1 Principles of PharmacologyChapter 33

2 Clinical PharmacologyStudy of the biological effects of a drug on a patient and the actions of the drug over time Medical assistants must understand: Drug action Typical side effects Route of administration Recommended dose Individual patient factors that can alter the drug’s effect and elimination Be prepared to provide safe drug therapy patient education. What information should the medical assistant understand before administering a medication or conducting patient education on a prescribed drug?

3 Government RegulationSeveral federal agencies regulate drugs in the United States. FDA regulates development and sale of prescription drugs and OTCs. New drugs must gain FDA approval before release. Drug must pass tests starting in the laboratory on animals and then in human clinical trials. Drug must have an acceptable benefit-to-risk ratio. Copyright awarded to pharmaceutical company for 17 years. FDA ensures generic brands are effective and safe. DEA enforces federal laws designed to control drug abuse and also educates the public on drug-abuse prevention. FTC regulates OTC advertisement. Explain the function of the FDA regarding prescription and OTC medications. What are the primary responsibilities of the DEA and the FTC?

4 Generic Drug StandardsGeneric must have the same active ingredients, labeled strength, route of administration, and dosage form. Do not have to replicate the human clinical trials but must prove the product performs exactly as the brand-name version. Generic must deliver the same amount of active ingredient into the bloodstream in the same amount of time. Label must contain the same information. Manufacturing process must have comparable quality and production standards. FDA has found no difference in rates of side effects between brand name and generic drugs. Summarize federal generic drug standards.

5 Controlled Substances Act (CSA)DEA enforces CSA regulations. Drug that has potential for illegal use and abuse must be placed on controlled substance list. Any new medication that has action similar to a drug already on the controlled list is automatically considered a controlled substance. CSA divides controlled substances into five sections according to drug addictive abilities and potential for abuse. Refer to Table 33-1 Explain the criteria for making a drug a controlled substance.

6 Classification of Controlled SubstancesSchedule I—No accepted medical use; illegal to possess. Examples: heroin, LSD, Quaalude, amphetamines. Schedule II—Severe restrictions; high potential for abuse. Examples: morphine, cocaine, cannabis, Percodan. Schedule III—Accepted use; moderate to low physical and high psychological dependence. Examples: Tylenol with codeine, paregoric, anabolic steroids. Schedule IV—Accepted for use; low potential for abuse. Examples: Librium, Valium, Darvon, Tranxene, Xanax. Schedule V—Accepted for use; low potential for abuse; drug mixtures that contain limited amounts of narcotics. Describe the five controlled substance schedules. Provide two examples of medications that are classified in each schedule.

7 Regulations for Management of Controlled SubstancesPhysician Controlled Substance Registration Certificate DEA registration number must be included on all prescriptions for controlled substances. Renewable every 3 years and specific to site of practice. Documentation Number of doses dispensed and administered. Count of doses on site before and after medication is dispensed. Specific forms developed for this purpose. Any discrepancy in drug count must be cosigned. Record keeping Records maintained on purchase and use. Kept separate from patient chart for 2 years. Be readily available for DEA inspection. There are specific regulations governing the management of controlled substances in the ambulatory healthcare setting.

8 Controlled Substance RegulationsControlled substance disposal Drug loss must be reported to DEA immediately. Drug disposal requires two employees to witness and document the procedure (Critical Thinking Application). Contact DEA for guidelines on disposal of large amount. Storage Immovable locked cabinet. Limited access to keys. MA must be aware of specific state regulations. Controlled substances must be disposed of and stored properly.

9 Controlled Substance PrescriptionsMust be written in ink or typed. Prescription must include name and address of patient; physician information including DEA number; amount prescribed, written out, and usually for small quantities; must be manually signed by the physician. Orders for Schedule II drugs cannot be phoned in except in an absolute emergency, and written prescription must be delivered to the pharmacy within 72 hours. Prescription cannot be refilled. Schedule III, IV, and V drugs may be prescribed by phone or written and refilled up to five times in a 6-month period. In some states Schedule V drugs can be dispensed by the pharmacist without a physician prescription. Regulations govern how controlled substances can be ordered and whether or not there can be refills for the prescription.

