Essentials of Pharmacology for Health ProfessionsEighth

Essentials of Pharmacology for
Health Professions
Eighth Edition
Chapter 16
Gastrointestinal Drugs
© 2019 Cengage. All rights reserved.
Introduction to Cost management© 2019 Cengage. All rights
reserved.
Introduction (1 of 2)
• Gastrointestinal drug categories
– Antacids
– Drugs for treatment of ulcers and gastroesophageal
reflux disease (GERD)
– Antispasmodics
– Management of inflammatory bowel disease
– Antidiarrheal agents

– Antiflatulents
– Laxatives and cathartics
– Antiemetics
reserved.
• The following slides discuss various gastrointestinal
drugs
– Refer to the chapter for specific side effects,
contraindications, and interactions
reserved.
Antacids
• Act by partially neutralizing gastric hydrochloric acid
– Widely available in many over-the-counter (OTC)
preparations for the relief of indigestion, heartburn, and
sour stomach

– Generally have a short duration of action, requiring
frequent administration
– May contain aluminum, calcium carbonate or
magnesium and sodium
reserved.
Agents for Treatment of Ulcers and GERD
(1 of 3)
• H2-blockers
– Reduce gastric acid secretion by acting as histamine2
blockers (Example: Pepcid)
– Reduce gastric acid released in response to stimuli
• Proton pump inhibitors (PPI)
– May be used long-term for severe GERD, to prevent
NSAID-induced ulcers, and for hypersecretory
conditions
– Omeprazole: gastric antisecretory agent

reserved.
(2 of 3)
• Gastric mucosal agents
– Misoprostol (Cytotec)
▪ Synthetic form of prostaglandin E1
▪ Inhibits gastric acid secretion and protects the mucosa
from the irritant effect of certain drugs
– Sucralfate (Carafate)
▪ Inhibitor of pepsin, given on an empty stomach
▪ Reacts with HCl to form a paste that adheres to the
mucosa, protecting the ulcer from irritation
reserved.
(3 of 3)
• Helicobacter pylori treatment

– Bacterial infection
– Treated successfully with multiple-drug regimens (over
14 days).
– See Chapter 17
• See Table 16-1
reserved.
Antispasmodics/Anticholinergics
• Help to calm the bowel
– Work by decreasing motility (smooth muscle tone) in the
GI tract
• Dicyclomine (Bentyl)
– Used for treatment of irritable bowel syndrome and other
functional disturbances of GI motility
reserved.
Agents for Inflammatory Bowel Disease

• Inflammatory bowel disease (IBD)
– Chronic condition that causes inflammation in the lining
of the GI tract
– Includes Crohn’s disease and ulcerative colitis
• Salicylates
– Designed to reach the ileum and colon, bypassing the
stomach and upper intestines
– Examples: mesalamine and sulfasalazine used for
Crohn’s disease and ulcerative colitis
• Glucocorticoids
reserved.
Antidiarrheal Drugs (1 of 3)
• Act in various ways
– Reduce the number of loose stools
– Patients experiencing diarrhea are instructed to stay
hydrated
• Salicylates

– Bismuth subsalicylate (e.g., Kaopectate, Pepto-Bismol)
has anti-infective and antisecretory properties, a direct
mucosal protective effect, and weak antacid and anti-
inflammatory effects
reserved.
• Opiate agonists
– Act by slowing intestinal motility, allowing for more
reabsorption of fluid
– Example: Loperamide
• Probiotics
– Living microorganisms that can alter a patient’s intestinal
flora; may provide benefit in numerous GI diseases
▪ Lactobacillus
▪ Saccharomyces boulardii (Florastor)

reserved.
• Clostridium difficile infection
– One of the most common causes of infectious diarrhea
in the United States
– Symptoms include watery diarrhea, nausea, and/or
abdominal pain or tenderness
– Caused by eradication of native intestinal flora with
broad-spectrum antimicrobials and overuse of PPI and
H2-blocker therapy
– Oral medications include metronidazole (Flagyl) or
vancomycin
reserved.
Antiflatulents
• For the symptomatic treatment of gastric bloating and
postoperative gas pains

– Help to break up gas bubbles in the GI tract
– Simethicone
• See Table 16-2
reserved.
Laxatives and Cathartics (1 of 4)
• Laxatives promote evacuation of the intestine and are
used to treat constipation
– Included in this category are cathartics, or purgatives
▪ Promote rapid evacuation of the intestine and alteration of
stool consistency
– Divided into seven categories according to action (see
Chapter text for list)
reserved.
• Bulk-forming laxatives

– Soften the stool by absorbing water and increase fecal
mass to facilitate defecation
• Stool softeners
– Surface-acting agents that moisten stool through a
detergent action
• Emollients
– Promote stool movement through the intestines by
softening and coating the stool
reserved.
• Saline laxatives
– Promote secretion of water into the intestinal lumen
– Should be taken infrequently, in single doses
• Stimulant laxatives
– Cathartic in action; produce strong peristaltic activity;
may alter intestinal secretions in several ways
– Produce some degree of abdominal discomfort

reserved.
• Osmotic laxatives
– Exert an action that draws water from the tissues into
the feces and reflexively stimulates evacuation
• Chloride channel activator
– Lubiprostone increases intestinal fluid secretion by
activating chloride channels in the epithelium
• Mu-opioid receptor agonist
– Opioid induced constipation
• See Table 16-3
reserved.
Antiemetics (1 of 4)
• For the prevention or treatment of nausea, vomiting,
vertigo, or motion sickness

– Many different products are available, varying in their
actions, condition treated, and route of administration
• See Table 16-4
reserved.
• Anticholinergics
– Dimenhydrinate (Dramamine) or scopolamine: for the
treatment of motion sickness
▪ Available in a transdermal patch
– Meclizine (Antivert): antihistamine for the prevention and
treatment of nausea, vomiting, and/or vertigo associated
with motion sickness
reserved.
• Antidopaminergics

– Dopamine receptor antagonists interfere with the
stimulation of chemoreceptor trigger zone (CTZ) in the
brain, thereby blocking messages to the GI tract
– Most frequently used agents to control nausea and
vomiting in this class:
▪ Prochlorperazine (Compazine): no longer marketed,
caused extrapyramidal reactions
▪ Phenergan, Reglan
reserved.
• Serotonin receptor antagonists
– Preferentially block serotonin receptors found centrally in
the CTZ and peripherally in the intestines to control
emesis
▪ Serotonin is a major neurotransmitter involved in emesis
located in the gut

– Ondansetron (Zofran) and dolasetron (Anzemet)
▪ For the prevention and treatment of post-operative
(PONV) and chemotherapy-induced nausea and vomiting
(CINV)
Health Professions
Eighth Edition
Chapter 17
Anti-infective Drugs
reserved.
Introduction
• Treatment of infection
– Complicated by the great variety of medications
available and their differing modes of action
– First step: identify the causative organism and specific

medication to which it is sensitive
▪ Culture and sensitivity (C&S) tests
o Wound, throat, urine or blood
o Usually not available for 24-48 hours
reserved.
Resistance (1 of 2)
• Organisms may build up resistance to drugs and are
therefore, no longer effective because of:
– Frequent use
– Incomplete treatment
• Anti-infective resistance is caused by many factors
– Complex strategies needed to combat the problem
• Seventy percent of bacteria that cause HAI’s are
resistant to at least one drug
– Example: MRSA

reserved.
Resistance (2 of 2)
• Selection of anti-infective drugs
– Infection site
– Status of hepatic and/or renal function
– Patient age
– Pregnancy or lactation
– Likelihood of organisms developing resistance
– Known allergy to the anti-infective drug
reserved.
Adverse Reactions
• Three categories
– Allergic hypersensitivity
▪ Over-response of the body to a specific substance
(anaphylaxis)
– Direct toxicity
▪ Results in tissue damage

– Indirect toxicity or superinfection
▪ Manifested as a new infection due to absence of normal
flora in the intestines or mucous membranes
reserved.
Vaccines/Immunizations
• Centers for Disease Control and Prevention (CDC)
– Currently recommends routine vaccination
▪ Prevent 17 vaccine-preventable diseases that occur in
infants, children, adolescents, or adults
▪ Information regarding vaccines and immunizations
changes from time to time and requirements may vary by
state, territory, or country
reserved.
Antibiotics
• Refers to a large spectrum of medicines that are useful

for treating and preventing infections by bacteria.
• No effect on viruses, fungal or other types of infection
• Improper use causes resistance
• Side effects, precautions, contraindications and
interactions are listed for each drug. Refer to the
Chapter text.
reserved.
Aminoglycosides
• Treats many infections caused by:
– Gram-negative bacteria (e.g., Escherichia coli and
Pseudomonas)
– Gram-positive bacteria (e.g., Staphylococcus aureus)
• Effective in short-term treatment of many serious
infections
– Septicemia (e.g., bacteria in bloodstream causing low
blood pressure) when less toxic drugs are ineffective or

contraindicated
reserved.
Cephalosporins
• Semisynthetic beta-lactam antibiotic derivatives
produced by a fungus
– Related to penicillins
▪ Some patients allergic to penicillin are also allergic to
cephalosporins
• Classified as first, second, third, or fourth, or fifth
generation
– According to organisms susceptible to their activity
reserved.
Macrolides
• Treats many infections of the respiratory tract, skin
conditions, or for some sexually transmitted infections

