Commonly Used Drugs Julie Beauregard, MLIS

Outline Antibiotics Diuretics Non-steroidal anti-inflammatory drugs (NSAIDs) Beta-blockers Steroids Anticoagulants

Antibiotics

Diuretics

Non-steroidal anti-inflammatory drugs (NSAIDs)

Beta-blockers

Steroids

Anticoagulants

Antibiotics Adapted from a presentation by Jennifer Lyon, delivered at EBL’s Knowledge Building session in 2007.

What Antibiotics Do Antibiotics may either kill bacteria (“bacteriocidal”) or stop bacteria from dividing and producing more bacteria (“bacteriostatic”).

Antibiotics may either kill bacteria (“bacteriocidal”) or stop bacteria from dividing and producing more bacteria (“bacteriostatic”).

Classifying Antibiotics Antibiotics can be classified by: Their biological source Plant, mold, soil microorganisms Their spectrum of action or coverage Broad/wide spectrum - effective against a wide range of bacteria Narrow spectrum - effective mainly against specific categories of bacteria e.g. Gram-positive or Gram-negative bacteria but not both Limited spectrum - effective against a single organism or disease Their mode of action How they fight bacteria

Antibiotics can be classified by:

Their biological source

Plant, mold, soil microorganisms

Their spectrum of action or coverage

Broad/wide spectrum - effective against a wide range of bacteria

Narrow spectrum - effective mainly against specific categories of bacteria

e.g. Gram-positive or Gram-negative bacteria but not both

Limited spectrum - effective against a single organism or disease

Their mode of action

How they fight bacteria

Types of Bacteria Bacteria can be classified in a number of ways. The ways that are most commonly considered for antibiotic coverage are: Gram Stain Shape Use of Oxygen

Bacteria can be classified in a number of ways. The ways that are most commonly considered for antibiotic coverage are:

Gram Stain

Shape

Use of Oxygen

Gram-negative vs. Gram-positive Bacteria Gram-negative or gram-positive classification represents a difference in the composition of the bacterial cell wall. Antibiotic “coverage” is based on whether it is effective against gram-positive, gram-negative or both types of bacteria. http://helios.bto.ed.ac.uk/bto/microbes/shape.htm

Gram-negative or gram-positive classification represents a difference in the composition of the bacterial cell wall.

Antibiotic “coverage” is based on whether it is effective against gram-positive, gram-negative or both types of bacteria.

Bacterial Shape The most common shapes are cocci (spherical), bacilli (rods), and spirochetes (spiral/helical). http://www.merck.com/mmhe/sec17/ch190/ch190a.html

The most common shapes are cocci (spherical), bacilli (rods), and spirochetes (spiral/helical).

Use of Oxygen Aerobic bacteria Staphylococcus, Streptococcal Anaerobic bacteria Clostridia Facultative bacteria Salmonella, E. coli

Aerobic bacteria

Staphylococcus, Streptococcal

Anaerobic bacteria

Clostridia

Facultative bacteria

Salmonella, E. coli

Antibiotic Modes of Action Inhibit synthesis of bacterial cell wall Act directly on the cell membrane of the bacteria, causing it to break open Inhibit bacterial protein synthesis Affect bacterial metabolism and growth

Inhibit synthesis of bacterial cell wall

Act directly on the cell membrane of the bacteria, causing it to break open

Inhibit bacterial protein synthesis

Affect bacterial metabolism and growth

Antibiotic Modes of Action Inhibit synthesis of bacterial cell wall Beta-lactams Polypeptides bacitracin (Baciguent®; BaciiM®) Glycopeptides vancomycin (Vancocin®), ramoplanin oritavancin, dalbavancin, telavancin Cycloserine (Seromycin®)

Inhibit synthesis of bacterial cell wall

Beta-lactams

Polypeptides

bacitracin (Baciguent®; BaciiM®)

Glycopeptides

vancomycin (Vancocin®), ramoplanin

oritavancin, dalbavancin, telavancin

Cycloserine (Seromycin®)

Beta-Lactam Antibiotics Biggest class of antibiotics Penicillins benzylpenicillin (Penicillin G), amoxicillin (Amoxil®) Cephalosporins/Cephamycins cephalexin (Keflex®), cefadroxil (Duricef®), cefdinir (Omnicef®) Carbapenems imipenem (Primaxin®), ertapemem (Invanz®), meropenem (Merrem®) Monobactam aztreonam (Azactam®)

Biggest class of antibiotics

Penicillins

benzylpenicillin (Penicillin G), amoxicillin (Amoxil®)

Cephalosporins/Cephamycins

cephalexin (Keflex®), cefadroxil (Duricef®), cefdinir (Omnicef®)

Carbapenems

imipenem (Primaxin®), ertapemem (Invanz®), meropenem (Merrem®)

Monobactam

aztreonam (Azactam®)

The Penicillin Family of Antibiotics Natural Penicillins Benzylpenicillin (Penicillin G) phenoxymethyl penicillin (Penicillin V) Synthetic Penicillins Penicillinase-resistant or anti-staph penicillins Methicillin, Oxacillin, Nafcillin, Cloxacillin, Dicloxacillin Aminopenicillins (Second Generation) Ampicillin, Amoxicillin Carboxypenicillins (Third Generation) Carbenicillin, Ticarcillin Ureidopenicillins (Fourth Generation) Piperacillin Penicillin plus ß-lactamase inhibitors Amoxicillin-clavulanic acid, ampicillin-sulbactam, ticarcillin-clavulanic acid, piperacillin-tazobactam

Natural Penicillins

Benzylpenicillin (Penicillin G)

phenoxymethyl penicillin (Penicillin V)

Synthetic Penicillins

Penicillinase-resistant or anti-staph penicillins

Methicillin, Oxacillin, Nafcillin, Cloxacillin, Dicloxacillin

Aminopenicillins (Second Generation)

Ampicillin, Amoxicillin

Carboxypenicillins (Third Generation)

Carbenicillin, Ticarcillin

Ureidopenicillins (Fourth Generation)

Piperacillin

Penicillin plus ß-lactamase inhibitors

Amoxicillin-clavulanic acid, ampicillin-sulbactam, ticarcillin-clavulanic acid, piperacillin-tazobactam

Antibiotic Modes of Action Act directly on the cell membrane of the bacteria, causing it to break open Polymyxins Colistin (polymyxin E) Polymyxin B Surfactin Daptomycin (Cubicin®)

Act directly on the cell membrane of the bacteria, causing it to break open

Polymyxins

Colistin (polymyxin E)

Polymyxin B

Surfactin

Daptomycin (Cubicin®)

Antibiotic Modes of Action Inhibit bacterial protein synthesis Aminoglycosides gentamicin (Genoptic®; Gentak®), streptomycin Chloramphenicol Tetracyclines tetracycline (Sumycin®), doxycycline (Adoxa®; Doryx®; Monodox®) Macrolides erythromycin (Erythrocin®; Eryderm®) azithromycin (Zithromax®) Clindamycin ( Cleocin®; ClindaMax®)