10 Drug Abuse Patients may misuse or abuse prescription, OTC, and illegal drugs. Drug dependence—inability to function unless under the influence of the substance. Can have acute and chronic effects Physical dependence (addiction)—biochemical changes within the body that require the substance to be used continuously in order for the person to function and to avoid physical discomfort Psychological dependence—compulsive craving for the substance Habituation—mild form (caffeine) Medical assistants must be alert for patients with drug-seeking behavior or with a history of substance abuse. What is the difference between physical and psychological substance abuse?

11 Prevention of Drug AbuseMonitor patients who repeatedly call for controlled substance prescription refills. Request medical records for patients with a history of controlled substance use. Keep prescription pads in a safe place. Store limited amount of controlled substances in office. Maintain complete and accurate records; keep patient records accurate and complete. Medical assistants should participate in facility efforts to prevent drug abuse.

12 Drug Names A single drug may have as many as three names: chemical, generic, and trade. Chemical name is the drug’s formula. Generic or official name is assigned to the drug and may reflect the chemical name. Is not protected by copyright law. The trade or brand name is the name given the compound by the developing pharmaceutical company and is protected by copyright for 17 years. Why does a single drug have three different names? What does each name indicate?

13 Approaches to Studying PharmacologyUsing drug reference materials is crucial to the safe administration of medications. Most drug reference books supply the action, indication, contraindications, precautions, adverse reactions, dosage, administration guidelines, and method of packaging. The most frequently consulted drug reference guide is the PDR, but package inserts also can be used. The medical assistant must be familiar with drug reference material, especially the PDR.

14 PDR Sections Manufacturer’s index—white: alphabetical listing of pharmaceutical companies Brand and generic section—pink: alphabetical listing with complete information of all drugs included in the PDR volume Product category index—blue: alphabetic listing according to drug category Product identification section—gray: illustrated section that shows actual size photographs of medications General and diagnostic product information area—white: alphabetical listing of diagnostic product information and their uses Refer to a PDR – which index is the simplest method for looking up a drug?

15 Pregnancy Risk CategoriesA Remote risk; controlled studies in women have failed to demonstrate risk to fetus B Slightly more risk than A; animal studies show no risk but controlled human studies have not been done or animal studies show risk, but controlled studies in women have shown no risk C Greater risk than B; Animal studies have shown risk, but no controlled human studies have been done or no studies have been done in animals or women D Proven risk of fetal harm; human studies show proof of fetal damage, but the potential benefits of use during pregnancy may make its use acceptable X Proven risk of fetal harm; studies in women or animals show definite risk of fetal abnormality; risks outweigh any possible benefit Why should pregnant and breastfeeding women be very cautious about taking any medication whether it is an OTC or a prescription? Which of these pregnancy risk categories carries the greater risk for the developing fetus?

16 Learning about Drugs Take opportunities to observe the use of drugs in patient care. Concentrate on the most important drugs in each classification. Learn about a drug’s primary action and use, then expand your knowledge to its other actions and uses. Why should the medical assistant be concerned about learning as much as possible about the medications prescribed in the practice where he or she is employed?

17 Drug Use Terminology Diagnostic — determines the cause of a particular health problem Palliative — does not cure but provides relief from pain or symptoms related to the disorder Prophylaxis — prevents occurrence of a condition Replacement — provides substances needed to maintain health Therapeutic — used to treat the disorder and cure it Provide an example for each category of drugs: Diagnostic – IV iodine Palliative – allergy medication (Allegra) or pain medication (Darvocet) Prophylaxis – birth control pills or vaccinations Replacement – insulin or Synthroid Therapeutic – antibiotics (Keflex) or blood pressure medicine (Propanolol)

18 Dispensing Drugs: Over-the-Counter DrugsOTC drugs may interfere or interact with prescription drugs. Gather information about OTC use at each office visit. Patient education for safe use of OTCs: Carefully read label and insert for use guidelines. Take only the recommended dose. Discard when expired. Inform the physician of OTC use. Be aware of OTC contraindications. Check with pharmacist if you have questions. Do you think the majority of patients read and understand OTC labels? Are they aware of the active ingredients in each product? Could they be taking OTCs that affect the outcomes or cause increased side effects of prescription drugs?