– Considered among the least toxic antibiotics
▪ Preferred for treating susceptible organisms under
conditions in which more toxic antibiotics might be
dangerous
reserved.
Penicillins
• Beta-lactam antibiotics produced from certain species
of a fungus
– Treats many streptococcal and some staphylococcal
and meningococcal infections
– Drug of choice for treatment of syphilis
– Used prophylactically to prevent recurrences of
rheumatic fever
reserved.
Carbapenems

• Belong to the beta-lactam class of antibiotics
– Have a very broad spectrum of activity against gram-
negative and gram-positive organisms
– Primary treatments include pneumonia, febrile
neutropenia, intra-abdominal infections, diabetic foot
infections, and significant polymicrobial infections
• See Table 17-1
reserved.
Quinolones
• For adult treatment of some infections of the urinary
tract, sinuses, lower respiratory tract, GI tract, skin,
bones, and joints, and in treating gonorrhea
– Some organisms are showing increased resistance
– Reserve for infections that require therapy with a
fluoroquinolone

reserved.
Tetracyclines
• Broad-spectrum antibiotics
– Treats infections caused by Lyme disease, rickettsia,
chlamydia, or some uncommon bacteria
– Some organisms are showing increasing resistance
– Use only when other antibiotics are ineffective or
contraindicated
reserved.
Antifungals (1 of 3)
• Treat specific susceptible fungal disease
– Medications are quite different in action and purpose
• Amphotericin B
– Administered IV for the treatment of severe systemic
and potentially fatal infections caused by susceptible
fungi, including Candida

reserved.
• Fluconazole (Diflucan)
– Works against many fungal pathogens, including most
Candida, without the serious toxicity of amphotericin B
• Micafungin (Mycamine)
– Given IV
– Provides new treatment options against Candida and
Aspergillus species
reserved.
• Nystatin
– Structurally related to Amphotericin B
– Orally treats oral cavity candidiasis
– Also used as a fungicide in the topical treatment of skin
and mucous membranes

reserved.
Antituberculosis Agents
• Tuberculosis (TB)
– Caused by a bacterium called Mycobacterium
tuberculosis, which primarily attacks the lungs
• Antituberculosis agents are administered for two
purposes
– To treat latent or asymptomatic infection (no evidence of
clinical disease)
– For treatment of active clinical tuberculosis and to
prevent relapse
– Treatment can be challenging
– See Table 17-2
reserved.
Miscellaneous Anti-Infectives (1 of 3)

• Clindamycin
– Treats serious respiratory tract infections, septicemia,
osteomyelitis, serious infections of the female pelvis
caused by susceptible bacteria, and for Pneumocystis
jirovecii pneumonia associated with AIDS
– Prophylactic use in dental procedures for penicillin-
allergic patients
– May be a viable therapeutic option for community-
acquired MRSA
reserved.
• Metronidazole (Flagyl)
– Synthetic antibacterial and antiprotozoal agent
– Effective against protozoa
– One of the most effective drugs against anaerobic
bacterial infections

– Also useful in treating Crohn’s disease, antibiotic-
associated diarrhea, rosacea, and H. pylori infection
reserved.
• Vancomycin
– Structurally unrelated to other available antibiotics
– IV vancomycin is used in the treatment of potentially life-
threatening infections caused by susceptible organisms
– Drug of choice for MRSA
reserved.
Agents for VRE
• Linezolid (Zyvox)
– Indicated for gram-positive infections
– Approved for the treatment of bacterial pneumonia skin,
skin structure infections, and MRSA and VRE infections

– Effective in treating diabetic foot infections
– Administered by IV infusion or orally
See Table 17-3
reserved.
Sulfonamides
• Among the oldest anti-infectives
– Increasing resistance of many bacteria has decreased
the clinical usefulness of these agents
• Used most effectively in combinations with other drugs
– Example: sulfamethoxazole and trimethoprim
– Resistance develops more slowly
reserved.
Urinary Anti-Infectives
• Urinary tract infection (UTI)
– Symptomatic inflammatory response from the presence

of microorganisms in the urinary tract
– One of the most common bacterial infections for which
patients seek treatment
– First-line urinary anti-infectives for empiric treatment of
uncomplicated lower UTI are sulfamethoxazole-
trimethoprim and nitrofurantoin
• See Table 17-4
reserved.
Antivirals
• Acyclovir
– Primarily treats herpes simplex, herpes zoster
(shingles), and varicella zoster (chickenpox) infections
• Neuraminidase inhibitors
– Indicated for the treatment of uncomplicated acute
illness due to influenza types A and B
• Ribavirin
– Treats infants and young children with respiratory

syncytial virus (RSV) infections via nasal and oral
inhalation, Lassa fever and Hepatitis C
• See Table 17-5
reserved.
Treatment of HIV/AIDS Infections (1 of 4)
• See Table 17-6
• Highly specialized field
– Those actively practicing in that field must be updated
frequently on the many new medications and frequently
changing protocols
• Treatment of HIV infection
– Consists of using highly active antiretroviral therapy
(HAART) combinations of three or more antiretroviral
(ARV) agents
reserved.

• Antiretroviral protease inhibitors (PIs)
– Block the activity of the HIV enzyme essential for viral
replication late in the virus life cycle
• Nucleoside reverse transcriptase inhibitors (NRTIs)
– Inhibit an enzyme responsible for viral replication early
in the virus life cycle
reserved.
• Non-nucleoside reverse transcriptase inhibitors
(NNRTIs)
– Inhibit an enzyme responsible for viral replication early
in the viral life cycle
• Fusion inhibitors (FIs)
– Block entry of HIV into cells, which may keep the virus
from reproducing

reserved.
• CCR5 antagonists
– Block a co-receptor required for HIV entry into human
cells
• Integrase inhibitor
– Raltegravir (Isentress): first ARV designed to slow the
advancement of HIV infection by blocking the enzyme
needed for viral replication
reserved.
HIV Information and Resources
• Sources of current recommendations for clinical use of
antiretrovirals (ARVs)
– Department of Health and Human Services
– Florida/Caribbean Aids Education and Training Center

– AETC National Resource Center Drug Interactions
– Johns Hopkins HIV Guide
– National HIV Telephone Consultation Service
– University of California, San Francisco
Health Professions
Eighth Edition
Chapter 18
Eye and Ear Medications
reserved.
• Most common eye diseases in Americans 40 years and
older
– Age-related macular degeneration, glaucoma, cataracts,
and diabetic retinopathy

• Conjunctivitis: inflammation of the conjunctiva (“pink
eye”)
– One of the most frequent causes of patient seeking help
– Allergens, irritants, abrasion, bacteria and viruses are
common causes
reserved.
• Medications for the eye
– Anti-infectives
– Anti-inflammatory agents
– Antiglaucoma agents
– Mydriatics (pupil dilation)
– Local anesthetics
• The following slides discuss various eye medications

reserved.
Anti-Infectives
• Treat superficial eye infections caused by susceptible
organisms
– Ointments are preferable to drops in children and
patients with poor adherence
– Drops are preferred in adults
▪ Ointments will cause blurring of vision for 20 minutes after
instillation
– Determine causative organism when possible
– Preparations can be single or in combination
• Antivirals
reserved.
Anti-Inflammatory Agents (1 of 4)
• Relieve eye or conjunctiva inflammation in allergic
reactions, burns, postoperatively, or irritation from

foreign substances
• Corticosteroids
– Useful in acute stages of eye injury
▪ Prevent scarring, for severe symptoms, or when condition
is unresponsive to other medications
▪ Do not use for extended periods of time
reserved.
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
– Treat postoperative inflammation following cataract
surgery
– Alternative to corticosteroids if a contraindication exists
• Immunologic agents
– Increases tear production in patient's with dry eye
reserved.

• Antihistamines/decongestants
– Block histamine receptors in conjunctiva, relieving ocular
pruritis associated allergic conjunctivitis
– Cause vasoconstriction of blood vessels, providing relief
from minor eye irritation and redness
reserved.
• Ophthalmic lubricants
– Provide a barrier function at the level of the conjunctival
mucosa
– Help to dilute and flush various allergens and
inflammatory mediators that may be present on the
ocular surface
• See Table 18-1

reserved.
Antiglaucoma Agents (1 of 5)
• Glaucoma
– A group of sight-threatening diseases of the eye in which
there is increased intraocular pressure (IOP) due to
obstruction of outflow of aqueous humor
▪ Causes deterioration of and damage to the optic nerve
resulting in vision loss
reserved.
• Glaucoma types
– Acute (angle-closure) glaucoma
▪ Characterized by a sudden onset of pain, blurred vision,
and a dilated pupil
▪ Considered a medical emergency
– Chronic (open-angle) glaucoma

▪ Much more common, often bilateral
▪ Develops slowly over a period of years with few
symptoms except a gradual loss of peripheral vision and
possibly blurred vision
reserved.
• Antiglaucoma drugs given to lower intraocular pressure
– Carbonic anhydrase inhibitors: reduce formation of
hydrogen and bicarbonate ions
▪ Diuretic effect; reduces production of aqueous humor
– Miotics: cause pupil to contract
▪ Reduce IOP by increasing aqueous humor outflow
reserved.
• Beta-adrenergic blockers: used topically to lower IOP

in open-angle glaucoma
– Decreased rate of aqueous humor production
• Alpha agonists: decreases formation and increases
outflow of aqueous humor
– Minimal effects on cardiovascular or pulmonary
hemodynamics
reserved.
• Prostaglandin analogs: greatest reduction in IOP by
increasing outflow of aqueous humor
– May be used concomitantly with other topical ophthalmic
drugs to lower IOP
• See Table 18-2
reserved.
Mydriatics

• Topically dilates the pupil for ophthalmic examinations
– Example: atropine
▪ Also acts as a cycloplegic (paralyzes the muscles of
accommodation)
▪ Drug of choice in eye examinations for children
▪ Often used for adults because of fast action and fast
recovery time
reserved.
Local Anesthetics
• Applied topically to the eye for minor surgical and
diagnostic procedures, removal of foreign bodies, or
painful injury
– Example: tetracaine (TetraVisc)
• See Table 18-3
reserved.

