hi this is the first powerpoint that i'm making for a study guide for the a-n-n-p exam that i plan on taking here in the upcoming may month i am currently reviewing the leak um study guide for the anp exam and we'll kind of cover some of those topics here in this powerpoint and in future powerpoints and then i plan on also doing the jalyair for the whole year of hollyer i believe is pronounced um review for the exam as well and i plan on doing kind of some kind of study guide with that as well on here but for this one this is going to be a pharmacology review from the leak material and this is kind of overall safety tips when administering medications and this is taken from the text and just kind of outline of the material that was highlighted there so hopefully it helps so starting out in chapter three of the leak material the pharmacology review they just kind of go over some important to know concepts and what to expect with the exam so it says that knowledge of drug interactions side effects contraindications and monitoring and patient outcomes are going to be more of the main focus of the exam it is important that we know of course lab tests that are required before starting medications and again the contraindications so safety is going to be a key a couple of examples of the text gabe that we should know is that thiazide diuretics are contraindicated in gout aces and arbs require that you monitor potassium and serum creatinine at baseline within the first month of starting a new acer arb and then periodically therefore there and after and then for anticoagulation therapy and inr monitoring for patients with afib their inr needs to be in between two and three but for patients with prosthetic heart valves that are being anticoagulated then they are going to be is that even then they are going to be at a inr of 2.5 to 3.5 also they emphasize knowing drug classes and the representative drugs for those classes however that doses are not going to be as emphasized and that the most common questions will be about disease management and which drug treats certain diseases more older drugs are going to be questioned for example isothromyosin doxycycline ameprazole prednisone and amoxicillin any meds that were released within the last 12 months it's safe to assume that those will not be on the a np exam and then important terminology that was covered was remembering the term half-life and that that is the amount of time it takes for a drug to decrease by 50 concentration another another important concept to review that will be necessary for us to have an understanding of on the a and np exam is the first pass effect and that is that all oral drugs except for the sublingual drugs they have to go through that first pass metabolism so inside the liver there are the site the cytochrome p450 system that metabolizes the drugs and then the remaining active drug is what's released and a good example that the text provides is of course insulin which is completely broken down by the gi tract and the enzymes there if taken orally so therefore they take it another route for example sub-q also carbamazepine and ortegritol is a strong inducer of the cyp-450 system and therefore lots of drug interactions can affect can occur with that medication also there was a lot of emphasis about different drugs that are affected by kidney disease of course our renal filtration system accounts for most of our drug excretion and so it's really important that we have an understanding of what drugs might affect our kidneys i try to make an acronym here the idea was kidneys or kidney collapse with nsaids so the first one being contrast which of course can increase the risk of kidney injury and then the oral sodium phosphate which is taken as a bowel prep that increases risk of kidney injury lithium needs to be monitored closely that can enjoy the kidneys aces there's a risk increased risk of hyperk hyperkalemia and then of course the potassium sparing diuretics that's going to be an issue with possible risk of hyperkalemia and then the last one there warfarin increased incidence of over coagulation with severe or chronic kidney disease and end-stage renal disease those are actually when the more severe cases they're at actual increased risk of hemorrhage and then i'm sorry the last one of course is nsaids which we know can be damaging to the kidneys so just to reiterate with the drugs that affect are affected by kidney disease the acronym is kidneys collapse with nsaids but it's c-o-l-a-p-s-w-n-saids contrast oral sodium phosphate lithium aces potassium sparing diuretics warfarin and nsaids kidneys claps with nsaids these are the drugs that we need to be aware of when considering kidney disease another list of medications that was emphasized by the leak review was quote unquote problem drugs and those are going to be drugs that actually inhibit or stop the cyp 450 sim system from working effectively and so there were a list of drugs that they discussed here but submedidine or tegamet um antifungals macrolides protease inhibitors citalopram grapefruit juice all of these actually inhibit the system and then then of course can cause drug interactions and complications with just drug administration not having the full effect or full therapeutic effect with our medications if we are combining these meds with them so we just need to be cognizant of our uh patient and what meds that they're on and then it actually elaborated in the text about grapefruit juice and it's just it's interesting because it's such a you know common thing that someone could buy at the grocery store but it actually lists off a lot of medications that it can adversely affect and so this is a important education point with our