19 Dispensing Drugs: Prescription DrugsWritten order by a physician for the dispensing and administration of a drug for a particular patient. Must be signed by a physician to be legal. MA may phone in a prescription to a pharmacy, but the order must first be written down and reviewed by the physician for accuracy. Phoned order must be documented on the patient chart as a record of the medication. The MA may write a prescription dictated by the physician, but the physician must review and sign the prescription. The MA may write a dictated prescription but the physician must review and sign it. The MA must use correct medical terminology and abbreviations.

20 Sample Prescription Explain the parts of the prescription.

21 Six Parts of a PrescriptionSuperscription: Patient's name and address, the date, and the symbol Rx (for the Latin “recipe,” meaning “take”) Inscription: Main part of the prescription; name of the drug, dosage form, and strength Subscription: Directions for the pharmacist; size of each dose, amount to be dispensed, and the form of the drug such as tablets or capsules Practice completing prescription forms.

22 Six Parts of a PrescriptionSignature: Directions for the patient; usually preceded by the symbol Sig: (for the Latin “signa,” meaning “mark”). The physician writes instructions for the label that tell the patient how, when, and in what quantities to use the medication. Refill information: May be regulated by federal law if drug is a controlled substance; must write number of times refill is allowed. Physician signature: Must include manual signature of the physician and DEA number when indicated.

23 Common Prescription AbbreviationsRefer to Table 33-3 for medical abbreviations that are used when writing prescription orders and documenting medication administration. Refer to Table 33-4 for TJC’s “Do Not Use” list of abbreviations and symbols Review these two tables and summarize what you have learned.

24 Preparing a PrescriptionRefer to Procedure 33-1 for steps in preparing a prescription for the physician’s signature. Perform the procedure using the correct format for writing a prescription. How should it be documented?

25 Drug Interactions with the Body: PharmacokineticsStudy of the movement of drugs throughout the body Four actions occur when a drug is taken: Absorption Distribution Metabolism Excretion Why are pharmacokinetic terms important for the MA to understand?

26 Pharmacokinetic TermsAbsorption: How a drug is absorbed into the body's circulating fluids May have local or systemic effect Rate of absorption depends on route of administration Oral—convenient, safe, relatively inexpensive Some drugs can be destroyed by the GI system Food slows absorption rate and may interfere with action Metabolism in liver may require higher oral dose Drug may require enteric coating to prevent destruction or GI irritation Some drugs are difficult to absorb through the GI mucosa The majority of systemic medications must first be absorbed into the bloodstream to be carried to the target tissue. Why are the majority of medications available in an oral dose? What are two examples of medications that are destroyed by the GI system and therefore must be ad ministered by injection? (Heparin and insulin)

27 Pharmacokinetic TermsParenteral—Administration of drugs by injection Administered directly into the bloodstream (IV) or into tissues with rich blood supply Fastest acting route of administration (IV, IM, SC) Rate of absorption increased with massage at site Pharmaceutical preparation may prolong absorption (PenG) Topical and mucous membrane absorption Local or systemic effects Examples: suppositories, nasal sprays, transdermal patches, inhalants Discuss the various routes of administration of medications. Which is the fastest route of administration and which is the slowest?

28 Pharmacokinetic TermsDistribution: How a drug is transported from the site of administration Drugs attach to plasma proteins and are carried in the bloodstream to target tissue Blood-brain barrier—functional barrier between brain cells and capillaries Metabolism: How the drug is inactivated, including the time it takes for a drug to be detoxified and broken down into byproducts Occurs in the liver for excretion in the kidneys Drug tolerance—liver destroys it so rapidly that doses must be increased continuously for the same effect The blood-brain barrier limits the ability of medications to pass into the brain. The liver is responsible for breaking down chemicals (drugs) and the kidneys excrete waste.

29 Pharmacokinetic TermsExcretion: The route by which a drug is excreted, or eliminated, from the body and the amount of time such a process requires Primarily eliminated by the kidneys, also by exhalation, milk glands, skin, and so on Drug half-life—time required for drug amount to be decreased by 50% Half-life used to determine frequency of medication administration to maintain therapeutic blood levels The half-life a drug is used by pharmaceutical companies to determine how frequently the medication must be administered to maintain therapeutic blood levels. Patients with liver and/or kidney disease are at risk for drug accumulation, toxicity, and increased side effects.

