosing intervals
Procanbid, Promine,
Procainamide may be required in patients with
Pronestyl, Rhythmin
hepatic failure.
Procarbazine Matulane
impairment.
Marked slowing of heart rate may
occur in patients with chronic liver
disease with conventional doses; low
initial dose and slow titration are
Propranolol Betachron, Inderal
suggested. Monitor more frequently in
patients with hepatic dysfunction;
regular heart rate monitoring is
recommended.
Pyrazinamide is contraindicated in
Pyrazinamide
patients with severe dysfunction.
Reduction of maintenance doses by
Cardioquin, Quinaglute, 50% may be necessary in patients with
Quinidine
Quinalan, Quinidex, Quinora hepatic impairment; monitor serum
levels closely.
Ranitidine may have minor changes in
half-life, distribution, clearance, and
Ranitidine Zantac bioavailability; no adjustment is
necessary; monitor serum levels and
liver function tests.
Copegus, Rebetol, Ribavirin is contraindicated in patients
Ribavirin
Ribasphere, Virazole with hepatic decompensation.
Dose reductions may be necessary to
reduce hepatotoxicity; use with caution
Rifampin Rifadin, Rimactane
or avoid in patients with hepatic
impairment.
Decrease dose in patients with hepatic
dysfunction. For IM, administer titrated
Risperidone Risperdal
oral doses prior to starting IM. For po,
start at 0.5 mg bid and titrate.
No adjustments are needed; monitor
closely. Decrease dose about 40% in
steady state in patients with mild to
Ritonavir Norvir
moderate impairment. No data are
available for patients with severe
impairment; monitor closely.
Use with caution in patients with mild
to moderate hepatic impairment;
Saquinavir Fortovase, Invirase
saquinavir is contraindicated in patients
with severe impairment.
Selective serotonin
reuptake inhibitors (SSRIs) Dose should be decreased or dosing
and serotonin- interval increased in patients with
norepinephrine reuptake hepatic insufficiency.
inhibitors:
A 20-mg dose is recommended for
patients with decreased hepatic
Citalopram Celexa
function; dosage may be increased to
40 mg/d only in nonresponsive patients.
A lower or less frequent dose is
recommended in patients with hepatic
Fluoxetine Prozac
impairment because of a prolonged
elimination half-life.
Decrease the dose or frequency, and
Fluvoxamine Luvox titrate slowly in patients with hepatic
insufficiency.
Dose initially at 10 mg qd or at 12.5 mg
qd of the controlled-release product;
Paroxetine Paxil doses should not exceed 40 mg qd or
50 mg qd of the controlled-release
product.
Decrease the dose, or increase the
Sertraline Zoloft
interval.
Decrease the dose by 50% in patients
Venlafaxine Effexor with mild to moderate hepatic
impairment.
Sodium nitroprusside Nipride, Nitropress
hepatic impairment.
Succinylcholine Anectine, Quelicin
disease.
Sulfamethoxazole-trimethoprim is
Sulfamethoxazole-
Bactrim, Setpra, Sulfatrim contraindicated in patients with marked
trimethoprim
hepatic damage if not monitored.
Sulfonylureas:
patients with hepatic disease.
Use conservative initial and
Chlorpropamide Diabinese
maintenance doses.
Glimepiride Amaryl
maintenance doses.
Glipizide Glucotrol Start dose at 2.5 mg po qd.
Glyburide Diabeta, Glynase, Micronase maintenance doses; avoid use in
patients with severe disease.
Tolazamide Tolinase
maintenance doses.
Tolbutamide Orinase
maintenance doses.
Dose at the low end of the dosing range
in patients with hepatic impairment;
Tacrolimus Prograf
consider dose adjustment; monitor
closely.
Androderm, Androgel,
Decrease dose in patients with
Delatestryl, Depo-
impairment; testosterone is
Testosterone Testosterone, First-
contraindicated in patients with severe
Testosterone MC, Striant,
hepatic impairment.
Testim, Testopel
Tetracycline Sumycin
impairment.
Aerolate, Aminophyllin,
Aquaphyllin, Asmalix,
Bronkodyl, Choledyl,
Duraphyl, Respbid, Slo-bid, Dose reduction may be necessary in
Theophylline Slo-Phyllin, Sustaire, Theo- patients with hepatic insufficiency;
24, Theobid, Theochron, monitor serum levels frequently.
Theoclear, Theo-Dur,
Theolair, Theon, Theospan,
Theovent, Truphylline
Dose adjustments may be necessary in
Tiagabine Gabitril patients with impairment caused by
decreased clearance.
No dose adjustment is necessary for
patients with mild impairment.
Tipranavir is contraindicated in patients
Tipranavir Aptivus
with moderate to severe hepatotoxicity;
monitor liver functions at baseline, then
Immediate release: Dose 50 mg po
q12h in patients with cirrhosis.
Tramadol Ultram
Extended release: This form is not
recommended.
Start low dose initially, and increase as
Tricyclic antidepressants:
needed and tolerated.
Clomipramine Anafranil
Desipramine Norpramin
Doxepin Sinequan
Imipramine Tofranil
Nortriptyline Pamelor
Protriptyline Vivactil
Avoid in patients with hepatic disease
Valproic acid Depakene, Depakote
or significant hepatic insufficiency.
Calan, Covera, Isoptin, Decrease dose by 20-50% in patients
Verapamil
Verelan with impairment.
If bilirubin is > 3 mg/100mL, reduce
Vinblastine Velban
dose by 50%.
If bilirubin is > 3 mg/100mL, reduce
Vincristine Vincasar PFS
dose by 50%.
Use initial dose of 5 mg or less, with
Warfarin Coumadin adjustments based on international
normalized ratio.
Consider a decreased dose in patients
Zafirlukast Accolate with impairment; monitor for adverse
effects.
Avoid in patients with liver function
Zalcitabine Hivid tests > 5 times the upper limit of
normal.
Decrease daily dose or extend dosing
Zidovudine Retrovir
interval.
Reference
Appendix D: Top 200 Prescription Drugs
The following list of the top 200 prescriptions for 2007 is ranked by number of U.S. prescriptions
dispensed. The list was obtained with permission from RxList at www.rxlist.com with data
furnished by Verispan VONA.
Rank Trade name Generic name

1. Lipitor Atorvastatin
2. Singulair Montelukast
3. Lexapro Escitalopram
4. Nexium Esomeprazole
5. Synthroid Levothyroxine
6. Plavix Clopidogrel
7. Toprol XL Metoprolol
8. Prevacid Lansoprazole
9. Vytorin Ezetimibe-simvastatin
10. Advair Diskus Fluticasone-salmeterol (inhaled)
11. Zyrtec Cetirizine
12. Effexor XR Venlafaxine
13. Protonix Pantoprazole
14. Diovan Valsartan
15. Fosamax Alendronate
16. Zetia Ezetimibe
17. Crestor Rosuvastatin
18. Levaquin Levofloxacin
19. Diovan HCT Hydrochlorothiazide-valsartan
20. Klor-Con Potassium chloride
21. Cymbalta Duloxetine
22. Actos Pioglitazone
23. Premarin Tabs Estrogens (conjugated)
24. ProAir HFA Albuterol (inhaled)
25. Celebrex Celecoxib
26. Flomax Tamsulosin
27. Seroquel Quetiapine
28. Norvasc Amlodipine
29. Nasonex Mometasone nasal
30. Tricor Fenofibrate
31. Lantus Insulin glargine
32. Viagra Sildenafil
33. Altace Ramipril
34. Yasmin 28 Drospirenone-ethinyl estradiol
35. Levoxyl Levothyroxine
36. Adderall XR Amphetamine-dextroamphetamine
37. Lotrel Amlodipine-benazepril
38. Actonel Risedronate
39. Ambien CR Zolpidem
40. Cozaar Losartan
41. Coreg Carvedilol
42. Valtrex Valacyclovir
43. Lyrica Pregabalin
44. Concerta Methylphenidate
45. Ambien Zolpidem
46. Risperdal Risperidone
47. Digitek Digoxin
48. Topamax Topiramate
49. Chantix Varenicline
50. Avandia Rosiglitazone
51. Lamictal Lamotrigine
52. Ortho Tri-Cyclen Lo Ethinyl estradiol-norgestimate
53. Xalatan Latanoprost ophthalmic
54. Aciphex Rabeprazole
55. Hyzaar Hydrochlorothiazide-losartan
56. Spiriva Tiotropium (inhaled)
57. Wellbutrin XL Bupropion HCl
58. Lunesta Eszopiclone
59. Benicar Olmesartan
60. Benicar HCT Hydrochlorothiazide-olmesartan
61. Aricept Donepezil
62. Avapro Irbesartan
63. Detrol LA Tolterodine
64. Trinessa Ethinyl estradiol and norgestimate
65. Cialis Tadalafil
66. Combivent Albuterol-ipratropium (inhaled)
67. Budeprion XL Bupropion HCl
68. Yaz Drospirenone-ethinyl estradiol
69. Glycolax Polyethylene glycol 3350
70. Imitrex Oral Sumatriptan
71. Evista Raloxifene
72. NuvaRing Etonogestrel-ethinyl estradiol (vaginal)
73. Omnicef Cefdinir
74. Nisapan Niacin
75. Tri-Sprintec Ethinyl estradiol-norgestimate
76. Boniva Ibandronate
77. Flovent HFA Fluticasone (inhaled)
78. Avelox Moxifloxacin
79. Abilify Aripiprazole
80. Avalide Hydrochlorothiazide-irbesartan
81. Requip Ropinirole
82. Zyrtex Syrup Cetirizine
83. Coumadin Tabs Warfarin
84. Zyprexa Olanzapine
85. Depakote ER Divalproex sodium
86. Nasacort AQ Triamcinolone (nasal)
87. Skelaxin Metaxalone
88. Allegra-D Fexofenadine-pseudoephedrine
89. Humalog Insulin lispro
90. Vigamox Moxifloxacin ophthalmic
91. Endocet Acetaminophen-oxycodone
92. Budeprion SR Bupropion XL
93. Depakote Divalproex sodium
94. Namenda Memantine
95. Lidoderm Lidocaine topical
96. Strattera Atomoxetine
97. Aviane Ethinyl estradiol-levonorgestrel
98. Patanol Olopatadine (ophthalmic)
99. Proventil HFA Albuterol (inhaled)
100. Clarinex Desloratadine
101. Thyroid, Armour Thyroid desiccated
102. Astelin Azelastine (nasal)
103. Zyrtex-D Cetirizine-pseudoephedrine
104. Tussionex Chlorpheniramine-hydrocodone
105. Caduet Amlodipine-atorvastatin
106. Avodart Dutasteride
107. Keppra Levetiracetam
108. Januvia Sitagliptin
109. Kariva Desogestrel-ethinyl estradiol
110. Prempro Estrogens (conjugated)-medroxyprogesterone
111. Rhinocort Aqua Budesonide (nasal)
112. Levitra Vardenafil
113. Ortho Evra Ethinyl estradiol-norelgestromin (transdermal)
114. Low-Ogestrel Ethinyl estradiol-norgestrel
115. Vivelle-DOT Estradiol (transdermal)
116. Apri Desogestrel-ethinyl estradiol
117. Loestrin 24 Fe Ethinyl estradiol-norethindrone
118. Levothroid Levothyroxine
119. Necon 1/35 Ethinyl estradiol-norethindrone
120. Fosamax Plus D Alendronate-cholecalciferol
121. Byetta Exenatide
122. Pulmicort Respules Budesonide (inhaled)
123. Paxil CR Paroxetine
124. Glipizide XL Glipizide
125. Provigil Modafinil
126. Trileptal Oxcarbazepine
127. Humulin N Insulin (NPH)
128. Lumigan Bimatoprost (ophthalmic)
129. Alphagan P Brimonidine (ophthalmic)
130. Xopenex HFA Levalbuterol (inhaled)
131. Tobradex Tobramycin-dexamethasone (ophthalmic)
132. Trivora-28 Ethinyl estradiol-levonorgestrel
133. Atacand Candesartan
134. Xopenex Levalbuterol (inhaled)
135. Cosopt Dorzolamide-timolol (ophthalmic)
136. Geodeon Oral Ziprasidone
137. Micardis Telmisartan
138. Lovaza Omega-3 acid ethyl esters
139. Micardis HCT Telmisartan/hydrochlorothiazide
140. Focalin XR Dexmethylphenidate
141. OxyContin Oxycodone
142. Mirapex Pramipexole
143. Prometrium Progesterone (micronized)
144. Humulin 70/30 Insulin (NPH/regular)
145. Ciprodex Otic Ciprofloxacin-dexamethasone (otic)
146. Restasis Cyclosporine (ophthalmic)
147. Suboxone Buprenorphine-naloxone
148. Zymar Gatifloxacin (ophthalmic)
149. Arimidex Anastrozole
150. Sprintec Ethinyl estradiol-norgestimate
151. Dilantin Kapseals Phenytoin
152. Fluzone Influenza vaccine
153. BenzaClin Benzoyl peroxide-clindamycin (topical)
154. Vesicare Solifenacin
155. Asacol Mesalamine
156. Avandamet Metformin-rosiglitazone
157. Lanoxin Digoxin
158. Travantan Travoprost (ophthalmic)
159. Zoloft Sertraline
160. Bactroban Mupirocin (topical)
161. Tamiflu Oseltamivir
162. Guaifenex PSE Guaifenesin-pseudoephedrine
163. Differin Adapalene (topical)
164. Premarin Vaginal Estrogens (conjugated, vaginal)
165. Pseudovent 400 Pseudoephedrine HCl (extended-release)-guaifenesin
166. Vagifem Estradiol (vaginal)
167. Levora Ethinyl estradiol-levonorgestrel
168. Relpax Eletriptan
169. Allegra-D 24 Hour Fexofenadine-pseudoephedrine
170. Methylin Methylphenidate
171. AndroGel Testosterone (topical)
172. Aggrenox Aspirin-dipyridamole
173. Propecia Finasteride
174. Asmanex Mometasone (inhaled)
175. NovoLog Mix 70/30 Insulin aspart protamine-insulin aspart
176. Uroxatral Alfuzosin
177. Estrostep Fe Ethinyl estradiol-norethindrone
178. Sular Nisoldipine
179. Lescol XL Fluvastatin
180. Novolin 70/30 Insulin (NPH/regular)
181. Epipen epinephrine
182. Actoplus Met Pioglitazone HCl-metformin HCl
183. M-Oxy Oxycodone
184. Rozerem Ramelteon
185. Enablex Darifenacin
186. Jantoven Warfarin
187. Catapres-TTS Clonidine (transdermal)
188. Junel Fe Ethinyl estradiol-norethindrone
189. Coreg CR Carvedilol
190. Ortho Tri-Cyclen Ethinyl estradiol-norgestimate
191. Primacare One Prenatal vitamin supplement
192. Zovirax Topical Acyclovir (topical)
193. Trilyte Polyethylene glycol-electrolytes
194. Aldara Imiquimod
195. Necon 0.5./35E Norethindrone-ethinyl estradiol
196. Arthrotec Diclofenac sodium-misoprostol
197. Ultram ER Tramadol
198. Ceron-DM Chlorpheniramine-dextromethorphan-phenylephrine
199. Ethedent 1.1% sodium fluoride
200. Elidel Pimecrolimus (topical)
Reference
RxList. The Top 200 Prescriptions for 2007 by Number of U.S. Prescriptions Dispensed. Available
at: www.rxlist.com/script/main/hp.asp.
Appendix E: Top 200 Over-the-Counter Products
The following is a list of the top 200 over-the-counter (OTC) and health and beauty care brands based on dollar
amount sold in 2004. The list was obtained with permission from Drug Topics 2007 .
Rank Product
1. Private label cold, allergy, and sinus tablets or packets
2. Private label internal analgesic tablets
3. Prilosec OTC antacid tablets
4. Private label mineral supplements
5. Always sanitary napkins or liners
6. Advil internal analgesic tablets
7. Tylenol internal analgesic tablets
8. Listerine mouthwash and dental rinse
9. Dove nondeodorant bar soap
10. Depend adult incontinence products
11. Private label adult incontinence products
12. Private label first-aid ointments and antiseptics
13. Aleve internal analgesic tablets
14. Ensure weight control or nutritionals, liquid or powder
15. Private label multivitamins
16. Nicorette antismoking gum
17. Poise adult incontinence products
18. Private label first-aid tape, bandages, gauze, or cotton
19. Gillette Mach3 cartridges
20. Private label laxative tablets
21. Claritin cold, allergy, and sinus tablets or packets
22. Claritin D cold, allergy, and sinus tablets or packets
23. Tampax Pearl tampons
24. Private label baby wipes
25. Private label antacid tablets
26. Benadryl cold, allergy, and sinus tablets or packets
27. Private label antismoking gum
28. Mucinex cold, allergy, and sinus tablets or packets
29. Nature's Bounty mineral supplements
30. Tampax tampons
31. Crest toothpaste
32. Degree deodorant
33. Nature Made mineral supplements
34. Private label cotton balls and cotton swabs
35. Gillette Fusion cartridges
36. Playtex Gentle Glide tampons
37. Private label one- and two-letter vitamins
38. Loreal Superior Preference hair coloring
39. Olay Regenerist facial antiaging
40. Airborne cold, allergy, and sinus tablets or packets
41. Tylenol PM internal analgesic tablets
42. Nature Made one- and two-letter vitamins
43. Alli weight control candy or tablets
44. Crest Whitening Plus Scope toothpaste
45. Mucinex DM cold, allergy, and sinus tablets or packets
46. Sudafed PE cold, allergy, and sinus tablets or packets
47. Stayfree sanitary napkins or liners
48. Private label cold, allergy, and sinus liquid or powder
49. Private label nasal spray, drops, or inhaler
50. Bayer internal analgesic tablets
51. Loreal Excellence hair coloring
52. Private label eye or lens care solutions
53. Kotex sanitary napkins or liners
54. Centrum Silver multivitamins
55. PediaSure weight control or nutritionals, liquid or powder
56. Colgate Total toothpaste
57. Secret Platinum deodorants
58. Private label sanitary napkins or liners
59. Huggies Natural Care baby wipes
60. Vicks Nyquil cold, allergy, and sinus liquid or powder
61. Private label mouthwash or dental rinse
62. Q-tips cotton balls and cotton swabs
63. Colgate toothpaste
64. Tylenol cold, allergy, and sinus tablets or packets
65. Just For Men hair coloring
66. Clairol Nice 'n Easy hair coloring
67. Alcon Opti-Free Replenish eye or lens care solutions
68. Band-Aid first-aid tape, bandages, gauze, or cotton
69. Slim Fast Optima weight control or nutritionals, liquid or powder
70. Gillette Mach3 Turbo cartridges
71. Alcon Opti-Free Express eye or lens care solutions
72. Osteo Bi-Flex mineral supplements
73. Motrin IB internal analgesic tablets
74. Private Label weight control or nutritionals, liquid or powder
75. LifeScan OneTouch glucose
76. Gillette Fusion Power cartridges
77. Zantac 150 antacid tablets
78. Clairol Natural Instincts hair coloring
79. Serenity adult incontinence products
80. Commit antismoking tablets
81. Kleenex Cottonelle moist towelettes
82. Softsoap Liquid Hand Soap
83. Private label anti-itch treatments (including calamine)
84. Nicroderm CQ antismoking patch
85. Revlon Colorsilk hair coloring
86. Crest Pro Health toothpaste
87. Abreva lip balm or cold sore medication
88. Children's Motrin internal analgesic liquids
89. Neosporin first-aid ointments and antiseptics
90. Huggies baby wipes
91. L'Oreal Feria hair coloring
92. Dove liquid body wash and all other
93. Old Spice High Endurance deodorants
94. Private label pregnancy test kits
95. Breathe Right nasal strips
96. Centrum multivitamins
97. Vaseline Intensive Care hand and body lotion
98. Imodium AD diarrhea tablets
99. Garnier Nutrisse hair coloring
100. Crest Pro Health mouthwash or dental rinse
101. Theraflu cold, allergy, and sinus tablets or packets
102. Boost weight control or nutritionals, liquid or powder
103. Pampers baby wipes
104. Futuro muscle and body support devices
105. Sensodyne toothpaste
106. Private label suntan lotion and oil
107. Crest Whitestrips tooth bleaching or whitening powder or pills
108. Excedrin internal analgesic tablets
109. Icy Hot external analgesic rubs
110. Kotex Security tampons
111. Pepcid AC antacid tablets
112. Pepto-Bismol stomach remedy liquid or powder
113. Metamucil laxative or stimulant liquid, powder, or oil
114. Bausch & Lomb ReNu MultiPlus eye or lens care solutions
115. Vicks humidifiers or vaporizers
116. Private label vaginal treatments
117. Ensure Plus weight control or nutritionals, liquid or powder
118. Alka Seltzer Plus cold, allergy, and sinus liquid or powder
119. Private label manual toothbrushes
120. Private label internal analgesic liquids
121. Coppertone suntan lotion and oil
122. Dove deodorants
123. Coppertone Sport suntan lotion and oil
124. Zicam nasal spray, drops, or inhaler
125. Right Guard Sport deodorants
126. Secret deodorants
127. Dulcolax laxative tablets
128. Pepcid Complete antacid tablets
129. ThermaCare heat or ice packs
130. Tylenol Arthritis internal analgesic tablets
131. Omron blood pressure kit
132. Old Spice Red Zone deodorants
133. Private label hand and body lotion
134. Monistat 1 vaginal treatments
135. Private label disposables
136. Tylenol internal analgesic liquids
137. Maybelline Great Lash mascara
138. First Response pregnancy test kits
139. Children's Tylenol cold, allergy, and sinus liquid or powder
140. One A Day multivitamins
141. Private label laxative or stimulant liquid, powder, or oil
142. Ace muscle and body support devices
143. Always Fresh sanitary napkins or liners
144. Fixodent denture adhesives
145. Crest Whitening Expressions toothpaste
146. Private label liquid hand soap
Slim-Fast Optima Meal On-the-Go weight control or nutritionals, liquid or
147.
powder
148. Irish Spring deodorant bar soap
149. Scope mouthwash or dental rinse
150. Gax-X antacid tablets
151. Cologate Max Fresh toothpaste
152. Axe liquid body wash and all other
153. Private label antismoking patch
154. Vicks Dayquil cold, allergy, and sinus tablets or packets
155. Preparation H hemorrhoidal cream, ointment or spray
156. Pampers Sensitive baby wipes
157. Mennen Speed Stick deodorants
158. Kotex Lightdays sanitary napkins or liners
159. Tylenol Sinus cold, allergy, and sinus tablets or packets
160. Claritin RediTabs cold, allergy, and sinus tablets or packets
161. Excedrin Migraine internal analgesic tablets
162. Private label tampons
163. Gillette M3 Power cartridges
164. Wet Ones moist towelettes
165. Dial deodorant bar soap
166. Monistat 3 vaginal treatments
167. L'Oreal Natural Match hair coloring
168. Bengay external analgesic rubs
169. Advanced Listerine mouthwash or dental rinse
170. Secret Clinical Strength deodorants
171. Gillette Venus cartridges
172. Alavert cold, allergy, and sinus tablets or packets
173. Children's Tylenol internal analgesic liquids
174. Rogaine hair growth products
175. Tums E-X antacid tablets
176. Advil PM internal analgesic tablets
177. Robitussin cold, allergy, and sinus liquid or powder
178. Mucinex D cold, allergy, and sinus tablets or packets
179. Imodium Advanced diarrhea tablets
180. Vicks VapoRub chest rubs
181. Ban deodorants
182. Afrin nasal spray, drops, or inhaler
183. Private label diarrhea tablets
184. Olay Definity facial antiaging
185. Skintimate shaving cream
186. Private label moist towelettes
187. e.p.t. pregnancy test kits
188. Olay Complete facial moisturizers
189. Nature's Bounty one-and two-letter vitamins
190. Midol feminine pain relievers
191. Lever 2000 deodorant bar soap
192. Private label glucose
193. Purell hand sanitizers
194. Chapstick lip balm or cold sore medication
195. Gillette Custom Plus disposables
196. Rolaids antacid tablets
197. Alcon Systane eye or lens care solutions
198. Suave Naturals regular shampoo
199. Gillette Sensor Excel cartridges
200. Banana Boat suntan lotion and oil
Reference
Top 200 OTC/HBC brands in 2007. Drug Topics . Available at:

