Neupogen IV

Just a reminder that Neupogen IV needs to be diluted in D5w.

stress dose steroids peri-op

I was asked about dosing steroids peri- op for a patient who has been on long term prednisone and was about to have a C-section. I was not very familiar with this so I thought I would share what I found out. Information is also in the Lexi Drug Handbook under Hydrocortisone and I put a folder with information in the drawer of knowledge. Thank you to Nick, Chanda, and Kevin for helping me find information.



Stress dose steroids should be given around surgery for patients who have been recieving an equivalent of prednisone 5 mg /day. The stress dose should be given no more than 1-3 days peri-op and the dose is proportionate to the severity of the surgery. After the stress dosing period patients can resume their normal dosage of whatever steroid they are on.



The rationale behind this is that patients on long term steroids have suppression of the HPA axis so they may be unable to produce this physiologic response to stress such as surgery. In patients not on steroids, the HPA axis is activated during surgery.



Stress dose steroids are also recommended in patients who have recently stopped taking steroids if they had been on them long term. The HPA axis may take up to a year to recover after stopping long-term steroids. Short bursts of steroids would not fall under this category (pts taking steroids <1>

Here is a sample dosing schedule:

Surgery Type:

Minor (outpatient): Hydrocortisone 25 mg x1

Moderate (total joint): Hydrocortisone 25mg q12h x1 day

Hydrocortisone 25mg x1 the next day

Major (CABG): Hydrocortisone 50mg IV q8h x1day

Hydrocortisone 50mg IV q12h x1day

Hydrocortisone 25mg IV q12h x1day

Rx Tidbits from Nick

If somebody is not getting adequate relief from morphine they can take dextromethorphan OTC and that will increase morphine levels by inhibiting the metabolism of morphine by 2D6.

Quinolones can increase your risk for seizure by enhancing the release of glutamine, a neurotransmitter involved with seizures.

Nick -- what did you say about lasix? Was it that Lasix is bid 6 hrs apart and that is how it got part of it's name -- lasix? Please correct me if I am wrong.

surgery tidbits

I got asked the other day from surgery for some 'tetracaine with epi'. Thanks to Chanda, she knew what this was. You can print a label under 'surgery patient' and we have to compound it.

Today I got asked from anesthesia for 'quad strength' norepi and epi. I didn't know what this was...as well as everyone else I asked. I called the anesthesiologist (sp) back and asked if they just wanted a concentrated drip and they said 'yes'.

H1N1 Influenza Management CE at KU Pharmacy School 10/1/09

Sorry it took so long for me to get this out!

Stormont Pharmacists in attendance: Amber, Seth, Jenny C.

Speaker: Infection Control Nurse at KC hospital

-The rate of H1N1 deaths so far are lower than the flu but it is who it is killing that is bothersome (opposite of seasonal flu). About 99% of all flu cases right now in the US is H1N1. The seasonal flu won't hit until later this winter.

-There are 3 types of influenza - A - B - C - the H1N1 is influenza "A". Generally in the seasonal flu vaccine there are always 2 types of "A" and one type of "B".

- "H" stands for hemagglutinin and "N" stands for Neuramindase. There are 15 different hemagglutinins and 9 different neuramindases.

- Some people >50 may have some mild immunity.

- More lung damage (long term lung damage) seen with H1N1. Average length of time on ventilator is 25 days. Average length of hospital stay is 6-8 weeks.

-25-30 % of people will become ill and unable to work for 7-10 days. Economic impact estimated at $71-$165 billion.

-Who is at risk? infants, young age 4-24 yrs, people with underlying conditions (lung conditions, diabetes), pregnant and post partum women, immunosuppressed, obesity BMI >30

-Symptoms: fever >100, muscle aches, malaise, runny nose, cough, diarrhea in some

- Testing for H1N1 not usually recquired or recommended. The Rapid Influenza Testing is only 10-50 % accurate.