Inhibit bacterial protein synthesis

Aminoglycosides

gentamicin (Genoptic®; Gentak®), streptomycin

Chloramphenicol

Tetracyclines

tetracycline (Sumycin®), doxycycline (Adoxa®; Doryx®; Monodox®)

Macrolides

erythromycin (Erythrocin®; Eryderm®)

azithromycin (Zithromax®)

Clindamycin ( Cleocin®; ClindaMax®)

Antibiotic Modes of Action Affect bacterial metabolism and growth Rifamycin rifampin (Rifadin®) Quinolines/Fluoroquinolones ciprofloxacin (Cipro®; Ciloxan®; Proquin®) levofloxacin (Levaquin®; Quixin®; Iquix®) Antimetabolites Sulfonamides trimethoprim (Primsol®; Proloprim®)

Affect bacterial metabolism and growth

Rifamycin

rifampin (Rifadin®)

Quinolines/Fluoroquinolones

ciprofloxacin (Cipro®; Ciloxan®; Proquin®)

levofloxacin (Levaquin®; Quixin®; Iquix®)

Antimetabolites

Sulfonamides

trimethoprim (Primsol®; Proloprim®)

Nicknames Physicians tend to use shortened nicknames for some antibiotics. vancomycin (Vancocin®)=Vanc clindamycin (ClindaMax®)=Clinda azithromycin (Zithromax®)=Zithro

Physicians tend to use shortened nicknames for some antibiotics.

vancomycin (Vancocin®)=Vanc

clindamycin (ClindaMax®)=Clinda

azithromycin (Zithromax®)=Zithro

References Access Medicine [database on the Internet]. Drug Index. McGraw-Hill. c2008. Calderwood SB. Overview of beta-lactam antibiotics. UpToDate [database on the Internet]. c2008 [updated 2008 Oct 16; cited 200 May 13]. Centers for Disease Control and Prevention. Atlanta: CDC; [updated 2008 Apr 30; cited 2008 May 13]. Vancomycin-resistant enterococci (VRE). Available at: http://www.cdc.gov/ncidod/dhqp/ar_VRE_publicFAQ.html . Hentges DJ. Anaerobes: Genral Characteristics, Chapt. 17. In: Samuel Baron, editor. Medical Microbiology. Galvenston, TX, University of Texas.. Available at: http://www.gsbs.utmb.edu/microbook/ch017.htm . Porter RS, editor. Anaerobic Bacteria In: Merck Manual Online. Whitehouse Station, NJ, c2008 [cited 2008 May 13]. Available from: http://www.merck.com/mmpe/sec14/ch178/ch178a.html Porter RS, editor. Bacterial Infections In: Merck Manual Home Edition Online. Whitehouse Station, NJ, c2008 [cited 2008 May 13]. Available from: http://www.merck.com/mmhe/print/sec17/ch190/ch190a.html . Wikipedia [database on the Internet]. Antibiotic. [updated 2008 May 12; cited 2008 May 13]. Available from: http://en.wikipedia.org/wiki/Antibiotic . Wright AJ. The penicillins. Mayo Clin Proc. 1999 Mar;74(3):290-307. Erratum in: Mayo Clin Proc 1999. Nov;74(11):1184.

Access Medicine [database on the Internet]. Drug Index. McGraw-Hill. c2008.

Calderwood SB. Overview of beta-lactam antibiotics. UpToDate [database on the Internet]. c2008 [updated 2008 Oct 16; cited 200 May 13].

Centers for Disease Control and Prevention. Atlanta: CDC; [updated 2008 Apr 30; cited 2008 May 13]. Vancomycin-resistant enterococci (VRE). Available at: http://www.cdc.gov/ncidod/dhqp/ar_VRE_publicFAQ.html .

Hentges DJ. Anaerobes: Genral Characteristics, Chapt. 17. In: Samuel Baron, editor. Medical Microbiology. Galvenston, TX, University of Texas.. Available at: http://www.gsbs.utmb.edu/microbook/ch017.htm .

Porter RS, editor. Anaerobic Bacteria In: Merck Manual Online. Whitehouse Station, NJ, c2008 [cited 2008 May 13]. Available from: http://www.merck.com/mmpe/sec14/ch178/ch178a.html

Porter RS, editor. Bacterial Infections In: Merck Manual Home Edition Online. Whitehouse Station, NJ, c2008 [cited 2008 May 13]. Available from: http://www.merck.com/mmhe/print/sec17/ch190/ch190a.html .

Wikipedia [database on the Internet]. Antibiotic. [updated 2008 May 12; cited 2008 May 13]. Available from: http://en.wikipedia.org/wiki/Antibiotic .

Wright AJ. The penicillins. Mayo Clin Proc. 1999 Mar;74(3):290-307. Erratum in: Mayo Clin Proc 1999. Nov;74(11):1184.

Diuretics

Diuretics (also called ‘water pills’) are a class of drugs that reduces fluid volume in the body. What are Diuretics?

Diuretics (also called ‘water pills’) are a class of drugs that reduces fluid volume in the body.

Diuretics cause the kidneys to increase the volume of urine excreted (diuresis), as well as increase the rate of sodium excretion (natriuresis). Sodium levels that are too high for too long, can cause volume overload and edema. How do Diuretics Work?

Diuretics cause the kidneys to increase the volume of urine excreted (diuresis), as well as increase the rate of sodium excretion (natriuresis).

Sodium levels that are too high for too long, can cause volume overload and edema.

Common Conditions for Diuretic Use Hypertension Edema Heart failure Liver cirrhosis Kidney disorders Overdose/poisoning Glaucoma Osteoporosis Kidney stones

Hypertension

Edema

Heart failure

Liver cirrhosis

Kidney disorders

Overdose/poisoning

Glaucoma

Osteoporosis

Kidney stones

These types work in different parts of the nephron. Loop Thiazide Potassium-sparing Major Types of Diuretics

These types work in different parts of the nephron.

Loop

Thiazide

Potassium-sparing

http://kidney.niddk.nih.gov/kudiseases/pubs/glomerular/

Loop Diuretics Most powerful class of diuretic Act rapidly, within 1 hour Large output of urine Short duration of action, complete within 6 hours Effective for emergency use Inhibits Na + and Ca + re-absorption in loop of Henle Used primarily to treat edema related to congestive heart failure, hepatic cirrhosis and nephrotic syndrome Also used to treat drug overdose and hypertension

Most powerful class of diuretic

Act rapidly, within 1 hour

Large output of urine

Short duration of action, complete within 6 hours

Effective for emergency use

Inhibits Na + and Ca + re-absorption in loop of Henle

Used primarily to treat edema related to congestive heart failure, hepatic cirrhosis and nephrotic syndrome

Also used to treat drug overdose and hypertension

Loop Diuretics: Side Effects Common Side Effects: Hypokalemia=low potassium Hypotension Weakness, lethargy, cramps, and dizziness Osteoporosis in postmenopausal women Kidney stones Hyperglycemia Gout

Common Side Effects:

Hypokalemia=low potassium

Hypotension

Weakness, lethargy, cramps, and dizziness

Osteoporosis in postmenopausal women

Kidney stones

Hyperglycemia

Gout

Loop Diuretics Commonly Prescribed the U.S. furosemide (Lasix®) bumetanide (Bumex®) torsemide (Demadex®) ethacrynic acid (Edecrin®)

furosemide (Lasix®)

bumetanide (Bumex®)

torsemide (Demadex®)

ethacrynic acid (Edecrin®)

