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Pharmacology - Chapter 5 - Therapy for Viral Infections and Immunizations

Part One (Pages 1-10) Part Two (Pages 11-20) Part Three (Pages 21-30) Part Four (Pages 31-40) Part Five (Pages 41-46)

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Pharmacology - Chapter 5 - Therapies for Viral Infection and Immunization

Part One Part Two Part Three Part Four

Transcription under the cut!

Immunization

Common Vaccines

Travel vaccines

Recommended when traveling from areas of low infection rates to areas of high infection rates

Given two or more weeks before travel to give the immune system time to mount sufficient response

Travel clinics may be located in clinics or pharmacies and provide immunizations and advice about what vaccines are necessary

Common side effects

Fever

Headache

Upset stomach

Local injection-site irritation

Mild skin rash

Irritability

Managing side effects

Acetaminophen for 24-48 hours after vaccine given

Caution and considerations

Patients to receive vaccine information sheet (VIS) and sign a consent form as required by law

Healthcare personnel trained in vaccine administration must be trained in CPR

Most vaccines are to be stored in the refrigerator or freezer with storage temperatures strictly followed

Must be used right away and not refrigerated again if warmed to room temperature

Must be used within minutes to hours if reconstituted

Advance mixing of vaccines not recommended

Vaccines not to be mixed in same syringe with other medications

Complementary and Alternative Therapy

Andrographis

May reduce symptom severity and duration of influenza if started within 36 to 48 hours

Side effects include chest discomfort, headache, nausea, rash

Colloidal silver

Used topically and orally for infections

Side effects include argyria, neurologic deficits, kidney damage

Elderberry

May be used for influenza when initiated within 48 hours of symptoms

Chapter Summary

Viruses replicate by using the host cell's metabolic processes

Antiherpes agents include acyclovir, famciclovir, valacyclovir, and valganciclovir

Anti-influenza agents include amatadine, oseltamivir, rimantadine, and zanamivir

HIV is a virus that converts its RNA into DNA and inserts the copy into the DNA of the host cell

The standard of care for HIV patients involves a combination of antiretroviral drugs

The CDC releases vaccination recommendations and schedules

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Pharmacology - Chapter 5 - Therapies for Viral Infections and Immunizations

Part One Part Two Part Three Part Five

Transcription under the cut!

HIV/AIDS and Antiretroviral Agents

Integrase Inhibitors

Blocks the action of integrase, an enzyme needed for HIV to reproduce; decreased HIV level; increased WBC

Dolutegravir (Tivicay)

Believed to work better than other integrase inhibitors in viral resistance; side effects include elevated serum lipase, insomnia, elevated liver enzymes, hyperglycemia

Risk of fat redistribution and hypersensitivity reaction

Elvitagravir (Vitekta)

Side effects include depression, fatigue, insomnia, headache, diarrhea, abdominal pain

Risk of lactic acidosis, to be avoided in severe liver impairment

Raltegravir (Isentress)

Side effects include nausea, headache, diarrhea, pyrexia, and creatine kinase elevation

Risk of myopathy, rhabdomyolysis, creatine kinase elevation; chewable tablets contain phenylalanine

Work Wise

Raltegravir film-coated tablets and chewable tablets or oral suspensions are not bioequivalent. This means they cannot be substituted on a mg-for-mg basis.

Responding to Exposure to HIV

Healthcare worker risks

Exposure to blood and other bodily fluids

Needlestick injuries

Postexposure Prophylaxis (PEP)

Can decrease the risk of infection by 80%

Should start within 2 hours of exposure

Combining Antiretroviral Medications

Advantage

Improved adherence

Disadvantage

Fixed doses unsuitable for unstable patients

Examples

Efavirenz-emtricitabine-tenofovir (Atripla)

Lamivudine-zidovudine (Combivir)

Abacavir-lamivudine (Epzicom)

Elvitegravir-cobicistat-emtricibine-tenofovir (Stribild)

Emtricitabine-tenofovir (Truvada)

Immunization

Immunization

The process whereby a person acquires immunity or resistance to an infectious disease

Methods of acquiring immunity

Passive immunity

Antibodies transferred to an individual

Occurs naturally during pregnancy

Occurs artificially through administration of immunoglobulin

Active immunity

Individual makes own antibodies

Occurs naturally following exposure to pathogens

Occurs artificially through vaccination

Live attenuated vaccines

Use live but weakened pathogens to induce an immune response

Inactivated vaccines

Use pathogens that have been killed

Pharm Facts

Community immunity describes a situation in which a sufficient proportion of a population has immunity to an infectious disease (usually through vaccination or prior exposure). Community immunity, in theory, makes it less likely for diseases to spread from person-to-person; this means that protection is extended to those within the community that do not have immunity. Another term for community immunity is herd immunity.

Immunization Schedule

Schedule source

Adults and childhood vaccination schedules are published by the CDC

Vaccines for children

Most lead to lifetime immunity

Boosters given for continued protection

Vaccines for healthcare workers

Hepatitis B vaccination and annual influenza vaccine often required by employers

Common Vaccines

Role of pharmacy technicians

Screen patients

Complete necessary forms

Stock and store vaccines

Draw up vaccine for pharmacist to administer

Common Vaccines

BCG

HIB+Hep B

Meningococcal

Varicella

Diphtheria, Pertussis, and Tetanus

HPV

Pneumococcal

Yellow Fever

Haemophilus influenzae type B (HiB)

Influenza

Polio

Zoster

Hepatitis A (HAV)

Japanese encephalitis

Rotavirus

Hepatitis B (Hep B)

Measles, Mumps, and Rubella

Typhoid

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Pharmacology - Chapter 5 - Therapies for Viral Infections and Immunizations

Part One Part Two Part Four Part Five

Transcription under the cut!