-Complications - primary cause of death is acute resp distress syndrome, 2nd cause of death bacterial pneumonia

-How long to stay at home? kids are going back to school too soon. Kids shed virus from nose longer than adults. Kids should return to school after 24 hrs of being afebrile w/o antipyretics. Health care worker those around people at risk should stay home 7 days from onset of symptoms or resolution of fever

-treatment: supportive care for mild cases, for severe cases: antivirals, hydration, ventilator

-H1N1 vaccine: Prioritize: 1) pregnant 2) caregivers for kids <6 mths 3) health care/ER workers 4) people b/w ages 6mth-24 yo 5) people 25-64 who are at high risk b/c of underlying conditions

-H1N1 vaccine: single IM dose for adults, kids <10>50 b/c it has not been studied in these populations.

-It takes 2 weeks for the vaccine to 'get on board'.

-You can get both seasonal flu and H1N1 vaccine at the same time.

Vfend talk at Brick Oven last Wed night

Here is what I learned at the talk about Vfend last Wed at Brick Oven. Other pharmacists in attendance were Jeff, Kerry, Ann, and Doug. If you were there please feel free to add to this!

If you have a catheter in you are at risk for fungal infections. Also, if you have a TPN or are immunocompromised.

Candida is the most common fungal infection but now there are many different strains.

If you start the antifungals early you decrease the mortality rate drastically....so it is good to do prophylaxis b/c it can take a few days for the cultures to come back...then you can just dc the antifungal if you don't need it. It is best to start it w/in 12-24 hrs.

Vfend has ALOT of drug interactions. Carbamazepine, phenytoin, rifampin....plus several others I can't remember. So, that is something we can watch out for.

Vfend has EXCELLENT oral bioavailability so if they have a working gut no need for IV.

Vfend works better than Diflucan b/c it works on 2 different pathways and Diflucan just works on one.

If it is an uncomplicated fungal infection use Diflucan b/c it is cheaper.

Other tidbits:

Vancomycin doesn't reach high levels in the lungs so if you have MRSA in the lungs use Zyvox. Zyvox reaches concentrations in the lungs 5-6 x that of vanco.

A common mistake in dosing Vanco is to increase the dose instead of decreasing the frequency. You are not concerned about high peaks but rather a consistent trough of 15-20. So, if it is 1 G q12h and you get a low trough do q8h.

There is no need to use Zosyn for community acquired pneumonia.

He talked about continuous infusion antibiotics, such as Zosyn, and how studies have said it works better but it isn't catching on yet.

Sorry guys, that last post was from my lovely fiancee...

thoughts

I think you are pretty special. XOXO

OMNICELL

I learned something new today. Omnicell will not accept 4 digits past a decimal point. For example when entering levothyroxine 0.075mg 1/2 tab bid (0.0375mg) it will cross to clinicomp, but it won't be anywhere on the omnicell screen. So, after taking 6 hours to figure this out, we ended up entering the dose in mcg...

Pregnancy & H1N1 Vaccine

The CDC is also recommending H1N1 vaccine for all pregnant woman as well.

Pregnancy & H1N1

More on H1N1 from your H1N1 specialist:

If you look up the pregnancy risk factor for both Tamiflu and Relenza you will find them both to be a risk factor C. However, the CDC does recommend treatment and prophylaxis in pregnant women. The flu seems to be more severe in pregnant women than in non-pregnant individuals and not treating has been linked to increased maternal mortality.

The manufacturers have based their risk rating on animal studies that have shown minor skeletal deformities, however no adverse effects have occurred in humans (or their fetuses) who have taken either antiviral. Also, and an in vitro study of a human placenta found that the active metabolite in Tamiflu does not cross the placenta.

Interestingly enough, Tamiflu is the drug of choice for the TREATMENT of influenza in pregnancy. This is because it is systemically absorbed. (I know that sounds backwards, but it must provide better protection for the infant) However, Relenza is the drug of choice for PROPHYLAXIS in pregnancy. This is because it is not systemically absorbed.

Fun Facts From Rotations

Here are some things I learned on my rotation this week.