patients it can negatively affect if the patient's also taking while drinking grapefruit juice statins erythromycin calcium channel blockers antiviral medications amio benzos carbamazepine boost bar there was multiple drugs that were listed that can be negatively impacted by having an intake of grapefruit juice and the effect it has on that cyp 450 system and how we metabolize them metabolize our drugs so it's just something that we need to be aware of as a care providers also i try to make another acronym here to help um keep the list fresh in the mind so again this is a list of medications that inhibit the cyp 450 system that that system that metabolizes our drugs and and the acronym that i came up with reads camp c-a-m-p celexa serves deadly grape juice to the 450 system so camp is an acronym c-a-m-p standing for the cementidine anti-fungal macrolides protease inhibitors and then camp celexa to remember slexa serving deadly grape juice grape juice all of those which affect negatively affect our cyp 450 system and our metabolism of drugs camp celexa serves deadly grapefruit juice to the cyp 450 system so the next last list of medications that the leak review discusses is just another overall review of meds that just have glaring safety issues that we need to be aware of as providers and people prescribing medication and so there was a specific list of medications that it said for us to review according to leak for the a np exam so i tried to list them here and then come up with a weird acronym again to help with the memory of it but the first one being h2 antagonists so ranitidine femotidine those medications we need to be alert of mental status changes and those can signal signify kidney disease and then of course we need to be avoiding these medications those h2 antagonists with our patients with a creatinine clearance of less than 50. um next up is the ppi the proton pump inhibitors those have a safety warning that is omeprazole more commonly known we know that one there is an increased risk of fracture with postmenopausal women there's an increased risk of pneumonia c diff hypomagnesemia and b12 and iron male absorption as well also atrophic gastritis and kidney disease not to mention omeprazole interacts with warfarin diazepam carbamazepine phenytoin and ketoconazole so a lot of medications that those proton pump inhibitors the omeprazole interacts with and so we just need to be aware of that and make sure it's not interacting with any of their other meds that they're on and then the next drug was the vitamin k antagonist or warfarin very common drug with our patients we need to know that these interact with g herbs so garlic ginger ginkgo ginseng also feverfew green tea and fish oil are also listed along with multiple different drugs but warfarin interacts with a lot of different things so we just need to be aware educating your patients and then of course if they are on warfarin and they need to have any kind of procedure done they need to discontinue their warfarin seven days before surgery and then let's see the next one is the tzd's or pioglitazone this one has a black box warning so we need to really know this one it can cause or even exacerbate chf and it's actually contraindicated in patients with a history of mi stroke bladder cancer diabetes type 1 eye or liver problems again that's the pioglitazone or the tzds i'm not even going to try to say the whole word but also we want to stop of course if we see our patients having dyspnea weight gain cough as these can be signs of heart failure and then continuing on with the list of medications that we need to be alert of is the atypical antipsychotics risperdal olanzapine quidipine there's a high risk of weight gain metabolic syndrome type 2 diabetes so we need to be monitoring their weight at least every three months their tsh their lipids their blood glucose their a1c and their bmi and then there's actually another black box warning with these atypical anti-antipsychotics and that there's a higher mortality rate in elderly patients so that's going to you know play a big role in if we are prescribing this to our 65 and older population and then the next one is the bisphophonate phonates hopefully i said that right alandronate is an example but these actually can cause erosive esophagitis so if patients are coming in having chest pain with eating painful swallowing difficulty swallowing heartburn any of those we're going to stop also obviously we're going to stop the medication but also if they're experiencing burning in their mid back or jaw pain the leak review points those two specific terms out that those can be actual signs of osteonecrosis if our patient is taking any of these medications we have an important education point that we need to teach them to take them alone upon awakening empty stomach with the eight ounce of eight ounces of water only um so they'll have it before breakfast they don't mix it like i said with any other meds and then they actually want to refrain from laying down after taking it for 30 minutes and really kind of let that digest and then it's contraindicated in anyone with active gi disease chronic kidney disease or varices or strictures so it's important to know as well and then lastly on this list is the lingosamides or clindamycin which we should be familiar with and that carries with it a risk of c death next up on the list of drugs to be cognizant of is statins and that of course includes our statin drugs the simvastatin atorvastatin provocatin all those meds that end in statin we want to educate our patients that we do not mix these with grapefruit juices we kind of touched on earlier that it interacts with while grapefruit juice interacts with our cyp 450 