30 Terms Related to Drug InteractionsAntagonism The action of one drug decreases the intensity or shortens the duration of action of another drug. Synergism One drug increases the intensity or prolongs the action of another drug. Potentiation A form of synergism in which the action of one of the drugs is increased by the presence of another drug. In this case the two drugs have different actions, but one increases the effect of the other. An example of synergism is three different antibiotics prescribed to treat tuberculosis or several different HIV drugs prescribed to treat the infection. An example of potentiation is the use of Lasix (diuretic) with an antihypertensive medication to more effectively lower blood pressure.

31 Top 50 Prescribed Drugs Refer to Table 33-5 for details about the most frequently prescribed medications in the United States. Review the list of the top 50 medications. Do you recognize any of them? Describe the purpose of the top 10 medications.

32 Factors That Affect Drug ActionBody weight Age Sex Time of day Pathological factors Immune responses Multiple patient factors can affect the action of drugs and help determine the appropriate dose and route of administration.

33 Factors That Affect Drug ActionPsychological factors Tolerance Accumulation Idiosyncrasy

34 Geriatric Responses to MedicationsIncreased risk of stomach irritation and ulceration Increased likelihood of drug storage in fat; may lead to drug toxicity Decreased ability for drugs to pass through cell membranes; increases drug blood levels Decline in liver function Decreased kidney function Peripheral vascular disease decreases distribution of drugs to periphery Increased risk of vertigo and confusion Aging persons are exceptionally sensitive to medication adverse reactions. A safety measure for aging persons taking multiple prescription medications is to have all prescriptions filled at the same pharmacy so the pharmacist is alerted if any of the drugs negatively impact others and so that the patient receives proper education on all medications.

35 Classifications of Drug ActionsDrugs are generally classified according to their actions on the body or according to the body system they affect. May have multiple actions and therefore multiple classifications. Explain how medications may be classified.

36 Adrenergics Action: Constricts blood vessels, narrows the lumen of a vessel Examples: Epinephrine, phenylephrine (Neo-Synephrine) Primary use: Stops superficial bleeding, increases and sustains blood pressure, and relieves nasal congestion Epinephrine may be combined with local anesthetics to constrict blood vessels at the site and therefore decrease the amount of localized bleeding. Discuss the adverse effects of epinephrine.

37 Adrenergic-Blocking AgentsAction: Vasodilation; decreases blood pressure; increases muscle tone of GI walls. Examples: Lisinopril (Prinivil); amlodipine (Norvasc); metoprolol (Toprol-XL); methyldopa (Aldomet); propranolol (Inderal); atenolol (Tenormin); carvedilol (Coreg); tamsulosin (Flomax). Primary uses: Control of hypertension and peripheral vascular disease; treatment of prostatic hypertrophy. Explain how these medications result in a decrease in blood pressure. Why are these medications effective for the treatment of peripheral vascular disease?

38 Analgesics Action: Lessens the sensory function of the brain Examples:Nonnarcotic—aspirin; acetaminophen (Tylenol); ibuprofen (Advil, Motrin) Narcotic—oxycodone (OxyContin); meperidine (Demerol); hydrocodone (Vicodin); propoxyphene (Darvon) Primary use: Pain relief Explain the difference between an analgesic and an anesthetic. Explain the difference between narcotic and non-narcotic analgesics.

39 Anesthetics Action: Produces insensibility to pain or the sensation of pain Examples: Bupivacaine (Marcaine); lidocaine (Xylocaine); lidocaine topical (Lidoderm). Primary use: Local or general anesthesia Explain the difference between local and systemic anesthetics. A helpful learning tool is that local anesthetics end in the suffix “caine”.

40 Antacids Action: Decreases the acidity in the stomachExamples: omeprazole (Prilosec); esomeprazole (Nexium); rabeprazole (Aciphex); lansoprazole (Prevacid); pantoprazole (Protonix); magaldrate (Riopan); calcium carbonate (Maalox) Primary use: Treatment of gastric hyperacidity Explain the function of prescription medications for hyperacidity. Ask students to name OTCs that perform this function.

41 Antianxiety Action: Reduces anxiety and tensionExamples: Chlordiazepoxide (Librium); diazepam (Valium); alprazolam (Xanax) Primary use: Produces calmness and releases muscle tension Are any of these drugs included in the controlled substance list? What schedule? What are the primary side effects of these medications?