Otic (Ear) Medications (1 of 3)
• Made up of three parts: outer, middle and inner
• Serve two purposes: hearing and balance
• Common ear conditions
– Ear infections
– Earwax (cerumen) buildup
• Otitis media
– Bacteria in the middle ear which leads to inflammation
– Treatment includes an antibiotic and NSAIDS
reserved.
• Topical preparations for ear infections
– “swimmers ear” or otitis externa
– Cipro, Floxin and Cortisporin are the most common
– Prescribed for 7-14 days
– Drops that are designed to treat pain and inflammation
associated with ear infections

▪ Vosol, Auralgan
– Systemic Preparations
▪ Refer to Chapter 17: Amoxicillin and Augmentin
reserved.
• Earwax buildup and blockage
– Earwax (cerumen) in the canal can inhibit hearing and
can cause pain
– Most common in older adults
– Debrox is an OTC that is used to soften and loosen
excessive earwax
• See Table 18-4
Health Professions
Eighth Edition
Chapter 19

Analgesics, Sedatives, and
Hypnotics
reserved.
• Analgesics, sedatives, and hypnotics
– Depress central nervous system (CNS) action to varying
degrees
– Some drugs can be classified into more than one
category, depending on the dosage
▪ Analgesics: relieve pain
▪ Sedatives: calm, soothe, or produce sedation
▪ Hypnotics: produce sleep
reserved.

• The following slides discuss various analgesics,
sedatives, and hypnotics
precautions, contraindications, and interactions
reserved.
Analgesics (1 of 8)
• Pain is the most common reason for patients to seek
out medical care
– Most common types: back, neck, migraine, and facial or
jaw pain
– Is subjective: can be experienced or perceived only by
the individual subject. Pain scale: 1 to 10
– Can be blocked by endorphins
▪ Endogenous analgesics produced within the body as a
reaction to severe pain or intense exercise

reserved.
Analgesics (2 of 8)
• Opioid analgesics
– Full or pure agonists, partial agonists, or mixed agonist-
antagonists
▪ Each bind to specific receptors with varying degrees of
action
▪ Classified as controlled substances
▪ Potential for abuse and psychological dependence
▪ Tolerance and physiological dependence
• See Table 19-1
reserved.
Analgesics (3 of 8)
• Opioid induced constipation (OIC)
– Not-self limiting
– Occurs because the digestive tract contains similar

receptors (mu) that are targeted in pain relief, slowing
the transit time
– Most of the time, hydration, stool softeners or stimulant
are effective
– For severe OIC, prescription strength medication is
required.
reserved.
Analgesics (4 of 8)
• Tramadol (Ultram)
– Centrally acting synthetic analog of codeine with a dual
mechanism of action
– Produces analgesia by weak inhibition of norepinephrine
and serotonin reuptake; is an opioid receptor agonist
– Less potential for abuse or respiratory depression
(although both may occur)

reserved.
Analgesics (5 of 8)
• Nonopioid analgesics
• See Table 19-2
– Many available without prescription as over-the-counter
(OTC) medications
– Given for relieving mild to moderate pain, fever, and anti -
inflammatory conditions
– Used as a coanalgesic in severe acute or chronic pain
requiring opioids
reserved.
Analgesics (6 of 8)
• Salicylates (aspirin) are most commonly used for their
analgesic and antipyretic properties, as well as for their
anti-inflammatory action
• Acetaminophen has analgesic and antipyretic
properties, but very little effect on inflammation. (major

changes in Tylenol dosing)
• Aspirin and acetaminophen are frequently combined
with opioids or with other drugs for more effective
analgesic action
• Nonsteroidal anti-inflammatory drugs (NSAIDS) are
discussed in Chapter 21
reserved.
Analgesics (7 of 8)
• Adjuvant analgesics
– May enhance analgesic effect with opioids and
nonopioids, produce analgesia alone, or reduce side
effects of analgesics
– Treatment for nerve pain and fibromylagia
• Tricyclic antidepressants
– Treats fibromyalgia and nerve pain associated with
herpes, arthritis, diabetes, and cancer, migraine or

tension headaches, insomnia, and depression
– Pain often described as “burning”
reserved.
Analgesics (8 of 8)
• Anticonvulsants
– Examples: Neurontin and Tegretol
– Commonly used for management of nerve pain
associated with neuralgia, herpes zoster (shingles), and
cancer
– Implemented when patient describes pain as “sharp,”
“shooting,” “shock-like pain,” or “lightning-like”
• See Table 19-3
reserved.
Local Anesthetic
• Lidocaine patch (Lidoderm)

– Approved for management of postherpetic neuralgia
– Can provide significant analgesia in other forms of
neuropathic pain
▪ Diabetic neuropathy and musculoskeletal pain such as
osteoarthritis and low back pain
– Provides pain relief through a peripheral effect and
generally has little, if any, central action
– Must be applied to intact skin
reserved.
Antimigraine agents
• Migraine is the most common neurovascular headache
and may include nausea, vomiting, and sensitivity to
light and noise.
– Simple/opioid analgesics and NSAIDs are effective,
especially if taken at initial sign of migraine
• Serotonin receptor agonists (SRAs)
– Action: serotonin levels decrease, while vasodilation and

inflammation of blood vessels in brain increase as
migraine symptoms worsen
▪ Effective treatment for nausea and vomiting
• See Table 19-4
reserved.
Sedatives and Hypnotics (1 of 2)
• Medications used to promote sedation in smaller
doses, and sleep in larger doses
• Insomnia is one of the most prevalent sleep disorders
• Antihistamines (Benadryl) and Barbiturates
• Benzodiazepines (BZDs) and nonbenzodiazepines
– Less abuse potential
– Withdrawal effects are observed after long-term use and
respiratory depression (when taken with alcohol) can be
potentially fatal

reserved.
• Melatonin receptor agonist
– Ramelteon (Rozerem): first FDA-approved prescription
medication that acts on melatonin receptor
▪ Mimics action of melatonin to trigger sleep onset
▪ Dependence and abuse potential are eliminated
▪ Not classified as a controlled substance
▪ Works quickly, generally inducing sleep in less than one
hour
• See Table 19-5
Health Professions
Eighth Edition
Chapter 20
Psychotropic Medications, Alcohol,
and Drug Abuse

reserved.
• Psychotropic refers to any substance that acts on the
mind
– Psychotropic medications are drugs that can exert a
therapeutic effect on a person’s mental processes,
emotions, or behavior
▪ Classified according to the purpose for administration:
CNS stimulants, antidepressants, anxiolytics, antimanic,
and antipsychotic medications
reserved.
• The following slides discuss various psychotropic
medications

– Refer to the chapter for specific side effects, precautions
or contraindications, and interactions
• Drug and alcohol abuse is also discussed
– Refer to the chapter for specific symptoms and
treatment options
reserved.
CNS Stimulants (1 of 2)
• CNS (central nervous system) stimulant medications
– Given to promote CNS functioning
• Caffeine
– Helps fight fatigue and drowsiness
▪ Examples: NoDoz, Vivarin, and caffeine citrate
– Prolonged, high intake of caffeine in any form may
produce tolerance, habituation, and psychological
dependence
• See Table 20-1

reserved.
• Amphetamine/methylphenidate preparations
– Controlled substances (Schedule II)
– Treats attention-deficit hyperactivity disorder (ADHD) in
children over age six and for narcolepsy
▪ Examples: Adderall and Ritalin
• Wakefulness-promoting agents
– Provigil is a psychostimulant approved for narcolepsy,
sleep apnea, and shift-work sleep disorder
reserved.
Selective Norepinephrine Reuptake
Inhibitor (SNRI) for ADHD
• Atomoxetine (Strattera)
– Selective norepinephrine reuptake inhibitor
– First nonstimulant, noncontrolled drug approved for

attention-deficit hyperactivity disorder (ADHD)
– Structurally related to fluoxetine
– Does not have a potential for abuse, has less insomnia,
less effect on growth, and has been shown to be safe
and effective
reserved.
Antidepressants (1 of 5)
• Major depressive disorder (MDD)
– Caused by a chemical imbalance in the brain
– Mental disorder characterized by an all-encompassing
low mood accompanied by low self-esteem and loss of
interest or pleasure in normally enjoyable activities
– Antidepressant medications, sometimes called mood
elevators, are used primarily to treat patients with
various types of depression
▪ “Black box” warning

reserved.
• Tricyclic antidepressants
– Mechanism of action involves potentiation of
norepinephrine and serotonin activity by blocking their
reuptake
• Monamine oxidase inhibitors (MAOIs)
– Mechanism of action involves increasing concentrations
of serotonin, norepinephrine, and dopamine in the
neuronal synapse by inhibiting the MAO enzyme that
degrades or breaks down these nuerotransmitters
reserved.
• Selective serotonin reuptake inhibitors (SSRIs)
– First-line medications for treatment of depression