HIV/AIDS and Antiretroviral Agents

NNRTIs

Inhibits HIV reverse transcriptase by obstructing the enzyme's mechanical action

Delaviridine (Rescriptor)

Cytochrome P-450 inhibitor; side effects include central obesity/weight gain, Stevens-Johnson syndrome

Avoid antacids one hour before and one hour after administration

Efavirenz (Sustiva)

To be taken on an empty stomach; side effects include dizziness, headache, vivid dreams, nightmares, hallucinations

Bedtime dosing may improve tolerability of CNS side effects; risk of hepatic failure; may cause false-positive cannabinoid tests; not to be used in pregnancy

Etravirine (Intelence)

Should always be given with another HIV drug; decreased HIV level; increased WBC; side effects include rash, nausea, hypersensitivity, fat redistribution

Not to be used in treatment-naive patients, should be taken with food

Nevirapine (Viramune)

To be started at low dose; side effects include rash, liver problems, severe allergic reaction

Risk of liver toxicity and severe skin reaction during the first 6 weeks of therapy

Rilpivirine (Edurant)

For first-time users of HIV drugs; should not be taken with other NNRTIs; side effects include depression, rash, headache, insomnia

To be used with caution if viral load greater than 100,000 copies/mL

Protease Inhibitors

Decreases formation of protease enzyme, which cleaves certain HIV protein precursors necessary for the formation of new infectious virions

Typically combined with other HIV drugs; metabolized through cytochrome P-450 resulting in many drug interactions which are sometimes severe; not to be used with statins; side effects include redistribution of body fat, facial atrophy, breast enlargement, hyperglycemia, hyperlipidemia; possibility of increased bleeding episodes in patients with hemophilia.

Atazanavir (Reyataz)

Given with ritonavir; does not increase cholesterol or triglycerides, common side effect is jaundice

Risk of developing diabetes, kidney dysfunction, liver dysfunction

Darunavir (Prezista)

Must be given with ritonavir; side effects include headache, nausea, diarrhea; to be stored and dispensed in original container

Caution in sulfa allergy, may exacerbate kidney and liver toxicity, not to be used in children <3 years old

Fosamprenavir (Lexiva)

A prodrug of the PI amprenavir, which it has largely replaced in therapy

Caution in sulfa allergy, associated with liver toxicity

Indinavir (Crixivan)

To be stored in original container, patients to drink 48 ounces of water daily, not to be taken with high-fat food or grapefruit juice if taken without ritonavir

Risk of kidney toxicity

Kioubavir-Ritonavir (Kaletra)

Less cramping since includes lower dose of ritonavir; diarrhea and nausea still present

Oral liquid contains high percentage of alcohol and propylene glycol

Nelfinavir (Viracept)

Main side effect is diarrhea which resolves with continued use

May dissolve nelfinavir tablets in small amount of water, consume immediately, and then rinse glass consuming any dose left; avoid mixing with acidic beverages or acidic food

Ritonavir (Norvir)

Used as a boost to increase serum concentrations and decrease frequency of other PIs; given at a low dose; side effects include altered taste; must be stored in refrigerator

Risk of serious drug interactions; caution in cardiac arrhythmias

Saquinavir (Invirase)

Avoid sunlight; side effects include diarrhea, nausea, abdominal discomfort; must be taken with ritonavir; does not cause lipid abnormalities

Risk of QT interval prolongation, formulated with lactose

Tipranavir (Aptivus)

Improved dissolution and bioavailability; given with ritonavir; side effects include diarrhea, nausea, vomiting, headache, fatigue; to be stored in refrigerator

Risk of intracranial hemorrhage, hepatotoxicity, hepatitis; dehydrated ethanol in capsules; vitamin E in oral solution

Fusion Inhibitor

Enfurvirtide (Fuzeon)

Prevents HIV from entering immune cells

Given subcutaneously; reserved for patients resistant to older drugs; reaction at injection site common; side effects include diarrhea, nausea, fatigue

Risk for hypersensitivity reactions and pneumonia; not appropriate for treatment-naive patients

Chemokine Coreceptor Antagonist

Maraviroc (Selzentry)

Prevents HIV from attaching and entering into immune cells

To be given with other antiretroviral drugs; side effects include cough, abdominal pain, dizziness, fever

Risk for hepatotoxicity with allergic features, monitor closely for infection

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Pharmacology - Chapter 5 - Therapies for Viral Infections and Immunizations

Part One Part Three Part Four Part Five

Transcription under the cut!

Antiviral Agents (Nonretroviral)

Antiherpes Agents

Valacyclovir (Valtrex)

Used in: Shingles in immunocompromised adults and genital herpes

Side effects: confusion, hallucinations, seizures, nausea, vomiting, diarrhea, constipation

Caution in older adults

Valganciclovir (Valcyte)

Side effects: hypertension, headache, insomnia, diarrhea, vomiting, tremor, fever, increased serum creatinine

Risk of severe hematologic effects, fertility impairment, birth defects, cancer

Anti-Influenza Agents

Amantadine (Symmetrel)

Used for: prophylaxis and treatment of influenza A

Side effects: dizziness, headache, weakness

Caution in older patients

Oseltamivir (Tamiflu)

Used for: prophylaxis and treatment of influenza A and B

Side effects: vomiting, nausea, abdominal pain, diarrhea, nose bleeds, eye infections

Caution in cardiovascular disease, hepatic impairment, renal impairment; avoid formulations with benzyl alcohol in neonates; oral suspension contains sorbitol

Rimantadine (Flumadine)

Used for: prophylaxis and treatment of influenza A

Side effects: dizziness, headache, weakness, GI effects

Caution in hepatic impairment, renal impairment, psychosis, seizures; caution in older adults

Zanamivir (Relenza)

Used for: prophylaxis and treatment of influenza A and B

Side effects: headache, throat/tonsil discomfort, cough

Caution in patients sensitive to milk products

Other Antiviral Agents

Ribavirin (Virazole)

Used for: treatment of respiratory syncytal virus (RSV)

Side effects: fatigue, headache, insomnia, nausea, anorexia

Risk of hemolytic anemia when used orally, not to be used as monotherapy for hepatitis C, risk of sudden respiratory deterioration in pediatric patients, risk of teratogenic and embryocidal effects, caution in patients using mechanical ventilation