Thiazide Diuretics This is a moderate diuretic Acts within 1-2 hours Diuretic effects last for 12-24 hours Effective for long-term use Inhibits Na + and Cl - re-absorption from distal convoluted tubules Decreases Ca + excretion Used as first line therapy for uncomplicated hypertension Also used to treat edema associated with heart, liver and renal disease, as well as kidney stones and osteoporosis

This is a moderate diuretic

Acts within 1-2 hours

Diuretic effects last for 12-24 hours

Effective for long-term use

Inhibits Na + and Cl - re-absorption from distal convoluted tubules

Decreases Ca + excretion

Used as first line therapy for uncomplicated hypertension

Also used to treat edema associated with heart, liver and renal disease, as well as kidney stones and osteoporosis

Thiazide Diuretics: Side Effects Common Side Effects: Cramps, dizziness, weakness, lethargy Hypokalemia=low potassium Hyponatremia=low sodium Hypercalcemia=high calcium Hyperglycemia Rare Side Effects: Rashes, vertigo, headache, GI upsets, photosensitivity, reversible impotence, pancreatitis, blood diseases.

Common Side Effects:

Cramps, dizziness, weakness, lethargy

Hypokalemia=low potassium

Hyponatremia=low sodium

Hypercalcemia=high calcium

Hyperglycemia

Rare Side Effects:

Rashes, vertigo, headache, GI upsets, photosensitivity, reversible impotence, pancreatitis, blood diseases.

Thiazide Diuretics Commonly Prescribed the U.S. Hydrochlorothiazide (or HCTZ) (Microzide®, Hydrocot®) Trichlormethiazide (Aquacot®, Naqua®) Chlorothiazide (Diuril®) Bendroflumethiazide (Naturetin-5®) Methyclothiazide (Aquatensen®, Enduron®) Polythiazide (Renese®)

Hydrochlorothiazide (or HCTZ) (Microzide®, Hydrocot®)

Trichlormethiazide (Aquacot®, Naqua®)

Chlorothiazide (Diuril®)

Bendroflumethiazide (Naturetin-5®)

Methyclothiazide (Aquatensen®, Enduron®)

Polythiazide (Renese®)

Potassium-sparing Diuretics Mild diuretics Diuretic effect lasts for several hours Do not cause K + to be depleted Na + channel blocker acting in the cortical collecting ducts Potassium-sparing diuretics do not worsen diabetes or gout Because of their mild diuretic effects, they are often combined with other diuretics for treatment congestive heart failure

Mild diuretics

Diuretic effect lasts for several hours

Do not cause K + to be depleted

Na + channel blocker acting in the cortical collecting ducts

Potassium-sparing diuretics do not worsen diabetes or gout

Because of their mild diuretic effects, they are often combined with other diuretics for treatment congestive heart failure

Potassium-sparing Diuretics: Side Effects Potassium retention (hyperkalemia) causing muscle weakness and abnormal heartbeat. Nausea and gastrointestinal problems are common side effects

Potassium retention (hyperkalemia) causing muscle weakness and abnormal heartbeat.

Nausea and gastrointestinal problems are common side effects

Potassium-sparing Diuretics Commonly Prescribed the U.S. triamterene (Dyrenium®) eplerenone (Inspra®) amiloride (Midamor®) spironolactone (Aldactone®) Shown to cause tumors in lab rats, carries black box warning

triamterene (Dyrenium®)

eplerenone (Inspra®)

amiloride (Midamor®)

spironolactone (Aldactone®)

Shown to cause tumors in lab rats, carries black box warning

References Beers MH, Jones TV, editors. Problems with Electrolyte Balance. In: Merck Manual of Health and Aging Online. Merck Research Laboratories, Whitehouse Station, NJ: c2005. [cited 2008 May 13]. Available at: http://www.merck.com/pubs/mmanual_ha/sec3/ch18/ch18d.html. Jackson EK. Diuretics. In: Goodman and Gilman’s Pharmacological Basis of Therapeutics, 11th Edition. [book on the Internet]. Brunton LL, editor. McGraw Hill: 2007. [cite 2008 May 13]. Oxford Reference Online. Thiazide Diuretics. In: An A-Z of Medicinal Drugs. [book on the Internet]. Oxford University Press, c2003. [cited 2008 May 13]. Oxford Reference Online. Loop Diuretics. In: An A-Z of Medicinal Drugs. [book on the Internet]. Oxford University Press, c2003. [cited 2008 May 13]. Oxford Reference Online. Potassium-sparing Diuretics. In: An A-Z of Medicinal Drugs. [book on the Internet]. Oxford University Press, 2003. [cited 2008 May 13]. Mayo Foundation for Medical Education and Research. Diuretics. [updated 2008 Dec 22; cited 2008 May 13]. Available at: http://www.mayoclinic.com/health/diuretics/HI00030 .

Beers MH, Jones TV, editors. Problems with Electrolyte Balance. In: Merck Manual of Health and Aging Online. Merck Research Laboratories, Whitehouse Station, NJ: c2005. [cited 2008 May 13]. Available at: http://www.merck.com/pubs/mmanual_ha/sec3/ch18/ch18d.html.

Jackson EK. Diuretics. In: Goodman and Gilman’s Pharmacological Basis of Therapeutics, 11th Edition. [book on the Internet]. Brunton LL, editor. McGraw Hill: 2007. [cite 2008 May 13].

Oxford Reference Online. Thiazide Diuretics. In: An A-Z of Medicinal Drugs. [book on the Internet]. Oxford University Press, c2003. [cited 2008 May 13].

Oxford Reference Online. Loop Diuretics. In: An A-Z of Medicinal Drugs. [book on the Internet]. Oxford University Press, c2003. [cited 2008 May 13].

Oxford Reference Online. Potassium-sparing Diuretics. In: An A-Z of Medicinal Drugs. [book on the Internet]. Oxford University Press, 2003. [cited 2008 May 13].

Mayo Foundation for Medical Education and Research. Diuretics. [updated 2008 Dec 22; cited 2008 May 13]. Available at: http://www.mayoclinic.com/health/diuretics/HI00030 .

NSAIDs: Non-steroidal Anti-inflammatory Drugs

What are NSAIDs? NSAIDs are a group of drugs that control pain and reduce inflammation and fever. These drugs also have cardioprotective effects and may prevent certain cancers.

NSAIDs are a group of drugs that control pain and reduce inflammation and fever. These drugs also have cardioprotective effects and may prevent certain cancers.

How do NSAIDs work? NSAIDs inhibit the enzyme cyclooxygenase (COX), which regulates prostaglandin synthesis. Main types of prostaglandins. ’ Maintenance ’--produced by COX-1 enzyme, regulates gastric mucosal lining, vascular homeostasis, platelet aggregation and renal blood flow. Expressed in most tissues. ‘ Inflammatory ’--produced by COX-2 enzyme, increases inflammation and pain. Expressed in the brain, bones, kidneys and female reproductive system. Nonselective NSAIDs Selective COX-2 Inhibitors

NSAIDs inhibit the enzyme cyclooxygenase (COX), which regulates prostaglandin synthesis.