http://drugtopics.modernmedicine.com/drugtopics/data/articlestandard//drugtopics/082008/492702/article.pdf
.
Appendix F: Drugs Excreted in Breast Milk
The following list is not comprehensive; generics and alternate brands of some products may exist.
When recommending drugs to pregnant or nursing patients, always check product labeling for
specific precautions.
Bactrim CombiPatch Dilantin Foradil Lamictal

Accolate
Baraclude Combipres Dilaudid Fortamet Lamisil
Accuretic
Benadryl Combivir Diovan Fortaz Lamprene
Aciphex
Bentyl Combunox Diprivan Fosamax Lanoxicaps
Actiq
Betapace Compazine Diuril Fosamax Plus D Lanoxin
Activella
Bextra Cordarone Dolobid Furosemide Lariam
Actonel
Bexxar Corgard Dolophine Gabitril Lescol
Actonel with Calcium
Bicillin Cortisporin Doral Galzin Letairis
ActoPlus Met
Blocadren Corzide Doryx Garamycin Levbid
Actos
Boniva Cosopt Droxia Glucophage Levitra
Adalat
Brethine Coumadin Duraclon Glucovance Levlen
Adderall
Brevicon Covera-HS Duragesic Glumetza Levlite
Advicor
Brontex Cozaar Duramorph Glyset Levora
Aggrenox
Byetta Crestor Duratuss Guaifed Levothroid
Aldactazide
Caduet Crinone Duricef Halcion Levoxyl
Aldactone
Cafergot Cyclessa Dyazide Haldol Levsin
Aldomet
Calan Cymbalta Dyrenium Helidac Levsinex
Aldoril
Campral Cystospaz EC-Naprosyn Hycamtin Lexapro
Alesse
Capoten Cytomel Ecotrin Hydrocet Lexiva
Alfenta
Capozide Cytotec E.E.S. Hydrocortone Lialda
Allegra-D
Captopril Cytoxan Effexor HydroDIURIL Lindane
Aloprim
Carbatrol Dapsone Elavil Iberet-Folic Lioresal
Altace
Cardizem Daraprim Elestat Ifex Lipitor
Ambien
Cataflam Darvon EMLA Imitrex Lithium
Amerge
Catapres Darvon-N Enduron Imuran Lithobid
Anafranil
Ceclor Decadron Epzicom Inderal Lo/Ovral
Anaprox
Cefizox Deconsal II Equetro Inderide Loestrin
Androderm
Cefobid Demerol ERYC Indocin Lomotil
Aplenzin
Cefotan Demulen EryPed INFeD Loniten
Apresoline
Ceftin Depacon Ery-Tab Inspra Lopressor
Aralen
Celebrex Depakene Erythrocin Invanz Lortab
Arthrotec
Celexa Depakote Erythromycin Invega Lotensin
Asacol
Cerebyx DepoDur Esgic-plus Inversine Lotrel
Ativan
Ceredase Depo-Provera Eskalith Ionsys Luminal
Augmentin
Cipro Desogen Estrogel Isoptin Luvox
Avalide
Ciprodex Desoxyn Estrostep Janumet Lyrica
Avandamet
Claforan Desyrel Evista Kadian Macrobid
Avandia
Clarinex Dexedrine Factive Kaletra Macrodantin
Avelox
Claritin DextroStat FazaClo Keflex Marinol
Axid
Claritin-D D.H.E. 45 Felbatol Keppra Maxipime
Axocet
Cleocin Diabinese Feldene Kerlone Maxzide
Azactam
Climara Diastat Femhrt Ketek Mefoxin
Azasan
Clozaril Diflucan Fiorinal Klonopin Menostar
Azathioprine
Codeine Digitek Flagyl Kronofed-A Metaglip
Azulfidine
Combigan Dilacor Floxin Kutrase (continued)
Methergine Sanctura
Norinyl Ponstel Tiazac
Methotrexate Sandimmune Vaseretic
Noritate Prandimet Timolide
MetroCream Santura XR Vasotec
Normodyne Pravachol Timoptic
MetroGel Sarafem Ventavis
Norpace Premphase Tindamax
MetroLotion Seconal Verelan
Norplant Prempro Tobi
Mexitil Sectral Vermox
Norpramin Prevacid Tofranil
Micronor Semprex-D Versed
Nor-QD Prevacid Tolectin
NapraPAC
Microzide Septra Vibramycin
Novantrone Toprol-XL
Prevpac
Migranal Seroquel Vibra-Tabs
Nubain Toradol
Prinzide
Miltown Seroquel XR Vicodin
Nucofed Trandate
Pristiq
Minizide Sinequan Vigamox
Nydrazid Tranxene
Prograf
Minocin Slo-bid Viramune
Oramorph Trental
Proloprim
Mirapex Soma Voltaren
Oretic Tricor
Prometrium
Mircette Sonata Vytorin
Ortho-Cept Triglide
Pronestyl
M-M-R II Soriatane Vyvanse
Ortho-Cyclen Trilafon
Propofol
Mobic Spiriva Wellbutrin
Ortho-Novum Trileptal
Prosed/DS
Modicon Sprycel Xanax
Ortho Tri- Tri-Levlen
Cyclen Protonix
Moduretic Stadol Xolair
Tri-Norinyl
Orudis Provera
Monodox
Tri-Norinyl
Orudis Provera
Monodox Stavzor Zantac
Triostat
Ovcon Prozac
Monopril Streptomycin Zarontin
Triphasil
Oxistat Pseudoephedrine
Morphine Stromectol Zaroxolyn
Trisenox
OxyContin Pulmicort
MS Contin Symbyax Zegerid
Trivora
OxyFast Pyrazinamide
MSIR Symmetrel Zemplar
Trizivir
OxyIR Quinidex
Myambutol Synthroid Zestoretic
Trovan
Pacerone Quinine
Mycamine Tagamet Zetia
Truvada
Pamelor Raptiva
Mysoline Tambocor Ziac
Tygacil
Pancrease Reglan
Namenda Tapazole Zinacef
Tylenol
Paxil Relpax
Naprelan Tarka Zithromax
Tylenol with
PCE Renese Codeine
Naprosyn Tasigna Zocor
Pediapred Requip Ultane
Nascobal Tavist Zoloft
Pediazole Reserpine Ultram
Naturethroid Tazicef Zomig
Pediotic Restoril Unasyn
Necon Tazidime Zonalon
Pentasa Retrovir Uniphyl
NegGram Tegretol Zonegran
Pepcid Rifadin Uniretic
Nembutal Tenoretic Zosyn
Periostat Rifamate Unithroid
Neoral Tenormin Zovia
Persantine Rifater Urimax
Neurontin Tenuate Zovirax
Pfizerpen Rimactane Valium
Niaspan Tequin Zyban
Phenergan Risperdal Valtrex
Nicotrol Testoderm Zydone
Phenobarbital Rocaltrol Vanceril
Niravam Thalitone Zyloprim
Phenytek Rocephin Vancocin
Nizoral Theo-24
Phenytek Rocephin Vancocin
Nizoral Theo-24 Zyprexa
Phrenilin Roxanol Vantin
Norco Theo-Dur Zyrtec
Plan B Rozerem Vascor
Nordette Thorazine
Reference
LaGow B, ed. Drug Topics Red Book. Montvale, N.J.: Thomson Healthcare; 2009.
Appendix G: Drugs That May Cause Photosensitivity
The drugs in this table are known to cause photosensitivity in some individuals. Effects can range
from itching, scaling, rash, and swelling to skin cancer, premature skin aging, skin and eye burns,
cataracts, reduced immunity, blood vessel damage, and allergic reactions.
The list is not all inclusive; it shows only representative brands of each generic. When in doubt,
always check specific product labeling. Individuals should be advised to wear protective clothing
and to apply sunscreens while taking the following medications.
Generic name Trade name

Acamprosate Campral
Acetazolamide Diamox
Acitretin Soriatane
Acyclovir Zovirax
Alendronate Fosamax
Aliskiren-hydrochlorothiazide Tekturna HCT
Alitretinoin Panretin
Almotriptan Axert
Amiloride-hydrochlorothiazide Moduretic
Aminolevulinic acid Levulan Kerastick
Amiodarone Cordarone, Pacerone
Amitriptyline-chlordiazepoxide Etrafon, Limbitrol
Amitriptyline-perphenazine
Amlodipine-atorvastatin Caduet
Amoxapine Asendin
Amphetamine aspartate-amphetamine sulfate-dextroamphetamine
Adderall XR
saccharate-dextroamphetamine sulfate
Anagrelide Agrylin
Aripiprazole Abilify
Atazanavir Reyataz
Atenolol-chlorthalidone Tenoretic
Atorvastatin Lipitor
Atovaquone-proguanil Malarone
Azatadine-pseudoephedrine Rynatan, Trinalin
Azithromycin Zithromax, Zmag
Benazepril Lotensin
Benazepril-hydrochlorothiazide Lotensin HCT
Bendroflumethiazide-nadolol Corzide
Bexarotene Targretin
Bismuth-metronidazole-tetracycline Helidac
Bismuth subcitrate potassium-metronidazole-tetracycline Pylera
Bisoprolol-hydrochlorothiazide Ziac
Brompheniramine-dextromethorphan-phenylephrine Alacol DM, Dimetane DX
Brompheniramine-dextromethorphan-pseudoephedrine Bromfed-DM
Buffered aspirin-pravastatin Pravigard PAC
Bupropion Wellbutrin, Zyban
Candesartan-hydrochlorothiazide Atacand HCT
Capecitabine Xeloda
Captopril Capoten
Captopril-hydrochlorothiazide Capozide
Carbatrol, Equetro, Tegretol,
Carbamazepine
Tegretol-XR
Palgic-D, Palgic-DS,
Carbinoxamine-pseudoephedrine
Pediatex-D
Carvedilol Coreg
Carvedilol phosphate Coreg CR
Celecoxib Celebrex
Cetirizine Zyrtec
Cetirizine-pseudoephedrine Zyrtec-D
Cevimeline Evoxac
Chlorhexidine gluconate Hibistat
Chloroquine Aralen
Chlorothiazide Diuril
Chlorothiazide sodium Diuril I.V.
Chlorpheniramine-hydrocodone-pseudoephedrine Tussend
Chlorpheniramine-phenylephrine Rynatan
Chlorpromazine Thorazine
Chlorpropamide Diabinese
Chlorthalidone Thalitone
Chlorthalidone-clonidine Clorpres
Cidofovir Vistide
Ciprofloxacin Cipro, Cipro XR
Citalopram Celexa
Clemastine Tavist
Clindamycin phosphate Clindagel
Clonidine-chlorthalidone Clorpres
Clozapine Clozaril, Fazzaclo
Coagulation Factor IX (recombinant) BeneFIX
Cromolyn sodium Gastrocrom
Cyclobenzaprine Flexeril
Cyproheptadine Periactin
Dacarbazine DTIC-Dome
Dantrolene Dantrium
Demeclocycline Declomycin
Desipramine Norpramin
Diclofenac potassium Cataflam
Diclofenac sodium Voltaren
Diclofenac sodium-misoprostol Arthrotec
Diflunisal Dolobid
Dihydroergotamine D.H.E. 45
Diltiazem Cardizem, Tiazac
Diphenhydramine Benadryl
Divalproex Depakote
Doxepin Sinequan
Doryx, Periostat,
Doxycycline hyclate
Vibramycin, Vibra-Tabs
Doxycycline monohydrate Monodox
Duloxetine Cymbalta
Efalizumab Raptiva
Enalapril Vasotec
Enalapril-felodipine Lexxel
Enalapril-hydrochlorothiazide Vaseretic
Enalaprilat (injection) Vasotec IV
Epirubicin Ellence
Eprosartan mesylate-hydrochlorothiazide Teveten HCT
Erythromycin-sulfisoxazole Pediazole
Escitalopram oxalate Lexapro
Esomeprazole Nexium
Estazolam ProSom
Estradiol Estrogel, Gynodiol
Eszopiclone Lunesta
Ethionamide Trecator-SC
Etodolac Lodine
Felbamate Felbatol
Fenofibrate Lofibra, Tricor, Triglide
Floxuridine Sterile FUDR
Flucytosine Ancobon
Fluorouracil Efudex
Fluoxetine Prozac, Sarafem
Fluoxetine-olanzapine Symbyax
Fluphenazine Prolixin
Flutamide Eulexin
Fluvastatin Lescol, Lescol XL
Fluvoxamine Luvox, Luvox CR
Fosinopril Monopril
Fosphenytoin Cerebyx
Furosemide Lasix
Gabapentin Neurontin
Gatifloxacin Tequin
Gemfibrozil Lopid
Gemifloxacin mesylate Factive
Gentamicin Garamycin
Glatiramer acetate Copaxone
Glimepiride Amaryl
Glimepiride-pioglitazone hydrochloride Duetact
Glimepiride-rosiglitazone maleate Avandaryl
Glipizide Glucotrol
Glyburide DiaBeta, Glynase, Micronase
Glyburide-metformin HCl Glucovance
Fulvicin P/G, Grifulvin,
Griseofulvin
Gris-PEG
Haloperidol Haldol
Hexachlorophene pHisoHex
Hydralazine-hydrochlorothiazide Hydra-Zide
HydroDIURIL, Microzide,
Hydrochlorothiazide
Oretic
Hydrochlorothiazide-fosinopril Monopril HCT
Hydrochlorothiazide-irbesartan Avalide
Hydrochlorothiazide-lisinopril Prinzide, Zestoretic
Hydrochlorothiazide—losartan potassium Hyzaar
Hydrochlorothiazide-methyldopa Aldoril
Hydrochlorothiazide-metoprolol tartrate Lopressor HCT
Hydrochlorothiazide-moexipril Uniretic
Hydrochlorothiazide-propranolol Inderide
Hydrochlorothiazide-quinapril Accuretic
Hydrochlorothiazide-spironolactone Aldactazide
Hydrochlorothiazide-telmisartan Micardis HCT
Hydrochlorothiazide-timolol Timolide
Hydrochlorothiazide-triamterene Dyazide, Maxide
Hydrochlorothiazide-valsartan Hydroflumethiazide Diovan HCT
Hydroxocobalamin Cyanokit Antidote
Hydroxychloroquine Plaquenil
Hypericum Kira, St. John's wort
One-A-Day Tension &
Hypericum-vitamin B1-vitamin C-kava-kava
Mood
Ibuprofen Motrin
Imatinib Mesylate Gleevec
Imipramine Tofranil
Imiquimod Aldara
Indapamide Lozol
Interferon alfa-2b, recombinant Intron A
Interferon alfa-n3 (human leukocyte derived) Alferon-N
Interferon beta-1a Avonex
Interferon beta-1b Betaseron
Irbesartan-hydrochlorothiazide Avalide
Isocarboxazid Marplan
Isoniazid-pyrazinamide-rifampin Rifater
Isotretinoin Accutane, Amnesteem
Itraconazole Sporanox
Ketoprofen Orudis, Oruvail
Lamotrigine Lamictal
Leuprolide acetate Lupron, Lupron Depot
Levamisole Levamisole
Levofloxacin Levaquin
Levofloxacin-5% dextrose Levaquin Injection
Lisinopril Prinivil, Zestril
Lisinopril-hydrochlorothiazide Prinzide, Zestoretic
Lomefloxacin Maxaquin
Loratadine Claritin
Loratadine-pseudoephedrine Claritin-D
Losartan Cozaar
Losartan-hydrochlorothiazide Hyzaar
Lovastatin Altoprev, Mevacor
Lovastatin-niacin Advicor
Maprotiline Ludiomil
Mefenamic acid Ponstel
Meloxicam Mobic
Mesalamine Pentasa
Methazolamide Glauctabs, Neptazane
Methotrexate Trexall
Methoxsalen 8-MOP, Oxsoralen, Uvadex
Methyclothiazide Enduron
Methyldopa-hydrochlorothiazide Aldoril
Metolazone Mykrox, Zaroxolyn
Metoprolol succinate Toprol-XL
Metoprolol tartrate Lopressor
Minocycline Dynacin, Minocin, Solodyn
Mirtazapine Remeron
Moexipril Univasc
Moexipril-hydrochlorothiazide Uniretic
Moxifloxacin Avelox
Nabilone Cesamet
Nabumetone Relafen
Nadolol-bendroflumethiazide Corzide
Nalidixic acid Neggram
Naproxen Naprosyn, EC-Naprosyn
Anaprox, Anaprox DS,
Naproxen sodium
Naprelan
Naratriptan Amerge
Nefazodone Serzone
Nifedipine Adalat CC, Procardia
Nisoldipine Sular
Norfloxacin Noroxin
Nortriptyline Pamelor
Ofloxacin Floxin
Olanzapine Zyprexa
Olanzapine-fluoxetine Symbyax
Olmesartan medoxomil-hydrochlorothiazide Benicar HCT
Olsalazine Dipentum
Omeprazole-sodium bicarbonate Zegerid
Oxaprozin Daypro
Oxcarbazepine Trileptal
Oxycodone Roxicodone
Oxytetracycline Terramycin
Panitumumab Vectibix
Pantoprazole Protonix
Paroxetine hydrochloride Paxil
Paroxetine mesylate Pexeva
Pastinaca sativa Parsnip
Pentosan polysulfate Elmiron
Pentostatin Nipent
Perphenazine Trilafon
Pilocarpine Salagen
Piroxicam Feldene
Polymyxin B sulfate-trimethoprim sulfate Polytrim
Polythiazide Renese
Polythiazide-prazosin Minizide
Porfimer sodium Photofrin
Pramipexole dihydrochloride Mirapex
Pravastatin Pravachol
Pregabalin Lyrica
Prochlorperazine Compazine, Compro
Promethazine Phenergan
Protriptyline Vivactil
Pyrazinamide Pyrazinamide
Pyrimethamine-sulfadoxine Fansidar
Quetiapine Seroquel
Quinapril Accupril
Quinapril-hydrochlorothiazide Accuretic
Quinidine gluconate Quinidine
Quinidine sulfate Quinidex
Rabeprazole sodium Aciphex
Ramipril Altace
Rasagiline mesylate Azilect
Riluzole Rilutek
Risperidone Risperdal, Risperdal Consta
Ritonavir Norvir
Rizatriptan Maxalt, Maxalt-MLT
Ropinirole Requip
Rosuvastatin Crestor
Ruta graveolens Rue
Saquinavir mesylate Invirase
Selegiline Eldepryl, Emsam
Sertraline Zoloft
Sibutramine Meridia
Sildenafil Viagra
Simvastatin Zocor
Simvastatin-ezetimibe Vytorin
Sirolimus Rapamune
Somatropin Serostim
Sotalol Betapace, Betapace AF
Sulfamethoxazole-trimethoprim Bactrim, Septra
Sulfasalazine Azulfidine
Sulfisoxazole acetyl Gantrisin Pediatric
Sulindac Clinoril
Sumatriptan Imitrex
Tacrolimus Prograf, Protopic
Tazarotene Tazorac
Telmisartan-hydrochlorothiazide Micardis HCT
Tetracycline Sumycin
Thalidomide Thalomid
Thioridazine hydrochloride Thioridazine HCI
Thiothixene Navane
Tiagabine Gabitril
Tigecycline Tygacil
Tolazamide Tolinase
Tolbutamide Orinase
Topiramate Topamax
Tretinoin Avita, Retin-A
Triamcinolone acetonide Azmacort Inhalation
Triamterene Dyrenium
Triamterene-hydrochlorothiazide Dyazide, Maxzide
Trifluoperazine Trifluoperazine
Trimipramine Surmontil
Trovafloxacin Trovan
Valacyclovir Valtrex
Valdecoxib Bextra
Valproate Depacon
Valproic acid Depakene
Valsartan-hydrochlorothiazide Diovan HCT
Vardenafil Levitra
Varenicline tartrate Chantix
Venlafaxine Effexor, Effexor XR
Verteporfin Visudyne
Vinblastine Velban
Voriconazole Vfend
Zalcitabine Hivid
Zaleplon Sonata
Ziprasidone Geodon
Zolmitriptan Zomig
Zolpidem Ambien, Ambien CR
Reference
Appendix H: Drug Information Resources by Category
General Drug Information
AHFS Drug Information (www.ahfsdruginformation.com)
Drug Information Handbook
Facts & Comparisons (www.factsandcomparisons.com)
Lexi-Comp Online (http://online.lexi.com)
Micromedex DRUGDEX (www.micromedex.com/products/drugdex/)
Physicians' Desk Reference
UpToDate (www.uptodateonline.com/online)
Adverse Drug Reactions and Specific Uses
Clinical Alerts (www.nlm.nih.gov/databases/alerts/clinical_alerts.html)
Davies's Textbook of Adverse Drug Reactions
Institute for Safe Medication Practices (www.ismp.org)
Meyler's Side Effects of Drugs
Side Effects of Drugs Annual
U.S. Food and Drug Administration (FDA) MedWatch Program