HIV/AIDS and Antiretroviral Agents

Definitions

Retrovirus

Uses RNA as its genetic material

Reverse transcriptase

The enzyme retroviruses use to become part of the host's DNA

Human immunodeficiency virus (HIV)

A retrovirus that attaches to receptors on the surface of CD4 cells

Uses reverse transcriptase to convert its genetic material from RNA to DNA

Acquired immunodeficiency syndrome (AIDS)

Syndrome which occurs when patients have advanced and severe forms of HIV

Antiretroviral drugs

Difficult to tolerate due to side effects and drug interactions

Can be combined in a "cocktail" which attacks viral replication in multiple stages

Must be taken chronically

Some cocktails available as a single tablet

Safety Alert

One of the biggest problems when treating HIV is nonadherence with the drug regimen because problematic side effects and complex dosing

Stage One: Binding

Stopped by: CCR5 antagonists

Stage Two: Fusion

Stopped by: Fusion inhibitors

Stage Three: Reverse transcription

Stopped by: Non-nucleoside reverse transcriptase inhibitors (NNRTIs), Nucleoside reverse transcriptase inhibitors (NRTIs)

Stage Four: Integration

Stopped by: Integrase inhibitors

Stage Five: Replication

Stage Six: Assembly

Stage Seven: Budding

Stopped by: Protease inhibitors (PIs)

NRTIs and NtRTIs

Inhibit reverse transcriptase which prevents the formation of a DNA copy of viral RNA

Side effects: nausea, diarrhea, abdominal pain which improve in first few weeks.

More permanent effects: lactic acidosis with hepatic steatosis

Abacavir (Ziagen)

An NRTI; one of the few HIV drugs that penetrate the CNS

Increased toxicity when combined with alcohol, risk of hypersensitivity reactions

Didanosine (Videx)

An NRTI; always combined with two other antiretroviral drugs

Must be taken on an empty stomach, cannot be taken with members of its own class

Emtricitabine (Emtriva) and Lamivudine (Epivir)

Emtricitabine: an NRTI; may discolor the skin; not to be used for treatment of hepatitis

Lamivudine: an NRTI; may precipitate pancreatitis, used to treat HIV and chronic hepatitis B; risk of HIV resistance when taken by hepatitis B patients who have undiagnosed HIV infection

Both drugs: may cause fat redistribution, caution in renal dysfunction

Stavudine (Zerit)

An NRTI; side effects: peripheral neuropathy, pancreatitis, dyslipidemia, fatty liver, lactic acidosis

Risk of pancreatitis when combined with didanosine, use with caution in patients with peripheral neuropathy

Tenofovir disoproxil fumarate (Viread)

An NtRTI; limiting toxicity is kidney related; side effects: dizziness, depression, skin rash, dyslipidemia

Avoid concomitant drugs which are toxic to the kidneys, should be discontinued in patients experiencing decreased renal function

Zidovudine (Retrovir)

An NRTI; use in combination with lamivudine +/- a PI for needlestick or sexual exposure; side effects: diarrhea, GI pain, nausea, rash, anemia

Risk of neutropenia and anemia, caution in patients with compromised bone marrow function, risk of myopathy and myositis

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Pharmacology - Chapter 5 - Therapy for Viral Infections and Immunizations

Part Two Part Three Part Four Part Five

Transcription under the cut!

Chapter 5 - Therapy for Viral Infections and Immunizations

Chapter Topics

Viruses and viral infections

Antiviral agents (nonretroviral)

HIV/AIDS and antiretroviral agents

Immunization

Complementary and alternative therapies

Learning Objectives

Explain the differences between bacteria, fungi, and viruses, and why the drugs used to treat them must have very different mechanisms of action

Differentiate antiviral and antiretroviral drugs by their indications, therapeutic effects, side effects, dosages, and administration

Use antiviral and antiretroviral terminology correctly in written and oral communication

Identify drugs used for HIV and understand their synergism

Describe the importance of immunization

Identify common vaccines and their side effects

Viruses and Viral Infections

Virus

A minute infectious agent smaller than a bacterium

Consists of segments of DNA or RNA surrounded by a protein coating or capsule

Requires host cells to reproduce

Stage of Viral Infection

Virus attaches to human cell

Virus penetrates the cell

Virus escapes into cytoplasm

Virus presents its DNA or RNA to the cell nucleus

Virus converts cell activity to viral activity

Virus produces new viral particles

Influenza (the flu)

Symptoms include vague discomfort, tiredness, muscle pain, headache, chills, fever.

Patients at risk for complications include the elderly; patients with cardiovascular disease, renal disease, diabetes, asthma; immunocompromised patients.

Annual vaccinations recommended for those at risk for complications.

Hepatitis

Inflammation of the liver

Various forms referred to as hepatitis A through G

Severity range from benign to serious

HIV

Considered a chronic disease

Important to monitor for drug interactions

Regimens usually contain at least three drugs

Classification of viral infections

Viral duration and severity

Acute

Chronic

Slow

Extent of viral infection

Local

Generalized

Latent Viruses

A virus that lies dormant after an infection and then later becomes active

Examples include herpes virus and HIV

Virus and Cell Interaction

Immunoglobulin

A type of antibody that matches a specific antigen

Produced by host in response to viral antigens

May prevent a virus from attaching to a cell or may destroy a virus

Interferons

Induce production of hundreds of other proteins which may disrupt viral replication

Host-specific since are encoded in host cell DNA

Vaccination

Description

Exposing a patient to a component of a virus or an altered viral strain in order to produce antibodies

When later exposed to the actual virus, infection does not develop because natural defenses have been primed

Viral Mutations

Makes effective vaccine production difficult

Example is influenza vaccine which must be reformulated each year

Antiviral Agents (Nonretroviral)

Antiviral Drugs

Risk of toxicity to host since virus uses host's cellular processes to function and replicate

Formulated to prevent viral replication without interfering with normal host cell function

Therapeutic Uses of Antiviral Drugs

Herpes simplex 1

Herpes simplex 2

Varicella-zoster

Cytomegalovirus (Human Herpes Virus 5)