Main types of prostaglandins.

’ Maintenance ’--produced by COX-1 enzyme, regulates gastric mucosal lining, vascular homeostasis, platelet aggregation and renal blood flow. Expressed in most tissues.

‘ Inflammatory ’--produced by COX-2 enzyme, increases inflammation and pain. Expressed in the brain, bones, kidneys and female reproductive system.

Nonselective NSAIDs

Selective COX-2 Inhibitors

Conditions for NSAID Use Pain, Fever, Inflammation/redness Headaches, arthritis, sports injuries, cold and allergies, acute gout, lupus, menstrual pain Cardiovascular Disease/Antiplatelet Therapy Myocardial infarction, stroke, unstable angina, peripheral vascular disease Cancer Treatment and Prevention Colorectal cancer

Pain, Fever, Inflammation/redness

Headaches, arthritis, sports injuries, cold and allergies, acute gout, lupus, menstrual pain

Cardiovascular Disease/Antiplatelet Therapy

Myocardial infarction, stroke, unstable angina, peripheral vascular disease

Cancer Treatment and Prevention

Colorectal cancer

Commonly Used NSAIDs Non-selective NSAIDs aspirin (Bayer®, Excedrin®) ibuprofen (Motrin®, Advil®, Nuprin®) naproxen (Aleve®) etodolac (Lodine®) indomethacin (Indocin®) meclofenamate (Meclomen®) piroxicam (Feldene®) nabumetone (Relafen®) COX-2 Inhibitors celecoxib (Celebrex®) rofecoxib (Vioxx®) valdecoxib (Bextra ®)

Non-selective NSAIDs

aspirin (Bayer®, Excedrin®)

ibuprofen (Motrin®, Advil®, Nuprin®)

naproxen (Aleve®)

etodolac (Lodine®)

indomethacin (Indocin®)

meclofenamate (Meclomen®)

piroxicam (Feldene®)

nabumetone (Relafen®)

COX-2 Inhibitors

celecoxib (Celebrex®)

rofecoxib (Vioxx®)

valdecoxib (Bextra ®)

Pharmacological Action Absorbed mostly from the stomach and intestinal mucosa Absorption approaches 100% Metabolized by the liver

Absorbed mostly from the stomach and intestinal mucosa

Absorption approaches 100%

Metabolized by the liver

Adverse Effects Most side effects are due to the inhibition COX-1 Gastrointestinal Upper gastrointestinal bleeding Ulcer perforation Dyspepsia Diarrhea Nausea and vomiting Renal Salt and fluid retention Acute renal insufficiency due to vasoconstriction

Most side effects are due to the inhibition COX-1

Gastrointestinal

Upper gastrointestinal bleeding

Ulcer perforation

Dyspepsia

Diarrhea

Nausea and vomiting

Renal

Salt and fluid retention

Acute renal insufficiency due to vasoconstriction

Adverse Effects (cont’d) Cardiovascular Worsening of hypertension Worsening of heart failure Increased risk of stroke Hepatic Acute liver injury Central Nervous System Aseptic Meningitis Psychosis Cognitive dysfunction

Cardiovascular

Worsening of hypertension

Worsening of heart failure

Increased risk of stroke

Hepatic

Acute liver injury

Central Nervous System

Aseptic Meningitis

Psychosis

Cognitive dysfunction

NSAIDs and Cancer Treatment and Prevention If COX-2 enzyme is over-expressed, it produces large quantities of prostaglandin A1 and A2, which then bind to a tumor suppressor, p53, inhibiting its activity. p53 promotes apoptosis (programmed cell death) when cellular DNA is damaged and cannot be repaired (e.g. tumor cells). Regular aspirin use has been associated with a 20-40% reduction in the risk of colorectal cancer.

If COX-2 enzyme is over-expressed, it produces large quantities of prostaglandin A1 and A2, which then bind to a tumor suppressor, p53, inhibiting its activity.

p53 promotes apoptosis (programmed cell death) when cellular DNA is damaged and cannot be repaired (e.g. tumor cells).

Regular aspirin use has been associated with a 20-40% reduction in the risk of colorectal cancer.

References Dube C; Rostom A; Lewin G; Tsertsvadze A; Barrowman N; Code C; Sampson M; Moher D. The use of aspirin for primary prevention of colorectal cancer: a systematic review prepared for the U.S. Preventive Services Task Force. Ann Intern Med. 2007 Mar 6;146(5):365-75. Johnsen JI, Lindskog M, Ponthan F, Pettersen I, Elfman L, Orrego A, Sveinbjornsson B, Kogner P. Cyclooxygenase-2 is expressed in neuroblastoma, and nonsteroidal anti-inflammatory drugs induce apoptosis and inhibit tumor growth in vivo. Cancer Res. 2004 Oct 15;64(20):7210-5. Ogbru O. Nonsteroidal Antiinflammatory Drugs (NSAIDs). MedicineNet, Inc; [updated 2005 Sept 18; cited 2008 May 13]. Available at: http://www.medicinenet.com/nonsteroidal_antiinflammatory_drugs/article.htm Solomon, DH. NSAIDs: Mechanism of Action. UpToDate. [Database on the Internet]. c2008 [updated 2008 Jan; cited 2008 May 13].

Dube C; Rostom A; Lewin G; Tsertsvadze A; Barrowman N; Code C; Sampson M; Moher D. The use of aspirin for primary prevention of colorectal cancer: a systematic review prepared for the U.S. Preventive Services Task Force. Ann Intern Med. 2007 Mar 6;146(5):365-75.

Johnsen JI, Lindskog M, Ponthan F, Pettersen I, Elfman L, Orrego A, Sveinbjornsson B, Kogner P. Cyclooxygenase-2 is expressed in neuroblastoma, and nonsteroidal anti-inflammatory drugs induce apoptosis and inhibit tumor growth in vivo. Cancer Res. 2004 Oct 15;64(20):7210-5.

Ogbru O. Nonsteroidal Antiinflammatory Drugs (NSAIDs). MedicineNet, Inc; [updated 2005 Sept 18; cited 2008 May 13]. Available at: http://www.medicinenet.com/nonsteroidal_antiinflammatory_drugs/article.htm

Solomon, DH. NSAIDs: Mechanism of Action. UpToDate. [Database on the Internet]. c2008 [updated 2008 Jan; cited 2008 May 13].

References cont’d Solomon, DH. NSAIDs: Overview of adverse effects. UpToDate. [Database on the Internet]. c2008 [updated 2008 Jan; cited 2008 May 13]. Solomon, DH. NSAIDs: Cardiovascular effects. UpToDate. [Database on the Internet]. c2008 [updated 2008 Feb 8; cited 2008 May 13]. Solomon, DH. Overview of selective COX-2 inhibitors. UpToDate. [database on the Internet]. c2008 [updated 2006 Apr 10; cited 2008 May 13]. Su M, Nagdev A. NSAID Intoxication. UpToDate. [Database on the Internet]. c2008 [updated 2008 Jan; cited 2008 May 13].

