Bookdrug Classification 3 K

Study Unit
Drug Classifications:
Body Systems
The body has one goalsurvival. The body systems function
to achieve this goal, but theyre not immune to disease and
infection, among other problems. Along with surgery and
other procedural treatments, pharmaceuticals are designed to
alleviate or repair any sort of malfunction in the body. There
are numerous types of pharmaceuticals that target different
areas of the body and produce a wide range of effects.
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When you complete this study unit, youll be
able to
Discuss pharmacology basics
List the four types of drug names, several major drug
references, and the two agencies of drug regulation and
enforcement
Describe the routes and forms of drug administration
Define drug action and effect, and explain the effect of
drugs according to specific classifications
Calculate basic pharmacology mathematics and dosages
Identify medications related to different body systems
Remember to regularly check My Courses on your student homepage.
Your instructor may post additional resources that you can access to
enhance your learning experience.
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UNDERSTANDING THE BASICS
OF PHARMACOLOGY 1
Drug Sources 2
History of Pharmacology 6
Regulation of Drugs 6
Controlled Substances 8
Review of Using a Physicians Desk
Reference (PDR) 8
UNDERSTANDING DRUG USE 11
Indications for and Uses of Medications 11
Interpreting and Documenting Medication Orders 13
Interpreting Drug Labels 16
Measurement Systems and Their Equivalents 18
UNDERSTANDING PRESCRIPTIONS 24
Parts of a Prescription 24
Types of Prescriptions 32
Introduction to Drug Monographs/
Package Inserts 38
Drug Nomenclature 43
Generic Products 44
Patents 44
Drug Manufacturers 44
Administration of Drugs 45
Drug Classifications 51
Drug Action and Effect 55
DRUG CLASSIFICATIONS ACCORDING
TO BODY SYSTEM 60
Integumentary System 60
Musculoskeletal System 78
Cardiovascular System 80
Respiratory System 90
Gastrointestinal System 98
Sensory System 103
Nervous System 104
Endocrine System 110
Urinary/Excretory System 115
Reproductive System 116
Contents
vi
Lymphatic System 117
Anesthesia 118
Genetic Engineering 119
Antineoplastic Agents 120
Immunity/Vaccines 120
Psychiatric Drugs 122
Antilipemic Drugs 126
Vitamins, Minerals, and Herbals 127
SELF-CHECK ANSWERS 145
1
UNDERSTANDING THE BASICS
OF PHARMACOLOGY
Pharmacology is the study of the uses and effects of drugs on
the body. Drugs are substances that change physiological
processes within the bodychanges that can be therapeutic
(helpful) or toxic (harmful). The substances may be derived
from plants, animals, or minerals, or synthesized from chem-
icals in a laboratory.
Its important to be able to distinguish a pharmacologist from
a pharmacist, who dispenses pharmaceuticals at a pharmacy.
Pharmacologists, on the other hand, are scientists who study
all aspects of drugstheir origins, functions, chemistry,
effects, and uses. The broad field of pharmacology includes
several subdivisions:
Medicinal chemistrythe study of new-drug synthesis
Pharmacodynamicsthe study of drug action and effects
in the body
Pharmacokineticsthe study of the movement of drugs in
the body
Molecular pharmacologythe study of the interaction of
drugs with molecules such as DNA, RNA, and enzymes
Chemotherapythe treatment of disease with therapeutic
medications
Toxicologythe study of poisons
Drug Classifications:
Body Systems
Drug Classifications: Body Systems
2
Drug Sources
As early as 2000 BC, people were writing down recipes for
drugs. The medicinal qualities of opium, alcohol, and many
other substances have been long known. Today, drugs are
made from four sources: plants, animals, minerals, and syn-
thetic sources (Figure 1).
Plants
Plants have always provided effective folk remedies. Berries,
seeds, sap, stems, bark, leaves, oils, and roots were used in
these remedies. Today, plants are still important sources of
drugs. Even microscopic plants like bacteria, and fungi such
as yeasts and molds, are used to make drugs.
Minerals
Minerals are naturally occurring substances. They usually
come from the ground. Many minerals are also present in the
human body and must, in fact, occur in sufficient amounts
for the body to function properly. Salt, iron, and potassium
are just a few examples. Also, many drugs contain minerals;
theres magnesium in Milk of Magnesia, calcium in Tums,
and sulfur in Clearasil, just to name a few.
Animals
Animals provide another natural source of drugs. Substances
missing from a human body may be found in the body tis-
sues of animals. Many drug substances are taken from
animals that are slaughtered for food, particularly drugs used
in hormone replacement therapy. The insulin used to treat
diabetics often comes from the pancreas of cows or hogs.
Some drugs are even extracted from the human animal; for
instance, growth disorders may be treated with drugs from
the pituitary glands of cadavers.