– Greater safety in the cases of overdose
– Selectively block reabsorption of serotonin, helping to
restore the brain’s chemical balance
– Example: Prozac and Zoloft
reserved.
• Selective norepinephrine reuptake inhibitors (SNRIs)
– Inhibit reuptake of serotonin and norepinephrine
– Affective in patients with chronic pain
– Examples: Cymbalta and Effexor
reserved.
• Heterocyclic antidepressants
– Comparable efficacy to first-generation tricyclic
antidepressants,

– Differing effects on dopamine, norepinephrine, and
serotonin
– Distinctly different adverse effect profiles
– Examples: Wellbutrin and Remeron
• See Table 20-2
reserved.
Antimanic Agents
• Bipolar disorder
– Mental illness characterized by severe fluctuations in
mood extremes
– Patients may experience high (mania) and low
(depression) mood swings with a diminished capacity for
daily functioning
• Lithium
– Treatment of mania, lowered the suicide rate
– Serum levels are checked to prevent toxicity
• See Table 20-3

reserved.
Anxiolytics (1 of 2)
• Anxiety becomes a disorder when it becomes
excessive and difficult to control
• Types of anxiety disorders
– Social anxiety, post-traumatic stress disorder, panic
attacks, and obsessive compulsive behavior
• Benzodiazepines (BDZs)
– For short-term treatment of anxiety disorders, some
psychosomatic disorders and insomnia, and alcohol
withdrawal
– Examples: Valium, Klonopin, and Versed
reserved.
• Other anxiolytics

– Buspirone (BuSpar)
▪ Indicated for treatment of generalized anxiety disorder,
but not other anxiety disorders (or depression)
– Hydroxyzine (Vistaril)
▪ Used IM as a pre- and postoperative antiemetic and
sedative
• See Table 20-4
reserved.
Antipsychotic Medications/Major
Tranquilizers (1 of 3)
• Also called neuroleptics
– First and second generation agents
• Useful in two major areas
– Relieving symptoms of psychoses including delusion,
hallucinations, agitation, and combativeness
– Relieving nausea and vomiting

reserved.
• Modify disturbed behavior and relieve severe anxiety
without impairment of consciousness
• Work primarily by blocking dopamine receptors
– Results in unbalanced cholinergic activity
▪ Causes frequent extrapyramidal side effects to include
tardive dyskinesia
reserved.
• Atypical antipsychotics
– Block both serotonin and transiently block dopamine
receptors

– Less potential for adverse effects
• There is no “ideal” antipsychotic medication
– Both conventional and atypical antipsychotic
medications are associated with significant adverse drug
reactions
• See Table 20-5
reserved.
Drug Abuse (1 of 2)
• Drug abuse
– The use of a drug for other than therapeutic purposes
• Drug addiction
– A combination of tolerance, psychological dependence,
physical dependence, and withdrawal syndrome with
physiological effects
reserved.

Drug Abuse (2 of 2)
• Chemical dependency
– A condition in which alcohol or drugs have taken control
of an individual’s life and affect normal functioning
reserved.
Alcohol (1 of 2)
• Ethyl alcohol, ethanol)
– Classified as a psychotropic drug and a CNS depressant
– Number one drug problem in the U.S.
– Responsible for more than half of the traffic accidents in
the U.S and most commonly abused drug among
American teenagers
– Fast acing depressant and rapid absorbed from the GI
tract
– Prolonged use can cause CNS damage

reserved.
Alcohol (2 of 2)
• Alcohol poisoning
– Symptoms include cold, clammy skin; stupor; slow, noisy
respirations; and alcoholic breath
– Mortality associated with acute alcohol poisoning alone
is uncommon, but can be an important factor when
mixed with recreational drugs
– Treatment: Refer to chapter text for description
• Chronic alcoholism
– Refer to chapter text for symptoms and treatment
options
reserved.
Prescription Drug Abuse
• Nation's fastest growing drug problem
• Second most-abused category of drugs after marijuana
• According to the CDC, death rates from opioid

overdoses have more than tripled since 1999
• Proper disposal and storage is important for deterring
abuse
• Most often abused by medical professionals are
fentanyl, oxycodone, hydrocodone and BDZ’s
reserved.
Illegal Drug Abuse (1 of 7)
• Amphetamines
– Examples: methamphetamine (“crystal,” “crank,” “ice,”
“meth,” “speed”) and methylenedioxymethamphetamine
(MDMA, “Ecstasy”)
– Abrupt withdrawal may unmask mental problems
reserved.
• Marijuana

– Active ingredient: tetrahydrocannabinol (THC)
– CNS depressant, euphoriant, sedative, and hallucinogen
– Marinol is approved for the prevention of chemotherapy-
induced nausea and vomiting
• Synthetic cannabinoids
– “Spice”, “K2”, “skunk”, fake weed: shredded plant
material and chemical additives
reserved.
• Cocaine
– Highly addictive CNS stimulant
– Produces euphoria and increased expenditure of energy
• Hallucinogens
– Produce bizarre mental reactions and distortion of
physical senses
– Examples: lysergic acid (LSD) and phencyclidine (PCP)

reserved.
• Dextromethorphan (DXM)
– Semisynthetic morphine derivative
– Safe, effective, nonaddictive, OTC cough suppressant
when used appropriately
– Often abused by teens because of its phencyclidine-like
euphoric effect
reserved.
• Flunitrazepam (Rohypnol)
– Potent benzodiazepine approved for use in Central and
South America for ethanol withdrawal
– Known on the street as “roofies” and the “date-rape
drug”

reserved.
• Role of the medical personnel
– Have a thorough knowledge of psychotropic drugs,
action, and side effects
– Be willing to participate in the education of the patient,
patient’s family, and others
– Give competent care to those under the influence of
drugs in a nonjudgmental way
– Recognize drug abuse and make appropriate referrals
without exception
reserved.
• Role of the medical personnel
– Keep complete and accurate records of controlled

stocks of drugs that could be considered potential drugs
of abuse
– Report any observed drug abuse to the proper person in
authority
Health Professions
Eighth Edition
Chapter 21
Musculoskeletal and Anti-
Inflammatory Drugs
reserved.
Introduction
• Disorders of the musculoskeletal system are rather
common
– Drugs used to treat such conditions are classified in two

broad categories
▪ Skeletal muscle relaxants
▪ Nonsteroidal anti-inflammatory drugs (NSAIDs)
• The following slides discuss various musculoskeletal
and anti-inflammatory drugs
– Refer to the chapter for side effects, precautions or
reserved.
Skeletal Muscle Relaxants (1 of 2)
• Many disorders associated with pain, spasm, abnormal
contraction, or impaired mobility respond to skeletal
muscle relaxants
– Given only on a short-term basis
– Most affect the central nervous system
▪ No direct effect on skeletal muscle
▪ Reduces muscle spasm, causes alterations in the
perception of pain, and produces a sedative effect,

promoting rest and relaxation
reserved.
• Neuromuscular blocking agents (NMBAs)
– Cause a direct effect on the muscles including the
diaphragm
– Used during surgical, endoscopic, or orthopedic
procedures
– Potentially very dangerous
– Can result in respiratory arrest because of the potential
to paralyze the diaphragm
• See Table 21-1
reserved.
Anti-Inflammatory Drugs (1 of 4)
• Treat disorders in which the musculoskeletal system is

not functioning properly due to inflammation
– Examples: arthritis, bursitis, spondylitis, gout, and
muscle strains and sprains
• Nonsteroidal anti-inflammatory drugs (NSAIDS)
– Frequently given for lengthy time periods in maintenance
doses as low as possible for effectiveness
reserved.
• NSAIDs, such as ibuprofen, inhibit synthesis of
prostaglandins
– Substances responsible for producing much of the
inflammation and pain of rheumatic conditions, sprains,
and menstrual cramps
▪ No cure has been found for rheumatic disorders, but
many medications are used to alleviate pain
– Salicylates (e.g., aspirin) are the oldest drug in this

category with analgesic, anti-inflammatory, and
antipyretic effects
reserved.
• FDA warning regarding over-the-counter (OTC)
nonselective NSAIDs
– Should be used in strict accordance with label directions
– Self-treatment should not exceed ten days, unless
directed by a physician
reserved.
• COX-2 inhibitor
– Celecoxib (Celebrex): NSAID that exhibits anti-
inflammatory, analgesic, and antipyretic activities
– Selectively inhibits cyclooxygenase-2 (COX-2)

prostaglandin synthesis, does not inhibit COX-1
– Does not inhibit platelet aggregation (clotting) or inhibit
production of mucosal-protective prostaglandins
– Increases the risk of a cardiac event
• See Table 21-2
reserved.
Osteoporosis Therapy (1 of 7)
• Osteoporosis
– A systemic skeletal disease
▪ Characterized by low bone mass and deterioration of
bone tissue, leading to bone fragility and increased
susceptibility to fracture, especially of the hip, spine, and
wrist
▪ Most commonly affects postmenopausal women
– Diagnosis: measure bone mineral density
– Therapy includes calcium, vitamin D, and prescription
medications

reserved.
• Bisphosphonates
– Nonhormonal agents
– Act directly to inhibit bone reabsorption, increasing bone
mineral density at the spine and hip, and decreasing
incidence of first and future fracture
– Bind strongly to and accumulate in bone, creating a
reservoir of drug that is released back into systemic
circulation gradually over a period of months or years
after treatment is stopped
– Examples: Fosamax and Reclast
reserved.
• Hormones involved in osteoporosis therapy