Solomon, DH. NSAIDs: Overview of adverse effects. UpToDate. [Database on the Internet]. c2008 [updated 2008 Jan; cited 2008 May 13].

Solomon, DH. NSAIDs: Cardiovascular effects. UpToDate. [Database on the Internet]. c2008 [updated 2008 Feb 8; cited 2008 May 13].

Solomon, DH. Overview of selective COX-2 inhibitors. UpToDate. [database on the Internet]. c2008 [updated 2006 Apr 10; cited 2008 May 13].

Su M, Nagdev A. NSAID Intoxication. UpToDate. [Database on the Internet]. c2008 [updated 2008 Jan; cited 2008 May 13].

Beta-blockers

What are Beta-blockers? Beta-blockers (or ß-blockers) are a class of drugs that reduce blood pressure and improve blood flow. Other names: beta-adrenergic blocking agent beta-adrenergic antagonist beta-adrenergic receptor blocking agent beta antagonist

Beta-blockers (or ß-blockers) are a class of drugs that reduce blood pressure and improve blood flow.

Other names:

beta-adrenergic blocking agent

beta-adrenergic antagonist

beta-adrenergic receptor blocking agent

beta antagonist

How do Beta-blockers Work? Beta-blocking drugs occupy β receptors and competitively reduce receptor occupancy by catecholamines. β1-receptors are primarily found in the heart and in the kidneys. β2-receptors are primarily found in bronchial and peripheral vascular smooth muscles. Catecholamines are hormones/neurotransmitters produced by the adrenal glands. They are released into the blood during times of physical or emotional stress. The major catecholamines are dopamine, norepinephrine, and epinephrine (which used to be called adrenaline).

Beta-blocking drugs occupy β receptors and competitively reduce receptor occupancy by catecholamines.

β1-receptors are primarily found in the heart and in the kidneys.

β2-receptors are primarily found in bronchial and peripheral vascular smooth muscles.

Catecholamines are hormones/neurotransmitters produced by the adrenal glands. They are released into the blood during times of physical or emotional stress.

The major catecholamines are dopamine, norepinephrine, and epinephrine (which used to be called adrenaline).

Conditions for Beta-blocker Use Hypertension Angina Arrhythmia Heart Failure Myocardial Infarction prevention Glaucoma Generalized Anxiety Disorder Tremors Hyperthyroidism Migraines

Hypertension

Angina

Arrhythmia

Heart Failure

Myocardial Infarction prevention

Glaucoma

Generalized Anxiety Disorder

Tremors

Hyperthyroidism

Migraines

Common Beta-blockers Nonselective propranolol (Inderal®) sotalol (Betapace®) nadolol (Corgard®) timolol (Blocadren®) Beta-1 Selective atenolol (Tenormin®) metoprolol (Lopressor®, Toprol-XL®) bisoprolol (Zebeta®) acebutolol (Sectral®) nebivolol (Bystolic®)

Nonselective

propranolol (Inderal®)

sotalol (Betapace®)

nadolol (Corgard®)

timolol (Blocadren®)

Beta-1 Selective

atenolol (Tenormin®)

metoprolol (Lopressor®, Toprol-XL®)

bisoprolol (Zebeta®)

acebutolol (Sectral®)

nebivolol (Bystolic®)

Side Effects of Beta-blockers Fatigue, weakness Dizziness Cold hands Increase triglycerides; decrease HDL cholesterol Airway resistance

Fatigue, weakness

Dizziness

Cold hands

Increase triglycerides; decrease HDL cholesterol

Airway resistance

References Colucci WS. Molecular and cellular mechanisms of myocardial failure. Am J Cardiol 1997 Dec 4;80(11A):15L-25L. Hoffman BB. Adrenoceptor Antagonist Drugs, Chapter 10. In: Bertram G. Katzung editor. Basic & Clinical Pharmacology, 10 th Edition [Book on the Internet]. McGraw-Hill, c2007. [cited 2008 May 13]. Kannam JP, Aroesty JM, Gersh BJ. Beta blockers in the management of stable angina pectoris. UpToDate. [Database on the Internet]. c2008 [updated 2008 Feb 3; cited 2008 May 13]. Lexi-Comp [Database on the Internet]. Beta-Blockers. Lexi-Comp, Inc. c2008. Mayo Foundation for Medical Education and Research. Beta blockers. [updated 2006 Dec 22; cited 2008 May 13]. Available at: http://www.mayoclinic.com/health/beta-blockers/HI00059

Colucci WS. Molecular and cellular mechanisms of myocardial failure. Am J Cardiol 1997 Dec 4;80(11A):15L-25L.

Hoffman BB. Adrenoceptor Antagonist Drugs, Chapter 10. In: Bertram G. Katzung editor. Basic & Clinical Pharmacology, 10 th Edition [Book on the Internet]. McGraw-Hill, c2007. [cited 2008 May 13].

Kannam JP, Aroesty JM, Gersh BJ. Beta blockers in the management of stable angina pectoris. UpToDate. [Database on the Internet]. c2008 [updated 2008 Feb 3; cited 2008 May 13].

Lexi-Comp [Database on the Internet]. Beta-Blockers. Lexi-Comp, Inc. c2008.

Mayo Foundation for Medical Education and Research. Beta blockers. [updated 2006 Dec 22; cited 2008 May 13]. Available at: http://www.mayoclinic.com/health/beta-blockers/HI00059

References cont’d MedlinePlus Encyclopedia. Catecholamines—blood. National Library of Medicine. [updated 2007 Jan 22; cited 2008 May 13]. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/003561.htm Noth I, Schmidt GA. Management of the patient with severe COPD and coronary artery disease. UpToDate. [Database on the Internet]. c2008 [updated 2008 Feb 13; cited 2008 May 13]. Podrid PJ. Major side effects of beta blockers. UpToDate. [Database on the Internet]. c2008 [updated 2008 Feb 13; cited 2008 May 13]. Rosenson RS, Reeder GS, Kennedy HL. Beta blockers in the management of acute coronary syndrome. UpToDate. [Database on the Internet]. c2008 [updated 2008 Feb 7; cited 2008 May 13]. lRoss DS. Beta blockers in the treatment of hyperthyroidism. UpToDate. [Database on the Internet]. c2008 [updated 2006 Apr 18; cited 2008 May 13].

MedlinePlus Encyclopedia. Catecholamines—blood. National Library of Medicine. [updated 2007 Jan 22; cited 2008 May 13]. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/003561.htm

Noth I, Schmidt GA. Management of the patient with severe COPD and coronary artery disease. UpToDate. [Database on the Internet]. c2008 [updated 2008 Feb 13; cited 2008 May 13].

Podrid PJ. Major side effects of beta blockers. UpToDate. [Database on the Internet]. c2008 [updated 2008 Feb 13; cited 2008 May 13].

Rosenson RS, Reeder GS, Kennedy HL. Beta blockers in the management of acute

coronary syndrome. UpToDate. [Database on the Internet]. c2008 [updated 2008 Feb 7; cited 2008 May 13].

lRoss DS. Beta blockers in the treatment of hyperthyroidism. UpToDate. [Database on the Internet]. c2008 [updated 2006 Apr 18; cited 2008 May 13].