(www.fda.gov/medwatch/safety.htm)
Vaccine Adverse Event Reporting System (http://vaers.hhs.gov/professionals/index)
Chemical and Physical Properties
CRC Handbook of Chemistry and Physics Merck Index
Remington: The Science and Practice of Pharmacy
Textbook of Organic, Medicinal, and Pharmaceutical Chemistry
United States Pharmacopeia-National Formulary USP Dictionary

Compounding
Allen's Compounded Formulations
Handbook on Extemporaneous Formulations
International Academy of Compounding Pharmacists (www.iacprx.org)
Trissel's Stability of Compounded Formulations
Drug Interactions
Drug Interaction Facts
Evaluation of Drug Interactions
Hansten and Horn's Drug Interactions Analysis and Management
Lexi-Comp Online (http://online.lexi.com)
Liverpool HIV Pharmacology Group (www.hiv-druginteractions.org)
Micromedex DRUG-REAX (www.micromedex.com/products/drugreax/)
Foreign Drugs
British National Formulary (www.bnf.org/bnf/)
The British Pharmacopoeia (www.pharmacopoeia.co.uk/)
Drug Facts and Comparisons (Canadian Trade Name Index)
electronics Medicines Compendium (eMC) (www.medicines.org.uk)
Martindale: The Complete Drug Reference
Micromedex Index Nominum (www.micromedex.com/products/indexnominum/)
Royal Pharmaceutical Society of Great Britain (www.rpsgb.org.uk)
Immunology
Center for Biologics Evaluation and Research
(http://www.fda.gov/BiologicsBloodVaccines/default.htm)
Centers for Disease Control and Prevention (CDC) (www.cdc.gov/vaccines/)
Concepts in Immunology and Immunotherapeutics
Immunization Action Coalition (www.immunize.org)
ImmunoFacts (www.immunofacts.com)
U.S. Department of Health and Human Services (www.hrsa.gov/vaccinecompensation/)
Infectious Disease
Mandell, Douglas, and Bennett's Principles and Practice of Infectious Disease
Sanford Guide to Antimicrobial Therapy
Intravenous Compatibility and Stability
Guide to Parenteral Admixtures
Handbook on Injectable Drugs (Trissel's)
Micromedex IV Index (www.micromedex.com/products/ivindex/) (Trissel's)
Trissel's Tables of Physical Compatibility
King Guide to Parenteral Admixtures
Investigational Drugs
CenterWatch (www.centerwatch.com/patient/trials.html)
ImmunoFacts (www.immunofacts.com)
Inteleos (www.inteleos.com)
National Institutes of Health Clinical Trials Database (www.clinicaltrials.gov)
Pharmaceutical Research and Manufacturers of America (www.phrma.org)

Laboratory Tests
Basic Skills in Interpreting Laboratory Data
Clinical Guide to Laboratory Tests
Laboratory Tests and Diagnostic Procedures
Laboratory Test Handbook
Legal and Regulatory Issues
Code of Federal Regulations (Title 21)

(www.accessdata.fda.gov/SCRIPTs/cdrh/cfdocs/cfcfr/CFRSearch.cfm)
Guide to Federal Pharmacy Law
Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org)
National Association of Boards of Pharmacy (www.nabp.net)
Pharmacy Law Digest
United States Pharmacopeia-National Formulary
U.S. Drug Enforcement Administration (www.usdoj.gov/dea/)
U.S. Food and Drug Administration (www.fda.gov)
USP DI Volume III: Approved Drug Products and Legal Requirements
World Health Organization (www.who.int/en/)
Literature Search Databases
EMBASE (www.embase.com)
CINAHL (www.ebscohost.com/cinahl/)
IDIS (http://itsnt14.its.uiowa.edu/)
IPA (http://library.dialog.com/bluesheets/html/bl0074.html)
MEDLINE/PubMed (www.ncbi.nlm.nih.gov/pubmed/)
Ovid (www.ovid.com)
PsycINFO (www.apa.org/psycinfo/)
Manufacturer Information
American Drug Index
Drug Topics Red Book
Inteleos (www.inteleos.com)
Manufacturer Web sites (various)
Martindale: The Complete Drug Reference
Micromedex (www.micromedex.com/products/hcs/)
Mosby's GenRX
Physicians' Desk Reference
New Drug Approvals
CenterWatch (www.centerwatch.com/drug-information/)
Drugs@FDA (www.accessdata.fda.gov/scripts/cder/drugsatfda)
Medical Letter (www.medicalletter.org)
Pharmacist's Letter (www.pharmacistsletter.com)
The Pink Sheet (www.thepinksheet.com)
U.S. Food and Drug Administration (www.fda.gov)
Nonpharmacologic Use
Handbook of Nonprescription Drugs
Herbs of Choice
National Center for Alternative and Complementary Medicine (http://nccam.nih.gov)

National Institutes of Health Office of Dietary Supplements (http://dietary-
supplements.info.nih.gov)
Natural Medicines Comprehensive Database (http://www.naturaldatabase.com)
PDR for Nonprescription Drugs and Dietary Supplements
The Review of Natural Products
The Complete German Commission E Monographs
U.S. Food and Drug Administration Center for Food Safety and Applied Nutrition's Dietary
Supplements (www.fda.gov/Food/DietarySupplements/default.htm)
Patient Counseling
MD Consult (www.mdconsult.com)
Medication Teaching Manual (American Society of Health-System Pharmacists)
Micromedex CareNotes (www.micromedex.com/products/carenotes/)
Professional's Guide to Patient Drug Facts
UpToDate (www.uptodateonline.com/online)
Pharmacokinetics
Applied Pharmacokinetics
Clinical Pharmacokinetics
Pharmacology
Basic Concepts and Clinical Applications
Goodman and Gilman's The Pharmacological Basic of Therapeutics
Melmon and Morrelli's Clinical Pharmacology
Principles of Pharmacology
Textbook of Pharmacology
Poisoning and Toxicology
Clinical Management of Poisoning and Drug Overdose
Clinical Toxicology of Drugs
Goldfrank's Toxicologic Emergencies
Handbook of Poisoning
Micromedex POISINDEX (www.micromedex.com/products/poisindex/)
Physical and Theoretical Chemistry Laboratory Oxford University

(http://physchem.ox.ac.uk/MSDS/)
Poisoning and Toxicology Compendium
Principles of Clinical Toxicology
ToxNet (http://toxnet.nlm.nih.gov/)
U.S. Environmental Protection Agency Integrated Risk Information System

(http://www.epa.gov/iris/)
Pregnancy and Lactation
Breastfeeding: A Guide for the Medical Profession
Drugs in Pregnancy and Lactation
Drugs in Pregnancy and Breastfeeding (www.perinatology.com/exposures/druglist.htm)
Micromedex REPRORISK (www.micromedex.com/products/reprorisk/)
Product Identification
American Drug Index
Drug Information Online (http://www.drugs.com/imprints.php)
Drug Topics Red Book
Ident-A-Drug (http://identadrug.com)
Micromedex IDENTIDEX (www.micromedex.com/products/identidex/)
RxList (www.rxlist.com)
Renal Dose Adjustments
Drug Prescribing in Renal Failure
GlobalRPh.com (www.globalrph.com/renaldosing.htm)
Handbook of Dialysis
Shortage Information
ASHP Drug Shortage Center (www.ashp.org/shortages)
Drug wholesaler Web sites (various)
FDA Drug Shortage Resource Center (www.fda.gov/cder/drug/shortages/)
Specific Patient Population: Geriatric
Drug Therapy in the Elderly
Geriatric Dosage Handbook
Therapeutics in the Elderly
Specific Patient Population: Pediatric
The Harriet Lane Handbook
Lexi-Comp's Pediatric Dosage Handbook
Micromedex NeoFax (www.micromedex.com/products/neofax/)
Nelson Textbook of Pediatrics
Principles and Practice of Pediatrics
Teddy Bear Book: Pediatric Injectable Drugs
Therapeutics and Drug Therapy

Applied Therapeutics: The Clinical Use of Drugs Cecil Textbook of Medicine
Harrison's Principles of Internal Medicine
Medical Letter (www.medicalletter.org)
Merck Manual of Diagnosis and Therapy (http://www.merck.com/mmpe/)
Pharmacist's Letter (www.pharmacistsletter.com)
Pharmacotherapy: A Pathophysiologic Approach
Textbook of Therapeutics: Drug and Disease Management
The Washington Manual of Medical Therapeutics

Appendix I: Drugs That Should Not Be Crushed
The following list includes both various slow-release and enteric-coated products that should not be
crushed or chewed. Slow-release (SR) products are controlled-release, extended-release, long-
acting, or timed-release products. Enteric-coated (EC) products are delayed-release products. In
general, capsules containing SR or EC particles may be opened and their contents administered on a
spoonful of soft food. However, instruct patients not to chew the particles. (Patients should, in fact,
be discouraged from chewing any medication unless it is specifically formulated for that purpose.)
The list should not be considered all inclusive. Generic and alternate brands of some products may
exist. Tablets intended for sublingual or buccal administration (not included in this list) should also
be administered only as intended, in an intact form.
Drug Manufacturer Form