– Estrogen before menopause helps to maintain a normal
bone reabsorption rate in women
▪ Hormone replacement therapy (HRT), estrogen with or
without progestin, is recommended for postmenopausal
osteoporosis prevention only when unable to take other
agents, and when benefits outweigh risks
reserved.
• Selective estrogen-receptor modifiers (SERMs)
– Raloxifene (Evista) is a selective estrogen receptor
modifier with estrogen agonist activity on bone and lipids
and estrogen antagonist activity on breast and uterine
tissue
– Increase bone mineral density, decrease bone
reabsorption, and reduce fracture risk without promoting
breast or endometrial cancer

reserved.
• Calcitonin-salmon
– Synthetic form of the hormone calcitonin is available as
a nasal spray (Miacalcin) or as a subcutaneous injection
– Involves with calcium regulation, increases spinal bone
density, and provides an analgesic effect in acute
vertebral fractures
– Reserved for women who refuse or cannot tolerate HRT
or in whom HRT is contraindicated
reserved.
• Parathyroid hormone
– Teriparatide (Forteo) is an injectable form of parathyroid
hormone approved for postmenopausal women and

men with osteoporosis at a high risk for having a fracture
– Increases GI calcium absorption and renal tubular
reabsorption of calcium, increasing bone mineral
density, bone mass, and strength
reserved.
• Monoclonal antibodies
– Prolia: inhibits osteoclast activity
– Reserved for patients with a higher risk of fracture
– Subcutaneous injection given bi-annually
• See Table 21-3
Essentials of Pharmacology for Health Professions
Eighth Edition
Chapter 16
Gastrointestinal Drugs

Introduction to Cost management
1
Gastrointestinal drug categories
Antacids
Drugs for treatment of ulcers and gastroesophageal reflux
disease (GERD)
Antispasmodics
Management of inflammatory bowel disease
Antidiarrheal agents
Antiflatulents
Laxatives and cathartics
Antiemetics
The following slides discuss various gastrointestinal drugs
Refer to the chapter for specific side effects, contraindications,
and interactions
Antacids
Act by partially neutralizing gastric hydrochloric acid
Widely available in many over-the-counter (OTC) preparations
for the relief of indigestion, heartburn, and sour stomach

Generally have a short duration of action, requiring frequent
administration
May contain aluminum, calcium carbonate or magnesium and
sodium
Agents for Treatment of Ulcers and GERD (1 of 3)
H2-blockers
Reduce gastric acid secretion by acting as histamine2 blockers
(Example: Pepcid)
Reduce gastric acid released in response to stimuli
Proton pump inhibitors (PPI)
May be used long-term for severe GERD, to prevent NSAID-
induced ulcers, and for hypersecretory conditions
Omeprazole: gastric antisecretory agent
Gastric mucosal agents
Misoprostol (Cytotec)
Synthetic form of prostaglandin E1
Inhibits gastric acid secretion and protects the mucosa from the
irritant effect of certain drugs
Sucralfate (Carafate)
Inhibitor of pepsin, given on an empty stomach
Reacts with HCl to form a paste that adheres to the mucosa,
protecting the ulcer from irritation

Helicobacter pylori treatment
Bacterial infection
Treated successfully with multiple-drug regimens (over 14
days).
See Chapter 17
See Table 16-1
Antispasmodics/Anticholinergics
Help to calm the bowel
Work by decreasing motility (smooth muscle tone) in the GI
tract
Dicyclomine (Bentyl)
Used for treatment of irritable bowel syndrome and other
functional disturbances of GI motility
Agents for Inflammatory Bowel Disease
Inflammatory bowel disease (IBD)
Chronic condition that causes inflammation in the lining of the
GI tract
Includes Crohn’s disease and ulcerative colitis
Salicylates
Designed to reach the ileum and colon, bypassing the stomach
and upper intestines
Examples: mesalamine and sulfasalazine used for Crohn’s
disease and ulcerative colitis

Glucocorticoids
Act in various ways
Reduce the number of loose stools
Patients experiencing diarrhea are instructed to stay hydrated
Salicylates
Bismuth subsalicylate (e.g., Kaopectate, Pepto-Bismol) has
anti-infective and antisecretory properties, a direct mucosal
protective effect, and weak antacid and anti-inflammatory
effects
Opiate agonists
Act by slowing intestinal motility, allowing for more
reabsorption of fluid
Example: Loperamide
Probiotics
Living microorganisms that can alter a patient’s intestinal flora;
may provide benefit in numerous GI diseases
Lactobacillus
Saccharomyces boulardii (Florastor)

Clostridium difficile infection
One of the most common causes of infectious diarrhea in the
United States
Symptoms include watery diarrhea, nausea, and/or abdominal
pain or tenderness
Caused by eradication of native intestinal flora with broad-
spectrum antimicrobials and overuse of PPI and H2-blocker
therapy
Oral medications include metronidazole (Flagyl) or vancomycin
Antiflatulents
For the symptomatic treatment of gastric bloating and
postoperative gas pains
Help to break up gas bubbles in the GI tract
Simethicone
See Table 16-2
Laxatives promote evacuation of the intestine and are used to
treat constipation
Included in this category are cathartics, or purgatives
Promote rapid evacuation of the intestine and alteration of stool
consistency
Divided into seven categories according to action (see Chapter
text for list)

Bulk-forming laxatives
Soften the stool by absorbing water and increase fecal mass to
facilitate defecation
Stool softeners
Surface-acting agents that moisten stool through a detergent
action
Emollients
Promote stool movement through the intestines by softening and
coating the stool
Saline laxatives
Promote secretion of water into the intestinal lumen
Should be taken infrequently, in single doses
Stimulant laxatives
Cathartic in action; produce strong peristaltic activity; may alter
intestinal secretions in several ways
Produce some degree of abdominal discomfort
Osmotic laxatives
Exert an action that draws water from the tissues into the feces
and reflexively stimulates evacuation
Chloride channel activator
Lubiprostone increases intestinal fluid secretion by activating

chloride channels in the epithelium
Mu-opioid receptor agonist
Opioid induced constipation
See Table 16-3
For the prevention or treatment of nausea, vomiting, vertigo, or
motion sickness
Many different products are available, varying in their actions,
condition treated, and route of administration
See Table 16-4
Anticholinergics
Dimenhydrinate (Dramamine) or scopolamine: for the treatment
of motion sickness
Available in a transdermal patch
Meclizine (Antivert): antihistamine for the prevention and
treatment of nausea, vomiting, and/or vertigo associated with
motion sickness
Antidopaminergics
Dopamine receptor antagonists interfere with the stimulation of

chemoreceptor trigger zone (CTZ) in the brain, thereby blocking
messages to the GI tract
Most frequently used agents to control nausea and vomiting in
this class:
Prochlorperazine (Compazine): no longer marketed, caused
extrapyramidal reactions
Phenergan, Reglan
Serotonin receptor antagonists
Preferentially block serotonin receptors found centrally in the
CTZ and peripherally in the intestines to control emesis
Serotonin is a major neurotransmitter involved in emesis
located in the gut
Ondansetron (Zofran) and dolasetron (Anzemet)
For the prevention and treatment of post-operative (PONV) and
chemotherapy-induced nausea and vomiting (CINV)
Eighth Edition
Chapter 17
Anti-infective Drugs

22
Introduction
Treatment of infection
Complicated by the great variety of medications available and
their differing modes of action
First step: identify the causative organism and specific
medication to which it is sensitive
Culture and sensitivity (C&S) tests
Wound, throat, urine or blood
Usually not available for 24-48 hours
Resistance (1 of 2)
Organisms may build up resistance to drugs and are therefore,
no longer effective because of:
Frequent use
Incomplete treatment
Anti-infective resistance is caused by many factors
Complex strategies needed to combat the problem
Seventy percent of bacteria that cause HAI’s are resistant to at
least one drug
Example: MRSA
Resistance (2 of 2)

