Down on the Pharm Sponsored by Community Hospital and based on the EMS Village “Down on the Pharm...

Down on the PharmSponsored by Community Hospital and

based on the

EMS Village

“Down on the Pharm©” series

Down on the PharmSponsored by Community Hospital and

based on the

EMS Village

“Down on the Pharm©” series

Pharmacy update for EMS

Pharmacy update for EMS

RX List

The 10 most commonly prescribed

drugs

The 10 most commonly prescribed

drugs

As reported by:

Part OnePart One

The number one prescription drug for estrogen replacement

1. Premarin1. Premarin

Indications:

Reduces the risk of osteoporosis and heart disease in post-menopausal

women

Relieves symptoms of menopause

1. Premarin1. Premarin

Side Effects:

The most common side effect is nausea; which usually diminishes the longer therapy continues

May cause women to be more prone to gall bladder disease

PremarinPremarin

PremarinPremarin

Estrogen therapy can affect the effectiveness of two other drugs:

Can decrease the effects of oral anticoagulants (Coumadin)

Can decrease the effects of oral anti-diabetic agents, resulting in increased blood sugar

PremarinPremarinFor more information on estrogen

replacement therapy and Premarin go to:

Wyeth Product Page

http://www.wyeth.com/products/#

or

http://www.premarin.com/index.html

PremarinPremarin

EMS Note:

Be alert for hyperglycemia in patients recently started on

estrogen therapy.

Synthroid® is levothyroxine, a replacement thyroid hormone

About 20 million Americans have some form of thyroid disease

2. Synthroid2. Synthroid

Indications:

Levothyroxine is the drug of choice for thyroid hormone replacement therapy in people who have hypothyroidism

2. Synthroid2. Synthroid

SynthroidSynthroid

Thyroid dysfunction…...

What are the two types?

What causes them?

SynthroidSynthroid

Thyroid dysfunction…...

There are two ways people can become hypothyroid:

They can have an underactive thyroid gland that does not produce enough hormone.

SynthroidSynthroid

Or they may have had an overactive thyroid (hyperthyroidism), and their treatment consisted of surgery or

radioactive iodine to remove or destroy all or part of the gland. The treatment,

therefore, left them hypothyroid, requiring replacement therapy.

SynthroidSynthroid

Hyperthyroidism

May be due to an overactive thyroid gland

Or, if people take too much or too little of their replacement medicine, they can have the same symptoms as if their thyroid was making too much or too little hormone.

Signs of too much Synthroid® include: irritability, insomnia, nervousness,

headache, weight loss, tachycardia, and warm, moist skin.

SynthroidSynthroid

Signs of too little Synthroid® include: fatigue and lethargy, mild weight gain, cold and pale skin, and decreased pulse

and blood pressure

SynthroidSynthroid

SynthroidSynthroid

If someone stops taking the Synthroid® altogether,

they can go into myxedema coma, which is a life-

threatening condition.

SynthroidSynthroid

Prehospital care for myxedema coma includes life-support

measures and rapid transport to definitive care in the ED

What are the signs of myxedema and what is myxedema coma?

SynthroidSynthroid

Patients with myxedema complain of fatigue, lethargy, sleepiness, poor tolerance to cold, mental sluggishness, a tendency to

gain weight, and generalized aches and pains.

SynthroidSynthroid

Their faces often look puffy and waxy.Their skin is dry and coarse; their hair is coarse,

dry, and brittle, and it tends to fall out easily.

These and other symptoms are caused by a low metabolic rate resulting from a

deficiency of the thyroid hormone that stimulates metabolism

SynthroidSynthroid

What happens if myxedema is not

treated?

Myxedema coma, a rare, life-threatening condition, occurs in the progression of

hypothyroidism. It is seen more often in elderly women, and the coma often can be precipitated by infection, medication,

environmental exposure, and other metabolic-related stresses

SynthroidSynthroid

For more information on thyroid disease and myxedema Coma go to:

The Thyroid Newsroomhttp://home.about.com/health/index.htm

SynthroidSynthroid

SynthroidSynthroid

EMS Note:

There is no cardinal sign that a coma is due to hypothyroidism…. prehospital care providers can play a critical role in these patients’ care by getting a careful history from friends or

family members, and examining pill bottles in the home (or area of the call) to see if

Synthroid® is among the patient’s medications

3. Lipitor3. Lipitor

Lipitor is in a class of drugs called HMG-CoA Reductase Inhibitors

The drugs inhibit an enzyme necessary for the body to make cholesterol; therefore,

the body makes less cholesterol, lowering total cholesterol and LDL cholesterol

blood levels.