Abletex LA Able SR
Aciphex Eisai EC
Adalat CC Schering-Plough SR
Adderall XR Shire US SR
Advicor KOS SR
Aerohist Aero SR
Aerohist Plus Aero SR
Afeditab CR Watson SR
Aggrenox Boehringer Ingelheim SR
Ala-Hist Poly SR
Ala-Hist D Poly SR
Aleve Cold & Sinus Bayer HealthCare SR
Aleve Sinus & Headache Bayer HealthCare SR
Allegra-D 12 Hour Sanofi-Aventis SR
Allegra-D 24 Hour Sanofi-Aventis SR
Allerx Cornerstone SR
Allerx-D Cornerstone SR
Allfen MCR American SR
Allfen-DM MCR American SR
Alophen Numark EC
Altoprev First Horizon SR
Ambi 45/800 Ambi SR
Ambi 45/800/30 Ambi SR
Ambi 60/580 Ambi SR
Ambi 80/700 Ambi SR
Ambi 1000/55 Ambi SR
Ambien CR Sanofi-Aventis SR
Ambifed-G Ambi SR
Ambifed-G DM Ambi SR
Amdry-C Prasco SR
Amdry-D Prasco SR
Amibid LA Amide SR
Amrix ECR SR
Anextuss Cypress SR
Anti-tussive Qualitest SR
Aplenzin Biovail SR
Aquabid-DM Alphagen SR
Aquatab C Adams SR
Aquatab D Adams SR
Aquatab DM Adams SR
Arthrotec Pharmacia EC
Asacol Procter & Gamble EC
Ascocid-500-D Key SR
Ascocid-1000 Key SR
Ascriptin Enteric Novartis Consumer EC
Atrohist Pediatric Celltech SR
Augmentin XR GlaxoSmithKline SR
Avinza Ligand SR
Azulfidine Entabs Pharmacia EC
Bayer Aspirin Regimen Bayer HealthCare EC
Biaxin XL Abbott SR
Bidex-A SJ SR
Bidhist Cypress SR
Bidhist-D Cypress SR
Bisac-Evac G&W EC
Biscolax Global Source EC
Blanex-A Blansett SR
Bontril Slow-Release Valeant SR
Bromfed Victory SR
Bromfed-PD Victory SR
Bromfenex Ethex SR
Bromfenex PD Ethex SR
Bromfenex PE Ethex SR
Bromfenex PE Pediatric Ethex SR
Budeprion SR Teva SR
Budeprion XL Teva SR
Buproban Teva SR
Calan SR Pharmacia SR
Campral Forest EC
Carbatrol Shire US SR
Cardene SR Roche SR
Cardizem CD Biovail SR
Cardizem LA Kos SR
Cardura XL Pfizer SR
Carox Plus Seneca SR
Cartia XT Andrx SR
Cemill 500 Miller SR
Cemill 1000 Miller SR
Certuss-D Capellon SR
Cevi-Bid Lee SR
Chlorex-A Cypress SR
Chlor-Phen Truxton SR
Chlor-Trimeton Allergy Schering-Plough SR
Chlor-Trimeton Allergy Decongestant Schering-Plough SR
Cipro XR Schering-Plough SR
Claritin-D Schering-Plough SR
Claritin-D 12 Hour Schering-Plough SR
Claritin-D 24 Hour Schering-Plough SR
Coldamine Breckenridge SR
Coldex-A United Research SR
Concerta McNeil Consumer SR
Contac 12-Hour GlaxoSmithKline SR
Coreg CR GlaxoSmithKline SR
Correctol Schering-Plough EC
Cotazym-S Organon EC
Covera-HS Pfizer SR
CPM 8/PE 20/MSC 1.25 Cypress SR
CPM 12 Brighton SR
Creon 5 Solvay EC
Creon 10 Solvay EC
Creon 20 Solvay EC
Cymbalta Eli Lilly EC
Dairycare Plainview EC
Dallergy Laser SR
Dallergy-JR Laser SR
Deconamine SR Kenwood Therapeutics SR
Deconex Poly SR
Deconex DM Poly SR
Deconsal II Cornerstone SR
Depakote Abbott EC
Depakote ER Abbott SR
Depakote Sprinkles Abbott EC
Despec SR International Ethical SR
Detrol LA Pharmacia SR
Dexedrine Spansules GlaxoSmithKline SR
D-Feda II WE Pharmaceuticals SR
D-Hist D Midlothian SR
Diabetes Trio Mason Vitamins SR
Diamox Sequels Duramed SR
Dilacor XR Watson SR
Dilantin Pfizer SR
Dilantin Kapseals Pfizer SR
Dilatrate-SR Schwarz Pharma SR
Diltia XT Andrx SR
Dilt-CD Apotex SR
Dilt-XR Apotex SR
Dimetane Extentabs Wyeth SR
Disophrol Chronotab Schering-Plough SR
Ditropan XL Ortho-McNeil SR
Donnatal Extentabs PBM SR
Doryx Warner Chilcott EC
D-Phen 1000 Midlothian SR
Drexophed SR Qualitest SR
Drihist SR Prasco SR
Drixoral Schering-Plough SR
Drixoral Plus Schering-Plough SR
Drixoral Sinus Schering-Plough SR
Drize-R Monarch SR
Drysec AG Marin SR
D-Tab Palm SR
Dulcolax Boehringer Ingelheim EC
Duomax Capellon SR
Durahist Proethic SR
Durahist D Proethic SR
Durahist PE Proethic SR
Duratuss Victory SR
Duratuss CS Victory SR
Duratuss DA Victory SR
Duratuss GP Victory SR
Dynacirc CR Reliant SR
Dynahist-ER Pediatric Breckenridge SR
Dynex LA Athlon SR
Dynex VR Athlon SR
Dytan-CS Hawthorn SR
Easprin Harvest EC
EC Naprosyn Roche EC
Ecotrin GlaxoSmithKline EC
Ecotrin Adult Low Strength GlaxoSmithKline EC
Ecotrin Maximum Strength GlaxoSmithKline EC
Ecpirin Prime Marketing EC
Ed A-Hist Edwards SR
Effexor-XR Wyeth SR
Efidac 24 Chlorpheniramine Novartis Consumer SR
Efidac 24 Pseudoephedrine Novartis Consumer SR
Enablex Novartis SR
Endal Pediamed SR
Entab-DM Rising SR
Entercote Global Source EC
Entex LA Andrx SR
Entex PSE Andrx SR
Entocort EC Prometheus EC
Equetro Shire US SR
ERCY Warner Chilcott SR
Ery-Tab Abbott EC
Eskalith-CR GlaxoSmithKline SR
Execof Larken SR
Exefen-DM Larken SR
Exefen-DMX Larken SR
Exefen-PD Larken SR
ExeTuss-DM Larken SR
Extendryl G Fleming SR
Extendryl JR Fleming SR
Extendryl SR Fleming SR
Extress-30 Key SR
Extress-60 Key SR
Feen-a-mint Schering-Plough EC
Femilax G&W EC
Fero-Folic-500 Abbott SR
Fero-Grad-500 Abbott SR
Ferro-Sequels Inverness Medical SR
Ferrous Fumarate DS Vita-Rx SR
Fetrin Lunsco SR
Flagyl ER Pharmacia SR
Fleet Bisacodyl C.B. Fleet EC
Focalin XR Novartis SR
Folitab 500 Rising SR
Fortamet First Horizon SR
Fumatinic Laser SR
Genacote Wax EC
GFN 500/DM 30 Cypress SR
GFN 550/PSE 60 Cypress SR
GFN 550/PSE 60/DM 30 Cypress SR
GFN 600/Phenylephrine 20 Cypress SR
GFN 1200/DM 60/PSE 60 Cypress SR
GFN 1200/Phenylephrine 40 Cypress SR
Gilphex TR Gil SR
Giltuss TR Gil SR
Glucophage XR Bristol-Myers Squibb SR
Glucotrol XL Pfizer SR
Glumetza Depomed SR
G/P 1200/75 Cypress SR
Guaifenex DM Ethex SR
Guaifenex GP Ethex SR
Guaifenex PSE 60 Ethex SR
H 9600 SR Hawthorn SR
Halfprin Kramer EC
Hemax Pronova SR
Histacol LA Breckenridge SR
Hista-Vent DA Ethex SR
Hista-Vent PSE Ethex SR
Humavent LA WE Pharmaceuticals SR
Humibid Adams SR
Humibid DM Carolina SR
Humibid LA Carolina SR
Iberet-500 Abbott SR
Iberet-Folic-500 Abbott SR
Icar-C Plus SR Hawthorn SR
Imdur Schering-Plough SR
Inderal LA Wyeth SR
Indocin SR Forte Pharma SR
Innopran XL Reliant SR
Invega Janssen SR
Isochron Forest SR
Isopro Rugby SR
Isoptin SR FSC SR
Kadian Alphagen SR
Kaon-Cl 10 Savage SR
Keppra XR UCB SR
Klor-Con 8 Upsher-Smith SR
Klor-Con 10 Upsher-Smith SR
Klor-Con M10 Upsher-Smith SR
Klotrix Bristol-Myers Squibb SR
K-Tab Abbott SR
K-Tan Prasco SR
Lescol XL Novartis SR
Levall G Athlon SR
Levbid Alaven SR
Levsinex Schwarz Pharma SR
Lexxel AstraZeneca SR
Lialda Shire EC
Lipram 4500 Global EC
Lipram-PN10 Global EC
Liquibid-D Capellon SR
Liquibid-D 1200 Capellon SR
Liquibid-PD Capellon SR
Lithobid Capellon SR
Lodrane 12 hour ECR SR
Lodrane 12D ECR SR
Lodrane 24 ECR SR
Lodrane 24D ECR SR
Lohist-12 Larken SR
Lohist-12D Larken SR
Lusonex Wraser SR
Luvox CR Jazz Pharmaceuticals SR
Mag Delay Major EC
Mag64 Rising EC
Mag-SR Plus Calcium Cypress SR
Mag-Tab SR Niche SR
Maxifed MCR American SR
Maxifed DM MCR American SR
Maxifed DMX MCR American SR
Maxifed G MCR American SR
Maxiphen DM Ambi SR
Medent DM SJ SR
Medent PE SJ SR
Mega-C Merit SR
Melfiat Numark SR
Menopause Trio Mason Vitamins SR
Mestinon Timespan Valeant SR
Metadate CD Celltech SR
Metadate ER Celltech SR
Methylin ER Mallinckrodt SR
Micro-K Ther-Rx SR
Micro-K 10 Ther-Rx SR
Mild-C Carlson SR
Mindal DM Breckenridge SR
Montephen Monte Sano SR
MS Contin Purdue SR
Mucinex Adams SR
Mucinex D Adams SR
Mucinex DM Adams SR
Multi-Ferrous Folic United Research SR
Multiret Folic-500 Amide SR
Mydex Larken SR
Mydocs Centurion SSR
Myfortic Novartis EC
Nacon Cypress SR
Nalex-A Blansett SR
Naprelan Blansett SR
Nasatab LA ECR SR
New Ami-Tex LA Amide SR
Nexium AstraZeneca EC
Niaspan Kos SR
Nicomide Sirius SR
Nifediac CC Teva SR
Nifedical XL Teva SR
Nitrocot Truxton SR
Nitro-Time Time-Cap SR
Nohist Larken SR
Nohist-Plus Larken SR
Nohist-Plus JR Larken SR
Norel SR U.S. Pharmaceuticals SR
Norpace CR Pharmacia SR
Obstetrix EC Seyer Pharmatec EC
Omnihist LA WE Pharmaceuticals SR
Opana ER Endo SR
Oramorph SR AAI Pharma SR
Oracea Collagenex SR
Oruvail Wyeth SR
Oxycontin Purdue SR
Palcaps 10 Breckenridge EC
Palcaps 20 Breckenridge EC
Pancrease McNeil Consumer EC
Pancrease MT 10 McNeil Consumer EC
Pancrecarb MS-4 Digestive Care EC
Pancrelipase 4500 Mutual EC
Pangestyme CN 10 Ethex EC
Pangestyme CN 20 Ethex EC
Pangestyme EC Ethex EC
Pangestyme MT 16 Ethex EC
Pangestyme UL 12 Ethex EC
PanMist DM Pamlab SR
PanMist JR Pamlab SR
PanMist LA Pamlab SR
Panocaps Breckenridge EC
Panocaps MT 16 Breckenridge EC
Panocaps MT 20 Breckenridge EC
Papacon Consolidated Midland SR
Para-Time SR Time-Cap SR
Paser Jacobus SR
Pavacot Truxton SR
Paxil CR GlaxoSmithKline SR
PCE Dispertab Abbott SR
PCM LA Cypress SR
Pendex Cypress SR
Pentasa Shire US SR
Pentopak Zoetica SR
Pentoxil Upsher-Smith SR
Phenabid Gil SR
Phenabid DM Gil SR
Phenavent Ethex SR
Phenavent D Ethex SR
Phenavent LA Ethex SR
Phenavent PED Ethex SR
Phendiet-105 Truxton SR
Phenytek Mylan Bertek SR
Phlemex-PE Cypress SR
Plendil AstraZeneca SR
Poly Hist Forte Poly SR
Poly-Vent Poly SR
Poly-Vent Jr Poly SR
Prehist D Marnel SR
Prevacid Tap EC
Prilosec AstraZeneca EC
Prilosec OTC Procter & Gamble SR
Pristiq Wyeth SR
Procanbid Monarch SR
Procardia XL Pfizer SR
Prolex PD Blansett SR
Prolex D Blansett SR
Pronestyl-SR Bristol-Myers Squibb SR
Proquin XR Esprit SR
Prosed EC Star EC
Proset-D Blansett SR
Protid Lunsco SR
Protonix Wyeth EC
Prozac Weekly Eli Lilly EC
Pseubrom Alphagen SR
Pseubrom-PD Alphagen SR
Pseudocot-C Truxton SR
Pseudocot-G Truxton SR
Pseudovent Ethex SR
Pseudovent 400 Ethex SR
Pseudovent DM Ethex SR
Pseudovent PED Ethex SR
Quibron-T/SR Monarch SR
Quindal Qualitest SR
Ralix Cypress SR
Ranexa CV Therapeutics SR
Razadyne ER Ortho-McNeil SR
Reliable Gentle Laxative Ivex EC
Requip XL GlaxoSmithKline SR
Rescon-Jr Capellon SR
Rescon-MX Capellon SR
Respa-1st Respa SR
Respa-AR Respa SR
Respa-BR Respa SR
Respa-DM Respa SR
Respa-PE Respa SR
Respahist Respa SR
Respahist-II Respa SR
Respaire-60 SR Laser SR
Respaire-120 SR Laser SR
Rhinacon A Breckenridge SR
Risperdal Consta Janssen SR
Ritalin LA Novartis SR
Ritalin-SR Novartis SR
Rodex Forte Legere SR
Rondec-TR Biovail SR
Ru-Tuss Carwin SR
Ryneze Stewart-Jackson SR
Rythmol SR Reliant SR
SAM-e Pharmavite EC
Sanctura XR Allergen SR
Scopohist-PE Larken SR
Seroquel XR AstraZeneca SR
Simcor Abbott SR
Simuc-GP Cypress SR
Sinemet CR Bristol-Myers Squibb SR
Sinutuss DM WE Pharmaceuticals SR
Sinuvent PE WE Pharmaceuticals SR
Slo-Niacin Upsher-Smith SR
Slow Fe Novartis Consumer SR
Slow Fe with Folic Acid Novartis Consumer SR
Slow-Mag Purdue EC
Solodyn Medicis SR
Stahist Magna SR
St. Joseph Pain Reliever McNeil Consumer EC
Sudafed 12 Hour Pfizer SR
Sudafed 24 Hour Pfizer SR
Sudahist Larken SR
Sudal DM Atley SR
Sudal SR Atley SR
Sudatex-DM Larken SR
Sudatex-G Larken SR
Sudatrate Larken SR
Sudex Tab Atley SR
Sular First Horizon SR
Sulfazine EC Qualitest EC
Symax Duotab Capellon SR
Symax-SR Capellon SR
Tarka Abbott SR
Taztia XT Andrx SR
Tegretol-XR Novartis SR
Tenuate Dospan Sanofi-Aventis SR
Theo-24 UCB SR
Theochron Forest SR
Theo-Time Major SR
Tiazac Forest SR
Time-Hist MCR American SR
Toprol XL AstraZeneca SR
Totalday National Vitamin SR
Touro Allergy Dartmouth SR
Touro CC Dartmouth SR
Touro CC-LD Dartmouth SR
Touro DM Dartmouth SR
Touro HC Dartmouth SR
Touro LA Dartmouth SR
Touro LA-LD Dartmouth SR
Tranxene-SD Ovation SR
Trental Sanofi-Aventis SR
Trikof-D Respa SR
Trinalin Repetabs Schering-Plough SR
Trituss-ER Everett SR
Tussafed-LA Everett SR
Tussall-ER Everett SR
Tussi-Bid Capellon SR
Tussicaps Mallinckrodt SR
Tusso-DM Everett SR
Tusso-HC Everett SR
Tylenol Arthritis McNeil Consumer SR
Ultrabrom WE Pharmaceuticals SR
Ultrabrom PD WE Pharmaceuticals SR
Ultracaps MT 20 Breckenridge EC
Ultram ER Ortho-McNeil SR
Ultrase Axcan Scandipharm EC
Ultrase MT12 Axcan Scandipharm EC
Uniphyl Purdue SR
Uni-Tex United Research SR
Urimax Xanodyne EC
Uritact-EC Cypress EC
Urocit-K 5 Mission SR
Urocit-K 10 Mission SR
Uroxatral Sanofi-Aventis SR
Utira Hawthorn SR
Veracolate Numark EC
Verelan Schwarz Pharma SR
Verelan PM Schwarz Pharma SR
Videx EC Bristol-Myers Squibb EC
Vivitrol Cephalon SR
Vivotif Berne Berne Products EC
Voltaren Novartis EC
Voltaren-XR Novartis SR
Vospire Dava SR
Vospire ER Dava SR
We Mist LA WE Pharmaceuticals SR
We Mist II LA WE Pharmaceuticals SR
Wellbid-D Prasco SR
Wellbid-D 1200 Prasco SR
Wellbutrin SR GlaxoSmithKline SR
Wellbutrin XL GlaxoSmithKline SR
Wobenzym N Marlyn EC
Woman's Wellbeing Menopause Relief Consumer Choice SR
Xanax XR Pharmacia SR
Xedec II Cypress SR
Xiral Hawthorn SR
Xpect-AT Hawthorn SR
Xpect-HC Hawthorn SR
Xpect-PE Hawthorn SR
Zephrex LA Sanofi-Aventis SR
Zmax Pfizer SR
Zorprin Par SR
Zotex-12D Vertical SR
Zyban GlaxoSmithKline SR
Zyflo CR Critical Therapeutics SR
Zymase Organon EC
Zyrtec-D Pfizer SR
Reference
Appendix J: Use-in-Pregnancy Ratings
Introduction
The U.S. Food and Drug Administration's Use-in-Pregnancy rating system weighs the degree to
which available information has ruled out risk to the fetus against the drug's potential benefit to the
patient. The following is a list of drugs (by generic name) for which ratings are available.
X: Contraindication In Pregnancy
Studies in animals or humans or investigational or postmarketing reports have demonstrated fetal

risk, which clearly outweighs any possible benefit to the patient.
Acetohydroxamic acid
Acitretin
Ambrisentan
Amlodipine besylate-atorvastatin calcium
Anisindione
Atorvastatin calcium
Bexarotene
Bicalutamide
Bosentan
Cetrorelix acetate
Clomiphene citrate
Desogestrel-ethinyl estradiol
Diclofenac sodium-misoprostol
Dihydroergotamine mesylate
Dutasteride
Estazolam
Estradiol
Estradiol acetate
Estradiol cypionate-medroxyprogesterone acetate
Estradiol-levonorgestrel
Estradiol-norethindrone acetate
Estradiol valerate
Estrogens (conjugated)
Estrogens (conjugated)-medroxyprogesterone acetate
Estrogens (conjugated, synthetic A)
Estrogens (esterified)
Estrogens (esterified)-methyltestosterone
Estropipate
Ethinyl estradiol-drospirenone
Ethinyl estradiol-ethynodiol diacetate
Ethinyl estradiol-etonogestrel
Ethinyl estradiol-ferrous fumarate-norethindrone acetate
Ethinyl estradiol-levonorgestrel
Ethinyl estradiol-norelgestromin
Ethinyl estradiol-norethindrone
Ethinyl estradiol-norethindrone acetate
Ethinyl estradiol-norgestimate
Ethinyl estradiol-norgestrel
Ezetimibe-simvastatin
Finasteride
Fluorouracil
Fluoxymesterone
Flurazepam hydrochloride
Fluvastatin sodium
Follitropin alfa
Follitropin beta
Ganirelix acetate
Goserelin acetate
Histrelin acetate
Hydromorphone hydrochloride
Interferon alfa-2B (recombinant)-ribavirin
Iodine I 131 tositumomab-tositumomab
Isotretinoin
Leflunomide
Leuprolide acetate
Levonorgestrel
Lovastatin
Lovastatin-niacin
Medroxyprogesterone acetate
Megestrol acetate
Menotropins
Mequinol-tretinoin
Mestranol-norethindrone
Methotrexate sodium
Methyltestosterone
Miglustat
Misoprostol
Nafarelin acetate
Niacin-simvastatin
Norethindrone
Norethindrone acetate
Norgestrel
Oxandrolone
Oxymetholone
Plicamycin
Pravastatin sodium
Pravastatin sodium-aspirin (buffered)
Raloxifene hydrochloride
Ribavirin
Rosuvastatin calcium
Simvastatin
Tazarotene
Testosterone
Testosterone enanthate
Thalidomide
Tositumomab
Triptorelin pamoate
Warfarin sodium
D: Positive Evidence of Risk
Investigational or postmarketing data show risk to the fetus. Nevertheless, potential benefits may
outweigh the potential risk.
Aliskiren*
Aliskiren-hydrochlorothiazide
Alitretinoin
Alprazolam
Altretamine
Amiodarone hydrochloride
Amlodipine besylate-benazepril hydrochloride
Amlodipine besylate-olmesartan medoxomil
Amlodipine besylate-valsartan*
Anastrozole
Arsenic trioxide
Aspirin (buffered)-pravastatin sodium
Aspirin-dipyridamole
Atenolol
Azacitidine
Azathioprine
Azathioprine sodium
Benazepril hydrochloride*
Benazepril hydrochloride-hydrochlorothiazide*
Bendamustine hydrochloride
Bortezomib
Busulfan
Candesartan cilexetil*
Candesartan cilexetil-hydrochlorothiazide*
Capecitabine
Captopril*
Carbamazepine
Carboplatin
Carmustine (BiCNU)
Chlorambucil
Cladribine
Clofarabine
Clonazepam
Cytarabine liposome
Dactinomycin
Dasatinib
Daunorubicin citrate liposome
Daunorubicin hydrochloride
Demeclocycline hydrochloride
Dexrazoxane
Dexrazoxane hydrochloride
Diazepam
Divalproex sodium
Docetaxel
Doxorubicin hydrochloride
Doxorubicin hydrochloride liposome
Doxycycline
Doxycycline calcium
Doxycycline hyclate
Doxycycline monohydrate
Efavirenz
Enalapril maleate*
Enalapril maleate-hydrochlorothiazide*
Epirubicin hydrochloride
Eprosartan mesylate
Erlotinib
Exemestane
Floxuridine
Fludarabine phosphate
Flutamide
Fosinopril sodium*
Fosinopril sodium-hydrochlorothiazide*
Fosphenytoin sodium
Fulvestrant
Gefitinib
Gemcitabine hydrochloride
Gemtuzumab ozogamicin
Genistein-zinc chelazome-cholecalciferol
Goserelin acetate
Ibritumomab tiuxetan
Idarubicin hydrochloride
Ifosfamide
Imatinib mesylate
Irbesartan*
Irbesartan-hydrochlorothiazide*
Irinotecan hydrochloride
Ixabepilone
Letrozole
Lisinopril*
Lisinopril-hydrochlorothiazide*
Lithium carbonate
Losartan potassium*
Losartan potassium-hydrochlorothiazide*
Mechlorethamine hydrochloride
Melphalan
Melphalan hydrochloride
Mephobarbital
Mercaptopurine
Methimazole
Midazolam hydrochloride
Minocycline hydrochloride
Mitoxantrone hydrochloride
Moexipril hydrochloride*
Moexipril hydrochloride-hydrochlorothiazide*
Mycophenolic acid
Nelarabine
*Category C or D depending on the trimester the drug is given.
Neomycin sulfate-polymyxin B sulfate
Nicotine
Nilotinib
Nilotinib hydrochloride monohydrate
Olmesartan medoxomil
Oxaliplatin
Pamidronate disodium
Paroxetine hydrochloride
Paroxetine mesylate
Pemetrexed
Penicillamine
Pentobarbital sodium
Pentostatin
Perindopril erbumine*
Phenytoin
Procarbazine hydrochloride
Quinapril hydrochloride*
Quinapril hydrochloride-hydrochlorothiazide*
Ramipril*
Sorafenib
Streptomycin sulfate
Sunitinib
Tamoxifen citrate
Telmisartan
Telmisartan-hydrochlorothiazide
Temozolomide
Temsirolimus
Thioguanine
Tigecycline
Tobramycin
Topotecan hydrochloride
Toremifene citrate
Trandolapril*
Trandolapril-verapamil hydrochloride*
Tretinoin
Valproate sodium
Valproic acid
Valsartan*
Valsartan-hydrochlorothiazide*
Vinorelbine tartrate
Voriconazole
Zoledronic acid
C: Risk Cannot Be Ruled Out
Human studies are lacking, and animal studies are either positive for risk or lacking as well.
However, potential benefits may outweigh the potential risk.
Abacavir sulfate
Abacavir sulfate-lamivudine
Abacavir sulfate-lamivudine-zidovudine
Abciximab
Acamprosate calcium
Acetaminophen
Acetaminophen-butalbital-caffeine
Acetaminophen-caffeine-chlorpheniramine maleate-hydrocodone bitartrate-phenylephrine

hydrochloride
Acetazolamide
Acetazolamide sodium
Acyclovir
Adapalene
Adefovir dipivoxil
Adenosine
Alatrofloxacin mesylate
Albendazole
Albumin (human)
Albuterol
Albuterol sulfate
Albuterol sulfate-ipratropium bromide
Alclometasone dipropionate
Aldesleukin
Alemtuzumab
Alendronate sodium
Alendronate sodium-cholecalciferol
Aliskiren*
Allopurinol sodium
Almotriptan malate
Alpha1-proteinase inhibitor (human)
Alprostadil
Alteplase
Amantadine hydrochloride
Amifostine
Aminocaproic acid
Aminohippurate sodium
Aminolevulinic acid hydrochloride
Aminosalicylic acid
Amlodipine besylate
Amlodipine besylate-benazepril hydrochloride
Amlodipine besylate-olmesartan medoxomil*
Amlodipine besylate-valsartan*
Amoxicillin-clarithromycin-lansoprazole
Amphetamine aspartate-amphetamine sulfate-dextroamphetamine saccharate-dextroamphetamine

sulfate
Amprenavir
Anagrelide hydrochloride
Anthralin
Antihemophilic factor (human)
Antihemophilic factor (recombinant)
Anti-inhibitor coagulant complex
Antithymocyte globulin
Apomorphine hydrochloride