We had a gentlemen with a Hb=17.9 The range for men is 13.8 to 17.2
Polycythemia is the condition and in this case, it is smoker's polycythemia. There are multiple forms. Primary is of unknown cause. Secondary, has a known cause. Known causes include, COPD, carbon monoxide exposure (long-term like smoking), tumor of the kidney. In this patient case, the carbon monoxide from smoking attachs to the Hb allowing less oxygen transport to the tissue causing hypoxia at the tissue. This signals the body to increase erythropoietin production from the kidney, causing an increase in RBC production from the bone marrow. In COPD patients, inadequate oxygen exchange at the alveoli causes hypoxia at the tissue resulting in the same upregulation of erythropoietin production. Tumors in the kidney or malfuction in the bone marrow may also lead to polycythemia but have different etiologies.

Adcirca (Tadalafil, aka Cialis) was recently approved for treatment of pulmonary arterial hypertension at 40mg po Daily. Revatio (Sildenafil) is also used for treatment of PAH.

Sodium bicarbonate drips are used as renal protectants for patients undergoing procedures requiring a contrast dye. I knew about acetylcysteine, but not sodium bicarb.

Most importantly: If you drop a stent on the floor during an angioplasty, you lose $3000 and hopefully not your job.

aleplase equivalent to urokinase

Had fun with Dr. Misery tonight. He needed to "uncork" a cerebral shunt with a lytic. Had wanted 25,000 units of Urokinase. Us old folks have used it but it hasn't been on the market for several years. During the second phone call we had he did say he had used it in Canada. Then came the zinger "So what is the equivalent to alteplase?". After a lot of research, I found an article in Radiology journal that said "so approximately 31,000 units of Urokinase is equal to 1 mg of alteplase". After another talk, he decided on 2 mg of alteplase should do it. Who says nights are dull? (At the same time, ER wanted a STAT antibiotic and OR wanted a STAT Hemabate.)

FYI

You may already know, but in case you are on "Who wants to be a millionaire" and it's the million dollar question-now you know:

The first 4 letters in the drug warfarin stand for Wisconsin Alumni Research Foundation...
because they came up with the anticoagulant. It was originally used as a poison for rats because they would bleed out. Now they use it on humans. Makes you feel all warm and fuzzy inside...

Tikosyn Patient Education Kit

We have Tikosyn patient education take home kits in a big white envelope located by the Lovenox kits.

H1N1-Should we be afraid?

I've been asked by several lay people in the community about H1N1 recently, and I've heard all kinds of rumors some even from MDs. My Dad (who is a superintendent of schools) recently went to a conference on this pandemic teaching them how to handle the situation, prevent spread, etc. Here are some tidbits I have found interesting...and that helps me answer some questions:

Stats: (from CDC website)
*Between April 15 and July 24 there were 43,771 confirmed cases of swine flu in the US, of these 5011 were hospitalized and 302 people died. Also...
*The age group with the highest hospitalizations due to H1N1 is Age 0-4. The age group with the highest confirmed cases is age 5-24. The age group with the highest rate of death due to H1N1 is age 25-49.
*US mortality rate of H1N1 so far is 0.57%...average mortality rate of seasonal flu is 0.12%.
*They are estimating that 50% of the US population will become infected this fall (not all infected will necessarily have symptoms) They are also estimating 2million hospitalizations due to H1N1 and 30,000-90,000 deaths...35,000 people die annually from the seasonal flu.


Stats: (from KDHE website)
Sedgwick and Riley co. have the most cases at 42 and 34 respectively. Shawnee Co (Topeka) has 8 confirmed cases.

My opinion: (for what it is worth)
It is a little scary that the death rate of H1N1 is nearly 5x that of seasonal flu...however it is still only 0.5%. It is also concerning that normally healthy age groups are the ones contracting this flu. However, still most deaths occur in people with other underlying medical conditions. I think it is good to be a little scared b/c that will help everyone take precautions that will prevent the spread, but I don't think it is worth losing sleep at night worrying that you or someone you love will get Swine Flu.

