NSG 533 Advanced Pharmacology

48. Nausea / Vomiting When choosing an agent: Focus on individual patient, evaluate risk factors, and rule out other causes. Agent related variables (efficacy, ADR's, cost) Please review mechanisms, ADRs and Promethazine -Block DA2 receptors in the CTZ + have antihistaminic and anticholinergic effects.ADR's: EPS, sedation, hypotension Place in therapy: "general purpose antiemetics". not very effective in severe n/v (i.e. chemotherapy induced n/v (CINV)Example Lorazepam -Benzodiazepines bind to GABA-A receptors. GABA is the major inhibitory NT in the CNS benzodiazepines are sedatives, not antiemetic agents Sedative and anti-anxiety effects ’ reduce anticipatory N/V associated with chemotherapy ADRs - CNS - sedation, hallucinations, euphoria; CV - hypotension CINV - Evaluate emetogenic potential of regimen Mono therapy for chemotherapy with low and moderate emetogenic risk Aggressive (combination of agents with different mechanisms) antiemetics for highly emetogenic regimens and delayed CINV Examples Dexamethasone + metoclopramide + diphenhydramine + lorazepam Ondansetron + dexamethasone Ondansetron + metoclopramide Metoclopramide + dexamethasone Ondansetron + dexamethasone + prochlorperazine Ondansetron + dexamethasone + aprepitant 49. Erectile dysfunction -"The inability to attain or sustain an erection adequate for sexual stimulation": Can be the result of age related changes (e.g. diminished testosterone, altered response to NO, etc), comorbidities (e.g. DM, BPH, depression, etc .. Table 51-1), and medications (e.g. 5-alpha reductase inhibitors, beta-blockers, TCAs, etc. .. Table 51-2) 50. Before initiating treatment for ED: a physical examination and thorough medical, social, and medication histories with emphasis on cardiac disease must be taken to assess for ability to safely perform sexual activity and to assess for possible drug interactions Diagnosis should include PE (including a check for signs of hypogonadism), medication review, Hx, and labs ( HbA1C, PSA, FLP, testosterone) 51. ED treatment should include:: Non-pharmacological interventions Reduce fat and cholesterol in diet Decrease or limit alcohol consumption Eliminate tobacco use and substance abuse Weight loss if appropriate Regular exercise Co-morbidity (DM, HTN, etc.) management - including (if possible) removal of causal medications 67. BPH combination therapy: Alpha-blocker offer immediate relief; 5 alpha-RIs reduce prostate enlargement over time æIn patients with an enlarged prostate gland and an elevated PSA e1.4 ng/mL, combination drug therapy with an ±1a-drenergic antagonist and a 5±r-eductase inhibitor is more beneficial than single drug therapy. æRationale a-blocker offer immediate relief 5a-RIs reduce prostate enlargement æWorks better for those with obstructive symptoms æMay consider stopping a-blocker after 6-12 months, but should continue in those patients with severe symptoms as long as they are responding 68. BPH combination therapy: æ-blocker and anticholinergic (o²r3agonist) For men with low post-void residual urine volumes and irritative symptoms (e.g., frequency, urgency) that persist during treatment with an alpha-adrenergic antagonist, combination treatment with an anticholinergic agent can be tried æImproved storage voiding parameters and frequency compared with alpha-1-adrenergic antagonist therapy alone æFor patients who poorly tolerate anticholinergic adverse effects, an alternative is Mirabegron The risk of side effects, increased post-void residual urine volume, decreased maximal urinary flow rate, or acute urinary retention is low