42 Antibiotics Action: Kills or inhibits the growth of microorganismsExamples: Cefaclor (Ceclor); levofloxacin (Levaquin); tetracycline (Acromycin); amoxicillin (Augmentin); ciprofloxacin (Cipro) Primary use: Treatment of bacterial invasions and infections What are the primary side effects of antibiotics? The MA should ask patients about drug allergies each time they are seen in the office.

43 Anticholinergics Action: Parasympathetic blocking agent, reduces spasm in smooth muscle Examples: Scopolamine; atropine sulfate; tiotropium inhalation (Spiriva). Primary use: Dry secretions; prevent bronchospasm. Explain how Spiriva can help prevent bronchospasms. When are scopolamine and atropine typically prescribed?

44 Anticoagulants Action: Delays or blocks the clotting of bloodExamples: Heparin; warfarin sodium (Coumadin) Primary use: Prevention of blood clots; thrombophlebitis; prevention of clot formation. Explain the action of anticoagulants and the common misnomer of identifying these drugs as “blood thinners.” How is Heparin administered? What precautions/patient education should patients receive who are taking anticoagulants?

45 Anticonvulsants Action: Prevents seizures; reduces excessive stimulation of the brain Examples: Clonazepam (Klonopin); gabapentin (Neurontin); phenytoin (Dilantin); phenobarbital; carbamazepine (Tegretol); lamotrigine (Lamictal); pregabalin (Lyrica) Primary use: Treatment of epilepsy and other neurological disorders such as peripheral neuropathy What are the common side effects of these drugs? What is happening in the brain during a seizure?

46 Antidepressants Action: Treats depressionExamples: Venlafaxine hydrochloride (Effexor); sertraline (Zoloft); escitalopram (Lexapro); duloxetine (Cymbalta); bupropion (Wellbutrin); trazodone HCl (Desyrel); fluoxetine (Prozac); imipramine pamoate (Tofranil); amitriptyline (Elavil) Primary use: Mood elevator What precautions are recommended with teenagers prescribed antidepressants? Explain the importance of establishing therapeutic blood levels with these medications.

47 Antiemetics Action: Acts on hypothalamus center in the brainExamples: Prochlorperazine (Compazine); trimethobenzamide (Tigan); metoclopramide (Reglan); granisetron (Kytril); ondansetron (Zofran) Primary use: Prevent and relieve nausea and vomiting What patients may be prescribed these medications? What is their typical route of administration? Are there any significant contraindications for their use?

48 Antifungals Action: Slows or retards the multiplication of fungiExamples: Miconazole (Monistat); nystatin (Mycostatin); fluconazole (Diflucan); ketoconazole (Nizoral) Primary use: Treatment of systemic or local fungal infections When is Diflucan typically prescribed?

49 Antihistamines Action: Counteracts the effects of histamine; may inhibit gastric secretions Examples: Fexofenadine (Allegra); cetirizine (Zyrtec); chlorpheniramine (Chlor-Trimeton); diphenhydramine (Benadryl); promethazine (Phenergan); cimetidine (Tagamet); ranitidine (Zantac). Primary use: Relief of allergies; prevention of gastric ulcers Are there effective OTC antihistamines available? What are the typical side effects of these medications? Explain the difference between antihistamines prescribed for allergies and those prescribed for peptic ulcers.

50 Antihypertensives Action: Blocks nerve impulses that constrict arteries; or slows heart rate, decreasing contractility; or restricts the hormone aldosterone in the blood Examples: Amlodipine (Norvasc); atenolol (Tenormin); doxa-zosin mesylate (Cardura); metoprolol (Lopressor or Toprol); methyldopa (Aldomet); valsartan (Diovan); amlodipine (Lotrel) Primary use: Reduces and controls blood pressure Explain how the various types of antihypertensives work. Describe the typical side effects of these medications. Can certain OTCs cause side effects when taken with these drugs?