(atorvastatin)


Indications:

Lipitor is indicated for lowering of serum cholesterol when lifestyle changes are not

achieving success

(atorvastatin)


Actions:

Lipitor (atorvastin) blocks the production of cholesterol in the body

These actions are important in reducing the risk of hardening of the arteries,

which can lead to heart attacks, stroke, and peripheral vascular disease

(atorvastatin)

Atorvastatin is used to reduce the amounts of LDL (bad) cholesterol, total cholesterol, triglycerides (another type of fat), and apolipoprotein B (a protein

needed to make cholesterol)

Atorvastatin is also used to increase the level of HDL (good) cholesterol

LipitorLipitor (atorvastatin)

LipitorLipitor

Adverse Reactions:

Lipitor (as with other lipid-lowering therapies) has been associated with altered

liver function

Alcohol consumption combined with Lipitor may increase the risk…..may lead to

hepatic failure

(atorvastatin)

LipitorLipitor

Adverse Reactions:

Symptoms would include jaundice, dark or orange urine, scleral jaundice, abdominal

distention and pain

(atorvastatin)

LipitorLipitorAnother adverse reaction to Lipitor is myopathy (muscles aches or muscle

weakness)

Myopathy and muscle breakdown may lead to myoglobinurea (the presence of

myoglobin in the urine)

Myoglobin is the molecule that results from muscle tissue breakdown

(atorvastatin)

LipitorLipitor

The myoglobin molecule is large, and if large amounts are present

the patient may develop a condition in which the kidney’s function is impaired and renal

failure may develop

What is the condition?

(atorvastatin)

LipitorLipitor

Rhabdomyolysis….Symptoms may include muscle pain and weakness, brown or

dark red-tinged urine, decreased urine output

(atorvastatin)

LipitorLipitor

EMS Notes:

Trauma patients who are taking Lipitor have a higher risk of developing

rhabdomyolysis…why?

What other conditions may predispose patients to rhabdomyolosis?

(atorvastatin)

Trauma patients are at an increase risk of developing rhabdomyolysis

due to the destruction of muscle cells. When muscle cells are injured,

myoglobin is released.

For more information on Rhabdomyolosis go to:

http://www.mcphu.edu/continuing/cme/medicine/pathogen/introduc.htm

LipitorLipitor (atorvastatin)

Indications:Prilosec (Omeprazole) is used to

treat ulcers and acid reflux.

It acts to inhibit gastric secretion

4. Prilosec4. Prilosec (omeprazole)

We now know that peptic ulcer disease is primarily caused by an

infection with H. pylori, but Prilosec is often prescribed to treat

symptoms and decrease recurrence


Actions:Unlike the earlier ulcer and GERD drugs such as

ranitidine and cimetidine, which are H2 antagonists (and now available over the

counter), Prilosec® is a proton pump inhibitor. It binds with an enzyme that controls hydrogen

secretion. This blocks the final step in the production of gastric acid. This can inhibit

gastric acid secretion by up to 90%.


Side effects:

There are few side effects reported with Prilosec

The most common are headache, nausea and abdominal pain


Prilosec can affect other medications in two ways. One is

an interaction with metabolism in the liver; the other is by changing the pH of the stomach, which may

affect the absorption of some drugs.


Prilosec can prolong the elimination of diazepam, warfarin and phenytoin…..as well as other drugs that are metabolized by oxidation in the liver



EMS Note:

It is important for the EMS provider to be aware of these interactions because increased blood levels of diazepam and phenytoin can decrease the level of consciousness, and increased blood levels of warfarin can cause bleeding.