Steroids

Categories of Steroids Corticosteroids Glucocorticoids (e.g. cortisol) Mineralocorticoids (e.g. aldosterone) Sex Steroids/Hormones androgens, estrogens, and progestagens Anabolic steroids (related to testosterone)

Corticosteroids

Glucocorticoids (e.g. cortisol)

Mineralocorticoids (e.g. aldosterone)

Sex Steroids/Hormones

androgens, estrogens, and progestagens

Anabolic steroids (related to testosterone)

What are Glucocorticoids? Glucocorticoids are produced in the adrenal gland (e.g. cortisol) Cortisol is a hormone (also called the “stress hormone”) produced by the adrenal gland that increases blood pressure, controls inflammation and has immunosuppressive activity. Glucocorticoids suppress the immune system’s response (white blood cells) to injury or trauma, thus reducing inflammation. Administered locally or systemically

Glucocorticoids are produced in the adrenal gland (e.g. cortisol)

Cortisol is a hormone (also called the “stress hormone”) produced by the adrenal gland that increases blood pressure, controls inflammation and has immunosuppressive activity.

Glucocorticoids suppress the immune system’s response (white blood cells) to injury or trauma, thus reducing inflammation.

Administered locally or systemically

What are Mineralocorticoids? Mineralocorticoids are produced in the adrenal gland (i.e. aldosterone) Aldosterone helps regulates electrolyte and water balance in the cells by retaining sodium and excreting potassium in the urine. Maintains blood pressure Administered systemically

Mineralocorticoids are produced in the adrenal gland (i.e. aldosterone)

Aldosterone helps regulates electrolyte and water balance in the cells by retaining sodium and excreting potassium in the urine.

Maintains blood pressure

Administered systemically

Conditions for Corticosteroid Use Glucocorticoids Adrenal insufficiencies Arthritis Asthma Autoimmune diseases (e.g. lupus, multiple sclerosis) Skin conditions (e.g. eczema, rashes) Organ transplantation Cancer Mineralocorticoids Adrenal insufficiencies (e.g Addison’s disease) Idiopathic orthostatic hypotension Acid in the blood

Glucocorticoids

Adrenal insufficiencies

Arthritis

Asthma

Autoimmune diseases (e.g. lupus, multiple sclerosis)

Skin conditions (e.g. eczema, rashes)

Organ transplantation

Cancer

Mineralocorticoids

Adrenal insufficiencies (e.g Addison’s disease)

Idiopathic orthostatic hypotension

Acid in the blood

Common Corticosteroids hydrocortisone Cortef®, Hydrocortone®, Cortaid®, Cortizone®, etc cortisone Generic only prednisolone Econopred ® , Omnipred ® , Orapred ® , Pediapred ® , Pred Forte ® , Pred Mild ® , Prelone ® prednisone Sterapred® methylprednisolone Medrol®, Methylpred-DP®, Depo-Medrol®, Solu-Medrol®

hydrocortisone

Cortef®, Hydrocortone®, Cortaid®, Cortizone®, etc

cortisone

Generic only

prednisolone

Econopred ® , Omnipred ® , Orapred ® , Pediapred ® , Pred Forte ® , Pred Mild ® , Prelone ®

prednisone

Sterapred®

methylprednisolone

Medrol®, Methylpred-DP®, Depo-Medrol®, Solu-Medrol®

Common Corticosteroids (cont’d) triamcinolone Aristocort®, Azmacort®, Kenalog®, Nasacort®, Tri-Nasal®, Triderm® betamethasone Celestone®, Beta-Val®, Dibprolene®, Luxiq® dexamethasone Dexamethasone Intensol®, DexPak®, Maxidex®, TaperPak® fludrocortisone Florinef®

triamcinolone

Aristocort®, Azmacort®, Kenalog®, Nasacort®, Tri-Nasal®, Triderm®

betamethasone

Celestone®, Beta-Val®, Dibprolene®, Luxiq®

dexamethasone

Dexamethasone Intensol®, DexPak®, Maxidex®, TaperPak®

fludrocortisone

Florinef®

Adverse Effects of Corticosteroids Short-term side effects: Glaucoma Edema Hypertension Weight gain Mood swings Increased blood sugar Long-term side effects: Cataracts Infections Osteoporosis and bone fractures Irregular menstruation Skin degradation

Short-term side effects:

Glaucoma

Edema

Hypertension

Weight gain

Mood swings

Increased blood sugar

Long-term side effects:

Cataracts

Infections

Osteoporosis and bone fractures

Irregular menstruation

Skin degradation

Discontinuing Corticosteroids Withdrawing steroids are indicated when: Therapeutic effect has been reached No therapeutic effect has been achieved Risk of side effects outweigh benefit of the treatment Gradually tapering steroids is necessary to: Allow the adrenal glands to begin producing normal levels of natural cortisol Prevent fatigue, lightheadedness and body aches Immediate discontinuation may be necessary if: The patient develops steroid-induced acute psychosis The patient has a serious eye condition

Withdrawing steroids are indicated when:

Therapeutic effect has been reached

No therapeutic effect has been achieved

Risk of side effects outweigh benefit of the treatment

Gradually tapering steroids is necessary to:

Allow the adrenal glands to begin producing normal levels of natural cortisol

Prevent fatigue, lightheadedness and body aches

Immediate discontinuation may be necessary if:

The patient develops steroid-induced acute psychosis

The patient has a serious eye condition

References Brown ES, Chandler PA. Mood and Cognitive Changes During Systemic Corticosteroid Therapy. Prim Care Companion J Clin Psychiatry. 2001 Feb;3(1):17-21. Chrousos GP. Adrenocorticosteroids & Adrenocortical Antagonists. Chapter 39. In: Bertram G. Katzung editor. Basic & Clinical Pharmacology, 10 th Edition [Book on the Internet]. McGraw-Hill, c2007. [cited 2008 May 13]. Cleveland Clinic Foundation. Corticosteroids. c2008. [cited 2008 May 13]. Available at: http://www.clevelandclinic.org/health/health-info/docs/0200/0215.asp?index=4812 e.hormone. The Hormones: Corticoids. Center for Bioenvironmental Research at Tulane and Xavier Universities. [cited 2008 May 13]. Available at: http://e.hormone.tulane.edu/learning/corticoids.html Furst DE, Saag KG. Glucocorticoid withdrawal. UpToDate. [Database on the Internet]. c2008 [updated 2006 Dec 20; cited 2008 May 13]. Goldstein BG, Goldstein AO. General principles of dermatologic therapy and topical glucocorticoid use. UpToDate. [Database on the Internet]. c2008 [updated 2007 Nov 5; cited 2008 May 13]. Lexi-Comp [Database on the Internet]. Lexi-Comp, Inc. c2008.

Brown ES, Chandler PA. Mood and Cognitive Changes During Systemic Corticosteroid Therapy. Prim Care Companion J Clin Psychiatry. 2001 Feb;3(1):17-21.