51 Antiinflammatory Action: Antiinflammatory or antirheumatic Examples:Nonsteroidal (NSAIDs): Ibuprofen (Advil, Motrin); naproxen (Naprosyn); celecoxib (celebrex); etanercept (Enbrel) Steroidal (SAIDs): Dexamethasone (Decadron); prednisone (Cortisone); monte-lukast sodium (Singulair); fluticasone propionate (Flonase) Primary use: Treatment of arthritic and other inflammatory disorders Explain the difference between NSAIDs and SAIDs. What are some of the diseases that are treated with anti-inflammatory medications? What are the primary side effects of these drugs? Why is it important for patients to take these medications on a full stomach?

52 Antimigraines Action: Alter circulation to the brainExamples: Topiramate (Topamax); sumatriptan (Imitrex); zolmitriptan (Zomig) Primary use: To treat or prevent migraine headaches What are the typical side effects of these medications? Are all of these medications available in oral form? When should the patient treat a migraine with these medications?

53 Antineoplastics Action: Inhibits the development of and destroys cancerous cells Examples: Interferon alfa-2a (Roferon-A); hydroxyurea (Hydrea); cyclophosphamide (Cytoxan); fluorouracil (Adrucil) Primary use: Cancer chemotherapy What are the side effects of these drugs? How are they typically administered?

54 Antipruritics Action: Relieve itchingExamples: Calamine lotion; hydrocortisone ointment; Benadryl Primary use: Allergies or topical exposures that cause itching What is the typical route of administration of antipruritics?

55 Antipsychotics Action: Alter the chemical actions in the brainExamples: Quetapine (Seroquel); risperidone (Risperdal); aripiprazole (Abilify); olanzapine (Zyprexa) Primary use: Treat the symptoms of schizophrenia and bipolar disorder Explain the serious forms of mental illness that are treated with these medications. What are their typical side effects? Could there be a problem with long-term patient compliance with treatment?

56 Antipyretics Action: Reduces body temperatureExamples: Aspirin, acetaminophen, ibuprofen Primary use: Reduces fever Explain the difference between acetaminophen and ibuprofen. What precautions should be used with children and aspirin? What are the other classifications for aspirin?

57 Antispasmodics Action: Relieves or prevents spasms from musculoskeletal injury or inflammation Examples: Methocarbamol (Robaxin); carisoprodol (Soma); cyclobenzaprine (Flexeril) Primary use: Sport injuries Are there any other reasons these medications may be prescribed? What are their typical side effects?

58 Antitussives (Cough Suppressants)Action: Inhibits the cough center Examples: Narcotic: Codeine sulfate Nonnarcotic: Dextromethorphan (Romilar, Robitussin DM) Primary use: Temporarily suppresses a nonproductive cough; reduces the thickness of secretions Explain the difference between narcotic and nonnarcotic types. Are OTC cough preparations effective? What is another reason for prescribing codeine? Are there alcohol or driving restrictions for patients taking a codeine based cough preparation?

59 Bronchodilators Action: Relaxes the smooth muscle of the bronchiExamples: Aminophylline (Aminophyllin); theophylline (Theo-Dur); epinephrine (Adrenalin, Sus-Phrine); albuterol (Ventolin, Proventil); isoproterenol (Isuprel) Primary use: Treatment of asthma, bronchospasm; promotes bronchodilation When should rescue inhalers be used? What are some of the side effects of bronchodilators?

60 Cathartics (Laxatives)Action: Increases peristaltic activity of the large intestine Examples: Magnesium hydroxide (milk of magnesia); bisacodyl (Dulcolax); casanthranol (Peri-Colace); psyllium hydrophilic muciloid (Metamucil) Primary use: Increases and hastens bowel evacuation (defecation) Can a person develop habituation with the use of laxatives? What is the difference between Peri-Colace and MOM?

61 Contraceptives Action: Inhibits conceptionExamples: Medroxyprogesterone acetate (Depo-Provera); norgestrel (Ovrett); ethinyl estradiol and ethynodiol diacetate (Demulen 1/35); Ortho Evra; etonogestrel (NuvaRing) Primary use: Family planning Explain patient screening and education with oral birth control pills. What are the contraindications and precautions for women taking oral contraceptives? Explain Depo-Provera injections. Explain the placement of the NuvaRing.