Influenza

Respiratory syncytial virus (RSV)

Acyclovir (Zovirax)

Used for: genital herpes, shingles, chickenpox, herpes encephalitis, suppression of herpes

May cause: confusion, hallucinations, seizures

Caution in older adults

Famciclovir (Famvir)

Used for: shingles, recurrent herpes in immunocompromised patients, genital herpes

May cause: headache, nausea, diarrhea, fatigue

Caution in patients sensitive to milk products

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Pharmacology - Chapter 4 - Antibiotics and Antifungals

Part One (Slides 1-10)

Part Two (Slides 11-20)

Part Three (Slides 21-30)

Part Four (Slides 31-40)

Part Five (Slide 41)

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Pharmacology - Chapter 4 - Antibiotics and Antifungals - Part Five

Part One

Part Two

Part Three

Part Four

Transcription under the cut!

Chapter Summary

Some antibiotic suspensions are stored in the refrigerator while others may be stored at room temperature.

Ophthalmic antibiotics have strict manufacturing requirements which may result in increased expense.

Several sexually-transmitted infections may be treated with antibiotics.

Drugs that fight bacterial infections generally will not work for fungal infections.

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Pharmacology - Chapter 4 - Antibiotics and Antifungals - Part Four

Part One

Part Two

Part Three

Part Five

Transcription under the cut!

Fungi and Fungal Diseases

Fungus

Single-celled eukaryotic organism (has a defined nucleus)

Includes mushrooms, yeasts, and molds

How they differ from green plants

Lack chlorophyll

Reproduce by spores

How they differ from animal cells and bacteria

Have a rigid cell wall

How they differ from human cells

Human cell membranes contain cholesterol

Fungi cell membranes contain ergosterol

Fungal diseases

Mild, topical infections

Dermatophytes: athletes' foot and ringworm

Candida: vaginal yeast infections, oral thrush

Serious systemic infections

States of immunodeficiency

Drug therapy

Poor nutrition

IV catheters

Some cancers

Human immunodeficiency virus (HIV)

Antifungal Medications: Polyenes

How they work:

Amphotericin B: interferes with cell-wall permeability allowing electrolytes and other substances to leak out

Therapeutic uses:

Amphotericin B: life-threatening fungal infections

Nystatin: oral candidiasis, systemic fungal infections

Side effects:

Amphotericin B: nephrotoxicity, hepatotoxicity, fever, chills, shaking, headache, nausea, vomiting, depletion of electrolyte stores, anemia, phlebitis

Topical nystatin: hypersensitivity reactions

Oral nystatin: diarrhea, nausea, stomach pain, vomiting

Dispensing issues for amphotericin B: infuse slowly, use acetaminophen or diphenhydramine for infusion-related side effects, liposomal form for reduction of toxic effects, not to be "piggybacked" with other drugs, not to mixed with NS.

Examples of agents:

Amphotericin B (Abelcet, AmBisome, Amphotec)

Nystatin (Mycostatin)

Antifungal Medications: Azoles

How they work:

Inhibit the formation of the cell wall

Therapeutic uses:

Variable: oral candidiasis, vaginal candidiasis, skin infections, nail infections, oropharyngeal or systemic infections caused by Candida and Aspergillus

Side effects:

Of class: nausea, vomiting, abdominal pain, diarrhea

Voriconazole: transient vision changes, visual hallucinations, alopecia, nail changes or loss, skin rash

Topical agents: burning, discomfort, edema, pain

Dispensing issues:

Itraconazole capsules and solution not to be substituted for each other

Take itraconazole capsules with acidic food or drink

Take posaconazole with food

Infuse voriconazole over one to two hours and not with other drugs

Short expiration of voriconazole

Examples of agents:

Clotrimazole (Mycelex)

Ketoconazole (Nizoral)

Fluconazole (Diflucan)

Itraconazole (Sporanox)

Posaconazole (Noxafil)

Voriconazole (Vfend)

Put Down Roots:

Many antifungal names end in -zole, so if the generic form of the drug ends in -zole (especially -conazole), there is a good chance it is an antifungal.

Antifungal Medications: Echinocandins

Inhibit the synthesis of D-glucan, which is an integral part of the fungal cell wall.

Used for invasive Candida and Aspergillus in patients unresponsive to amphotericin B and itraconazole

Side effects: infusion and hypersensitivity reactions such as rash, redness, hypotension, angioedema, injection-site pain

Dispensing issues: reconstitute micafungin by swirling, protect micafungin from light

Examples of agents:

Caspofungin (Cancidas)

Micafungin (Mycamine)

Antifungal Medications: Miscellaneous

Examples of agents:

Butefine (Lotrimin Ultra, Mentax)

Ciclopirox (Loprox, Penlac)

Terbinafine (Lamisil AT)

Flucytosine (Ancobon)

Grisofulvin (Grilfulvin V, Gris-PEG)

Side effects:

Of butenafine: burning, contact dermatitis, erythema, irritation, pruritus, stinging

Of ciclopirox: acne, alopecia, contact dermatitis, dry skin, skin burning, eye pain, headache

Of terbinafine: headache, skin rash, diarrhea, dyspepsia, nasopharyngitis

Of flucytosine: leukopenia, GI symptoms such as nausea, vomiting; hepatic side effects

Dispensing issues:

Of griseofulvin: avoid use with alcohol, potential for contraceptive failure

Complementary and Alternative Therapies

Echinacea

Used to treat the common cold, RTIs, and vaginal yeast infections

Reduces the severity and length of symptoms

Variable concentrations in the products available

No standard dose established

Must be used multiple times a day and started at the first sign of infection

Zinc

Used to enhance wound healing and prevent wound-associated infections

No well-established dose

Chapter Summary

A bacteria is a single-celled organism that can cause infection in the body.

Bacteria can be classified by oxygenation needs, shape, growth arrangement, and Gram-stain results.

Several major classes of antibiotics and antifungals are available which vary in the spectrum of activity, side effect profile, contraindications, and drug interactions.