Chrousos GP. Adrenocorticosteroids & Adrenocortical Antagonists. Chapter 39. In: Bertram G. Katzung editor. Basic & Clinical Pharmacology, 10 th Edition [Book on the Internet]. McGraw-Hill, c2007. [cited 2008 May 13].

Cleveland Clinic Foundation. Corticosteroids. c2008. [cited 2008 May 13]. Available at: http://www.clevelandclinic.org/health/health-info/docs/0200/0215.asp?index=4812

e.hormone. The Hormones: Corticoids. Center for Bioenvironmental Research at Tulane and Xavier Universities. [cited 2008 May 13]. Available at: http://e.hormone.tulane.edu/learning/corticoids.html

Furst DE, Saag KG. Glucocorticoid withdrawal. UpToDate. [Database on the Internet]. c2008 [updated 2006 Dec 20; cited 2008 May 13].

Goldstein BG, Goldstein AO. General principles of dermatologic therapy and topical glucocorticoid use. UpToDate. [Database on the Internet]. c2008 [updated 2007 Nov 5; cited 2008 May 13].

Lexi-Comp [Database on the Internet]. Lexi-Comp, Inc. c2008.

References cont’d Mayo Foundation for Medical Education and Research. Prednisone and corticosteroids: Balance the risks and benefits. [updated 2006 June 7; cited 2008 May 13].Available at: http://www.mayoclinic.com/health/steroids/HQ01431 MedlinePlus Encyclopedia. Steroids. National Library of Medicine. [updated 2008 May 7; cited 2008 May 13]. Available at: http://www.nlm.nih.gov/medlineplus/steroids.html National Cancer Institute. NCI Drug Dictionary—prednisolone. [cited 2008 May 13]. Available at: http://www.cancer.gov/Templates/drugdictionary.aspx?CdrID=43296 National Institute on Drug Abuse. NIDA InfoFacts: Steroids (Anabolic-Androgenic). [updated 2007 Mar; cited 2008 May 13]. Available at: http://www.nida.nih.gov/infofacts/steroids.html National Jewish Medical and Research Center. About Steroids (Inhaled and Oral Corticosteroids). [updated 2006 Feb; cited 2008 May 13]. Available at: http://www.njc.org/disease-info/treatments/long-term/steroids/corticosteroids.aspx Porter RS, editor. Rhematoid Arthritis (RA). In: Merck Manual Home Edition Online. Whitehouse Station, NJ, c2008 [cited 2008 May 13]. Available from: http://merck.com/mmhe/sec05/ch067/ch067b.html#sb067_1

Mayo Foundation for Medical Education and Research. Prednisone and corticosteroids: Balance the risks and benefits. [updated 2006 June 7; cited 2008 May 13].Available at: http://www.mayoclinic.com/health/steroids/HQ01431

MedlinePlus Encyclopedia. Steroids. National Library of Medicine. [updated 2008 May 7; cited 2008 May 13]. Available at: http://www.nlm.nih.gov/medlineplus/steroids.html

National Cancer Institute. NCI Drug Dictionary—prednisolone. [cited 2008 May 13]. Available at: http://www.cancer.gov/Templates/drugdictionary.aspx?CdrID=43296

National Institute on Drug Abuse. NIDA InfoFacts: Steroids (Anabolic-Androgenic). [updated 2007 Mar; cited 2008 May 13]. Available at: http://www.nida.nih.gov/infofacts/steroids.html

National Jewish Medical and Research Center. About Steroids (Inhaled and Oral Corticosteroids). [updated 2006 Feb; cited 2008 May 13]. Available at: http://www.njc.org/disease-info/treatments/long-term/steroids/corticosteroids.aspx

Porter RS, editor. Rhematoid Arthritis (RA). In: Merck Manual Home Edition Online. Whitehouse Station, NJ, c2008 [cited 2008 May 13]. Available from: http://merck.com/mmhe/sec05/ch067/ch067b.html#sb067_1

Anticoagulants

What are Anticoagulants? Anticoagulants (also called blood thinners) are a group of drugs that decrease the formation of blood clots .

Anticoagulants (also called blood thinners) are a group of drugs that decrease the formation of blood clots .

Indications of Anticoagulants Anticoagulants are used prophylactically and therapeutically for: Thromboembolic events Pulmonary embolism Deep vein thrombosis Unstable angina Myocardial infarction Stroke

Anticoagulants are used prophylactically and therapeutically for:

Thromboembolic events

Pulmonary embolism

Deep vein thrombosis

Unstable angina

Myocardial infarction

Stroke

Categories of Anticoagulants Vitamin K antagonists warfarin (Coumadin®) Inhibitors of thrombin Unfractionated heparin (UFH) Hep-Lock®, HepFlush-10® Low molecular weight heparin (LMWH) enoxaparin (Lovenox®), dalteparin (Fragmin®) Newer Anticoagulants fondaparinux (Arixtra®)--related to heparin bivalirudin (Angiomax®) Lepirudin (Refludan®) argatroban (no generic)

Vitamin K antagonists

warfarin (Coumadin®)

Inhibitors of thrombin

Unfractionated heparin (UFH)

Hep-Lock®, HepFlush-10®

Low molecular weight heparin (LMWH)

enoxaparin (Lovenox®), dalteparin (Fragmin®)

Newer Anticoagulants

fondaparinux (Arixtra®)--related to heparin

bivalirudin (Angiomax®)

Lepirudin (Refludan®)

argatroban (no generic)

How do Anticoagulants Work? Warfarin depletes vitamin K, which is required for producing many blood clotting factors Administered by mouth Dietary vitamin K is restricted Heparin increases the activity of antithrombin III, which inactivates the clotting factor thrombin Administered by injection Newer anticoagulants inhibit the activity of thrombin by directly binding to it Administered by injection

Warfarin depletes vitamin K, which is required for producing many blood clotting factors

Administered by mouth

Dietary vitamin K is restricted

Heparin increases the activity of antithrombin III, which inactivates the clotting factor thrombin

Administered by injection

Newer anticoagulants inhibit the activity of thrombin by directly binding to it

Administered by injection

Adverse Events Warfarin: Hemorrhage, bleeding, hematomas, anemia, nausea, vomiting, diarrhea, headache Heparin: UFH: Hemorrhage, bleeding, thrombocytopenia, skin necrosis, bruising, fever headache, GI issues, osteoporosis, elevated liver enzymes LMWH: Hemorrhage, bleeding, bruising, GI issues, fever

Warfarin:

Hemorrhage, bleeding, hematomas, anemia, nausea, vomiting, diarrhea, headache

Heparin:

UFH: Hemorrhage, bleeding, thrombocytopenia, skin necrosis, bruising, fever headache, GI issues, osteoporosis, elevated liver enzymes

LMWH: Hemorrhage, bleeding, bruising, GI issues, fever

Antiplatelets What are antiplatelets? Antiplatelets inhibit platelets from aggregating to form blood clots Commonly used antiplatelets aspirin (Bayer®, Excedrin®), clopidogrel (Plavix®) abciximab (ReoPro®) Conditions Stroke, myocardial infarction, arteriosclerosis Adverse effects Bleeding, hemorrhage, GI issues, headache, fever, hypotension, thrombocytopenia

What are antiplatelets?