Recommendations from the CDC to prevent transmission of H1N1:
1. If you have a fever...STAY HOME until fever is gone...w/o the use of antipyretics. Also try to stay away from others as much as possible.
2. Wash your hands often...especially after you cough or sneeze.
3. Avoid touching your eyes, nose, mouth
4. Cover your nose/mouth with a tissue when you cough/sneeze, then throw away tissue.

*I feel like the above is common sense with the exception of #1. We tend to feel an obligation to go to work even when we are sick, but that has been the strongest recommendation. My dad was told at his conference that if his whole cafeteria staff is out sick...so be it...it is better than spreading H1N1 to every child and then every family in town.

Treatment: (I'm almost done...I promise)
Tamiflu and Relenza are both currently recommended for treatment and prophylaxis of H1N1. I was told by a prescriber in the community that Tamiflu is not recommended but this is FALSE. There are a few cases of resistance to Tamiflu, but the CDC still feels that for the most part it is effective. This Link http://www.cdc.gov/h1n1flu/recommendations.htm provides very good info on treatment on prophylaxis for all ages if you need help.

I know we are tired of this subject...So sorry to talk about it so long, but I thought most of this was useful info (which is why I looked it up) Hopefully you won't revoke my posting rights :o)

Does the fax server need Viagra?

Is it up or not? Here is how to tell.

Picking Interfaces -> Faxing -> View -> Fax Log in GE will display a list of all the current faxes in the queue. If the times are very close to the current time then the system is working. These are the individual faxes and where they are in the queue.

Pressing the Status button from this screen then pressing Find will give a list of the last tasks that the fax server did. If the Check for Images times are close to real time then it is working. You can also reach this by picking Interfaces -> Faxing -> Status button -> Find button

If it is down (and needs the Viagra), call GE and tell them to reboot the server.

Can you teach an old doc new heparin protocol?

Interesting note. A doctor can order heparin dosing by PTTs but has to write his own sliding scale since we are now using the new orders. They can't use the old sliding orders. (per Katie)

S.T.A.T. orders

Just FYI, I received a call from the respiratory charge asking me to enter an Albuterol neb treatment as a once dose. I asked for an order, and she said it is part of the "STAT" orders. Not knowing what the "STAT" orders were, I asked her to please fax them. I believe, and after concurring with Super-Mindy, am positive these orders are standing orders for the S.T.A.T. team that tries to avert a code blue. There are orders for Change in Mental Status, Acute Dyspnea, Chest Pain, Seizure, and Acute Bleeding. Drug orders include Naloxone, D50W, NTG and Albuterol. I printed a copy and set it on the counter for all to see. Enjoy.....

Intrathecal MTX and Hydrocortisone

Currently, only three agents are licensed for intrathecal chemotherapy
They are methotrexate, cytarabine (a.k.a. Ara-C) and hydrocortisone

Today we made an intrathecal chemo with MTX and hydrocortisone in the same syringe. The MTX must be diluted to 2.5-5 mg/ml. You must use all PF products when mixing items for intrathecal use!! To use the hydrocortisone, the diluent in the acti-vial is NOT PF and therefore you have to pull out the diluent and replace it with PF NS.

Digifab

I was asked to dose Digifab (for digoxin toxicity) today and I have never done a Digifab order before. There are 2 digoxin antidotes - Digibind and Digifab. We carry Digifab. It comes 40 mg/vial. There is a chart in the package insert for dosing. You either have to know the body load of digoxin in mg and divide by 0.5 OR or you have to know the digoxin level. In this case, we had a level (thank goodness....b/c what does body load mean?). You also need to know their weight. The chart will tell you how many vials to give.

1 vial of Digifab and Digibind will bind to 0.5 mg digoxin.

Symptoms of life threatening toxicity due to digoxin overdose include severe arrhytmias, bradycardia, heart block not responsive to atropine, and/or hyperkalemia.

Thank you for your interest in reading about Digifab.