For further information on GERD go to:

Gerd Information Resource Centerhttp://www.gerd.com/home.htm

http://www.gerd.com/home.htm

5. Hydrocodone 5. Hydrocodone(Vicodan, Lortab)

Hydrocodone is an opioid pain reliever, also known by brand names Vicodin®

and Lortab®, is a synthetic opioid combined with acetaminophen


Indications:

Prescribed for a wide range of conditions, from acute pain associated with broken bones, to chronic pain associated with

cancer and traumatic injuries

Side effects:

Side effects of hydrocodone are no different from other opioids, and

include: sedation, lightheadedness, lethargy, constipation.

What other drugs fall into the opioid category?


What are the signs of an opiate overdose?


Overdose:

Opiates cause respiratory depression (dose related)

A patient taking opioids will usually have constricted pupils


What is the prehospital protocol for opiate overdose?


Naloxone is the drug of choice for severe respiratory depression


Remember that the duration of action of naloxone is shorter than that of the opioid, so

sedative and respiratory depression may unexpectedly return when the naloxone wears

off, and the opioid effects take over again.



As with any opioid analgesic, there is a great potential for abuse……..

If a patient is taking hydrocodone / APAP, find out why the medication was

prescribed, and how many pills the patient takes every day.

Encourage the patient to be honest with you, because a thorough understanding of a

patient’s actual medication use is critical to proper treatment

both in pre-hospital care and in the ED


Patients taking opioids for a period of time can develop a physical dependence on the drug. Stopping the drug suddenly

can cause withdrawal



Signs and symptoms of opioid withdrawal include: irritability,

sleeplessness, restlessness, tremor, nausea, vomiting, diarrhea, and

abdominal cramps. Peak severity of withdrawal symptoms typically occurs 36 to 72 hours after the last dose of

the opioid


EMS Note:

A careful history and scene survey can tip you off quickly if a patient’s decreased LOC is related to the use of opioid analgesics.

6. Albuterol 6. Albuterol

Albuterol is classifies as a beta adrenergic agonist (stimulator)

Albuterol dilates bronchial airways by relaxing the surrounding bronchial muscles

It may be prescribed in an oral form, or as an inhaler

The inhaled form of Albuterol starts working within 15 minutes and can last up to 6 hours

Usual dosing will be 2 puffs every 4 hours


Adverse Reactions:

Albuterol can cause side effects including palpitations, fast heart rate, elevated blood pressure, tremor, nausea, nervousness, dizziness, sleeplessness, and heart burn.

Throat irritation and nose bleeds can also occur


Albuterol should be used with caution in patients with coronary heart disease or in patients with cardiac rhythm disturbances

In rare patients, inhaled albuterol can paradoxically precipitate life threatening

bronchospasm

What is a paradoxical effect?

6. Albuterol6. Albuterol

Use of albuterol together with other stimulant medications is discouraged

because of their combined effects on the heart rate, blood pressure, and the potential for causing chest pain in

patients with underlying coronary heart disease.


Tricyclic antidepressants, such as ELAVIL, should not be used together with

albuterol because of their combined toxicity to the vascular system


EMS Note:

Albuterol may increase the anxiety level in an already anxious patient.


Norvasc®, the most commonly prescribed calcium channel blocking

agent, is used to treat high blood pressure or chronic stable angina.

It is prescribed alone or in combination with other drugs for each condition.

7. Norvasc7. Norvasc (amlodipine)

Actions:

By blocking calcium channels, this drug prevents calcium from entering the cardiac and smooth muscle cells.

This action, in turn, causes dilation of peripheral arteries and arterioles, decreases the strength of cardiac contraction, and may decrease heart rate.


Norvasc® has less effect on the heart’s contraction and rate than

other calcium channel blockers and a greater effect on vessel dilation


Some other Calcium Channel Blockers include

bepridil diltiazem felodipine flunarizine isradipine nicardipine

nifedipine nimodipine nisoldipine verapamil


Adverse Effects:

The most common adverse effects are headache, edema flushing, palpitations, and dizziness

Patients may also experience nausea, fatigue, drowsiness and abdominal pain



Congestive heart failure may occur as a result of calcium channel blocker therapy

What signs and symptoms might the patient exhibit?

EMS Note:

A sudden stop in therapy (if the patient forgets to get the prescription renewed, or can’t afford to get more pills) can cause an increase in frequency and duration of chest pain.