Aripiprazole
Armodafinil
Arnica montana-herbals (multiple)-sulfur
Asparaginase
Atomoxetine hydrochloride
Atovaquone
Atovaquone-proguanil hydrochloride
Atropine sulfate-benzoic acid-hyoscyamine sulfate-methenamine-methylene blue-phenyl salicylate
Atropine sulfate-hyoscyamine sulfate-scopolamine hydrobromide
Azelastine hydrochloride
Bacitracin zinc-neomycin sulfate-polymyxin B sulfate
Baclofen
BCG (live, intravesical)
Becaplermin
Beclomethasone dipropionate
Beclomethasone dipropionate monohydrate
Benazepril hydrochloride*
Benazepril hydrochloride-hydrochlorothiazide*
Bendroflumethiazide
Benzocaine
Benzonatate
Benzoyl peroxide
Benzoyl peroxide-clindamycin
Benzoyl peroxide-erythromycin
Betamethasone dipropionate
Betamethasone dipropionate-clotrimazole
Betamethasone valerate
Betaxolol hydrochloride
Bethanechol chloride
Bevacizumab
Bimatoprost
Bisacodyl-polyethylene glycol-potassium chloride-sodium bicarbonate-sodium chloride
Bisoprolol fumarate
Bisoprolol fumarate-hydrochlorothiazide
Bitolterol mesylate
Black widow spider antivenin (equine)
Botulinum toxin type A
Botulinum toxin type B
Brimonidine tartrate-timolol maleate
Brinzolamide
Brompheniramine maleate-dextromethorphan hydrobromide-phenylephrine hydrochloride
Budesonide
Bupivacaine hydrochloride
Bupivacaine hydrochloride-epinephrine bitartrate
Buprenorphine hydrochloride
Buprenorphine hydrochloride-naloxone hydrochloride
Bupropion hydrobromide
Bupropion hydrochloride
Butabarbital-hyoscyamine hydrobromide-phenazopyridine hydrochloride
Butalbital-acetaminophen
Butenafine hydrochloride
Butoconazole nitrate
Butorphanol tartrate
Caffeine citrate
Calcipotriene
Calcitonin-salmon
Calcitriol
Calcium acetate
Candesartan cilexetil*
Candesartan cilexetil-hydrochlorothiazide*
Capreomycin sulfate
Captopril*
Carbetapentane tannate-chlorpheniramine tannate
Carbetapentane tannate-chlorpheniramine tannate-ephedrine tannate-phenylephrine tannate
Carbidopa-entacapone-levodopa
Carbidopa-levodopa
Carbinoxamine maleate-dextromethorphan hydrobromide-pseudoephedrine hydrochloride

Carteolol hydrochloride
Carvedilol
Caspofungin acetate
Celecoxib
Cetirizine hydrochloride
Cetuximab
Cevimeline hydrochloride
Chloramphenicol
Chloroprocaine hydrochloride
Chlorothiazide
Chlorothiazide sodium
Chlorpheniramine maleate-methscopolamine nitrate-phenylephrine hydrochloride
Chlorpheniramine maleate-pseudoephedrine hydrochloride
Chlorpheniramine polistirex-hydrocodone polistirex
Chlorpheniramine tannate-phenylephrine tannate
Chlorpropamide
Chlorthalidone-clonidine hydrochloride
Choline magnesium trisalicylate
Ciclesonide
Cidofovir
Cilostazol
Cinacalcet hydrochloride
Ciprofloxacin-dexamethasone
Ciprofloxacin hydrochloride
Ciprofloxacin hydrochloride-hydrocortisone
Citalopram hydrobromide
Clarithromycin
Clobetasol propionate
Clonidine
Clonidine hydrochloride
Codeine phosphate-acetaminophen
Colistimethate sodium
Colistin sulfate-hydrocortisone acetate-neomycin sulfate-thonzonium bromide
Corticorelin ovine triflutate
Cyanocobalamin
Cycloserine
Cyclosporine
Cytomegalovirus immune globulin
Dacarbazine
Daclizumab
Dantrolene sodium
Dapsone
Darbepoetin alfa
Darifenacin
Deferoxamine mesylate
Delavirdine mesylate
Denileukin diftitox
Desloratadine
Desloratadine-pseudoephedrine sulfate
Desoximetasone
Desvenlafaxine
Dexamethasone
Dexamethasone sodium phosphate
Dexmethylphenidate hydrochloride
Dexrazoxane
Dextroamphetamine sulfate
Diazoxide
Dichlorphenamide
Diclofenac epolamine
Diclofenac potassium
Diclofenac sodium
Diflorasone diacetate
Diflunisal
Digoxin
Digoxin immune Fab (ovine)
Diltiazem hydrochloride
Dimethyl sulfoxide
Dinoprostone
Diphtheria and tetanus toxoids and acellular pertussis vaccine (adsorbed)
Diphtheria and tetanus toxoids and acellular pertussis vaccine (adsorbed)-hepatitis B Vaccine,
(recombinant)-poliovirus vaccine (inactivated)
Dirithromycin
Dofetilide
Donepezil hydrochloride
Dorzolamide hydrochloride
Dorzolamide hydrochloride-timolol maleate
Doxazosin mesylate
Dronabinol
Drotrecogin alfa (activated)
Duloxetine hydrochloride
Echothiophate iodide
Econazole nitrate
Efalizumab
Eflornithine hydrochloride
Eletriptan hydrobromide
Enalapril maleate*
Enalapril maleate-felodipine*
Enalapril maleate-hydrochlorothiazide*
Entacapone
Entecavir
Epinastine hydrochloride
Epinephrine
Epoetin alfa
Eprosartan mesylate
Erythromycin ethylsuccinate-sulfisoxazole acetyl
Escitalopram oxalate
Eszopiclone
Ethionamide
Ethotoin
Etidronate disodium
Exenatide
Ezetimibe
Factor IX complex
Felodipine
Fenofibrate
Fentanyl
Fentanyl citrate
Fentanyl hydrochloride
Ferrous fumarate-folic acid-intrinsic factor concentrate-liver preparations-vitamin B12-vitamin C-

vitamins with iron
Fexofenadine hydrochloride
Fexofenadine hydrochloride-pseudoephedrine hydrochloride
Filgrastim
Flecainide acetate
Fluconazole
Flucytosine
Fludrocortisone acetate
Flumazenil
Flunisolide
Fluocinolone acetonide
Fluocinolone acetonide-hydroquinone-tretinoin
Fluocinonide
Fluorometholone
Fluorometholone-sulfacetamide sodium
Fluoxetine hydrochloride
Fluoxetine hydrochloride-olanzapine
Flurandrenolide
Flurbiprofen sodium
Fluticasone furoate
Fluticasone propionate
Fluticasone propionate HFA
Fluticasone propionate-salmeterol xinafoate
Fluvoxamine maleate
Fomivirsen sodium
Formoterol fumarate
Fosamprenavir calcium
Foscarnet sodium*
Fosinopril sodium*
Fosinopril sodium-hydrochlorothiazide*
Frovatriptan succinate
Furosemide
Gabapentin
Gallium nitrate
Ganciclovir
Ganciclovir sodium
Gatifloxacin
Gemfibrozil
Gemifloxacin mesylate
Gentamicin sulfate
Gentamicin sulfate-prednisolone acetate
Glimepiride
Glimepiride-rosiglitazone maleate
Glipizide
Glipizide-metformin hydrochloride
Globulin, immune (human)
Globulin, immune (human)-Rho (D) immune globulin (human)
Glyburide
Gramicidin-neomycin sulfate-polymyxin B sulfate
Guaifenesin-hydrocodone bitartrate
Haemophilus B conjugate vaccine
Haemophilus B conjugate vaccine-hepatitis B vaccine (recombinant)
Halobetasol propionate
Haloperidol decanoate
Hemin
Heparin sodium
Hepatitis A vaccine (inactivated)
Hepatitis A vaccine (inactivated)-hepatitis B vaccine (recombinant)
Hepatitis B immune globulin (human)
Hepatitis B vaccine (recombinant)
Homatropine methylbromide-hydrocodone bitartrate
Homeopathic formulations
Hydralazine hydrochloride-isosorbide dinitrate
Hydrochlorothiazide
Hydrocodone bitartrate
Hydrocodone bitartrate-acetaminophen
Hydrocodone bitartrate-ibuprofen
Hydrocortisone
Hydrocortisone acetate
Hydrocortisone acetate-neomycin sulfate-polymyxin B sulfate

Hydrocortisone acetate-pramoxine hydrochloride
Hydrocortisone butyrate
Hydrocortisone-neomycin sulfate-polymyxin B sulfate
Hydrocortisone probutate
Hydromorphone hydrochloride
Hydroquinone
Hyoscyamine sulfate
Ibandronate sodium
Ibutilide fumarate
Iloprost
Imiglucerase
Imipenem-cilastatin
Imiquimod
Immune globulin intravenous (human)
Indinavir sulfate
Indocyanine green
Influenza virus vaccine
Insulin aspart
Insulin aspart protamine (human)-insulin aspart (human)
Insulin glargine
Insulin glulisine
Interferon alfa-2B (recombinant)
Interferon alfacon-1
Interferon alfa-N3 (human leukocyte derived)
Interferon beta-1A
Interferon beta-1B
Interferon gamma-1B
Iodoquinol-hydrocortisone
Irbesartan*
Irbesartan-hydrochlorothiazide*
Iron dextran
Isoniazid-pyrazinamide-rifampin
Isosorbide mononitrate
Isradipine
Itraconazole
Ivermectin
Ketoconazole
Ketorolac tromethamine
Ketotifen fumarate
Labetalol hydrochloride
Lamivudine
Lamivudine-zidovudine
Lamotrigine
Lanreotide acetate
Lanthanum carbonate
Latanoprost
Levalbuterol hydrochloride
Levalbuterol tartrate
Levamisole hydrochloride
Levetiracetam
Levobunolol hydrochloride
Levofloxacin
Linezolid
Lisdexamfetamine
Lisinopril*
Lisinopril-hydrochlorothiazide*
Lomefloxacin
Lopinavir-ritonavir
Losartan potassium*
Losartan potassium-hydrochlorothiazide*
Loteprednol etabonate
Lubiprostone
Mafenide acetate
Magnesium salicylate tetrahydrate
Measles, mumps, and rubella virus vaccine (live)
Measles virus vaccine (live)
Mebendazole
Mecamylamine hydrochloride
Mecasermin [rDNA origin]
Medrysone
Mefenamic acid
Mefloquine hydrochloride
Meloxicam
Meningococcal polysaccharide diphtheria toxoid conjugate vaccine
Meningococcal polysaccharide vaccine
Meperidine hydrochloride
Mepivacaine hydrochloride
Metaproterenol sulfate
Metaraminol bitartrate
Metformin hydrochloride-pioglitazone hydrochloride
Metformin hydrochloride-repaglinide
Metformin hydrochloride-rosiglitazone maleate
Methamphetamine hydrochloride
Methazolamide
Methenamine mandelate-sodium acid phosphate
Methocarbamol
Methoxsalen
Methoxy polyethylene glycol-epoetin beta
Methscopolamine nitrate-pseudoephedrine hydrochloride

Methyldopa-chlorothiazide
Methyldopa-hydrochlorothiazide
Methylphenidate hydrochloride
Metipranolol
Metoprolol succinate
Metoprolol tartrate
Metoprolol tartrate-hydrochlorothiazide
Metyrosine
Mexiletine hydrochloride
Micafungin sodium
Midodrine hydrochloride
Mivacurium chloride
Modafinil
Moexipril hydrochloride*
Moexipril hydrochloride-hydrochlorothiazide*
Mometasone furoate
Mometasone furoate monohydrate
Morphine sulfate
Morphine sulfate, liposomal
Moxifloxacin hydrochloride
Mumps virus vaccine (live)
Muromonab-CD3
Mycophenolate mofetil hydrochloride
Mycophenolic acid
Nabumetone
Nadolol
Nadolol-bendroflumethiazide
Naloxone hydrochloride-pentazocine hydrochloride
Naltrexone hydrochloride
Naphazoline hydrochloride
Naproxen
Naproxen sodium
Naratriptan hydrochloride
Natamycin
Nateglinide
Nebivolol
Nefazodone hydrochloride
Neomycin sulfate-dexamethasone sodium phosphate
Neomycin sulfate-polymyxin B sulfate-prednisolone acetate
Nesiritide
Nevirapine
Niacin
Nicardipine hydrochloride

Nifedipine
Nilutamide
Nimodipine
Nisoldipine
Nitroglycerin
Norfloxacin
Ofloxacin
Olanzapine
Olmesartan medoxomil-hydrochlorothiazide
Olopatadine hydrochloride
Olsalazine sodium
Omega-3-acid ethyl esters
Omeprazole
Oprelvekin
Orphenadrine citrate
Oseltamivir phosphate
Oxcarbazepine
Oxycodone hydrochloride-acetaminophen
Oxycodone hydrochloride-ibuprofen
Oxymorphone hydrochloride
Palifermin
Paliperidone
Palivizumab
Pancrelipase
Paricalcitol
Paroxetine hydrochloride
Paroxetine mesylate
PEG-3350-potassium chloride-sodium bicarbonate-sodium chloride
Pegademase bovine
Pegaspargase
Pegfilgrastim
Peginterferon alfa-2A
Peginterferon alfa-2B
Pemirolast potassium
Pentazocine hydrochloride-acetaminophen
Pentoxifylline
Perindopril erbumine*
Phenoxybenzamine hydrochloride
Phentermine hydrochloride
Pilocarpine hydrochloride
Pimecrolimus
Pimozide
Pioglitazone hydrochloride
Pirbuterol acetate
Piroxicam
Plasma fractions (human)-rabies immune globulin (human)
Plasma protein fraction (human)
Pneumococcal vaccine (diphtheria conjugate)
Pneumococcal vaccine (polyvalent)
Podofilox
Polyethylene glycol
Polyethylene glycol-potassium chloride-sodium bicarbonate-sodium chloride
Polyethylene glycol-potassium chloride-sodium bicarbonate-sodium chloride-sodium sulfate
Polymyxin B sulfate-trimethoprim sulfate
Polythiazide-prazosin hydrochloride
Porfimer sodium
Potassium acid phosphate
Potassium chloride
Potassium citrate
Potassium phosphate-sodium phosphate
Pralidoxime chloride
Pramipexole dihydrochloride
Pramlintide acetate
Pramoxine hydrochloride-hydrocortisone acetate
Prazosin hydrochloride
Prednisolone acetate
Prednisolone acetate-sulfacetamide sodium
Prednisolone sodium phosphate

Pregabalin
Promethazine hydrochloride
Propafenone hydrochloride
Proparacaine hydrochloride
Propranolol hydrochloride
Pseudoephedrine hydrochloride
Pyrimethamine
Quetiapine fumarate
Quinapril hydrochloride*
Quinidine sulfate
Rabies vaccine
Raltegravir potassium
Ramelteon
Ramipril*
Ranolazine
Rasburicase
Remifentanil hydrochloride
Repaglinide
Reteplase
Rho (D) immune globulin (human)
Rifampin
Rifapentine
Rifaximin
Riluzole
Rimantadine hydrochloride
Risedronate sodium
Risedronate sodium-calcium carbonate
Risperidone
Rituximab
Rizatriptan benzoate
Rocuronium bromide
Rofecoxib
Romiplostim
Ropinirole hydrochloride
Rosiglitazone maleate
Rotigotine
Rubella virus vaccine (live)
Salmeterol xinafoate
Sapropterin dihydrochloride
Sargramostim
Scopolamine
Selegiline hydrochloride
Selenium sulfide
Sertaconazole nitrate
Sertraline hydrochloride
Sevelamer carbonate
Sevelamer hydrochloride
Sibutramine hydrochloride monohydrate
Sirolimus
Sodium benzoate-sodium phenylacetate
Sodium phenylbutyrate
Sodium polystyrene sulfonate
Sodium sulfacetamide-sulfur
Solifenacin succinate
Somatropin
Somatropin (rDNA origin)
Stavudine
Streptokinase
Succimer
Sulfacetamide sodium
Sulfamethoxazole-trimethoprim
Sulfanilamide
Sumatriptan
Sumatriptan succinate
Tacrine hydrochloride
Tacrolimus
Telithromycin
Telmisartan*
Telmisartan-hydrochlorothiazide*
Tenecteplase
Terazosin hydrochloride
Teriparatide
Tetanus and diphtheria toxoids (adsorbed)
Tetanus immune globulin (human)
Theophylline
Theophylline anhydrous
Thiabendazole
Thrombin
Thyrotropin alfa
Tiagabine hydrochloride
Tiludronate disodium
Timolol hemihydrate
Timolol maleate
Timolol maleate-hydrochlorothiazide
Tinidazole
Tiotropium bromide
Tipranavir
Tizanidine hydrochloride
Tobramycin-dexamethasone
Tobramycin-loteprednol etabonate
Tolcapone
Tolterodine tartrate
Topiramate
Tramadol hydrochloride
Tramadol hydrochloride-acetaminophen
Trandolapril*
Trandolapril-verapamil hydrochloride*
Travoprost
Tretinoin
Triamcinolone acetonide
Triamterene
Triamterene-hydrochlorothiazide
Trientine hydrochloride
Triethanolamine polypeptide oleate-condensate
Trifluridine
Trimethoprim hydrochloride
Trimipramine maleate
Tropicamide-hydroxyamphetamine hydrobromide
Trospium chloride
Trovafloxacin mesylate
Tuberculin purified protein derivative (diluted)

Typhoid vaccine (live) oral Ty21a
Unoprostone isopropyl
Urea
Valdecoxib
Valganciclovir hydrochloride
Valsartan*
Valsartan-hydrochlorothiazide*
Varenicline tartrate
Varicella virus vaccine (live)
Venlafaxine hydrochloride
Verapamil hydrochloride
Verteporfin
Vitamin K1
Yellow fever vaccine
Zalcitabine
Zaleplon
Zanamivir
Zidovudine
Ziprasidone mesylate
Zolmitriptan
Zolpidem tartrate
Zonisamide

B: No Evidence of Risk in Humans
Animal findings show risk whereas human findings do not, or, if no adequate human studies have
been done, animal findings are negative.
Acarbose
Acrivastine
Acyclovir
Acyclovir sodium
Adalimumab
Agalsidase beta
Alefacept
Alfuzosin hydrochloride
Alosetron hydrochloride
Alvimopan
Amiloride hydrochloride
Amiloride hydrochloride-hydrochlorothiazide
Amoxicillin
Amoxicillin-clavulanate potassium
Amphotericin B
Amphotericin B-cholesteryl sulfate complex
Amphotericin B lipid complex
Amphotericin B (liposomal)
Ampicillin sodium-sulbactam sodium
Anakinra
Antithrombin III
Aprepitant
Aprotinin
Argatroban
Arginine hydrochloride
Atazanavir sulfate
Azelaic acid
Azithromycin
Azithromycin dihydrate
Aztreonam
Balsalazide disodium
Basiliximab
Bivalirudin
Brimonidine tartrate
Budesonide
Bupropion hydrochloride
Cabergoline
Carbenicillin indanyl sodium
Cefaclor
Cefazolin sodium
Cefdinir
Cefditoren pivoxil
Cefepime hydrochloride
Cefixime
Cefoperazone sodium
Cefotaxime sodium
Cefotetan disodium
Cefoxitin sodium
Cefpodoxime proxetil
Cefprozil
Ceftazidime sodium
Ceftibuten dihydrate
Ceftizoxime sodium
Ceftriaxone sodium
Cefuroxime
Cefuroxime axetil
Cephalexin
Certolizumab pegol
Cetirizine hydrochloride
Ciclopirox
Ciclopirox olamine
Cimetidine
Cimetidine hydrochloride
Cisatracurium besylate
Clindamycin hydrochloride-clindamycin phosphate