Selection of anti-infective drugs
Infection site
Status of hepatic and/or renal function
Patient age
Pregnancy or lactation
Likelihood of organisms developing resistance
Known allergy to the anti-infective drug
Adverse Reactions
Three categories
Allergic hypersensitivity
Over-response of the body to a specific substance (anaphylaxis)
Direct toxicity
Results in tissue damage
Indirect toxicity or superinfection
Manifested as a new infection due to absence of normal flora in
the intestines or mucous membranes
Vaccines/Immunizations
Centers for Disease Control and Prevention (CDC)
Currently recommends routine vaccination
Prevent 17 vaccine-preventable diseases that occur in infants,
children, adolescents, or adults
Information regarding vaccines and immunizations changes
from time to time and requirements may vary by state, territory,
or country

Antibiotics
Refers to a large spectrum of medicines that are useful for
treating and preventing infections by bacteria.
No effect on viruses, fungal or other types of infection
Improper use causes resistance
Side effects, precautions, contraindications and interactions are
listed for each drug. Refer to the Chapter text.
Aminoglycosides
Treats many infections caused by:
Gram-negative bacteria (e.g., Escherichia coli and
Pseudomonas)
Gram-positive bacteria (e.g., Staphylococcus aureus)
Effective in short-term treatment of many serious infections
Septicemia (e.g., bacteria in bloodstream causing low blood
pressure) when less toxic drugs are ineffective or
contraindicated
Cephalosporins
Semisynthetic beta-lactam antibiotic derivatives produced by a
fungus
Related to penicillins
Some patients allergic to penicillin are also allergic to
cephalosporins
Classified as first, second, third, or fourth, or fifth generation

According to organisms susceptible to their activity
Macrolides
Treats many infections of the respiratory tract, skin conditions,
or for some sexually transmitted infections
Considered among the least toxic antibiotics
Preferred for treating susceptible organisms under conditions in
which more toxic antibiotics might be dangerous
Penicillins
Beta-lactam antibiotics produced from certain species of a
fungus
Treats many streptococcal and some staphylococcal and
meningococcal infections
Drug of choice for treatment of syphilis
Used prophylactically to prevent recurrences of rheumatic fever
Carbapenems
Belong to the beta-lactam class of antibiotics
Have a very broad spectrum of activity against gram-negative
and gram-positive organisms
Primary treatments include pneumonia, febrile neutropenia,
intra-abdominal infections, diabetic foot infections, and
significant polymicrobial infections

See Table 17-1
Quinolones
For adult treatment of some infections of the urinary tract,
sinuses, lower respiratory tract, GI tract, skin, bones, and joints,
and in treating gonorrhea
Some organisms are showing increased resistance
Reserve for infections that require therapy with a
fluoroquinolone
Tetracyclines
Broad-spectrum antibiotics
Treats infections caused by Lyme disease, rickettsia, chlamydia,
or some uncommon bacteria
Some organisms are showing increasing resistance
Use only when other antibiotics are ineffective or
contraindicated
Treat specific susceptible fungal disease
Medications are quite different in action and purpose
Amphotericin B
Administered IV for the treatment of severe systemic and
potentially fatal infections caused by susceptible fungi,

including Candida
Fluconazole (Diflucan)
Works against many fungal pathogens, including most Candida,
without the serious toxicity of amphotericin B
Micafungin (Mycamine)
Given IV
Provides new treatment options against Candida and Aspergillus
species
Nystatin
Structurally related to Amphotericin B
Orally treats oral cavity candidiasis
Also used as a fungicide in the topical treatment of skin and
mucous membranes
Antituberculosis Agents
Tuberculosis (TB)
Caused by a bacterium called Mycobacterium tuberculosis,
which primarily attacks the lungs
Antituberculosis agents are administered for two purposes
To treat latent or asymptomatic infection (no evidence of

clinical disease)
For treatment of active clinical tuberculosis and to prevent
relapse
Treatment can be challenging
See Table 17-2
Clindamycin
Treats serious respiratory tract infections, septicemia,
osteomyelitis, serious infections of the female pelvis caused by
susceptible bacteria, and for Pneumocystis jirovecii pneumonia
associated with AIDS
Prophylactic use in dental procedures for penicillin-allergic
patients
May be a viable therapeutic option for community-acquired
MRSA
Metronidazole (Flagyl)
Synthetic antibacterial and antiprotozoal agent
Effective against protozoa
One of the most effective drugs against anaerobic bacterial
infections
Also useful in treating Crohn’s disease, antibiotic-associated
diarrhea, rosacea, and H. pylori infection

Vancomycin
Structurally unrelated to other available antibiotics
IV vancomycin is used in the treatment of potentially life-
threatening infections caused by susceptible organisms
Drug of choice for MRSA
Agents for VRE
Linezolid (Zyvox)
Indicated for gram-positive infections
Approved for the treatment of bacterial pneumonia skin, skin
structure infections, and MRSA and VRE infections
Effective in treating diabetic foot infections
Administered by IV infusion or orally
See Table 17-3
Sulfonamides
Among the oldest anti-infectives
Increasing resistance of many bacteria has decreased the
clinical usefulness of these agents
Used most effectively in combinations with other drugs
Example: sulfamethoxazole and trimethoprim
Resistance develops more slowly

Urinary Anti-Infectives
Urinary tract infection (UTI)
Symptomatic inflammatory response from the presence of
microorganisms in the urinary tract
One of the most common bacterial infections for which patients
seek treatment
First-line urinary anti-infectives for empiric treatment of
uncomplicated lower UTI are sulfamethoxazole-trimethoprim
and nitrofurantoin
See Table 17-4
Antivirals
Acyclovir
Primarily treats herpes simplex, herpes zoster (shingles), and
varicella zoster (chickenpox) infections
Neuraminidase inhibitors
Indicated for the treatment of uncomplicated acute illness due to
influenza types A and B
Ribavirin
Treats infants and young children with respiratory syncytial
virus (RSV) infections via nasal and oral inhalation, Lassa fever
and Hepatitis C
See Table 17-5
See Table 17-6

Highly specialized field
Those actively practicing in that field must be updated
frequently on the many new medications and frequently
changing protocols
Treatment of HIV infection
Consists of using highly active antiretroviral therapy (HAART)
combinations of three or more antiretroviral (ARV) agents
Antiretroviral protease inhibitors (PIs)
Block the activity of the HIV enzyme essential for viral
replication late in the virus life cycle
Nucleoside reverse transcriptase inhibitors (NRTIs)
Inhibit an enzyme responsible for viral replication early in the
virus life cycle
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Inhibit an enzyme responsible for viral replication early in the
viral life cycle
Fusion inhibitors (FIs)
Block entry of HIV into cells, which may keep the virus from
reproducing

CCR5 antagonists
Block a co-receptor required for HIV entry into human cells
Integrase inhibitor
Raltegravir (Isentress): first ARV designed to slow the
advancement of HIV infection by blocking the enzyme needed
for viral replication
HIV Information and Resources
Sources of current recommendations for clinical use of
antiretrovirals (ARVs)
Department of Health and Human Services
Florida/Caribbean Aids Education and Training Center
AETC National Resource Center Drug Interactions
Johns Hopkins HIV Guide
National HIV Telephone Consultation Service
University of California, San Francisco
Eighth Edition
Chapter 18
Eye and Ear Medications

52
Most common eye diseases in Americans 40 years and older
Age-related macular degeneration, glaucoma, cataracts, and
diabetic retinopathy
Conjunctivitis: inflammation of the conjunctiva (“pink eye”)
One of the most frequent causes of patient seeking help
Allergens, irritants, abrasion, bacteria and viruses are common
causes
Medications for the eye
Anti-infectives
Anti-inflammatory agents
Antiglaucoma agents
Mydriatics (pupil dilation)
Local anesthetics
The following slides discuss various eye medications
Refer to the chapter for specific side effects, contraindications,
and interactions
Anti-Infectives
Treat superficial eye infections caused by susceptible organisms

Ointments are preferable to drops in children and patients with
poor adherence
Drops are preferred in adults
Ointments will cause blurring of vision for 20 minutes after
instillation
Determine causative organism when possible
Preparations can be single or in combination
Antivirals
Relieve eye or conjunctiva inflammation in allergic reactions,
burns, postoperatively, or irritation from foreign substances
Corticosteroids
Useful in acute stages of eye injury
Prevent scarring, for severe symptoms, or when condition is
unresponsive to other medications
Do not use for extended periods of time
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Treat postoperative inflammation following cataract surgery
Alternative to corticosteroids if a contraindication exists
Immunologic agents
Increases tear production in patient's with dry eye

Antihistamines/decongestants
Block histamine receptors in conjunctiva, relieving ocular
pruritis associated allergic conjunctivitis
Cause vasoconstriction of blood vessels, providing relief from
minor eye irritation and redness
Ophthalmic lubricants
Provide a barrier function at the level of the conjunctival
mucosa
Help to dilute and flush various allergens and inflammatory
mediators that may be present on the ocular surface
See Table 18-1
Glaucoma
A group of sight-threatening diseases of the eye in which there
is increased intraocular pressure (IOP) due to obstruction of
Causes deterioration of and damage to the optic nerve resulting
in vision loss