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Pharmacology - Chapter 4 - Antibiotics and Antifungals - Part Three

Part One

Part Two

Part Four

Part Five

Transcription under the cut!

Fighting Bacterial Infections

Major Classes of Antibiotic Drugs: Metronidazole

Therapeutic uses: Amebic dysentery, bacterial vaginosis, Clostridium difficile, Giardia infection, Helicobacter pylori ulcers, intestinal infections, rosacea, Trichomonas

Side effects: headache, anorexia, vomiting, diarrhea, abdominal cramps, metallic taste, urine discoloration

Dispensing issues: taking with food may reduce GI effects, potential for confusion between the topical and vaginal forms

Examples of agents: Metronidazole (Flagyl)

Major Classes of Antibiotic Drugs: Linezolid

How it works: Inhibits bacterial protein synthesis

Therapeutic uses: MRSA, VRE, other Gram positive infections

Side effects: headache, diarrhea, decreased hemoglobin, leukopenia, thrombocytopenia

Dispensing issues: protect from light

Examples of agents: Linezolid (Zyvox)

Major Classes of Antibiotic Drugs: Daptomycin

How it works: Inhibition of DNA and RNA synthesis

Therapeutic uses: Complicated skin and skin structure infections, Staphylococcus aureus blood infections

Side effects: anemia, diarrhea, vomiting, constipation, chest pain, peripheral edema, skin rash, respiratory side effects

Dispensing issues: dextrose-containing solutions not to be used, only NS or lactated Ringer's solution

Examples of agents: Daptomycin (Cubicin)

Storage of Liquid Antibiotics

Storage Requirements

Some antibiotics require refrigeration

Some antibiotics may be stored at room temperature

Appropriate for technicians to discuss this information with patient

Medication flavors

Technician may suggest and change flavors

Increases adherence in children

Ophthalmic Antibiotics

Manufacturing requirements

pH

Sterility

Dispensing issues

Expensive

Often rejected by insurance companies

Inform prescriber regarding medications insurance will most likely cover

Ophthalmic Products

Azithromycin (AzaSite)

Bacitracin (AK-Tracin)

Ciprofloxacin (Ciloxan)

Erythromycin (Ilotycin)

Gatifloxacin (Zymar)

Gentamicin (Gentak, Genoptic)

Moxifloxacin (Vigamox)

Ofloxacin (Ocuflox)

Sodium sulfacetamide (Bleph-10)

Tobramycin (Tobrex)

Sexually-Transmitted Infections

Definition

Genital system infections transmitted by sexual activity

Formerly known as venereal diseases

Prevention

Abstinence

Long-term monogamous relationship with an uninfected partner

Chlamydia

Caused by Chlamydia trachomatis

Often asymptomatic

Occurs frequently with gonorrhea

Potential for reinfection if partner not treated

Gonorrhea

Caused by Neisseria gonorrhoeae

Males: painful urination and discharge of pus

Females: abdominal pain due to PID

Long-term complications include sterility

Untreated infections may lead to systemic infections involving the heart, meninges, eyes, pharynx, joints

Occurs frequently with chlamydia

Syphilis: caused by Treponema pallidum

Primary-stage infection

Chancre at site of infection which heals in weeks

Fluids from chancre highly infectious

Bacteria enter bloodstream and lymphatic system

Secondary-stage infection

Skin rash, patchy hair loss, malaise, mild fever

Lesions highly infectious

Symptoms subside, disease becomes latent

Late- or tertiary-stage infection

Occurs after at least 10 years

Rubbery tissue masses in organs and on skin

Deafness, blindness, CNS lesions, perforation of the roof of the mouth may occur

Congenital syphilis

Pregnancy in tertiary-stage: neurologic damage to fetus

Pregnancy in primary- or secondary-stage: stillbirth

Nongonococcal urethritis

Caused by catheters, chemical agents, or sexual transmission

Male symptoms: mild

Female symptoms: serious

Vaginitis

Characterized by vaginal discharge and odor

Gardnerella vaginitis

Caused by interaction between the organism and anaerobic bacteria in the vagina

Frothy discharge, fishy odor, vaginal pH of 5 to 6

Trichomonas vaginalis

Bacteria found in males and females

Potential for infection if vaginal acidity is disturbed

Profuse, yellowish, or light cream-colored discharge with disagreeable odor

Irritation and itching

Agents for Treating Sexually-Transmitted Infections

Azithromycin (Zithromax)

Syphilis lesions (chancroid) in men

Chlamydia in women

Gonoccoccal in either sex

Ceftriaxone (Rocephin)

Penicillinase-producing bacteria

Tetracycline (Sumycin), Erythromycin (Ilotycin)

Chlamydia trachomatis

Penicillin G benzathine (Bicillin L-A)

Syphilis

Doxycycline (Doryx, Vibramycin)

Lymphogranuloma venereum

Metronidazole (Flagyl)

Gardnerella vaginitis

Safety Alert

Bicillin L-A and Bicillin C-R (which is combined with penicillin G procaine) are frequently dispensed in place of each other. However, the procaine in the Bicillin C-R makes it shorter acting. The longer-acting Bicillin L-A is needed for syphilis.

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Pharmacology - Chapter 4 - Antibiotics and Antifungals - Part Two

Part One

Part Three

Part Four

Part Five

Transcription under the cut!

Fighting Bacterial Infections

Major Classes of Antibiotic Drugs: Penicillins

Examples of agents

Amoxicillin (Amoxil, Moxatag)

Ampicillin

Penicillin G

Penicillin V (Pen VK)

Dicloxacillin

Nafcillin

Oxacillin

Piperacillin

Ticarcillin

Amoxicillin-clavulanate (Augmentin)

Ampicillin-sulbactam (Unasyn)

Piperacillin-tazobactam (Zosyn)

Ticarcillin-clavulanate (Timentin)

Safety Alert

Up to 10% of patients in the US report penicillin allergies. Although true penicillin allergies are serious and can be life-threatening, many self-reported allergies are in fact adverse drug reactions and not an allergic reaction. If you are taking a patient history, specifically ask what his or her reaction is to the offending agent.