Rh Factor

rhesus factor, Rh factor, Rh (a blood group antigen possessed by Rh-positive people; if an Rh-negative person receives a blood transfusion from an Rh-positive person it can result in hemolysis and anemia)

The only way antibodies are developed against the Rh factor is through placental sensitization or transfusion.

QUESTION: Does anyone know why we have WinRho in our Cubix fridge but they get Rhogam from radiology?? As far as I can tell, they are the same thing...just different brand names. Please enlighten me!

From "Royal Pains" - a great tv show

A side effect of chlorpromazine is photosensitivity. Excess exposure to sunlight can turn the skin blue.

From the desk of Jenny Lou

New drug: Vimpat (lacosamide) is an anticonvulsant. We have a pt on this right now.

New drug: Savella (milnacipran) is for fibromyagia. It inhibits NE and 5HT reuptake. A pt also came in on this.

This next bit of drug trivia comes from our esteemed colleague Nick:

Drugs that can cause osteoporosis:

1. corticosteroids
2. heparin
3. cancer drugs
4. phenytoin

IV Filters

I happened across this (in SV net...the black hole of info) while looking for another IV policy and thought it might be beneficial (and I knew I would never be able to find it again)

Use 0.22 micron filter for:
non-lipid containing admixtures (parenteral nutrition)
Mannitol
Gangiclovir
Digiband
Phenytoin for infusion
Thrombolytic agent for infusion
Taxol (has its own tubing with filter)
Rifampin
All infusions via central lines/PICC except for the following:
• IV push medications
• Amphotericin B
• Nitroglycerin
• Insulin
• Vincristine
• Diprivan
• Albumin
• Lipids
• Blood/Blood Products
Use 1.2 micron filter for 3-in-1 lipid containing TPN and lipid fluids via a central line.
Midlines are treated as a peripheral IV site in regards to filtering.

Breaking news: Totect Policy

Per 6 north policy/mysterious fax sent to pharmacy:

If Totect is needed on the unit for a suspected anthracycline extravasation please call the pharmacy department A.S.A.P. Pharmacy staff will go over to the Cancer Center at any time and bring the Totect drug kit over to the hopital to be given.

I believe "at any time" should be taken to mean immediately, not at our leisure, as there will be no time to lose.

Totect or Zinecard is also known as Dexrazoxane generically. Totect is indicated for anthracycline-induced extravasation, while Zinecard is used as a cardioprotectant in women with metastatic breast cancer who have received a total cumulative dose of doxorubicin of 300mg/m2 and need to continue therapy.

PPIs vs Plavix Major Drug interaction!!

1) Interaction Effect: increased risk for thrombosis
2) Summary: The use of a proton pump inhibitor with clopidogrel may decrease the ability of clopidogrel to prevent acute myocardial events. In two studies, omeprazole significantly decreased the effect of clopidogrel on platelet inhibition.
Consider using a histamine-2 receptor antagonist in patients who require acid-lowering therapy
Severity: major Onset: delayed Substantiation: established

Probable Mechanism: decreased platelet inhibitory effect of clopidogrel by esomeprazole

LC Bead Embolization Therapy (we are treating a patient using doxorubicin)

Using tiny chemotherapy-soaked beads to choke off and kill cancerous liver tumors is becoming more successful, according to research being presented at the 21st annual International Symposium on Endovascular Therapy (ISET).Transarterial chemoembolization (TACE) is a minimally invasive therapy that takes a two-pronged approach to treating cancer. Interventional physicians use minimally invasive methods to deliver the beads (also called microspheres) to the blood vessels that feed the tumor. The beads are combined with cancer-killing chemotherapeutic agents and then delivered to the blood vessels. The beads lodge in the blood vessels, blocking blood flow to the artery and cutting off the blood supply to the tumor - known as embolization. Several studies being presented at ISET report on advances in the treatment.The most effective way to treat most cancerous tumors is by surgically removing them. However, more than two-thirds of people with liver cancer aren't candidates for surgery due to the size or location of the tumor, or because the tumor has grown into the blood vessels. Doctors have turned to other methods of treatment, including TACE. Because the chemotherapy is delivered directly to the tumor - rather than to the entire body as is the case with traditional chemotherapy - side effects usually are lessened.On average, only about one in four liver cancer patients is alive after two years. Although TACE typically is used to slow the disease, not cure it, improvements in the beads are making it more effective and promising as a cure in some cases. Improvements include beads that absorb the chemotherapeutic agent (rather than just being mixed with it), and then release the drug once in the body, as well as modifications to uniformity and size of the beads themselves so that they can more fully block the blood vessel and further guard against potential leakage of blood that could feed the tumor.More than 21,000 people are diagnosed with liver and bile duct cancer, and more than 18,000 will die of the disease each year, according to the American