Glaucoma types
Acute (angle-closure) glaucoma
Characterized by a sudden onset of pain, blurred vision, and a
dilated pupil
Considered a medical emergency
Chronic (open-angle) glaucoma
Much more common, often bilateral
Develops slowly over a period of years with few symptoms
except a gradual loss of peripheral vision and possibly blurred
vision
Antiglaucoma drugs given to lower intraocular pressure
Carbonic anhydrase inhibitors: reduce formation of hydrogen
and bicarbonate ions
Diuretic effect; reduces production of aqueous humor
Miotics: cause pupil to contract
Reduce IOP by increasing aqueous humor outflow
Beta-adrenergic blockers: used topically to lower IOP in open-
angle glaucoma
Decreased rate of aqueous humor production
Alpha agonists: decreases formation and increases outflow of
aqueous humor
Minimal effects on cardiovascular or pulmonary hemodynamics

Prostaglandin analogs: greatest reduction in IOP by increasing
May be used concomitantly with other topical ophthalmic drugs
to lower IOP
See Table 18-2
Mydriatics
Topically dilates the pupil for ophthalmic examinations
Example: atropine
Also acts as a cycloplegic (paralyzes the muscles of
accommodation)
Drug of choice in eye examinations for children
Often used for adults because of fast action and fast recovery
time
Local Anesthetics
Applied topically to the eye for minor surgical and diagnostic
procedures, removal of foreign bodies, or painful injury
Example: tetracaine (TetraVisc)
See Table 18-3

Made up of three parts: outer, middle and inner
Serve two purposes: hearing and balance
Common ear conditions
Ear infections
Earwax (cerumen) buildup
Otitis media
Bacteria in the middle ear which leads to inflammation
Treatment includes an antibiotic and NSAIDS
Topical preparations for ear infections
“swimmers ear” or otitis externa
Cipro, Floxin and Cortisporin are the most common
Prescribed for 7-14 days
Drops that are designed to treat pain and inflammation
associated with ear infections
Vosol, Auralgan
Systemic Preparations
Refer to Chapter 17: Amoxicillin and Augmentin
Earwax buildup and blockage
Earwax (cerumen) in the canal can inhibit hearing and can cause
pain
Most common in older adults

Debrox is an OTC that is used to soften and loosen excessive
earwax
See Table 18-4
Eighth Edition
Chapter 19
Analgesics, Sedatives, and Hypnotics
70
Analgesics, sedatives, and hypnotics
Depress central nervous system (CNS) action to varying degrees
Some drugs can be classified into more than one category,
depending on the dosage
Analgesics: relieve pain
Sedatives: calm, soothe, or produce sedation
Hypnotics: produce sleep

The following slides discuss various analgesics, sedatives, and
hypnotics
Refer to the chapter for specific side effects, precautions,
Analgesics (1 of 8)
Pain is the most common reason for patients to seek out medical
care
Most common types: back, neck, migraine, and facial or jaw
pain
Is subjective: can be experienced or perceived only by the
individual subject. Pain scale: 1 to 10
Can be blocked by endorphins
Endogenous analgesics produced within the body as a reaction
to severe pain or intense exercise
Analgesics (2 of 8)
Opioid analgesics
Full or pure agonists, partial agonists, or mixed agonist-
antagonists
Each bind to specific receptors with varying degrees of action
Classified as controlled substances
Potential for abuse and psychological dependence
Tolerance and physiological dependence
See Table 19-1

Analgesics (3 of 8)
Opioid induced constipation (OIC)
Not-self limiting
Occurs because the digestive tract contains similar receptors
(mu) that are targeted in pain relief, slowing the transit time
Most of the time, hydration, stool softeners or stimulant are
effective
For severe OIC, prescription strength medication is required.
Analgesics (4 of 8)
Tramadol (Ultram)
Centrally acting synthetic analog of codeine with a dual
mechanism of action
Produces analgesia by weak inhibition of norepinephrine and
serotonin reuptake; is an opioid receptor agonist
Less potential for abuse or respiratory depression (al though
both may occur)
Analgesics (5 of 8)
Nonopioid analgesics
See Table 19-2
Many available without prescription as over-the-counter (OTC)
medications
Given for relieving mild to moderate pain, fever, and anti-

inflammatory conditions
Used as a coanalgesic in severe acute or chronic pain requiring
opioids
Analgesics (6 of 8)
Salicylates (aspirin) are most commonly used for their analgesic
and antipyretic properties, as well as for their anti -inflammatory
action
Acetaminophen has analgesic and antipyretic properties, but
very little effect on inflammation. (major changes in Tylenol
dosing)
Aspirin and acetaminophen are frequently combined with
opioids or with other drugs for more effective analgesic action
Nonsteroidal anti-inflammatory drugs (NSAIDS) are discussed
in Chapter 21
Analgesics (7 of 8)
Adjuvant analgesics
May enhance analgesic effect with opioids and nonopioids,
produce analgesia alone, or reduce side effects of analgesics
Treatment for nerve pain and fibromylagia
Tricyclic antidepressants
Treats fibromyalgia and nerve pain associated with herpes,
arthritis, diabetes, and cancer, migraine or tension headaches,
insomnia, and depression
Pain often described as “burning”

Analgesics (8 of 8)
Anticonvulsants
Examples: Neurontin and Tegretol
Commonly used for management of nerve pain associated with
neuralgia, herpes zoster (shingles), and cancer
Implemented when patient describes pain as “sharp,”
“shooting,” “shock-like pain,” or “lightning-like”
See Table 19-3
Local Anesthetic
Lidocaine patch (Lidoderm)
Approved for management of postherpetic neuralgia
Can provide significant analgesia in other forms of neuropathic
pain
Diabetic neuropathy and musculoskeletal pain such as
osteoarthritis and low back pain
Provides pain relief through a peripheral effect and generally
has little, if any, central action
Must be applied to intact skin
Antimigraine agents
Migraine is the most common neurovascular headache and may
include nausea, vomiting, and sensitivity to light and noise.
Simple/opioid analgesics and NSAIDs are effective, especially
if taken at initial sign of migraine

Serotonin receptor agonists (SRAs)
Action: serotonin levels decrease, while vasodilation and
inflammation of blood vessels in brain increase as migraine
symptoms worsen
Effective treatment for nausea and vomiting
See Table 19-4
Medications used to promote sedation in smaller doses, and
sleep in larger doses
Insomnia is one of the most prevalent sleep disorders
Antihistamines (Benadryl) and Barbiturates
Benzodiazepines (BZDs) and nonbenzodiazepines
Less abuse potential
Withdrawal effects are observed after long-term use and
respiratory depression (when taken with alcohol) can be
potentially fatal
Melatonin receptor agonist
Ramelteon (Rozerem): first FDA-approved prescription
medication that acts on melatonin receptor
Mimics action of melatonin to trigger sleep onset
Dependence and abuse potential are eliminated
Not classified as a controlled substance
Works quickly, generally inducing sleep in less than one hour
See Table 19-5

Eighth Edition
Chapter 20
Psychotropic Medications, Alcohol, and Drug Abuse
85
Psychotropic refers to any substance that acts on the mind
Psychotropic medications are drugs that can exert a therapeutic
effect on a person’s mental processes, emotions, or behavior
Classified according to the purpose for administration: CNS
stimulants, antidepressants, anxiolytics, antimanic, and
antipsychotic medications
The following slides discuss various psychotropic medications
Refer to the chapter for specific side effects, precautions or

Drug and alcohol abuse is also discussed
Refer to the chapter for specific symptoms and treatment
options
CNS (central nervous system) stimulant medications
Given to promote CNS functioning
Caffeine
Helps fight fatigue and drowsiness
Examples: NoDoz, Vivarin, and caffeine citrate
Prolonged, high intake of caffeine in any form may produce
tolerance, habituation, and psychological dependence
See Table 20-1
Amphetamine/methylphenidate preparations
Controlled substances (Schedule II)
Treats attention-deficit hyperactivity disorder (ADHD) in
children over age six and for narcolepsy
Examples: Adderall and Ritalin
Wakefulness-promoting agents
Provigil is a psychostimulant approved for narcolepsy, sleep
apnea, and shift-work sleep disorder

Selective Norepinephrine Reuptake Inhibitor (SNRI) for ADHD
Atomoxetine (Strattera)
Selective norepinephrine reuptake inhibitor
First nonstimulant, noncontrolled drug approved for attention-
deficit hyperactivity disorder (ADHD)
Structurally related to fluoxetine
Does not have a potential for abuse, has less insomnia, less
effect on growth, and has been shown to be safe and effective
Major depressive disorder (MDD)
Caused by a chemical imbalance in the brain
Mental disorder characterized by an all-encompassing low mood
accompanied by low self-esteem and loss of interest or pleasure
in normally enjoyable activities
Antidepressant medications, sometimes called mood elevators,
are used primarily to treat patients with various types of
depression
“Black box” warning
Tricyclic antidepressants
Mechanism of action involves potentiation of norepinephrine
and serotonin activity by blocking their reuptake
Monamine oxidase inhibitors (MAOIs)
Mechanism of action involves increasing concentrations of
serotonin, norepinephrine, and dopamine in the neuronal
synapse by inhibiting the MAO enzyme that degrades or breaks

down these nuerotransmitters
Selective serotonin reuptake inhibitors (SSRIs)
First-line medications for treatment of depression
Greater safety in the cases of overdose
Selectively block reabsorption of serotonin, helping to restore
the brain’s chemical balance
Example: Prozac and Zoloft
Selective norepinephrine reuptake inhibitors (SNRIs)
Inhibit reuptake of serotonin and norepinephrine
Affective in patients with chronic pain
Examples: Cymbalta and Effexor
Heterocyclic antidepressants
Comparable efficacy to first-generation tricyclic
antidepressants,
Differing effects on dopamine, norepinephrine, and serotonin
Distinctly different adverse effect profiles
Examples: Wellbutrin and Remeron
See Table 20-2