For more information about calcium channel blockers got to:

The Rx Listhttp://www.rxlist.com/


Claritin is an antihistamine

Indication: for control of allergy symptoms such as runny nose, itchy and

watery eyes, itchy palate (roof of the mouth) and sneezing.

8. Claritin8. Claritin (loratadine)

8. Claritin8. Claritin (loratadine)

Claritin is popular due to the lessed risk of drowsiness associated with the drug

9. Trimox9. Trimox (amoxicillin)

Trimox is a brand name of the antibiotic amoxicillin. Amoxicillin is one of the many penicillins, and is used to treat

infections most commonly in the respiratory system, GU tract, skin, soft

tissue, bone, and joints


Amoxicillin is also part of the multi-drug therapy used to treat duodenal ulcers, now believed to be caused by H. pylori

bacteria


Adverse Reactions:

Signs of hypersensitivity include: nausea, vomiting, and an itchy rash (called pruritus), which may or may not progress to the symptoms associated with anaphylaxis


What are the signs of an anaphylactic reaction?


Tachycardia, dyspnea, diaphoresis, wheezing, stridor and circulatory

collapse are the signs of an anaphylactic reaction

What is the treatment for an anaphylactic reaction?


For more information on Trimox got to:

http://www.bms.com/medicines/data/

10. Prozac10. Prozac

Prozac belongs to a category of medications called selective serotonin

re-uptake inhibitors, or SSRIs


These drugs were originally designed to be used as antidepressants, they are

also prescribed for obsessive-compulsive disorder, panic attacks, and a variety of

other conditions such as anorexia nervosa and fibromyalgia

(fluoxetine)


Indications:

In 5 and 6 week studies, Prozac was shown to significantly decrease depression, sleep

disorder, and anxiety

It can help treat bulimia, obsessive compulsive disorder and PMDD (pre-

menstraul dysphoric disorder

(fluoxetine)

10. Prozac10. Prozac (fluoxetine)

Side Effects:headache tremor nervousness anxiety difficulty concentrating

nausea diarrhea dry mouth changes in appetite or weightweakness increased sweating

sleepiness insomnia


Contraindications:

Prozac should never be taken with drugs in the MAOI class (Monoamine Oxidase

Inhibitors)

These drugs include: Parnate, Marplan, and Nardil

Serotonergic Syndrome, a life threatening condition, may result…..


Contraindications:Serotonergic Syndrome: May include high

blood pressure, nausea and vomiting, fever, rigidity, rapidly fluctuating vital signs, shock, and mental changes.


MAO Inhibitors were prescribed for treatment of depression

They are rarely prescribed in the advent of the newer antidepressants

such as Prozac

They caused serious side effects


MAO Inhibitors react with:

Foods that have a high tyramine content (most common in foods that are aged or fermented to increase their flavor), such as cheeses; fava or broad bean pods; yeast or meat

extracts; smoked or pickled meat, poultry, or fish; fermented sausage (bologna, pepperoni, salami, summer sausage) or other fermented meat; sauerkraut; or any overripe fruit.

Alcoholic beverages or alcohol-free or reduced-alcohol beer and wine. Large amounts of caffeine-containing food or

beverages such as coffee, tea, cola, or chocolate.


Contraindications:Prozac should not be started until two weeks after stopping therapy with an MAO inhibitor. Because Prozac takes a

long time to be eliminated from the body, patients should wait at least five weeks after stopping Prozac before starting an

MAO inhibitor


Overdose:Prozac® ingested alone as an overdose is generally not life threatening. Common signs and symptoms include drowsiness, tachycardia, nausea, vomiting and tremor. Prozac® ingestion becomes more toxic when combined with alcohol.


Overdose:Fatalities seen with Prozac® overdose are usually associated with ingestion of other drugs that are far more dangerous than the Prozac® itself.


For more info on Prozac and MAOI drugs go to:

http://my.webmd.com/content/article/1680.50554

Post Test and Evaluation

To receive your CEUs you must complete the post test and evaluation. After completion, mail

them, along with a self-addressed, stamped envelope to:

Terri Norris, EMS Coordinatorc/o Emergency Center

2615 E. High St.Springfield, Ohio

45505

Click here to go to the Post Test and Evaluation

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