Major Classes of Antibiotic Drugs: Cephalosporins

How they work: Kill bacteria by inhibiting the formation of their cell wall

Therapeutic uses: Depending on generation of cephalosporin: dental work, oral infections, surgical prophylaxis, upper respiratory tract and sinus infections, UTIs, meningitis, intra-abdominal infections

Side effects: nausea, vomiting, diarrhea, headache, dizziness, mental disturbances, seizures, heart palpitations, bleeding abnormalities

Dispensing issues: allergies, high sugar content of cefdinir suspension, refrigerate suspensions except cefdinir and cefixime

Examples of agents:

Cefazolin (Ancef)

Cephalexin (Keflex)

Cefaclor (Ceclor)

Cefotetan (Cefotan)

Cefoxitin (Mefoxin)

Cefuroxime (Zinacef)

Cefdinir (Omnicef)

Cefditoren (Spectracef)

Cefixime (Suprax)

Cefotaxime (Suprax)

Cefotaxime (Claforan)

Cefpodoxime (Claforan)

Ceftazidime (Fortaz, Tazicef)

Ceftibutin (Cedax)

Ceftriaxone (Rocephin)

Cefepime (Maxipime)

Ceftaroline (Teflaro)

Safety Alert

Alert the pharmacist and prescriber if a patient who is allergic to penicillin is prescribed a cephalosporin. Even if the prescriber wants the drug dispensed, it is important to document this communication in case the person does have a cross-reaction.

Major Classes of Antibiotic Drugs: Carbapenems and Monobactams

How they work: Kill bacteria by inhibiting the formation of their cell wall

Therapeutic uses: Intra-abdominal infections, complicated skin/skin structure infections, complicated UTIs

Side effects of carbepenems: skin rash, headache, anemia, pain

Aztreonam inhalation: sore throat, cough, nasal congestion, wheezing, fever, chest discomfort

Aztreonam IV: neutropenia, increased liver enzymes, skin rash

Dispensing issues: special compounding and stability information on doripenem

Examples of agents:

Carbapenems:

Doripenem (Doribex)

Ertapenem (Invanz)

Imipenem-cilastatin (Primaxin)

Meropenem (Merrem I.V.)

Monobactam:

Aztreonam (Azactam)

Major Classes of Antibiotic Drugs: Vancomycin

How it works: Not fully understood, most likely inhibits cell wall formation

Therapeutic uses: MRSA infections, endocarditis, Clostridium difficile infections

Side effects: nephrotoxicity, ototoxicity

Dispensing issues: drug:diluent ratio is 1 gm:200 mL, mix in larger amount of fluid to prevent red man syndrome

Examples of agents: Vancomycin

Major Classes of Antibiotic Drugs: Lincosamides and Macrolides

How they work: Block bacterial ability to produce needed proteins for survival

Therapeutic uses:

Lincosamides: acne, dental work, anaerobic pneumonia, bone infections, bowel infections, female genital infections, intra-abdominal infections

Macrolides: chlamydia, group A beta-hemolytic streptococcus, influenza, Legionnaire's disease, mycoplasma pneumonia, streptococcus pneumonia

Side effects: stomach upset, nausea, vomiting, heartburn, abdominal pain, diarrhea

Dispensing issues: take with food, seek medical attention for severe abdominal pain or diarrhea, clindamycin used topically for acne

Examples of agents:

Lincosamide:

Clindamycin (Cleocin)

Macrolides:

Azithromycin (Zitromax, Z-Pak, Z-Max, Zitromax, Tri-Pak)

Clarithromycin (Biaxin)

Erythromycin (EES, Eryc, EryPed, Ery-Tab, Erythrocin, Pediazole)

Work Wise

The azithromycin Z-Pak is an example of a drug that is supplied in a dose pack but can be dispensed from a bottle. The 250 mg and 500 mg tablets can be dispensed in a bottle or as a package. Just put same instructions on the label and use the same strength of the drug that is in the package.

Major Classes of Antibiotic Drugs: Aminoglycosides

How they work: Kill bacteria by blocking their ability to make essential proteins for survival

Therapeutic uses: Life-threatening infections due to Gram negative aerobes, sepsis, peritonitis

Side effects: nephrotoxicity, ototoxicity

Dispensing issues: variable doses, dosing is individualized and based on patient weight or therapeutic levels

Examples of agents:

Amikacin

Gentamicin (Garamycin, Gentak)

Tobramycin (TOBI, Tobrex)

Major Classes of Antibiotic Drugs: Tetracyclines

How they work: Inhibit protein synthesis within bacterial cells

Therapeutic uses: Acne, anthrax, chronic bronchitis, Lyme disease, Mycoplasma pneumoniae infection, Rickettsia infection, chlamydia

Side effects: upset stomach, nausea, vomiting, photosensitivity, permanent tooth discoloration

Dispensing issues: may be taken with food, apply sunscreen, expired product may degrade and cause kidney failure

Examples of agents:

Doxycycline (Vibramycin, Oracea, Adoxa)

Minocycline (Minocin, Solodyn)

Tetracycline (Sumycin)

Major Classes of Antibiotic Drugs: Fluoroquinolones

How they work: Inhibit the enzyme that helps DNA to coil

Therapeutic uses: Bone and joint infections, eye infections, serious RTIs, serious UTIs, anthrax

Side effects: nausea, vomiting, dizziness, diarrhea, bitter taste in the mouth, liver toxicity, alterations in glucose metabolism. QT prolongation

Dispensing issues: taking with food may not reduce GI effects, dose conversions when switching from oral to IV doses, must be dispensed with a Medication Guide

Examples of agents:

Ciprofloxacin (Cipro)

Levofloxacin (Levaquin)

Moxifloxacin (Avelox)

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Pharmacology - Chapter 4 - Antibiotics and Antifungals - Part One

Part Two

Part Three

Part Four

Part Five

Transcription under the cut!