system so we want to refrain from grapefruit juice if they're taking statins and then also there's a few like very specific things to be aware of with our patient populations and taking stents according to the leak review so drug induced hepatitis or rhabdomyolysis those are higher incidence if they're mixed with azel anti-fungals also it's stated in the text that the highest risk of rhabdo is with patients taking also statins including i'm sorry in addition to statins a high dose of zocor which is considered 80 milligrams and they'll come in with complains of muscle pain weakness and then red very concentrated dark urine and then the chinese population are actually at an increased risk of myopathy or that muscle pain or rhabdo when taking 40 milligrams or more of simvastatin with niacin so those are pretty specific but important obviously to know with our patient population what we're prescribing and who we're prescribing it to and then also it is mentioned that with statins their creatinine kinase can increase something to monitor and then after the statins is inhaled corticosteroids they there's a concern here for adrenal insufficiency with our pediatric population so those that have been those pediatric patients that have been taking high doses of inhaled corticosteroids for more than six months um are going to be at a greater risk of adrenal adrenal insufficiency especially those children with a low bmi taking those high doses of those inhaled corticosteroids we're going to be suspicious of this with symptoms of such as hypoglycemia hypotension altered mental status weakness cushing features and then growth deceleration that's going to be a concern and then also after that was systemic glucocorticoids there's a concern here for cataracts osteoporosis skin changes telling tasia or easy bruising emotional liability weight gain high blood pressure so that both of those come with a lot of high risk and close monitoring to make sure they're not developing any of these side effects and then the last one was the phenytoin earliest signs of toxicity with this drug is going to be horizontal nystagmus at an unsteady gait so they're having central nervous system issues they're gonna if if it's severe enough they're gonna develop slurred speech lethargy altered mental even it could progress to a coma so we're going to want to keep check you know keep up to date with their levels of their medication and then monitor for symptoms of like neural symptoms neurological symptoms and then additional side effect that we need to be alert for with patients on the phenytoin is gingival hyperplasia so just something to be monitoring for and also may come up on our exam and then so i try to come up with kind of like a funny acronym to remember this list of drugs that we need to be alert of when administering medications in practice but also kind of red flags for what we might expect um on the a np exam these meds might be on there as these are big you know safety issues with meds so the list was h2 antagonist ppis vitamin k or warfarin satins the tzd's atypical antipsychotics bisphosphonates systemic glucocorticoids phenytoin inhaled corticosteroids and then the lyncosamides all of these are big safety issues with meds and so i came up with the acronym hpv stabs pickles h p v s t a b s p i c l and um so yeah maybe i'll help you remember the last topic that was really emphasized in the beginning of the pharmacology review and the leak text was the beers criteria and that is certain criteria that were made of medications that should be avoided in a population of 65 and older it was named after whoever came up with it his last name i'm pressure was beer but it again is meds that we want to avoid in our 65 and older population these include anti-psychotics river racks ban or debigatran tramadol and opioids and then so i came up with um a kind of a little story or acronym as well to hopefully help but what's lifted what's what was listed here was for the anti-psych issue with our patients in that population if they do need um anti-psych meds seroquel clozapine and primavencerin i'm not familiar with that one but those are the ones that may be used cautiously with this population but those are listed as less risky and then when discussing blood thinners the river rocks ban or the debigatran those have increased bleeding risk risk with our 65 and older population so instead warfarin or other direct oral anticoagulants are going to be a safer route with those patients as far as tramadol it's the text talks about a risk of low sodium or hyponatremia from siadh and then also with opioids it specifies that if patients are on opioids do not combine with benzos or gabapentinoids as these can cause severe respiratory depression so of course we don't want to do that to our patients and then i came up with a little acronym here and like i said story sort of but stella arto is older than 65 years and still takes her seroquel and warfarin with a beer so stella artois of course is a beer that we all know so stella became her name our toe is an acronym a-r-t-o anti-psychotics rivaroxaban tramadol and opioids are toe so stella arto is older than 65 of course that's the parameters and then still takes her seroquel and warfarin with the beer so i put those in there because of course if we're doing an antipsychotic seroquel as a safe option or safer um and then warfarin was the preferred route for aunt blood thinners so it's she is able to still be taking those medications that population is funny that she would take it with the beer just because it's the beers criteria but of course if our patient comes to us and says they take their pills with liquor we should educate them on why that's a bad idea