3
SOURCES OF DRUGS
Example
Trade or
Generic Name
Classification
Plants
cinchona bark
purple foxglove
plant
poppy plant
(opium)
Quinidine
Digitalis
Paregoric,
Morphine,
Codeine
antiarrhythmic
cardiotonic
antidiarrheal
analgesic
analgesic,
antitussive
Minerals
magnesium
silver
gold
Milk of Magnesia
Silver Nitrate
Solganol, Auranofin
antacid, laxative
ophthalmic, anti-infective
(eye drops placed in the
eyes of newborns to kill
gonorrheal arthritis)
anti-inflammatory;
used in the treatment of
rheumatoid arthritis
Animals
pancreas of
cow, hog
stomach of
cow, hog
thyroid gland of
animals
Insulin
Pepsin
Thyroid, USP
antidiabetic hormone
digestive hormone
hormone
Synthetic
Sources
meperidine
diphenoxylate
sulfisoxazole
Demerol
Lomotil
Gantrisin
analgesic
antidiarrheal
anti-infective sulfonamide;
used in the treatment of
urinary tract infections
FIGURE 1Sources of Drugs
4
Synthetic Sources
The advances of science since the nineteenth century made it
possible to manufacture or synthesize drugs from chemicals
in a laboratory. Synthetic drugs duplicate the desired proper-
ties of natural substances. However, they dont have the
inconsistency and unpredictable side effects of other drugs,
because chemists can control the purity and the potency. The
most common synthetic drug is probably aspirin. Theres now
a synthetic replacement for insulin, and researchers hope to
develop synthetic drugs that will cure or prevent cancers.
New drugs are continuously being developed and tested
(Figure 2). First, scientists develop a new drug, which is first
known by its chemical name, but is usually referred to by its
generic name. Once the Food and Drug Administration (FDA)
approves the drug, the manufacturer markets the drug with
a brand name. Usually, the brand name is shorter than the
generic namea name that consumers can remember. The
brand name is also known as the trade or private name,
which means that the drug is the manufacturers product. A
superscript R on the product label indicates that the drug
has been registered by the U.S. Patent and Trademark Office,
and a superscript TM indicates a trademark.
A pharmaceutical company holds the patent to a new brand-
name drug for about 20 years after its discovery. During this
time, research and tests are conducted to approve the drug
for FDA sale. The company usually has 11 to 12 years of sole
rights to sell the drug to the public. After this time has
expired, other companies can make a generic version of the
drug. The generic version goes through a series of studies
and must have FDA approval before its marketed.
Lets take an example of a drug that everyone knows pretty
well. The chemical name of this drug is 2-(4-isobutylphenyl)
propionic acid. The generic name of this drug is ibuprofen.
Its a pain reliever and inflammation reducer thats approved
for use by adults and children. The drug was first synthe-
sized in the early 1960s in England and became available in
the United States in 1974 as part of the class of drugs known
as NSAIDs (non-steroidal anti-inflammatory drugs). This drug
was originally marketed in the United States by Upjohn as a
prescription-strength drug in the form of Motrin. It was ten
5
years later that an over-the-counter strength was approved.
Now we know this drug by many names: Motrin, Advil,
and others. Most of the time, you can also find this drug sim-
ply under its generic name, ibuprofen, on store shelves. As
you can see, the timeline for drugs production, even after
theyre discovered, can be lengthy!
Generic names are important to the pharmacologists who
study drugs and the pharmacists who dispense them. Unless
the physician stipulates no substitutions for a prescribed
trade name drug, laws in most states and provinces allow
pharmacists to substitute a less expensive generic equiva-
lent, meaning any product of the same generic name and
chemical composition. Its good to know that you dont have
to memorize all these names! There are reference books out
there, such as the Physicians Desk Reference (PDR), to help
you identify drugs by their different names.
FIGURE 2New drugs must go through a series of studies and
tests before they can be marketed.
6
History of Pharmacology
In 1796, the first vaccinations occurred. In the early nine-
teenth century, physiologists performed many pharmaco-
logical studies. Scientists studied the actions and effects of
drugs on animals. Anesthetics were first used in the nine-
teenth century. By the twentieth century, it was common
practice to use drugs to treat many different diseases.
Regulation of Drugs
The FDA
The Food and Drug Administration (FDA) is the government
agency that decides whether drugs may be sold and under
what legal restrictions. The term over-the-counter drug, or
OTC, is actually a legal term, indicating that the FDA has
placed no restrictions on the drug, as compared to a legend
drug, which can be distributed only by prescription because
it may cause harmful side effects if not used with caution.
And then there are controlled substances, drugs that are
downright dangerous and subject to abuse. Many controlled
substances do have acceptable medical usages and thus are
allowedunder very rigid rules.