Chapter 4 - Antibiotics and Antifungals

Chapter Topics

Fighting bacterial infections

Storage of liquid antibiotics

Ophthalmic antibiotics

Sexually-transmitted infections

Fungi and fungal diseases

Complementary and alternative therapies

Learning Objectives

Describe the differences between bacteria and fungi.

Identify the major types of antibiotics by drug class.

Determine which auxiliary labels to use when dispensing major types of antibiotics and antifungals.

Define therapeutic effects, side effects, contraindications, and administration routes of major antibiotics and antifungals.

Utilize appropriate antibiotic and antifungal general drug terminology in written and oral communication.

Describe treatment for common sexually-transmitted infections.

Discuss storage requirements of liquid antibiotics.

List common ophthalmic antibiotics.

Fighting Bacterial Infections

Bacteria

Single-celled organisms

Pathogenic bacteria

Bacteria that are harmful

Infection

Tissue damage caused by the presence of bacteria or their toxins

Work Wise

Many times bacteria names are abbreviated in the workplace. For example, you may hear Streptococcus pneumoniae called "Strep. pneumo." Clostridium difficile can be called "C. diff" and Escherichia coli is often referred to as "E. coli."

Types of bacteria

Aerobic bacteria

Need oxygen to live

Anaerobic bacteria

Can survive without oxygen

Shapes of bacteria

Cocci

Bacilli

Spirochetes

Gram positive bacteria

Have a thick cell wall which absorbs crystal violet

Gram negative bacteria

Have a thin cell wall which does not absorb crystal violet

Symptoms of bacterial infections

Fever of >101°F AND white blood cell count of >12,000/mm3

Antibiotic treatment and action

Antibiotic

A chemical substance with the ability to kill or inhibit microbial growth

Interferes with biological processes inside bacterial cells

Factors considered in antibiotic selection

Type of pathogen suspected

Antibiotic spectrum of activity

Location of the pathogen

Identifying bacteria and selecting drug treatment

Sample or swab taken from patient

Sample grown in laboratory culture

Culture and sensitivity (C&S) test performed

Nosocomial infections

Acquired while in a hospital or nursing-home

Often resistant to antibiotics and difficult to treat

Bactericidal agent

An antibiotic which kills the invading organism

Bacteriostatic agent

An antibiotic which inhibits the growth of bacteria

Evaluating the outcome of antibiotic treatment

Clinical response

Microbiologic response

Side effects and dispensing issues of antibiotics

Parenteral

Mix exactly as directed

Oral

Swab counting tray with alcohol

Gastrointestinal (GI) upset

Some antibiotics to be taken with food

Birth control pills

Interaction with antibiotics may decrease effectiveness

Around-the-clock administration

Purpose is to maintain consistent serum drug levels

Antimicrobial resistance

A defense mechanism of bacteria to resist or inactive antibiotics

Important for patients to complete course of antibiotics

Major Classes of Antibiotic Drugs: Sulfonamides and Nitrofurantoin

Sulfonamides: Block bacteria from making folic acid

Therapeutic Uses: UTIs, otitis media, lower respiratory tract infections, prophylaxis of Pneumocystis carinii

Side effects: rash, nausea, drug fever, vomiting, blood complications, kidney damage, Stevens-Johnson syndrome

Dispensing issues: avoid the sun, drink lots of liquids; wipe down counting trays

Examples of agents: Sulfamethoxazole-trimethoprim (Bactrim, Bactrim DS, Septra, Septra DS)

Nitrofurantoin: not well understood

Therapeutic use: UTIs

Side effects: nausea, vomiting, urine discoloration, false urine glucose tests

Examples of agents: Nitrofurantoin (Macrobid, Macrodantin)

Major Classes of Antibiotic Drugs: Penicillins

How they work: Kill bacteria by inhibiting the formation of their cell wall

Therapeutic uses: Abscesses, beta-hemolytic streptococcus, meningitis, otitis media, pneumonia, respiratory tract infections, Strep pharyngitis, tooth and gum infections, STIs, endocarditis due to streptococci

Side effects: stomach upset, diarrhea, mental disturbances seizures, kidney damage, bleeding abnormalities

Dispensing issues: allergies vs. side effects, take with food

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Pharmacology - Chapter 3 - Dispensing Medications

Part One (Pages 1-10)

Part Two (Pages 11-20)

Part Three (Pages 21-30)

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Pharmacology - Chapter 3 - Dispensing Medications - Part Three

Part One

Part Two

Transcription under the cut!

Factors that Influence Drug Action

Other Considerations in Older Adults

Adverse drug reactions

Beers List

Polypharmacy

Cognitive abilities

Nonadherence

Special Considerations in Children

Altered drug responses

Body weight commonly used for drug doses

OTC doses for very young or small children not on package

Calculations to be double checked

Doses to be reevaluated regularly

Allergic Response

Allergy

Hypersensitivity of the immune system induced by exposure to a particular substance

Allergens

Substances which cause an allergic reaction

Histamine

Produced by the body in response to an allergy

Signs of allergic reaction

Red, watery eyes

Sneezing

Urticaria

Rash

Bronchiolar constriction

Allergy documentation

Must be part of medication record

Teaching Patients Medication Management

Role of the pharmacy technician

Provide clearly written directions

Record medication history in profile including use of OTC medications

Explain that pharmacist is available to answer questions and provide instructions

Read exact wording on label, medication guide, or educational materials to patient

Ensure that patients know how to read medication labels

By law, no advice or counseling is to be provided by technician

Reasons for Nonadherence

Side effects

Failure to understand the disease

Confusion or complexity of the regimen

Simple forgetfulness

Medication Safety

Risk Evaluation and Mitigation Strategy (REMS) Program

Mandated by the FDA for certain medications

Goal is to ensure that benefits outweigh risks

Potential requirements

Dispensing a medication guide

Special dispensing and/or prescribing requirements

Completion of training by prescribers/pharmacists

Special dispensing procedures for technicians

Technician Role

Verify the patient's address, date of birth, phone numbers, allergies, conditions.