Clindamycin palmitate hydrochloride
Clindamycin phosphate
Clopidogrel bisulfate
Clotrimazole
Clozapine
Colesevelam hydrochloride
Cromolyn sodium
Cyclobenzaprine hydrochloride
Cyproheptadine hydrochloride
Dalfopristin-quinupristin
Dalteparin sodium
Dapiprazole hydrochloride
Daptomycin
Desflurane
Desmopressin acetate
Dicyclomine hydrochloride
Didanosine
Diphenhydramine hydrochloride
Dipivefrin hydrochloride
Dipyridamole
Dolasetron mesylate
Doripenem
Dornase alfa
Doxapram hydrochloride
Doxepin hydrochloride
Doxercalciferol
Edetate calcium disodium
Emtricitabine
Emtricitabine-tenofovir disoproxil fumarate
Enfuvirtide
Enoxaparin sodium
Eplerenone
Epoprostenol sodium
Ertapenem
Erythromycin
Erythromycin ethylsuccinate
Erythromycin stearate
Esomeprazole magnesium
Esomeprazole sodium
Etanercept
Ethacrynate sodium
Ethacrynic acid
Etravirine
Famciclovir
Famotidine
Fenoldopam mesylate
Fondaparinux sodium
Galantamine hydrobromide
Glatiramer acetate
Glucagon
Glyburide-metformin hydrochloride
Granisetron hydrochloride
Hydrochlorothiazide
Ibuprofen
Indapamide
Infliximab
Insulin aspart
Insulin lispro (human)
Insulin lispro protamine (human)-insulin lispro
(human)
Ipratropium bromide
Iron sucrose
Isosorbide mononitrate
Lactulose
Lansoprazole
Lansoprazole-naproxen
Laronidase
Lepirudin
Levocarnitine
Levocetirizine dihydrochloride
Lidocaine
Lidocaine hydrochloride
Lidocaine-prilocaine
Lindane
Loperamide hydrochloride
Loracarbef
Loratadine
Malathion
Maraviroc
Meclizine hydrochloride
Memantine hydrochloride
Meropenem
Mesalamine
Metformin hydrochloride
Metformin hydrochloride-sitagliptin phosphate
Methohexital sodium
Methyldopa
Methylnaltrexone bromide
Metolazone
Metronidazole
Miglitol
Montelukast sodium
Mupirocin
Mupirocin calcium
Naftifine hydrochloride
Nalbuphine hydrochloride
Nalmefene hydrochloride
Naloxone hydrochloride
Naproxen sodium
Nedocromil sodium
Nelfinavir mesylate
Nitazoxanide
Nitrofurantoin macrocrystals
Nitrofurantoin macrocrystals-nitrofurantoin monohydrate
Nizatidine
Octreotide acetate
Omalizumab
Ondansetron
Ondansetron hydrochloride
Orlistat
Oxiconazole nitrate
Oxybutynin
Oxybutynin chloride
Oxycodone hydrochloride
Palonosetron hydrochloride
Pancrelipase
Pantoprazole sodium
Pegvisomant
Pemoline
Penciclovir
Penicillin G benzathine
Penicillin G benzathine-penicillin G procaine
Penicillin G potassium
Pentosan polysulfate sodium
Permethrin
Piperacillin sodium
Piperacillin sodium-tazobactam sodium
Praziquantel
Progesterone
Propofol
Pseudoephedrine hydrochloride
Pseudoephedrine sulfate
Psyllium preparations
Rabeprazole sodium
Ranitidine hydrochloride
Retapamulin
Rifabutin
Ritonavir
Rivastigmine tartrate
Ropivacaine hydrochloride
Saquinavir mesylate
Sevoflurane
Sildenafil citrate
Silver sulfadiazine
Sitagliptin phosphate
Sodium ferric gluconate
Somatropin
Sotalol hydrochloride
Sucralfate
Sulfasalazine
Tadalafil
Tamsulosin hydrochloride
Tenofovir disoproxil fumarate
Terbinafine hydrochloride
Ticarcillin disodium-clavulanate potassium
Ticlopidine hydrochloride
Tirofiban hydrochloride
Torsemide
Trastuzumab
Treprostinil sodium
Urokinase
Ursodiol
Valacyclovir hydrochloride
Vancomycin hydrochloride
Vardenafil hydrochloride
Zafirlukast
A: No Risk Shown in Controlled Studies
Adequate, well-controlled studies in pregnant women have failed to demonstrate risk to the fetus.
Liothyronine sodium
Liotrix
Nystatin
Reference
Appendix K: Sugar-Free Products
The following table, by therapeutic category, is a selection of drug products that contain no sugar.
When recommending these products to diabetic patients, keep in mind that many may contain
sorbitol, alcohol, or other sources of carbohydrates. This list should not be considered all inclusive.
Generics and alternate brands of some products may be available. Check product labeling for a
current listing of inactive ingredients.
Product Manufacturer
Analgesics
Addaprin tablets Dover
Aminofen tablets Dover
Aminofen Max tablets Dover
Aspirtab tablets Dover
Back Pain-Off tablets Medique
Backprin tablets Hart Health and Safety
Buffasal tablets Dover
Dyspel tablets Dover
I-Prin tablets Medique
Medi-Seltzer Effervescent tablets Medique
Methadose solution Mallinckrodt
Methadose Sugar-Free Oral Concentrate Mallinckrodt
Ms.-Aid tablets Medique
Silapap Children's elixir Silarx
Antacids and antiflatulents
Alcalak chewable tablets Medique
Dimacid chewable tablets Otis Clapp & Son
Diotame chewable tablets Medique
Diotame suspension Medique
Mylanta gelcaplets Johnson & Johnson/Merck
Mylanta tablets Johnson & Johnson/Merck
Neutralin tablets Dover
Pepto-Bismol tablets Procter & Gamble
Turns E-X chewable tablets GlaxoSmithKline Consumer
Turns E-X sugar-free tablets GlaxoSmithKline Consumer
Antiasthmatic and respiratory agents
Jay-Phyl syrup Pharmakon
Antidiarrheals
Diarrest tablets Dover
Imogen liquid Pharm Generic
Blood modifiers and iron preparations
I.L.X. B-12 elixir Kenwood
Nephro-Fer tablets R&D
Corticosteroids
Pediapred solution Celltech
Cough, cold, and allergy preparations
Accuhist drops Pediamed
Accuhist PDX drops solution Pediamed
Alacol solution Ballay
Alacol DM syrup Ballay
Amerifed liquid Ambi
Amerifed DM liquid Ambi
Amerituss AD solution Ambi
Anaplex DM syrup ECR
Anaplex DMX syrup ECR
Anaplex HD syrup ECR
Andehist DM NR syrup Cypress
Andehist NR syrup Cypress
Aquatab C tablets Deston
Aridex solution Gentex
Baltussin solution Ballay
Benadryl-D Allergy & Sinus Children's Solution Johnson & Johnson
Bromhist-DM solution Cypress
Bromhist Pediatric solution Cypress
Bromphenex DM solution Breckenridge
Bromphenex HD solution Breckenridge
Bromplex DM solution Prasco
Bromplex HD solution Prasco
Bromtuss DM solution Breckenridge
Broncotron liquid Seyer Pharmatec
Broncotron-D suspension Seyer Pharmatec
B-Tuss liquid Blansett
Carbaphen 12 suspension Gil
Carbaphen 12 Ped suspension Gil
Carbatuss-12 suspension GM
Carbatuss-CL solution GM
Carbetaplex liquid Breckenridge
Carbetaplex solution Breckenridge
Carbofed DM drops Hi-Tech
Carbofed DM liquid Hi-Tech
Carbofed DM syrup Hi-Tech
Cardec solution Qualitest
Cardec DM syrup Qualitest
Cetafen Cold tablets Hart Health and Safety
Cetafen Cough & Cold tablets Hart Health and Safety
Cheratussin DAC liquid Qualitest
Chlordex GP syrup Cypress
Codal-DM syrup Cypress
Codiclear DH solution Victory
ColdCough syrup Breckenridge
ColdCough HC syrup Breckenridge
ColdCough PD syrup Breckenridge
ColdCough solution Breckenridge
ColdCough HCM solution Breckenridge
ColdCough PD solution Breckenridge
ColdCough XP solution Breckenridge
Coldonyl tablets Dover
Colidrops Pediatric liquid A. G. Marin
Cordron-DM NR solution Cypress
Cordron-HC solution Cypress
Cordron-HC NR solution Cypress
Cordron NR solution Cypress
Corfen DM solution Cypress
Coughtuss solution Breckenridge
Crantex syrup Breckenridge
Crantex HC syrup Breckenridge
Dacex-DM solution Cypress
Dallergy drops Laser
Dallergy solution Laser
De-Chlor DM solution Cypress
De-Chlor DR solution Cypress
De-Chlor HD solution Cypress
Despec liquid International Ethical
Despec-SF liquid International Ethical
Diabetic Tussin Allergy Relief liquid Health Care Products
Diabetic Tussin Allergy Relief tablets Health Care Products
Diabetic Tussin Cold & Flu gelcaplets Health Care Products
Diabetic Tussin DM liquid Health Care Products
Diabetic Tussin EX liquid Health Care Products
Diabetic Tussin solution Health Care Products
Diphen capsules Medique
Donatussin drops Laser
Donatussin solution Laser
Double-Tussin DM liquid Reese
Drocon-CS solution Cypress
Duratuss DM elixir Victory
Duratuss DM solution Victory
Dynatuss HC solution Breckenridge
Dytan-CS tablets Hawthorn
Dytan-HC suspension Hawthorn
Emagrin tablets Otis Clapp & Son
Emagrin Forte tablets Otis Clapp & Son
Endacof-DM solution Larken
Endacof-HC solution Larken
Endacof-PD solution Larken
Endacof-XP solution Larken
Endal HD Plus liquid Pediamed
Ganidin NR liquid Cypress
Gani-Tuss NR liquid Cypress
Gani-Tuss-DM NR liquid Cypress
Genebronco-D liquid Pharm Generic
Genecof-HC liquid Pharm Generic
Genecof-XP liquid Pharm Generic
Genedel syrup Pharm Generic
Genedotuss-DM liquid Pharm Generic
Genelan liquid Pharm Generic
Genetuss-2 liquid Pharm Generic
Genexpect DM liquid Pharm Generic
Genexpect-PE liquid Pharm Generic
Genexpect-SF liquid Pharm Generic
Gilphex TR tablets Gil
Giltuss liquid Gil
Giltuss Ped-C solution Gil
Giltuss Pediatric liquid Gil
Giltuss TR tablets Gil
Guiadex DM liquid Breckenridge
Guiadex DM solution Breckenridge
Guiaplex HC solution Breckenridge
Halotussin AC liquid Axiom
Halotussin DAC solution Axiom
Histinex HC syrup Ethex
Histinex PV syrup Ethex
Hydro-Tussin CBX solution Ethex
Hydro-Tussin DHC solution Ethex
Hydro-Tussin DM elixir Ethex
Hydro-Tussin EXP solution Ethex
Hydro-Tussin HC syrup Ethex
Hydro-Tussin HD liquid Ethex
Hydro-Tussin XP syrup Ethex
Jaycof Expectorant syrup Pharmakon
Jaycof-HC liquid Pharmakon
Jaycof-XP liquid Pharmakon
Liquicough DM solution Breckenridge
Liquicough HC solution Breckenridge
Lodrane liquid ECR
Lodrane D suspension ECR
Lodrane XR suspension ECR
Lohist-LQ solution Larken
Lohist-PD solution Larken
Lortuss DM solution Proethic
Marcof Expectorant syrup Marnel
Maxi-Tuss HCG solution MCR American
Maxi-Tuss HCX solution MCR American
M-Clear solution R. A. McNeil
M-Clear JR solution R. A. McNeil
Metanx tablets Pamlab
Mintuss NX solution Breckenridge
Nalex-A liquid Blansett
Nalex-DH liquid Blansett
Nasop suspension Hawthorn
Neo DM drops Laser
Neo DM suspension Laser
Neo DM syrup Laser
Neotuss-D liquid A. G. Marin
Neotuss S/F liquid A. G. Marin
Niferex elixir Ther-Rx
Norel DM liquid US Pharmaceutical
Nycoff tablets Dover
Organidin NR liquid MedPointe
Organidin NR tablets MedPointe
Pancof EXP syrup Pamlab
Pancof HC solution Pamlab
Pancof XP solution Pamlab
Panmist DM syrup Pamlab
Pediatex HC solution Zyber
Phanasin syrup Pharmakon
Phanasin Diabetic Choice syrup Pharmakon
Phanatuss syrup Pharmakon
Phanatuss DM Diabetic Choice syrup Pharmakon
Phanatuss-HC Diabetic Choice solution Pharmakon
Phena-HC solution GM
Phenabid tablets Gil
Phenabid DM tablets Gil
Phena-S liquid GM
Phena-S 12 suspension GM
Phendacof HC syrup Larken
Phendacof Plus solution Larken
Poly Hist DM solution Poly
Poly Hist HC solution Poly
Poly Hist PD solution Poly
Poly-Tussin solution Poly
Poly-Tussin DM syrup Poly
Poly-Tussin HD syrup Poly
Poly-Tussin XP solution Poly
Pro-Clear solution Pro-Pharma
Pro-Red solution Pro-Pharma
Prolex DM liquid Blansett
Quintex syrup Qualitest
Relacon-HC solution Cypress
Rescon-DM liquid Capellon
Rindal HD liquid Breckenridge
Rindal HD Plus solution Breckenridge
Rondec solution Alliant
Rondec DM solution Alliant
Ru-Tuss DM solution Carwin
Ru-Tuss DM syrup Carwin
Safetussin liquid Kramer
Scot-Tussin Diabetes CF liquid Scot-Tussin
Scot-Tussin DM Cough Chasers lozenges Scot-Tussin
Scot-Tussin DM solution Scot-Tussin
Scot-Tussin DM Maximum Strength Scot-Tussin
Scot-Tussin Expectorant solution Scot-Tussin
Scot-Tussin Senior solution Scot-Tussin
Siladryl Allergy solution Silarx
Sildec syrup Silarx
Sildec-DM syrup Silarx
Sildec-PE solution Silarx
Sildec-PE syrup Silarx
Sildec PE-DM solution Silarx
Sildec PE-DM syrup Silarx
Silexin syrup Otis Clapp & Son
Silexin tablets Otis Clapp & Son
Sil-Tex liquid Silarx
Siltussin DAS liquid Silarx
Siltussin DM DAS Cough Formula syrup Silarx
Siltussin SA liquid Silarx
Siltussin SA syrup Silarx
Statuss Green liquid Magna
Sudafed Children's solution Pfizer
Sudafed Children's Cold & Cough solution Pfizer
Sudafed Children's Nasal Decongestant liquid Pfizer
Sudafed Children's PE Cough & Cold liquid Pfizer
Sudanyl tablets Dover
Sudatuss-SF liquid Pharm Generic
Supress DX Pediatric drops Kramer-Novis
Suttar-SF syrup Gil
Tanacof XR suspension Larken
Triant-HC solution Hawthorn
Tricodene syrup Pfeiffer
Trituss solution Everett
Tri-Vent DM solution Ethex
Tri-Vent DPC syrup Ethex
Tusdec-DM solution Cypress
Tusnel solution Llorens
Tussafed syrup Everett
Tussafed-EX Pediatric drops Everett
Tussafed-HC syrup Everett
Tussafed-HCG solution Everett
Tussall solution Everett
Tussi-Organidin DM NR solution Victory
Tussi-Organidin DM-S NR solution Victory
Tussi-Organidin NR solution Victory
Tussi-Organidin-S NR solution Victory
Tussi-Pres liquid Kramer-Novis
Tussplex DM solution Breckenridge
Vazol solution Wraser
Vi-Q-Tuss syrup Qualitest
Welltuss EXP solution Prasco
Z-Cof HC solution Zyber
Z-Cof HCX solution Zyber
Z-Tuss DM syrup Magna
Z-Tuss Expectorant solution Magna
Fluoride preparations
Fluor-A-Day liquid Pharmascience
Fluor-A-Day tablets Pharmascience
Flura-Loz tablets Kirkman
Lozi-Flur lozenges Dreir
Sensodyne with Fluoride Gel GlaxoSmithKline Consumer
Sensodyne with Fluoride Cool Gel GlaxoSmithKline Consumer
Sensodyne with Fluoride Tartar Control Toothpaste GlaxoSmithKline Consumer
Sensodyne with Fluoride Toothpaste GlaxoSmithKline Consumer
Sensodyne with Fluoride Toothpaste Original Flavor GlaxoSmithKline Consumer
Sensodyne Tartar Control with Whitening Toothpaste GlaxoSmithKline Consumer
Laxatives
Benefiber powder Novartis
Citrucel powder GlaxoSmithKline Consumer
Colace solution Purdue Products
Colace Liquid 1% solution Purdue Products
Fiber Choice tablets CNS
Fiber Ease liquid Plainview
Fibro-XL capsules Key
Genfiber powder Teva
Konsyl powder Konsyl
Konsyl Easy Mix Formula powder Konsyl
Konsyl-Orange powder Konsyl
Metamucil Smooth Texture powder Procter & Gamble
Reguloid Powder Rugby
Reguloid Powder Orange Flavor Rugby
Reguloid Powder Regular Flavor Rugby
Senokot Wheat Bran Purdue Products
Miscellaneous
Acidoll capsules Key
Alka-Gest tablets Key
Bicitra solution Ortho-McNeil
Cafergot tablets Sandoz
Colidrops Pediatric drops A. G. Marin
Cytra-2 solution Cypress
Cytra-K crystals Cypress
Cytra-K solution Cypress
Mason Natural Drinkin' Buddy tablets Mason Vitamins
Melatin tablets Mason Vitamins
Namenda solution Forest
Neutra-Phos powder Ortho-McNeil
Neutra-Phos-K powder Ortho-McNeil
Polycitra-K crystals Ortho-McNeil
Polycitra-K solution Ortho-McNeil
Polycitra-LC solution Ortho-McNeil
Prosed-DS tablets Esprit
Questran Light powder Par
Soltamox solution Cytogen
Mouth and throat preparations
Cepacol Dual Relief Sore Throat spray Combe
Cepacol Maximum Strength spray Combe
Cepacol Sore Throat + Coating Relief lozenges Combe
Cepacol Sore Throat lozenges Combe
Cheracol Sore Throat spray Lee
Chloraseptic spray Prestige
Cylex lozenges Pharmakon
Diabetic Tussin cough drops Health Care Products
Diabetic Tussin cough lozenges Health Care Products
Fisherman's Friend lozenges Mentholatum
Fisherman's Friend Sugar-Free Mint lozenges Mentholatum
Fresh N'Free liquid Geritrex
Larynex lozenges Dover
Listerine Pocketpaks film Pfizer
Luden's lozenges Johnson & Johnson
Luden's Sugar-Free Wild Cherry throat drops Johnson & Johnson
Medikoff drops Medique
Medikoff Sugar-Free drops Medique
N'ice lozenges Heritage/Insight
Oragesic solution Parnell
Orajel Dry Mouth Moisturizing gel Del
Orajel Dry Mouth Moisturizing spray Del
Orasept Mouthwash and Gargle liquid Pharmakon
Sepasoothe lozenges Medique
Thorets Maximum Strength lozenges Otis Clapp & Son
Throto-Ceptic spray S.S.S.
Triaminic Sore Throat spray Novartis
Vitamins, minerals, and supplements
Action-Tabs Made for Men Action Labs
Adaptosode for Stress liquid HVS
Adaptosode R+R for Stress liquid HVS
Adaptosode R+R for Acute Stress liquid HVS
Alamag tablets Medique
Alcalak tablets Medique
Apetigen elixir Kramer-Novis
Apptrim capsules Physician Therapeutics
Apptrim-D capsules Physician Therapeutics
Bevitamel tablets Westlake
Biosode liquid HVS
Biotect Plus caplets Gil
Bugs Bunny Complete tablets Bayer
C & M Caps-375 capsules Key
Cal-Cee tablets Key
Calcet Plus tablets Mission Pharmacal
Calcimin-300 tablets Key
Cal-Mint chewable tablets Freeda Vitamins
Cerefolin tablets Pamlab
Cerefolin NAC tablets Pamlab
Choice DM liquid Bristol-Myers Squibb
Chromacaps tablets Key
Delta D3 tablets Freeda Vitamins
Detoxosode liquid HVS
Dexfol tablets Rising
DHEA capsules ADH Health Products
Diatx ZN tablets Pamlab
Diet System 6 gum Applied Nutrition
Dimacid tablets Otis Clapp & Son
Diucaps capsules Legere
DI-Phen-500 capsules Key
DL-Phen-500 capsules Key
Electrotab tablets Hart Health and Safety
Ensure Nutra Shake Pudding Ross Products
Enterex Diabetic liquid Victus
Essential Nutrients Plus Silica tablets Action Labs
Evening Primrose Oil capsules National Vitamin
Evolve Softgel Bionutrics Health Products
Ex-L tablets Key
Extress tablets Key
Eyetamins tablets Rexall Consumer
Fem-Cal tablets Freeda Vitamins
Fem-Cal Citrate tablets Freeda Vitamins
Fem-Cal Plus tablets Freeda Vitamins
Ferrocite F tablets Breckenridge
Ferrocite Plus tablets Breckenridge
Folacin-800 tablets Key
Folbee tablets Breckenridge
Folbee Plus tablets Breckenridge
Foleve tablets Cura
Foleve Plus tablets Cura
Folplex 2.2 tablets Breckenridge
Foltx tablets Pamlab
Gabadone capsules Physician Therapeutics
Gram-O-Leci tablets Freeda Vitamins
Herbal Slim Complex capsules ADH Health Products
Hypertensa capsules Physician Therapeutics
Lynae Calcium with Vitamin C chewable tablets Boscogen
Lynae Chondroitin/Glucosamine capsules Boscogen
Lynae Ginse-Cool chewable tablets Boscogen
Mag-Caps capsules Rising
Mag-Ox 400 tablets Blaine
Mag-SR tablets Cypress
Magimin tablets Key