62 Decongestants Action: Relieves local congestion in the tissuesExamples: Ephedrine or phenylephrine (Neo-Synephrine); pseudoephedrine (Sudafed); oxymetazoline (Afrin); mometasone (Nasonex) Primary use: Relief of nasal and sinus congestion caused by common cold, hay fever, or upper respiratory tract disorders Can problems develop if nasal decongestant sprays are used too frequently? What are the side effects of these drugs?

63 Diuretics Action: Inhibits the reabsorption of sodium and chloride in the kidneys Examples: Hydrochlorothiazide (Dyazide, Esidrix, HydroDiuril); furosemide (Lasix); triamterene (Dyrenium) Primary use: Increases urinary output, decreases blood pressure Explain what patients taking diuretics should expect. Should they be concerned about potassium replacement? What common food will help maintain potassium levels? Explain why treatment of hypertension frequently includes the use of a diuretic.

64 Expectorants Action: Increases secretions and mucus from the bronchial tubes; allows patient to cough up secretions in lungs Examples: Diphenhydramine (Benylin); guaifenesin guaiacolate (Fenesin, Robitussin) Primary use: Upper respiratory tract congestion What is the purpose of an expectorant? Contrast this with the purpose of an antitussive.

65 Hemostatic Agents Action: Controls bleeding, a blood coagulantExamples: Phytonadione, vitamin K (Konakion); absorbable hemostatics, such as Gelfoam and Surgicel, are applied directly to a wound Primary use: Control of acute or chronic blood-clotting disorder; formation of absorbable, artificial clot Explain why chemicals are used to treat bleeding disorders. How do wound treatment products help control bleeding?

66 Hematopoietic Agents Action: Promotes red blood cell productionExamples: Epoetin-alfa (Epogen, Procrit) Primary use: Treatment of anemia in chemotherapy patients Explain why these products are important for patients receiving chemotherapy. Are there any side effects of these medications?

67 Hormone Replacement Action: Replaces hormones or compensates for hormone deficiency Examples: Insulin (Humulin); levothyroxine sodium (Synthroid or Levoxyl); estrogen (Premarin); vasopressin (Pitressin) Primary use: Maintenance of adequate hormone levels Explain the concern over routine estrogen replacement therapy for menopausal women. What are some of the significant side effects of these medications? Explain the estrogen patch. How is insulin administered? Where is it stored?

68 Hypnotics (Sedatives)Action: Induces sleep and lessens the activity of the brain Examples: Zolpidem tartrate (Ambien); eszopiclone (Lunesta); Secobarbital (Seconal); flurazepam (Dalmane); temazepam (Restoril); barbiturates Primary use: Insomnia; lower doses sedate Discuss the use of the popular sleep aids Ambien and Lunesta? Why do physicians typically limit the number of refills for these drugs? What are the typical side effects? What is the Pregnancy Risk category for these medications?

69 Lipid-Lowering AgentsAction: Decreases blood cholesterol levels and/or increases HDL levels Examples: Atorvastatin calcium (Lipitor); simvastatin (Zocor); ezetimibe (Vytorin or Zetia); rosuvastatin (Crestor); fenofibrate (Tricor). Primary use: Management of high blood cholesterol Explain the need for routine liver function test for patients taking statins. Explain lifestyle measures patients can use to help lower blood cholesterol levels. Explain the difference between HDL and LDL levels.

70 Miotics Action: Causes the pupil of the eye to constrictExamples: Carbachol (Isopto Carbachol); isoflurophate (Floropryl); pilocarpine (Isopto Carpine) Primary use: Counteracts pupil dilation What is the typical purpose for these medications? What is their route of administration?

71 Mydriatics (Anticholinergics)Action: Dilates the pupil of the eye Examples: Atropine sulfate (Isopto Atropine) Primary use: Ophthalmologic examinations Discuss adverse effects.

72 Narcotics Action: Depresses the central nervous system and causes insensibility or stupor Examples: Natural narcotics: Opium group (codeine phosphate, morphine sulfate) Synthetic narcotics: Meperidine (Demerol), methadone (Dolophine), and propoxyphene hydrochloride (Darvon) Primary use: Pain relief Relate this classification of medication to the controlled substance schedules. Are there any limitations on how these medications can be prescribed? Are there any other narcotic medications not included on this list? What are their typical side effects?