Ensure patient gets counseling.

E-Prescribing

Eliminates illegible prescriptions.

Automatically checks for drug allergies, interactions, dosing errors, and therapeutic duplications.

Potential for error reduction.

Physician Order Entry

Computerized physician order entry (CPOE)

Documented reduction in errors

Dispensing Cautions

Requirement to use original containers

Partial prescription not alllowed

Tamper-Resistant Pads

Required for prescribers who file for Medicaid reimbursement

If not used, prescriber will get call to verify prescription

Intent is to encourage e-prescribing

Medication Reconciliation

Improvement of patient safety during transitions of care from one level of care to another

Purpose of reconciliation is to communicate drug therapy information to next care setting

Understanding the Profession

Goals to Keep in Mind

Obtaining certification as a pharmacy technician

Securing employment in profession

Resourceful Organizations

Pharmacy Technician Certification Board (PTCB)

American Association of Pharmacy Technicians (AAPT)

National Pharmacy Technician Association (NPTA)

Chapter Summary

A prescription is a request for the dispensing of medications.

The "rights" for correct drug administration are the right patient, the right drug, the right strength, the right route, the right time, and the right documentation.

The three main routes of administration are oral, parenteral, and topical.

Several physiologic changes occur in the older adult leading to altered drug responses.

Drug doses in children are most often calculated using patient weight.

A pharmacy technician plays a positive role in influencing drug therapy.

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Pharmacology - Chapter 3 - Dispensing Medications - Part 2

Part One

Part Three

Transcription under the cut!

Dosage Forms and Route of Administration

Determining Route of Administration

Disease state

Area of the body

Drug's chemical composition

Patient age and condition

Convenience

Examples of Oral (PO) Route

Sublingual (Under the Tongue)

Oral (Swallowed)

Buccal (Dissolves in the Cheek)

Oral Dosage Forms

Capsules

Elixirs

Gels

Powders

Solution

Suspensions

Syrups

Tablets

Troches/Lozenges

Examples of Parenteral Route

Intramuscular (IM)

Intravenous (IV)

Intradermal

Subcutaneous (SC or SQ)

Intraspinal or Intrathecal

Parenteral Dosage Forms

Solutions

Suspensions

Examples of Topical Route

Transdermal

Inhalation

Ophthalmic

Otic

Nasal

Rectal

Vaginal

Topical Dosage Forms

Aerosols

Creams

Emulsions

Enemas

Gels

Inhalants

Lotions

Ointments

Pastes

Powders

Sponges

Sprays

Suppositories

Transdermal Patches

Factors that Influence Drug Action

Special Considerations in Older Adults

Changes in physiologic function

Visual changes

Auditory changes

Gastrointestinal changes

Pulmonary changes

Cardiovascular changes

Renal changes

Hormonal changes

Body composition changes

Altered drug responses

Absorption changes

Distribution changes

Metabolism changes

Elimination changes

Pharm Facts

Normally, blood flow (as measured per minute) decreases about 1% per year as an individual ages, beginning at about age 35 (40 percent from ages 35 to 75).

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Pharmacology - Chapter 3 - Dispensing Medications (Part One)

Part Two

Part Three

Transcription under the cut!

Chapter 3 - Dispensing Medications

Chapter Topics

The prescription

Correct drug administration "rights"

Dosage forms and routes of administration

Factors that influence drug action

Teaching patients medication management

Medication safety

Understanding the profession

Learning Objective

Describe the components of a prescription

State commonly used prescription abbreviations

Explain the "rights" of correct drug administration

Recognize common dosage forms

Name the routes of administration and their abbreviations

Recognize factors that influence the effects of drugs, particularly in older adults and pediatric populations

Describe the role of the pharmacy technician in medication safety

The Prescription

Prescription

A direction for medication to be dispensed to a patient written by a physician or qualified licensed practitioner and filled by a pharmacist.

Term used in noninstitutional settings.

Medication Order

A prescription issued in an institutional setting.

Components of a Prescription

Full name of patient

Date of prescription

Drug name

Dosage

Route of administration

Amount of drug to be dispensed Note: Amounts should be written out to prevent alterations

Signature of person authorized to prescribe

DEA number if a C-II, C-III, or C-IV drug

Generic permitted

Number of refills

Patient's name

Date prescription written

Inscription which includes name of drug, dose, quantities of ingredients

Signa or "sig" which are the directions for use

Number of refills or "no refills"

Signature and address of the physician

Indication of whether generic substitution is permitted

Drug Enforcement Administration (DEA) number if for a controlled substance

Abbreviations

Used on prescriptions

Standard usage for prescribers, pharmacists, and prescriptions

Not used for patient instructions or for verbal orders

Potential source of medication errors

Official "Do Not Use" Abbreviations

U, u (unit)

Mistaken for 0, 4, or cc

Write "unit"

IU (International Unit)

Mistaken for IV or 10

Write "International Unit"

Q.D., QD, q.d., qd (daily)

Mistaken for Q.O.D., QOD, q.o.d., qod

Write "daily"

Q.O.D., QOD, q.o.d., qod (every other day)

Mistaken for Q.D., QD, q.d., qd. Period after the Q mistaken for "I" and the "O" for "I"

Write "every other day"

Trailing zero (x.0 mg)

Decimal point is missed

Write x mg

Lack of trailing zero (.x mg)

Decimal point is missed

Write 0.x mg

MSO4 and MgSO4

Confused for one another

Write "morphine sulfate" or "magnesium sulfate"

Correct Drug Administration Rights

Introduction

Used as a guideline for filling prescriptions

Concepts used to avoid medication errors

Work Wise

If something seems strange about a prescription (like a dose), speak up. As a pharmacy technician, you are a valuable asset to your pharmacist. Your pharmacist will be glad you expressed your concern.

Right Drug

Right Strength

Right Route

Right Patient

Right Time

Right Documentation

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Pharmacology - Chapter 2 - Basic Concepts of Pharmacology

Part One (Pages 1-10)

Part Two (Pages 11-20)

Part Three (Pages 21-29)