Maginex tablets Logan
Magnacaps capsules Key
Mag-SR Plus Calcium tablets Cypress
Mangimin tablets Key
Medi-Lyte tablets Medique
Metanx tablets Pamlab
Multi-Delyn with Iron Liquid Silarx
Natelle tablets Pharmelle
Natelle C tablets Azur
Nephro-Fer tablets Watson
Neutra-Phos powder Ortho-McNeil
Neutra-Phos-K powder Ortho-McNeil
New Life Hair tablets Rexall Consumer
Niferex elixir Ther-Rx
Nutrisure OTC tablets Westlake
Nutrivit solution Llorens
Ob Complete tablets Vertical
O-Cal F.A. tablets Pharmics
Os-Cal 500+D tablets GlaxoSmithKline
Plenamins Plus tablets Rexall Consumer
Powervites tablets Green Turtle Bay Vitamin
Prostaplex Herbal Complex capsules ADH Health Products
Prostatonin capsules Pharmaton Natural Health
Protect Plus liquid Gil
Protect Plus NR Softgel Gil
Pulmona capsules Physician Therapeutics
Quintabs-M Tablets Freeda Vitamins
Replace capsules Key
Resource Arginaid powder Novartis Nutrition
Replace without Iron capsules Key
Ribo-100 T.D. capsules Key
Samolinic Softgel Key
Sea Omega 30 Softgel Rugby
Sea Omega 50 Softgel Rugby
Sentra AM capsules Physician Therapeutics
Sentra PM capsules Physician Therapeutics
Soy Care for Menopause capsules Inverness Medical
Span C tablets Freeda Vitamins
Strovite Forte syrup Everett
Sunnie tablets Green Turtle Bay Vitamin
Sunvite tablets Rexall Naturalist
Super Dec B100 tablets Freeda Vitamins
Super Quints B-50 tablets Freeda Vitamins
Supervite liquid Seyer Pharmatec
Suplevit liquid Gil
Theramine capsules Physician Therapeutics
Triamin tablets Key
Triamino tablets Freeda Vitamins
Ultramino powder Freeda Vitamins
Uro-Mag capsules Blaine
Vitafol tablets Everett
Vitamin C and Rose Hips tablets ADH Health Products
Vitrum Jr chewable Tablets Mason Vitamins
Xtramins tablets Key
Yohimbe Power Max 100 for Women tablets Action Labs
Yohimbe Power Max 1500 for Women tablets Action Labs
Yohimbized 1000 capsules Action Labs
Ze-Plus Softgel Everett
Reference
LaGow B, ed. Drug Topics Red Book. Montvale. N.J.: Thomson Healthcare; 2009.
Appendix L: Alcohol-Free Products
The following is a selection of alcohol-free products grouped by therapeutic category. The list is not
comprehensive. Generic and alternate brands may exist. Always check product labeling for
definitive information on specific ingredients.
Product Manufacturer
Analgesics
Acetaminophen Infants drops Ivax
Advil Children's suspension Wyeth Consumer
APAP elixir Bio-Pharm
Genapap Children's elixir Ivax
Genapap Infant's drops Ivax
Motrin Children's suspension McNeil Consumer
Motrin Infants' suspension McNeil Consumer
Silapap Infant's drops Silarx
Tylenol Children's suspension McNeil Consumer
Tylenol Extra Strength solution McNeil Consumer
Tylenol Infants' suspension McNeil Consumer
Antiasthmatic agents
Dy-G liquid Cypress
Jay-Phyl syrup Pharmakon
Anticonvulsants
Zarontin syrup Pfizer
Antiviral agents
Epivir Oral solution GlaxoSmithKline
Cough, cold, and allergy preparations
Accuhist PDX Drops solution Pediamed
Accuhist PDX syrup Pediamed
Alacol solution Ballay
Alacol DM syrup Ballay
Allanhist PDX syrup Allan
Altarussin syrup Altaire
Amerifed liquid Ambi
Amerifed DM liquid Ambi
Anaplex DM syrup ECR
Anaplex DMX suspension ECR
Anaplex HD syrup ECR
Andehist DM NR syrup Cypress
Andehist NR syrup Cypress
Aquatab DM syrup Adams
Aridex solution Gentex
Aridex-D solution Gentex
Atuss G syrup Atley
Baltussin solution Bailey
Banophen elixir Major
Benadryl Allergy solution Pfizer Consumer
Benadryl-D Allergy Johnson & Johnson
& Sinus Children's solution Consumer
Bromaline syrup Rugby
Bromaline DM elixir Rugby
Bromatan-DM suspension Cypress
Bromhist PDX solution Cypress
Bromhist Pediatric solution Cypress
Bromhist-DM solution Cypress
Bromhist-DM Pediatric syrup Cypress
Bromhist-NR solution Cypress
Bromhist-PDX syrup Cypress
Bromphenex DM solution Breckenridge
Bromphenex HD solution Breckenridge
Bromplex DM solution Prasco
Bromplex HD solution Prasco
Bromtuss DM solution Breckenridge
Broncotron liquid Seyer Pharmatec
Broncotron-D suspension Seyer Pharmatec
B-Tuss liquid Blansett
Carbaphen 12 suspension Gil
Carbaphen 12 Ped suspension Gil
Carbatuss liquid GM
Carbatuss-12 suspension GM
Carbatuss-CL solution GM
Carbetaplex solution Breckenridge
Carbetaplex TS suspension Breckenridge
Carbofed DM syrup Hi-Tech Pharmacal
Cardec solution Qualitest
Cardec DM solution Qualitest
Children's Dimetapp Cold & Allergy solution Wyeth Consumer
Children's Dimetapp DM Cold & Cough solution Wyeth Consumer
Children's Dimetapp Long Acting Cough Plus Cold solution Wyeth Consumer
Children's Dimetapp Nighttime Flu syrup Wyeth Consumer
Children's Mucinex syrup Adams
Children's Mucinex Cold solution Adams
Children's Mucinex Cough syrup Adams
Chlordex GP syrup Cypress
Chlor-Mes D solution Cypress
Codal-DM syrup Cypress
Codimal DH syrup Victory
Codimal DM syrup Victory
Codimal PH syrup Victory
Complete Allergy elixir Cardinal Health
Cordron-DM solution Cypress
Cordron-DM NR solution Cypress
Cordron-D NR solution Cypress
Cordron-HC solution Cypress
Cordron NR solution Cypress
Corfen DM solution Cypress
Coughtuss solution Breckenridge
Crantex syrup Breckenridge
Crantex HC syrup Breckenridge
Creomulsion Cough syrup Summit Industries
Creomulsion for Children syrup Summit Industries
Dacex-DM solution Cypress
Dallergy solution Laser
De-Chlor DM solution Cypress
De-Chlor DR solution Cypress
De-Chlor HD syrup Cypress
Dehistine syrup Cypress
Despec liquid International Ethical
Dex PC syrup Boca Pharmacal
Diabetic Tussin solution Health Care Products
Diabetic Tussin Allergy Relief liquid Health Care Products
Diabetic Tussin Cough lozenges Health Care Products
Diabetic Tussin DM liquid Health Care Products
Diabetic Tussin DM solution Health Care Products
Diabetic Tussin DM Maximum Strength liquid Health Care Products
Diabetic Tussin EX liquid Health Care Products
Diabetic Tussin Night Time Formula solution Health Care Products
Dimetapp Decongestant Pediatric drops Wyeth Consumer
Donatussin solution Laser
Donatussin DC syrup Laser
Donatussin DM solution Laser
Donatussin DM suspension Laser
Donatussin DM syrup Laser
Double-Tussin DM liquid Reese
Drocon-CS solution Cypress
Duratuss AC12 suspension Victory
Duratuss DM solution Victory
Duratan DM suspension Proethic
Duratuss DM12 suspension Victory
Dynatuss EX syrup Breckenridge
Dynatuss HC solution Breckenridge
Endacof DM solution Larken
Endacof HE solution Larken
Endacof XP solution Larken
Endal HD Plus liquid Pediamed
Father John's Medicine Plus drops Oakhurst
Ganidin NR liquid Cypress
Gani-Tuss NR liquid Cypress
Gani-Tuss-DM NR liquid Cypress
Genebronco-D liquid Pharm Generic
Genecof-HC liquid Pharm Generic
Genecot-XP liquid Pharm Generic
Genecof-XP syrup Pharm Generic
Genedel syrup Pharm Generic
Genedotuss-DM liquid Pharm Generic
Genepatuss liquid Pharm Generic
Genetuss-2 liquid Pharm Generic
Genexpect-DM liquid Pharm Generic
Genexpect-PE liquid Pharm Generic
Genexpect-SF liquid Pharm Generic
Giltuss liquid Gil
Giltuss HC syrup Gil
Giltuss Pediatric liquid Gil
Gauss Ped-C solution Gil
H-C Tussive syrup Vintage
Histacol DM Pediatric syrup Breckenridge
Histinex HC syrup Ethex
Histinex PV syrup Ethex
Histussin HC syrup Victory
Hydramine elixir Ivax
Hydrofed solution Larken
Hydro-Tussin CBX solution Ethex
Hydro-Tussin DI-IC solution Ethex
Hydro-Tussin DM elixir Ethex
Hydro-Tussin EXP solution Ethex
Hydro-Tussin HC syrup Ethex
Hydro-Tussin HD liquid Ethex
Hydro-Tussin XP syrup Ethex
Jaycof Expectorant syrup Pharmakon
Jaycof-HC liquid Pharmakon
Jaycof-XP syrup Pharmakon
Levall liquid Andrx Auriga
Levall solution Andrx Auriga
Levall 5.0 liquid Andrx Auriga
Lodrane liquid ECR
Lodrane D suspension ECR
Lodrane XR suspension ECR
Lohist D syrup Larken
Lohist DM syrup Larken
Lohist-LO solution Larken
Lortuss DM solution Proethic
Marcof Expectorant syrup Marnel
Maxi-Tuss HCG solution MCR American
Maxi-Tuss HCX solution MCR American
M-Clear solution R. A. McNeil
M-Clear JR solution R. A. McNeil
Medi-Brom elixir Medicine Shoppe
Mintuss G syrup Breckenridge
Mintuss MR syrup Breckenridge
Mintuss MS syrup Breckenridge
Mintuss NX solution Breckenridge
Motrin Cold Children's suspension McNeil Consumer
Myhist-DM solution Larken
Myhist-PD solution Larken
Nalex-A liquid Blansett Pharmacal
Nalex-DH liquid Blansett Pharmacal
Nasop suspension Hawthorn
Neotuss-D liquid A. G. Marin
Neotuss S/F liquid A. G. Marin
Norel DM liquid US Pharmaceutical
Novahistine DH solution Deston
Organidin NR liquid Medpointe
Pancof syrup Pamlab
Pancof EXP syrup Pamlab
Pancof HC solution Pamlab
Pancof XP solution Pamlab
PediaCare Children's syrup Johnson & Johnson Consumer
PediaCare Cough + Cold Children's liquid Johnson & Johnson Consumer
PediaCare Decongestant & Cough liquid Johnson & Johnson Consumer
PediaCare Long-Acting Johnson & Johnson
Cough solution Consumer
PediaCare Multi-Symptom Cold liquid Johnson & Johnson Consumer
PediaCare Nightrest liquid Johnson & Johnson Consumer
Pediahist DM syrup Boca Pharmacal
Pedia-Relief liquid Major
Phanasin syrup Pharmakon
Phanasin Diabetic Choice syrup Pharmakon
Phanatuss syrup Pharmakon
Phanatuss DM Diabetic Choice syrup Pharmakon
Phena-HC solution GM
Phena-HC Diabetic Choice solution Pharmakon
Phena-S liquid GM
Phena-S 12 suspension GM
Pneumotussin 2.5 syrup ECR
Poly Hist DM solution Poly
Poly Hist HC solution Poly
Poly Hist PD solution Poly
Poly-Tussin solution Poly
Poly-Tussin DM syrup Poly
Poly-Tussin HD syrup Poly
Poly-Tussin XP solution Poly
Pro-Clear solution Pro-Pharma
Prolex DM liquid Blansett Pharmacal
Pro-Red solution Pro-Pharma
Qual-Tussin DC syrup Pharmaceutical Associates
Quintex syrup Qualitest
Q-Tussin liquid Qualitest
Q-Tussin PE liquid Qualitest
Relacon-DM NR solution Cypress
Relacon-HC solution Cypress
Relasin DM solution Cypress
Rescon-DM liquid Capellon
Rescon-GG liquid Capellon
Rindal HD liquid Breckenridge
Rindal HD Plus solution Breckenridge
Robitussin Chest Congestion syrup Wyeth Consumer
Robitussin Cough & Allergy solution Wyeth Consumer
Robitussin Cough & Cold CF syrup Wyeth Consumer
Robitussin Cough & Congestion liquid Wyeth Consumer
Robitussin Cough, Cold & Flu Nighttime solution Wyeth Consumer
Robitussin Cough DM syrup Wyeth Consumer
Robitussin DM syrup Wyeth Consumer
Robitussin Head & Chest Congestion PE syrup Wyeth Consumer
Robitussin PE syrup Wyeth Consumer
Robitussin Pediatric Cough syrup Wyeth Consumer
Robitussin Pediatric Cough & Cold CF solution Wyeth Consumer
Robitussin Pediatric Cough & Cold Long-Acting solution Wyeth Consumer
Robitussin Pediatric Night Relief liquid Wyeth Consumer
Rondec solution Biovail
Rondec DM drops Biovail
Rondec DM solution Biovail
Ru-Tuss DM solution Sage
Scot-Tussin Diabetes CF liquid Scot-Tussin
Scot-Tussin DM solution Scot-Tussin
Scot-Tussin Expectorant solution Scot-Tussin
Scot-Tussin Original solution Scot-Tussin
Scot-Tussin Senior solution Scot-Tussin
Siladryl Allergy solution Silarx
Sildec syrup Silarx
Sildec-DM syrup Silarx
Sildec-PE solution Silarx
Sildec PE-DM solution Silarx
Sil-Tex liquid Silarx
Siltussin DAS liquid Silarx
Siltussin DM DAS Cough Formula syrup Silarx
Siltussin SA syrup Silarx
Simply Cough liquid McNeil Consumer
Sudafed Children's solution Pfizer
Sudafed Children's Cold & Cough solution Pfizer
Sudatuss DM syrup Pharm Generic
Sudatuss-2 liquid Pharm Generic
Sudatuss-SF liquid Pharm Generic
Triant-HC solution Hawthorn
TriTuss solution Everett
Tri-Vent DM solution Ethex
Tri-Vent DPC syrup Ethex
Tusdec-DM solution Cypress
Tusnel solution Llorens
Tusnel Pediatric solution Llorens
Tussafed-EX syrup Everett
Tussafed-EX Pediatric drops Everett
Tussafed-EX Pediatric liquid Everett
Tussafed-HC syrup Everett
Tussafed-HCG solution Everett
Tussall solution Everett
Tussinate syrup Pediamed
Tussi-Organidin DM NR solution Wallace
Tussi-Organidin DM-S NR solution Victory
Tussi-Organidin NR solution Wallace
Tussi-Organidin-S NR solution Victory
Tussi-Pres liquid Kramer-Novis
Tussi-Pres Pediatric solution Kramer-Novis
Tylenol Cold Children's suspension McNeil Consumer
Tylenol Cold Infants' drops McNeil Consumer
Tylenol Cold Plus Cough Children's suspension McNeil Consumer
Tylenol Cold Plus Cough Infants' suspension McNeil Consumer
Tylenol Flu Children's suspension McNeil Consumer
Tylenol Flu Night Time Max Strength liquid McNeil Consumer
Tylenol Sinus Children's suspension McNeil Consumer
Vazol solution Wraser Pharm
Vicks 44E Pediatric liquid Procter & Gamble
Vicks 44M Pediatric liquid Procter & Gamble
Vicks Dayquil Multi-Symptom liquid Procter & Gamble
Vicks Nyquil Children's liquid Procter & Gamble
Vicks Sinex spray Procter & Gamble
Vi-Q Tuss syrup Vintage
V-Tann suspension Breckenridge
Welltuss EXP solution Prasco
Z-Cof 8 DM suspension Zyber
Z-Cof 12 DM suspension Zyber
Z-Cof DM solution Zyber
Z-Cof DMX solution Zyber
Z-Cof HC solution Zyber
Z-Cof HCX solution Zyber
Z-Tuss Expectorant solution Magna
Z-Tuss DM syrup Magna
Ear, nose, and throat products
4-Way Saline Moisturizing Mist spray Bristol-Myers
Ayr Baby Saline spray B. F. Ascher
Bucalcide spray Seyer Pharmatec
Bucalsep solution Gil
Bucalsep spray Gil
Cheracol Sore Throat spray Lee
Fresh N'Free solution Geritrex
Gly-Oxide solution GlaxoSmithKline
Isodettes Sore Throat spray GlaxoSmithKline
Larynex lozenges Dover
Listermint solution Johnson & Johnson Consumer
Nasal Moist gel Blairex
Orajel Baby liquid Del
Orajel Baby Day & Night gel Del
Orajel Baby Nighttime gel Del
Orajel Baby Nighttime Teething Pain Medicine gel Del
Orajel Baby Teething Pain Medicine liquid Del
OraMagic Plus powder MPM Medical
OraMagicRx powder MPM Medical
Orasept Mouthwash/Gargle liquid Pharmakon
Tanac liquid Del
Throto-Ceptic spray S.S.S.
Triaminic Sore Throat spray Novartis Consumer
Vicks Sinex spray Procter & Gamble
Vicks Sinex 12 Hour spray Procter & Gamble
Zilactin Baby Extra Strength gel Zila Consumer
Gastrointestinal agents
Axid solution Braintree
Baby Gasz drops Lee
Colace solution Purdue
Colidrops Pediatric drops Dover
Gas Relief solution Perrigo
Imogen liquid Pharm Generic
Kaodene NN suspension Pfeiffer
Kaopectate Advanced Formula suspension Pharmacia Consumer
Liqui-Doss liquid Ferndale
Mylicon Infants' suspension Johnson& Johnson/Merck
Miscellaneous
Cytra-2 solution Cypress
Cytra-K solution Cypress
Faslodex solution AstraZeneca
Fluorinse solution Oral B
Namenda solution Forest
Primsol solution FSC
Topical products
Aloe Vesta 2-N-1 Antifungal ointment Convatec
Dermatone Lips 'n Face Protector ointment Dermatone
Dermatone Moisturizing Sunblock cream Dermatone
Dermatone Skin Protector cream Dermatone
Evoclin foam Connetics
Fleet Pain Relief pads Fleet
Fresh & Pure Douche solution Unico
Hendclens solution Woodward
Joint-Ritis Maximum Strength ointment Naturopathic
Neutrogena Acne Wash liquid Neutrogena
Neutrogena Antiseptic liquid Neutrogena
Neutrogena Antiseptic solution Neutrogena
Neutrogena Clear Pore gel Neutrogena
Neutrogena T/Derm liquid Neutrogena
Neutrogena Toner liquid Neutrogena
Neutrogena Toner solution Neutrogena
Podiclens spray Woodware
Sea Breeze Foaming Face Wash gel Clairol
Shade Uvaguard lotion Schering-Plough
Sportz Bloc cream Med-Derm
Therasoft Anti-Acne cream SFC/Solvent Free
Therasoft Skin Protectant cream SFC/Solvent Free
Tiger Balm Arthritis Rub lotion Prince of Peace Enterprises
Vitamins, minerals, and supplements
Adaptosode for Stress liquid HVS
Adaptosode R+R for Acute Stress liquid HVS
Apetigen elixir Kramer-Novis
Biosode liquid HVS
Detoxosode Products liquid HVS
Genesupp-500 liquid Pharm Generic
Genetect Plus liquid Pharm Generic
Multi-Delyn liquid Silarx
Multi-Delyn with Iron liquid Silarx
Nutrivit solution Llorens
Poly-Vi-Sol drops Mead Johnson
Poly-Vi-Sol with Iron drops Mead Johnson
Protect Plus liquid Gil
Strovite Forte syrup Everett
Supervite liquid Seyer Pharmatec
Suplevit liquid Gil
Tri-Vi-Sol with Iron drops Mead Johnson
Vitafol syrup Everett
Reference
Appendix M: Common Drug Interactions: Cytochrome P450 Interactions
Inducers (trade
Substrates (trade name) Inhibitors (trade name) name)
CYP1A2
Alosetron (Lotronex)
Amitriptyline (Elavil)
Anagrelide (Agrylin)
Aprepitant (Emend)
Caffeine
Cinacalcet (Sensipar)
Clomipramine (Anafranil)
Clozapine (Clozaril)
Cyclobenzaprine (Flexeril)
Desipramine (Norpramin)
Diazepam (Valium)
Diphenhydramine (Benadryl)
Erlotinib (Tarceva)
Flutamide (Eulexin)
Artemisinin
Fluvoxamine (Luvox)
Atazanavir (Reyataz)
Frovatriptan (Frova)
Cimetidine (Tagamet)
Gingko
Ciprofloxacin (Cipro)
Haloperidol (Haldol)
Clarithromycin (Biaxin)
Imipramine (Tofranil)
Enoxacin (Penetrex)
Indiplon
Erythromycin (E-Mycin)
Lidocaine
Cigarette smoke
Ethinyl estradiol
Melatonin
Phenobarbital
Fluvoxamine (Luvox)
Mexiletine (Mexitil) (Luminal)
Grapefruit juice
Mirtazapine (Remeron) Rifampin (Rifadin,
Rimactane)
Isoniazid (INH, Nydrazid)
Olanzapine (Zyprexa)
Ritonavir (Norvir)
Ketoconazole (Nizoral)
Ondansetron (Zofran)
Mexiletine (Mexitil)
Palonosetron (Aloxi)
Norfloxacin (Chibroxin,
Pimozide (Orap)
Noroxin, Norflox)
Propranolol (Inderal)
Tacrine (Cognex)
Ramelteon (Rozerem)
Thiabendazole (Mintezol)
Rasagiline (Azilect)
Zafirlukast (Accolate)
Ropinirole (Requip)
Zileuton (Zyflo)
Ropivacaine (Naropin)
R-warfarin (Coumadin)
Selegiline (Eldepryl)
Tacrine (Cognex)
Tamoxifen (Nolvadex)
Theophylline, aminophylline (Aerolate,