Antimanic Agents
Bipolar disorder
Mental illness characterized by severe fluctuations in mood
extremes
Patients may experience high (mania) and low (depression)
mood swings with a diminished capacity for daily functioning
Lithium
Treatment of mania, lowered the suicide rate
Serum levels are checked to prevent toxicity
See Table 20-3
Anxiety becomes a disorder when it becomes excessive and
difficult to control
Types of anxiety disorders
Social anxiety, post-traumatic stress disorder, panic attacks, and
obsessive compulsive behavior
Benzodiazepines (BDZs)
For short-term treatment of anxiety disorders, some
psychosomatic disorders and insomnia, and alcohol withdrawal
Examples: Valium, Klonopin, and Versed

Other anxiolytics
Buspirone (BuSpar)
Indicated for treatment of generalized anxiety disorder, but not
other anxiety disorders (or depression)
Hydroxyzine (Vistaril)
Used IM as a pre- and postoperative antiemetic and sedative
See Table 20-4
Antipsychotic Medications/Major Tranquilizers (1 of 3)
Also called neuroleptics
First and second generation agents
Useful in two major areas
Relieving symptoms of psychoses including delusion,
hallucinations, agitation, and combativeness
Relieving nausea and vomiting
Modify disturbed behavior and relieve severe anxiety without
impairment of consciousness
Work primarily by blocking dopamine receptors
Results in unbalanced cholinergic activity
Causes frequent extrapyramidal side effects to include tardive
dyskinesia

Atypical antipsychotics
Block both serotonin and transiently block dopamine receptors
Less potential for adverse effects
There is no “ideal” antipsychotic medication
Both conventional and atypical antipsychotic medications are
associated with significant adverse drug reactions
See Table 20-5
Drug Abuse (1 of 2)
Drug abuse
The use of a drug for other than therapeutic purposes
Drug addiction
A combination of tolerance, psychological dependence, physical
dependence, and withdrawal syndrome with physiological
effects
Drug Abuse (2 of 2)
Chemical dependency
A condition in which alcohol or drugs have taken control of an
individual’s life and affect normal functioning
Alcohol (1 of 2)
Ethyl alcohol, ethanol)

Classified as a psychotropic drug and a CNS depressant
Number one drug problem in the U.S.
Responsible for more than half of the traffic accidents in the
U.S and most commonly abused drug among American
teenagers
Fast acing depressant and rapid absorbed from the GI tract
Prolonged use can cause CNS damage
Alcohol (2 of 2)
Alcohol poisoning
Symptoms include cold, clammy skin; stupor; slow, noisy
respirations; and alcoholic breath
Mortality associated with acute alcohol poisoning alone is
uncommon, but can be an important factor when mixed with
recreational drugs
Treatment: Refer to chapter text for description
Chronic alcoholism
Refer to chapter text for symptoms and treatment options
Prescription Drug Abuse
Nation's fastest growing drug problem
Second most-abused category of drugs after marijuana
According to the CDC, death rates from opioid overdoses have
more than tripled since 1999
Proper disposal and storage is important for deterring abuse
Most often abused by medical professionals are fentanyl,
oxycodone, hydrocodone and BDZ’s

Amphetamines
Examples: methamphetamine (“crystal,” “crank,” “ice,” “meth,”
“speed”) and methylenedioxymethamphetamine (MDMA,
“Ecstasy”)
Abrupt withdrawal may unmask mental problems
Marijuana
Active ingredient: tetrahydrocannabinol (THC)
CNS depressant, euphoriant, sedative, and hallucinogen
Marinol is approved for the prevention of chemotherapy-
induced nausea and vomiting
Synthetic cannabinoids
“Spice”, “K2”, “skunk”, fake weed: shredded plant material and
chemical additives
Cocaine
Highly addictive CNS stimulant
Produces euphoria and increased expenditure of energy
Hallucinogens
Produce bizarre mental reactions and distortion of physical
senses

Examples: lysergic acid (LSD) and phencyclidine (PCP)
Dextromethorphan (DXM)
Semisynthetic morphine derivative
Safe, effective, nonaddictive, OTC cough suppressant when
used appropriately
Often abused by teens because of its phencyclidine-like
euphoric effect
Flunitrazepam (Rohypnol)
Potent benzodiazepine approved for use in Central and South
America for ethanol withdrawal
Known on the street as “roofies” and the “date-rape drug”
Role of the medical personnel
Have a thorough knowledge of psychotropic drugs, action, and
side effects
Be willing to participate in the education of the patient,
patient’s family, and others
Give competent care to those under the influence of drugs in a
nonjudgmental way

Recognize drug abuse and make appropriate referrals without
exception
Role of the medical personnel
Keep complete and accurate records of controlled stocks of
drugs that could be considered potential drugs of abuse
Report any observed drug abuse to the proper person in
authority
Eighth Edition
Chapter 21
Musculoskeletal and Anti-Inflammatory Drugs
114
Introduction
Disorders of the musculoskeletal system are rather common

Drugs used to treat such conditions are classified in two broad
categories
Skeletal muscle relaxants
Nonsteroidal anti-inflammatory drugs (NSAIDs)
The following slides discuss various musculoskeletal and anti -
inflammatory drugs
Refer to the chapter for side effects, precautions or
Many disorders associated with pain, spasm, abnormal
contraction, or impaired mobility respond to skeletal muscle
relaxants
Given only on a short-term basis
Most affect the central nervous system
No direct effect on skeletal muscle
Reduces muscle spasm, causes alterations in the perception of
pain, and produces a sedative effect, promoting rest and
relaxation
Neuromuscular blocking agents (NMBAs)
Cause a direct effect on the muscles including the diaphragm
Used during surgical, endoscopic, or orthopedic procedures
Potentially very dangerous
Can result in respiratory arrest because of the potential to
paralyze the diaphragm
See Table 21-1

Treat disorders in which the musculoskeletal system is not
functioning properly due to inflammation
Examples: arthritis, bursitis, spondylitis, gout, and muscle
strains and sprains
Nonsteroidal anti-inflammatory drugs (NSAIDS)
Frequently given for lengthy time periods in maintenance doses
as low as possible for effectiveness
NSAIDs, such as ibuprofen, inhibit synthesis of prostaglandins
Substances responsible for producing much of the inflammation
and pain of rheumatic conditions, sprains, and menstrual cramps
No cure has been found for rheumatic disorders, but many
medications are used to alleviate pain
Salicylates (e.g., aspirin) are the oldest drug in this category
with analgesic, anti-inflammatory, and antipyretic effects
FDA warning regarding over-the-counter (OTC) nonselective
NSAIDs
Should be used in strict accordance with label directions
Self-treatment should not exceed ten days, unless directed by a

physician
COX-2 inhibitor
Celecoxib (Celebrex): NSAID that exhibits anti-inflammatory,
analgesic, and antipyretic activities
Selectively inhibits cyclooxygenase-2 (COX-2) prostaglandin
synthesis, does not inhibit COX-1
Does not inhibit platelet aggregation (clotting) or inhibit
production of mucosal-protective prostaglandins
Increases the risk of a cardiac event
See Table 21-2
Osteoporosis
A systemic skeletal disease
Characterized by low bone mass and deterioration of bone
tissue, leading to bone fragility and increased susceptibility to
fracture, especially of the hip, spine, and wrist
Most commonly affects postmenopausal women
Diagnosis: measure bone mineral density
Therapy includes calcium, vitamin D, and prescription
medications

Bisphosphonates
Nonhormonal agents
Act directly to inhibit bone reabsorption, increasing bone
mineral density at the spine and hip, and decreasing incidence
of first and future fracture
Bind strongly to and accumulate in bone, creating a reservoir of
drug that is released back into systemic circulation gradually
over a period of months or years after treatment is stopped
Examples: Fosamax and Reclast
Hormones involved in osteoporosis therapy
Estrogen before menopause helps to maintain a normal bone
reabsorption rate in women
Hormone replacement therapy (HRT), estrogen with or without
progestin, is recommended for postmenopausal osteoporosis
prevention only when unable to take other agents, and when
benefits outweigh risks
Selective estrogen-receptor modifiers (SERMs)
Raloxifene (Evista) is a selective estrogen receptor modifier
with estrogen agonist activity on bone and lipids and estrogen
antagonist activity on breast and uterine tissue
Increase bone mineral density, decrease bone reabsorption, and
reduce fracture risk without promoting breast or endometrial
cancer

Essentials of Pharmacology for Health ProfessionsEighth

Essentials of Pharmacology for Health ProfessionsEighth

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