Pamidronate (Aredia)

pamidronate (Aredia)

Action: a bisphosphonate hypocalcemic agent

Uses: hypercalcemia, Paget's disease, bone lesions, bone metastases

Maximal response time 4-7 days.

Usual Dose: 30mg, 60mg, 90mg -- given once a week or once a month. However, for Paget's disease you can give 30 mg qd x3 days.

Do not give with decreased renal function.

Dilution: must dilute in 500-1000 ml

Hoorah for Amber! She made a good catch today. A patient was given Aredia yesterday and another Dr ordered it today. She noticed this and we called the Dr and he was unaware that a dose had been given yesterday. He said "Thank you and good catch!" Way to go Amber.

Great idea Jenny, this is much better than email. Just wanted to make sure you got this and I posted it right.

Vitamin D (courtesy of Jenny Cole)

Different Vitamin D forms:

vitamin D precursor: Ergocalciferol (Drisdol) (vitamin D2)

active vitamin D: Calcitriol (Rocaltrol - oral) (Calcijex - iv) (preferred in pts with end stage renal disease)

vitamin D analogs: paricalcitol (Zemplar - iv)
doxercalciferol (Hectoral -po or iv)

Vitamin D analogs offer an alternative for pts in whom persistent hypercalcemia develops with calcitriol therapy.

A bit of trivia: vitamin D2 is the form added to milk

Another bit of trivia...I know you are on the edge of your seat....vitamin D has to go through 2 enzymatic hydroxylations to get to its active form. The first hydroxylation is in the liver and the second is in the kidney where it is converted to calcitriol whose main function is to regulate calcium by enhancing calcium absorption in the small intestine and increases calcium and phosphorus reabsorption in the kidney.

I learned that Cosyntropin can be given by IV infusion (usually over 6 hrs for a 1 time dose). (This was actually Kerry's order that I butted in on)

I learned that Adenosine has a very short half life (<10 sec) and b/c of this should be ok with a breastfeeding mom (they only called 2 times with that question).

I was also reminded that Remicade needs an in-line filter.

Flomax cannot be given down a tube.

Moxatag and Truvada Info

Moxatag (775 mg Amoxicillin XR)
Approved 1/23/08 for adults and children>12 y/o
Used for tonsillitis or pharyngitis secondary to streptococcus pyogenes.

**Consists of 3 active amoxicillin components. 1 component is an immediate release component that releases in the stomach. The other 2 layers are delayed release and they release their effectiveness based on pH in the GI tract.**

Normal dose = 775 mg once daily x 10 days
Mech. of Action = Inhibits bacterial cell wall synthesis
Take tablet within 1 hr of finishing meal
Do not crush or chew
Clavulanic Acid: Part of the combo in Augmentin XR
Member of the beta lactam family of Abx with little or no intrinsic antibacterial activity of its own.
Used to enhance activity of Abx by blocking bacterial lactamasas
--blocks the active sites of these enzymes
--particularly active against the clinically important plasmid-mediated beta lactamases frequently responsible for transferred drug resistance to pen and ceph.
**I'm still not sure why you would use the Moxatag over the Augmentin since it doesn't have the clavulanic acid except that is is once daily dosing. How do doctors know if they need the clavulanic acid???