Aquaphyllin, Asmalix, Bronkodyl, Choledyl,
Constant-T, Duraphyl, Elixophyllin,
Phyllocontin, Quibron, Respbid, Slo-bid, Slo-
Phyllin, Sustaire, Theo-24, Theobid, Theochron,
Theoclear, Theo-Dur, Theolair, Theon,
Theospan, Theovent, Truphylline)
Thiabendazole (Mintezol)
Tizanidine (Zanaflex)
Triamterene
Zileuton (Zyflo)
Zolmitriptan (Zomig)
CYP2C9
Amprenavir (Agenerase)
Azapropazone Alcohol (intoxicating

dose)
Bosentan (Tracleer)
Amiodarone (Cordarone,
Candesartan (Atacand) Pacerone)
Celecoxib (Celebrex) Benzbromarone
Chlorpropamide (Diabinese) Cimetidine (Tagamet)
Diclofenac (Cataflam, Voltaren) Clopidogrel (Plavix)
Doxepin (Sinequan) Delavirdine (Rescriptor)
Dronabinol (Marinol) Disulfiram (Antabuse)
Fluoxetine (Prozac) Doxifluridine
Flurbiprofen (Ansaid) Efavirenz (Sustiva)
Fluvastatin (Lescol) Fluconazole (Diflucan)
Glimepiride (Amaryl) Fluorouracil (5-FU)
Glipizide (Glucotrol) Fluoxetine (Prozac)
Glyburide (DiaBeta) Fluvastatin (Lescol)

Glyburide (DiaBeta) Fluvastatin (Lescol)
Aminoglutethimide
(Cytadren)
Ibuprofen (Advil, Motrin) Fluvoxamine (Luvox)
Aprepitant (Emend)
Indomethacin (Indocin) Gemfibrozil (Lopid)
Barbiturates
Irbesartan (Avapro) Imatinib (Gleevec)
Bosentan (Tracleer)
Losartan (Cozaar) Isoniazid (INH, Nydrazid)
Carbamazepine
Melatonin Leflunomide (Arava)
(Tegretol)
Meloxicam (Mobic) Metronidazole (Flagyl)
Phenobarbital
(Luminal)
Montelukast (Singulair) Miconazole (Monistat)
Rifampin (Rifadin,
Naproxen (Aleve, Naprosyn) Modafinil (Provigil)
Rimactane)
Nateglinide (Starlix) Phenytoin (Dilantin)
Phenytoin (Dilantin) Sertraline (Zoloft)
Piroxicam (Feldene) Sitaxsentan
Ramelteon (Rozerem) Sulfamethoxazole

(Bactrim, Gantanol,
Rosiglitazone (Avandia) Septra, Sulfatrim)
Rosuvastatin (Crestor) Sulfaphenazole
Sildenafil (Viagra) Sulfinpyrazone

(Anturane)
Sitaxsentan
Trimethoprim (Bactrim,
Sulfamethoxazole (Bactrim, Gantanol, Septra, Primsol, Proloprim,
Sulfatrim) Septra, Sulfatrim,
Trimpex)
S-warfarin (Coumadin)
Valproic Acid
Tolbutamide (Orinase) (Depakene)
Torsemide (Demadex) Voriconazole (Vfend)
Valdecoxib (Bextra) Zafirlukast (Accolate)

Valsartan (Diovan)
Voriconazole (Vfend)
CYP2C19
Aprepitant (Emend)
Carisoprodol (Soma)
Citalopram (Celexa)
Chloramphenicol
Diazepam (Valium)
Delavirdine (Rescriptor)
Doxepin (Sinequan)
Efavirenz (Sustiva)
Escitalopram (Lexapro)
Felbamate (Felbatol)
Flunitrazepam
Fluconazole (Diflucan) Artemisinin
Fluoxetine (Prozac)
Fluoxetine (Prozac) Barbiturates
Fluvastatin (Lescol) Carbamazepine
Lansoprazole (Prevacid) (Tegretol)
Fluvoxamine (Luvox)
Mephenytoin (Mesantoin) Phenytoin (Dilantin)
Isoniazid (INH, Nydrazid)
Methadone Norethindrone
Moclobemide (Manerix) Rifampin
Lansoprazole (Prevacid) (Ramactane)
Nelfinavir (Viracept)
Moclobemide (Manerix) St. John's wort
Modafinil (Provigil)
Omeprazole (Prilosec)
Pantoprazole (Protonix)
Oxcarbazepine (Trileptal)
Pentamidine (Pentam)
Ticlopidine (Ticlid)
Phenobarbital
Phenytoin (Dilantin)
Proguanil (active metabolite)
Rabeprazole (Aciphex)
Sertraline (Zoloft)
Thalidomide (Thalomid)
CYP2D6
Almotriptan (Axert)
Alprenolol
Atomoxetine (Strattera)
Bisoprolol (Zebeta)
Carvedilol (Coreg)
Cevimeline (Evoxac)
Chlorpheniramine
Chlorpromazine (Thorazine)
Citalopram (Celexa)
Codeine
Darifenacin (Enablex)
Debrisoquin
Pacerone)
Dextromethorphan
Bupropion (Wellbutrin)
Dihydrocodeine
Chloroquine (Aralen)
Chlorpheniramine
Dolasetron (Anzemet)
Chlorpromazine
Donepezil (Aricept)
(Thorazine)
Doxepin (Sinequan)
Celecoxib (Celebrex)
Encainide
Citalopram (Celexa)
Flecainide (Tambocor)
Fluoxetine (Prozac)
Diphenhydramine
(Benadryl)
Fluvoxamine (Luvox)
Galantamine (Reminyl)
Fluoxetine (Prozac)
Hydrocodone
Halofantrine (Halfan)
Loratadine (Claritin) Rifampin (Rifadin,
Rimactane)
Hydroxychloroquine
Maprotiline (Ludiomil)
Imatinib (Gleevec)
Methadone
Paroxetine (Paxil)
Methamphetamine
Perphenazine (Trilafon)
Metoclopramide (Reglan)
Promethazine
Metoprolol (Lopressor)
(Phenergan)
Mexiletine (Mexitil)
Propafenone (Rhythmol)
Mianserin
Propoxyphene (Darvon)
Mirtazapine (Remeron)
Quinacrine
Nortriptyline (Aventyl, Pamelor)
Quinidine (Cardioquin,
Dura-Tabs, Quinaglute,
Quinidex)
Quinine
Oxycodone (Endocodone, OxyContin, OxyIR,
Ranolazine (Ranexa)
Percodan, Percolone, Roxicodone)
Risperidone (Risperdal)
Ritonavir (Norvir)
Paroxetine (Paxil)
Sertraline (Zoloft)
Perhexiline (Pexid)
Terbinafine (Lamisil)
Perphenazine (Trilafon)
Thioridazine (Mellaril)
Promethazine (Phenergan)
Propafenone (Rhythmol)
Protriptyline (Vivactil)
Ranolazine (Ranexa)
Sertindole (Serlect)
Sertraline (Zoloft)
Simvastatin (Zocor)
Thioridazine (Mellaril)
Timolol (Betimol, Blocadren, Timoptic)
Tolterodine (Detrol)
Tramadol (Ultram)
Trazodone (Desyrel)
Venlafaxine (Effexor)
Yohimbine
CYP2E1
Acetaminophen (Tylenol)
Chlorzoxazone (Parafon Forte)
Ethanol, enflurane, halothane, isoflurane,

methoxyflurane, sevoflurane
Chronic ethanol
Disulfiram (Antabuse) Isoniazid (INH,
Theophylline, aminophylline (Aerolate,
Nydrazid)
Aquaphyllin, Asmalix, Bronkodyl, Choledyl,
Constant-T, Duraphyl, Elixophyllin,
Phyllocontin, Quibron, Respbid, Slo-bid, Slo-
Phyllin, Sustaire, Theo-24, Theobid, Theochron,
Theoclear, Theo-Dur, Theolair, Theon,
Theospan, Theovent, Truphylline)
CYP3A
Alfentanil (Alfenta)
Alfuzosin (Uroxatral)
Almotriptan (Axert)
Alprazolam (Xanax)
Amiodarone (Cordarone)
Amlodipine (Norvasc)
Aprepitant (Emend)
Astemizole (Hismanal)
Atorvastatin (Lipitor)
Bepridil (Vascor)
Bexarotene (Targretin)
Bosentan (Tracleer)
Bromocriptine (Parlodel)
Budesonide (Entocort)
Bupivacaine (Sensorcaine)
Buprenorphine (Subutex)
Buspirone (Buspar)
Carbamazepine (Tegretol)
Cevimeline (Evoxac)
Chlorpheniramine
Cilostazol (Pletal)
Cisapride (Propulsid)
Citalopram (Celexa)
Clonazepam (Klonopin)
Colchicine
Conivaptan (Vaprisol)
Cyclophosphamide (Cytoxan)
Pacerone)
Cyclosporine (Gengraf, Neoral, Sandimmune)
Dapsone (Avlosulfon)
Aprepitant (Emend)
Darifenacin (Enablex)
Darunavir (Prezista)
Dasatinib (Sprycel)
Chloramphenicol
Dexamethasone (Decadron)
Dextromethorphan
Conivaptan (Vaprisol)
Diazepam (Valium)
Cyclosporine (Neoral)
Diclofenac (Voltaren)
Danazol (Danocrine)
Dihydroergotamine (D.H.E. 45)
Darunavir (Prezista) Aminoglutethimide
(Cytadren)
Diltiazem (Cardizem)
Dasatinib (Sprycel)
Barbiturates
Disopyramide (Norpace)
Bexarotene
Docetaxel (Taxotere)
Diltiazem (Cardizem) (Targretin)
Dolasetron (Anzemet)
Erythromycin (E-Mycin) Bosentan (Tracleer)
Donepezil (Aricept)
Estrogens Carbamazepine
(Tegretol)
Doxorubicin (Adriamycin)
Fluconazole (Diflucan)
Dexamethasone
Droperidol
Fluoxetine (Prozac) (Decadron)
Dutasteride (Avodart)
Fluvoxamine (Luvox) Efavirenz (Sustiva)
Ebastine (Kestine)
Fosamprenavir (Lexiva) Glucocorticoids
Efavirenz (Sustiva)
Grapefruit juice Griseofulvin
(Grisactin)
Eletriptan (Relpax)
Imatinib (Gleevec)
Eplerenone (Inspra)
Indinavir (Crixivan)
Nafcillin (Unipen)
Ergotamine (Ergomar)
Interleukin-10
Nevirapine
Erlotinib (Tarceva)
Isoniazid (INH, Nydrazid) (Viramune)
Erythromycin (E-Mycin)
Itraconazole (Sporanox) Oxcarbazepine
(Trileptal)
Phenobarbital
Estazolam (Prosom)
Lapatinib (Tykerb) (Luminal)
Estrogens
Miconazole (Monistat) Phenytoin (Dilantin)
Eszopiclone (Lunesta)
Mifepristone (Mifeprex) Primidone (Mysoline)
Ethosuximide (Zarontin)
Nefazodone (Serzone) Rifabutin
(Mycobutin)
Etoposide (Vepesid)
Nelfinavir (Viracept)
Rifampin (Rifadin,
Exemestane (Aromasin)
Nicardipine (Cardene) Rimactane)
Felodipine (Plendil)
Norfloxacin (Chibroxin, St. John's wort
Noroxin)
Fentanyl (Sublimaze)
Topiramate
Posaconazole (Noxafil) (Topamax)
Finasteride (Proscar)
Flunitrazepam
Quinupristin (Synercid)
Flurazepam (Dalmane)
Ranolazine (Ranexa)
Fosamprenavir (Lexiva)
Ritonavir (Norvir)
Galantamine (Reminyl)
Saquinavir (Fortovase,
Garlic
Invirase)
Gefitinib (Iressa)
Gingko
Telithromycin (Ketek)
Granisetron (Kytril)
Troleandomycin (TAO)
Halofantrine (Halfan)
Verapamil (Calan)
Ifosfamide (Ifex)
Imatinib (Gleevec)
Indiplon
Irinotecan (Camptosar)
Isradipine (DynaCirc)
Itraconazole (Sporanox)
Ivabradine
Ixabepilone (Ixempra)
Lansoprazole (Prevacid)
Lapatinib (Tykerb)
Levomethadyl (Orlaam)
Lidocaine
Loperamide (Imodium)
Loratadine (Claritin)
Losartan (Cozaar)
Lovastatin (Mevacor)
Maraviroc (Selzentry)
Mefloquine (Lariam)
Meloxicam (Mobic)
Methadone
Methylprednisolone
Midazolam (Versed)
Mifepristone (Mifeprex)
Mirtazapine (Remeron)
Montelukast (Singulair)
Nateglinide (Starlix)
Nefazodone (Serzone)
Nicardipine (Cardene)
Nifedipine (Adalat)
Nimodipine (Nimotop)
Nisoldipine (Sular)
Nitrendipine (Baypress)
Oxybutynin (Ditropan)
Oxycodone (Percodan)
Paclitaxel (Taxol)
Pantoprazole (Protonix)
Paricalcitol (Zemplar)
Pimozide (Orap)
Pioglitazone (Actos)
Praziquantel (Biltricide)
Prednisolone
Prednisone
Protease inhibitors
Quazepam (Doral)
Quetiapine (Seroquel)
Quinacrine
Quinidine (Cardioquin, Quinaglute, Quinidex)
Quinine

Ramelteon (Rozerem)
Ranolazine (Ranexa)
Repaglinide (Prandin)
Rifabutin (Mycobutin)
Ritonavir (Norvir)
Ropivacaine (Naropin)
Selegiline (Eldepryl)
Sertindole (Serlect)
Sertraline (Zoloft)
Sibutramine (Meridia)
Sildenafil (Viagra)
Simvastatin (Zocor)
Sirolimus (Rapammune)
Sitaxsentan
Solifenacin (Vesicare)
Sufentanil (Sufenta)
Sulfamethoxazole (Bactrim)
Sunitinib (Sutent)
Tacrolimus (Prograf)
Tadalafil (Cialis)
Tamsulosin (Flomax)
Teniposide (Vumon)
Terfenadine
Testosterone
Theophylline
Tiagabine (Gabitril)
Tinidazole (Tindamax)
Tipranavir (Aptivus)
Tolterodine (Detrol)

Tramadol (Ultram)
Trazodone (Desyrel)
Triamterene
Triazolam (Halcion)
Valdecoxib (Bextra)
Vardenafil (Levitra)
Venlafaxine (Effexor)
Verapamil (Calan)
Vesnarinone
Vinblastine (Velbane)
Vincristine (Oncovin)
Yohimbine
Ziprasidone (Geodon)
Zolpidem (Ambien)
Zonisamide (Zonegran)
Zopiclone (Imovane)
References
Hansten PD, Horn JR. The Top 100 Drug Interactions. Freeland, Wash.: H&H Publications; 2008.

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THE APhA COMPLETE REVIEW FOR PHARMACY - 7th Ed.

The APhA Complete Review for Pharmacy, Seventh Edition

Dick R. Gourley PharmD, FAPhA

James C. Eoff III PharmD

Acquiring Editor: Sandra J. Cannon

©2010 by the American Pharmacists Association

All rights reserved

Library of Congress Cataloging-in-Publication Data

The APhA complete review for pharmacy / Dick R. Gourley,

How To Order This Book

Eoff's NAPLEX Study Guide… xiii

2 Federal Pharmacy Law… 21

3 Dosage Forms and Drug Delivery Systems… 43

6 Pharmacokinetics, Drug Metabolism, and Drug Disposition… 109

7 Biotechnology and Pharmacogenomics… 135

9 Heart Failure… 179

10 Cardiac Arrhythmias… 199

11 Ischemic Heart Disease… 219

13 Diabetes Mellitus… 265

14 Thyroid, Adrenal, and Miscellaneous Endocrine Drugs… 289

16 Kidney Disease… 323

17 Critical Care, Fluids, and Electrolytes… 349

20 Solid Organ Transplantation… 409

21 Gastrointestinal Diseases… 427

22 Rheumatoid Arthritis, Osteoarthritis, Gout, and Lupus… 455

23 Pain Management and Migraines… 481

24 Seizure Disorders… 507

25 Psychiatric Disease… 531

26 Common Dermatologic Disorders… 561

27 Nonprescription Medications… 585

28 Asthma and Chronic Obstructive Pulmonary Disease… 613

29 Infectious Disease… 633

34 Geriatrics and Gerontology… 741

35 Toxicology and Chem-Bioterrorism… 759

37 Thromboembolic Disease… 799

A Normal Laboratory Values… 823

B Drugs in Renal Failure… 827

C Drugs in Hepatic Failure… 839

D Top 200 Prescription Drugs… 845

E Top 200 Over-the-Counter Products… 848

F Drugs Excreted in Breast Milk… 851

G Drugs That May Cause Photosensitivity… 853

H Drug Information Resources by Category… 857

I Drugs That Should Not Be Crushed… 860

K Sugar-Free Products… 879

L Alcohol-Free Products… 885

M Common Drug Interactions: Cytochrome P450 Interactions… 891

NAPLEX® is a trademark of the National Association of Boards of Pharmacy® (NABP®), and

DICK R. GOURLEY, PHARMD, FAPHA

About the Authors

Hassan Almoazen, PhD

W. Andrew Bell, PharmD

Ronald L. Braden, PharmD

Lawrence M. Brown, PharmD, PhD

Rex O. Brown, PharmD, BCNSP

Joyce E. Broyles, PharmD, BCNSP

Jason Carter, PharmD

Peter A. Chyka, PharmD, FAACT, DABAT

Catherine M. Crill, PharmD, BCPS, BCNSP