73 Oral Hypoglycemics Action: Decreases blood glucose levels by increasing insulin production and/or decreasing target cell resistance to insulin or by delaying glucose absorption Examples: Pioglitazone (Actos); rosiglitazone (Avandia); metformin HCL (Glucophage); acarbose (Precose); chlorpropamide (Diabinese); glimepiride (Amaryl); glipizide (Glucotrol); glyburide (Micronase) Primary use: Management of Type 2 diabetes mellitus Explain why these medications are prescribed for Type 2 diabetics. Explain the pathophysiology of Type 2 diabetes mellitus versus Type 1. Discuss lifestyle changes that should be emphasized with patients trying to control their blood glucose levels.

74 Osteoporosis TreatmentAction: Inhibits bone reabsorption and/or promotes usage of calcium Examples: Alendronate (Fosamax); risedronate (Actonel); calcitonin (Miacalcin nasal spray and Calcimar); dihydrotachysterol; etidronate (Di-dronel) Primary use: To promote bone mineral density and reverse the progression of osteoporosis What is osteoporosis? Explain how these medications are administered and patient precautions when taking these drugs. Explain the adverse reactions of these drugs.

75 Herbal and Alternative TherapiesAlternative therapies, often called either complementary or holistic medicine, are frequently used. Limited scientific studies prove the effectiveness of herbs; their use is definitely on the rise. Patients are hesitant to discuss the use of herbal products with physicians. Physicians need to assess potential drug-herb interactions. Need to be familiar with common alternative therapies and include questions about their use when gathering the patient's medication history. The MA should expect that many patients use alternative therapies. Patients should be asked about the use of alternative and herbal therapies when the patient/drug history is conducted. The MA should be familiar with typical herbal remedies and current research on their effectiveness and safety.

76 Regulation of Herbal ProductsFDA regulates dietary supplements under the Dietary Supplement Health and Education Act of 1994. Products are not registered with the FDA and do not have to go through a rigorous approval process. No standardization between products produced by different companies or among batches from the same company. By June of 2010 supplement manufacturers will have to show evidence that products are pure and contain what the label claims. Explain the role of the federal government and the regulation of herbal products. How will this change in 2010?

77 Dietary Supplement LabelsProduct name with the word "supplement" on the label Name and location of manufacturer or distributor Can state benefit claims but must include required FDA statements Directions for use Name of plant or part of plant used Blended products must list components and weight of each ingredient Nondietary ingredients such as fillers and artificial colors listed in descending order of weight May identify warnings about use but lack of warning does not mean adverse effects are absent Explain the requirements for dietary supplement drug labels. Are these products standardized?

78 Commonly Used Herbal ProductsTable 33-7 summarizes commonly used herbal products. Information about herbal remedies is constantly changing. Refer to the National Center for Complementary and Alternative Medicine at and the National Institutes of Health Office of Dietary Supplements at Share the NIH website with the class. Discuss Table 33-7. Ask students if they or anyone they know are using or have tried any of these products. Do they think they have been beneficial? Have they experienced any side effects?

79 Alternative TherapiesAcupuncture treatments use thin metal needles inserted through the skin to stimulate specific points in the body to restore and maintain health. Chiropractic practitioners perform manipulations or anatomical adjustments to correct alignment problems and help the body heal itself. Mind-body therapy uses biofeedback to teach patients to use their thoughts to control certain body reactions. Explain the various alternative therapies. Ask students if any of them have tried any of these therapies and their reactions to them.

80 Patient Education: InteractionsMonitor for pregnancy. Question drug allergies each office visit. Observe patient for 20 minutes after drug administration. Educate patient on possible drug side effects. Educate patient on dose, time of administration, and drug storage. Question patient on whether medication is being taken as ordered. Answer questions or consult the physician. Summarize the importance of medical assistant involvement in patient education regarding medication therapy. How can the MA promote treatment compliance and prevent patient complications from drug therapy?

81 Therapeutic Communications with Patients from Diverse CulturesInvestigate healing practices of the primary cultures in your area. Encourage cultural sensitivity in your co-workers. Provide patients with educational materials in their native language. Ask patients if they are using home remedies or are consulting a healer from their culture. If so, get as much detail as possible so you can share this information with the physician. Brainstorm with the class methods for therapeutically interacting with a multicultural patient population. Discuss possible methods for performing patient education with patients from various cultural backgrounds.