Antiplatelets inhibit platelets from aggregating to form blood clots

Commonly used antiplatelets

aspirin (Bayer®, Excedrin®),

clopidogrel (Plavix®)

abciximab (ReoPro®)

Conditions

Stroke, myocardial infarction, arteriosclerosis

Adverse effects

Bleeding, hemorrhage, GI issues, headache, fever, hypotension, thrombocytopenia

References Cucchiara B, Messe SR. Antiplatelet therapy for secondary prevention of stroke. UpToDate. [Database on the Internet]. c2008 [updated 2007 Apr 24; cited 2008 May 13]. First Consult [Database on the Internet]. Principles of anticoagulation. Elsevier Inc. c2008. [cited 2008 May 13]. Hennekens CH. Patient Information: Aspirin and heart disease. UpToDate, Inc. c2008. [updated 2007 Sept 18; cited 2008 May 13]. Available at: http://www.uptodate.com/patients/content/topic.do?topicKey=~6cTQKoLyIHUj1&selectedTitle=1~133&source=search_result Lexi-Comp [Database on the Internet]. Lexi-Comp, Inc. c2008. Lip, GYH, Pineo GF. Bauer KA. Patient Information: Deep vein thrombosis (DVT). UpToDate, Inc. c2008. [updated 2007 June 19; cited 2008 May 13]. Available at: http://patients.uptodate.com/topic.asp?file=blod_dis/7159&title=Heparin#18

Cucchiara B, Messe SR. Antiplatelet therapy for secondary prevention of stroke. UpToDate. [Database on the Internet]. c2008 [updated 2007 Apr 24; cited 2008 May 13].

First Consult [Database on the Internet]. Principles of anticoagulation. Elsevier Inc. c2008. [cited 2008 May 13].

Hennekens CH. Patient Information: Aspirin and heart disease. UpToDate, Inc. c2008. [updated 2007 Sept 18; cited 2008 May 13]. Available at: http://www.uptodate.com/patients/content/topic.do?topicKey=~6cTQKoLyIHUj1&selectedTitle=1~133&source=search_result

Lexi-Comp [Database on the Internet]. Lexi-Comp, Inc. c2008.

Lip, GYH, Pineo GF. Bauer KA. Patient Information: Deep vein thrombosis (DVT). UpToDate, Inc. c2008. [updated 2007 June 19; cited 2008 May 13]. Available at: http://patients.uptodate.com/topic.asp?file=blod_dis/7159&title=Heparin#18

References cont’d National Heart Lung and Blood Institute. How is pulmonary embolism treated? [cited 2008 May 13]. Available at: http://www.nhlbi.nih.gov/health/dci/Diseases/pe/pe_treatments.html Porter RS, editor. Bleeding and Clotting Disorders. In: Merck Manual Home Edition Online. Whitehouse Station, NJ, c2008 [cited 2008 May 13]. Available at: http://www.merck.com/mmhe/sec14/ch173/ch173a.html Porter RS, editor. Acute Coronary Syndromes (ACS). In: Merck Manual Online. Whitehouse Station, NJ, c2007 [updated 2007 Dec; cited 2008 May 13]. Available at: http://www.merck.com/mmpe/sec07/ch073/ch073c.html Valentine KA, Hull RD. Patient Information: Warfarin (Coumadin®). UpToDate, Inc. c2008. [updated 2007 July 25; cited 2008 May 13]. Available at: http://patients.uptodate.com/topic.asp?file=blod_dis/6066&title=Anticoagulants

National Heart Lung and Blood Institute. How is pulmonary embolism treated? [cited 2008 May 13]. Available at: http://www.nhlbi.nih.gov/health/dci/Diseases/pe/pe_treatments.html

Porter RS, editor. Bleeding and Clotting Disorders. In: Merck Manual Home Edition Online. Whitehouse Station, NJ, c2008 [cited 2008 May 13]. Available at: http://www.merck.com/mmhe/sec14/ch173/ch173a.html

Porter RS, editor. Acute Coronary Syndromes (ACS). In: Merck Manual Online. Whitehouse Station, NJ, c2007 [updated 2007 Dec; cited 2008 May 13]. Available at: http://www.merck.com/mmpe/sec07/ch073/ch073c.html

Valentine KA, Hull RD. Patient Information: Warfarin (Coumadin®). UpToDate, Inc. c2008. [updated 2007 July 25; cited 2008 May 13]. Available at: http://patients.uptodate.com/topic.asp?file=blod_dis/6066&title=Anticoagulants

Free Resources FDA – fda.gov, especially http://www.fda.gov/cder/index.html MedlinePlus Drugs and Supplements - http://www.nlm.nih.gov/medlineplus/druginformation.html

FDA – fda.gov, especially http://www.fda.gov/cder/index.html

MedlinePlus Drugs and Supplements - http://www.nlm.nih.gov/medlineplus/druginformation.html

Exercise

Matching Diuretic Steroid Anticoagulant NSAID Beta-Blocker Antibiotic clindamycin propranolol Coumadin® hydrochlorothiazide

Diuretic

Steroid

Anticoagulant

NSAID

Beta-Blocker

Antibiotic

Matching Antiplatelet Beta-blocker Steroid Antibiotic Anticoagulant NSAID prednisone celecoxib rifampin Plavix®

Antiplatelet

Beta-blocker

Steroid

Antibiotic

Anticoagulant

NSAID

Clinical Question: Antibiotics Is there clinical evidence indicating that a dual treatment strategy of Cell Wall Active and Protein Synthesis Inhibitor antibiotics is more effective than either therapy alone for pneumonia in pediatric patients?

Is there clinical evidence indicating that a dual treatment strategy of Cell Wall Active and Protein Synthesis Inhibitor antibiotics is more effective than either therapy alone for pneumonia in pediatric patients?

Clinical Question: Diuretics What kinds of cutaneous drug reactions are caused by the diuretic hydrochlorothiazide?

What kinds of cutaneous drug reactions are caused by the diuretic hydrochlorothiazide?

Clinical Question: NSAIDs Is there any evidence for increased risk of complications such as gastrointestinal (GI) bleeding with increased duration of NSAID use for arthritis?

Is there any evidence for increased risk of complications such as gastrointestinal (GI) bleeding with increased duration of NSAID use for arthritis?

Clinical Question: Beta-Blockers In adults with a history of chronic obstructive pulmonary disease (COPD), what is the probability of adverse events when giving them beta-blockers for treatment of hypertension?

In adults with a history of chronic obstructive pulmonary disease (COPD), what is the probability of adverse events when giving them beta-blockers for treatment of hypertension?

Clinical Question: Steroids Does the evidence support the use of systemic steroids in the prevention of post-extubation airway obstruction in critically ill adults?

Does the evidence support the use of systemic steroids in the prevention of post-extubation airway obstruction in critically ill adults?

Clinical Question: Anticoagulants What are the major complications associated with using anticoagulants, such as heparin, in the context of intracranial hemorrhage (ICH) secondary to cerebral venous thrombosis (CVT)?

What are the major complications associated with using anticoagulants, such as heparin, in the context of intracranial hemorrhage (ICH) secondary to cerebral venous thrombosis (CVT)?