Truvada (emtricitabine 200 mg + tenofovir 300 mg)
Emtricitabine = nucleoside analog
Tenofovir = nucleotide analog

Anti HIV drug used in combo with other meds to treat HIV-1 infection in adults.
Should not be used in combo with adefovir, tenofovir, lamivudine.
Does not cure HIV or reduce the chances of passing the virus on

Both ingredients ar part of the nucleoside reverse transcriptase inhibitor family
Usual dose = 1 tab daily with or without meals
Dosing interval must be increased in patients with renal impairment (CrCl<50). Not recommended if CrCl<30.

Reverse transcriptase is a viral DNA polymerase enzyme that retroviruses need to reproduce. It transcribs single stranded RNA into single stranded DNA. It helps in the formation of the double helix DNA.

Pricing: 30 tabs = $946.63 (wow!)

** There is a fabulous video on how Truvada works at www.truvada.com/pat100_about_truvada.aspx. Enjoy! **

Alpha 1 blockers:

{doxazosin, terazosin, prazosin}

-- act peripherally
--causes vasodilation of both arteries and veins (indirect vasodilator)
--causes less reflex tachycardia than direct vasodilators (hydralazine/minoxidil)

--side effects: dizziness, priapism, orthostatic hypotension, first dose syncope, peripheral edema

--drug drug interaction: NSAIDs can decrease antihypertensive properties of alpha 1 blockers

Alpha 2 agonists

{clonidine, guanfacine, methyldopa}

-- act centrally
--decrease sympathetic outflow to CV system

--side effects: sedation, dry mouth, bradycardia, withdrawal hypertension, orthostatic hypotension, depression, impotence, sleep disturbances


Beta Blockers

{atenolol, etc.}

--beta 1 = heart
--beta 2 = kidney, lungs, periphery

--used for lots of things: HTN, migraines, essential tremor, anxiety, hyperthyroidism, stage-fright, glaucoma

--blocks secretion of renin (renin is an enzyme secreted by kidney that is a potent vasoconstrictor)
--decreases contractility thus decreasing cardiac output
--decreases heart rate

-- avoid abrupt withdrawal
--side effects: dizziness, hypotension, sexual dysfunction, bronchospasm, heart failure, bradycardia

-- can increase triglycerides (except those with ISA activity)...seen mainly in non-selective beta blockers. Can also decrease HDL. I read that this is usually not clinically significant.
--can mask signs of insulin-induced hypoglycemia (non-selective beta blockers) that are associated with epinephrine release (palpitations, tremor, hunger) but they do not mask the sweating.
--can also inhibit insulin secretion and cause hyperglycemia in some pts

-- High lipid solubility = enters CNS more than hydrophilic....Propranolol has high lipid solubility so that is why it is used over other beta blockers for migraine prophylaxis.

ISA (intrinsic sympathomimetc activity)
--only partially stimulate the receptor. When given to a pt with a slow HR, may increase the HR. When given to a pt with a fast HR, may slow it.
--less likely to cause bracycardia, bronchospasm, reduced cardiac output, and increased triglycerides
Acebutolol (Sectral)
Carteolol (Cartrol)
Penbutolol(Visken)

Beta 1 only (cardioselective)
acebutolol
atenolol
betaxolol
bisoprolol

Combined alpha and beta blockers
Carvedilol (Coreg)
Labetalol (Normodyne, Trandate)

I was doing some reading on the 48hr question of phenazopyridine and I found (ontop of the methhemoglobinemia) that there is no additional benefit after 48 hours. It was mentioned that when the it is used with an antibiotic, the antibiotic will kill the bacteria that is causing the discomfort within the 48hrs and then the phenazopyridine should not be needed. Also, it can turn you skin color orange/yellow with prolonged use especially with patients with renal dysfunction.

I didn't know that APAP is an active metabolite of phenazopyridine. Thanks Chanda!

Great job on setting this blog up Jenny! I can't wait to learn! :)

Lyrica needs to be renally dosed.