The FDA sets legal standards for the strength, purity, and
quality in the manufacture of medications. In manufacturing
a drug, a pharmaceutical company must produce the exact
formula as approved by the FDA, with each dose at the exact
same strength. The drug must be clearly identified by color,
form, shape, size, and label.
The DEA
The FDA enforces laws pertaining to the manufacture, pack-
aging, and dispensing of prescription drugs and cosmetics
(Figure 3). The Drug Enforcement Administration (DEA), on the
other hand, regulates the manufacture and sale of dangerous
drugs such as narcotics. The DEA categorizes controlled sub-
stances under five schedules, based on the potential for
7
abuse and the medical usefulness of the drug. These sched-
ules include the regulations for how the drug may be
prescribed and stored.
Schedule I and II drugs are considered to have high abuse
and dependency potential. Schedule I includes drugs that are
limited to researchdrugs that are considered illegal for
human consumption. Schedule II drugs are those tightly
restricted drugs that are used as medication but are consid-
ered strongly addictive if not taken correctly. Schedule III
drugs still have a high possibility of dependence, but its gen-
erally only psychological addiction. Finally, Schedule IV and V
drugs have a low potential for abuse or dependency.
FIGURE 3Prescription
drugs and cosmetics must
be approved by the FDA.
8
Controlled Substances
The Controlled Substances Act of 1970 requires a pharmacist
to record the receipt and disposal of all controlled substances.
The records must be kept and filed for five years and be
available for inspection by authorized persons. Prescription
orders for controlled substances in Schedule II must be type-
written/computer-generated or written by hand in ink and
signed by the prescriber. Schedule II drugs cant be prescribed
over the telephone or sent by fax. Such prescription orders
cant be refilled. The prescriber must write a new prescription
if the drug is to be continued. Prescriptions for drugs covered
by Schedules III, IV, or V may be issued either orally or in
writing by the prescriber, and may be refilled no more than
five times and may not be filled or refilled more than six
months after date of issue. After five refills or six months, the
prescriber may write a new prescription.
The label of any controlled substance in Schedule II, III, IV,
or V, when dispensed to a patient from a prescription, must
contain the following warning: Caution: Federal law pro-
hibits the transfer of this drug to any person other than the
patient for whom it was prescribed. All prescriptions for a
controlled substance should be marked or stamped with a
red C. To write prescriptions for controlled substances, the
prescriber must register with the Drug Enforcement Agency.
The DEA then issues the prescriber a number. This number
is called the DEA number and must be indicated on all pre-
scriptions for controlled substances.
Review of Using a Physicians Desk
Reference (PDR)
Introduction
The Physicians Desk Reference, or PDR, is a compilation of
information on FDA-approved prescription (Rx) and over-the-
counter (OTC) drugs. The PDR, which is updated annually,
was initially designed to provide physicians with information
9
relevant to writing prescriptions. Its now widely available and
frequently used by other medical and health care providers
and even by consumers.
You may be wondering why we need a book such as the PDR.
As you can imagine, health care professionals are extremely
busy. Its convenient to have a comprehensive drug reference
book that can be accessed quickly and easily during patient
care. There are even some PDRs that are printed in smaller
type so that health care professionals can carry the book in
their lab coat pockets!
Classifications within the PDR
There are many different publishers of PDRs. For the purpose
of this course, were using the PDR Nurses Drug Handbook.
PDRs generally refer to a drugs generic name. Within the
PDR Nurses Drug Handbook are the generic name of the drug
in bold and the phonetic pronunciation. In the header are the
classification (the type of drug or class under which the drug
is listed), the FDAs pregnancy category, trade names (names
for which the drug is marketed), and whether the drug is pre-
scription or over-the-counter. After the header is additional
information, such as uses, contraindications, or symptoms or
conditions that make a particular treatment or procedure
inadvisable, side effects, laboratory test considerations, drug
interactions, dosages, and more.
Now, review the material youve studied here. Once you feel
you understand the material, complete Self-Check 1. Then
check your answers with those provided at the end of this
study unit. If youve missed any answers, or you feel unsure
of the material, review this section until you feel that you
understand the information presented.
10
Self-Check 1
At the end of each section of Drug Classifications: Body Systems, youll be asked to pause
and check your understanding of what youve just read by completing a Self-Check exer-
cise. Answering these questions will help you review what youve studied so far. Please
complete Self-Check 1 now.
Questions 110: Indicate whether each of the following statements is True or False.
_____1. Pharmacokinetics is the study of the movement of drugs through the body.
_____2. Chemists can control the potency and purity of synthetic drugs.
_____3. Insulin used to treat diabetics often comes from the pancreas of a cow.
_____4. A contraindication is confirmation that makes a particular treatment advisable.
_____5. After approval by the FDA, a manufacturer markets a new drug by the
chemical name.
_____6. The DEA enforces laws pertaining to the manufacture, packaging, and dispensing of
prescription drugs and cosmetics.
_____7. Information on FDA-approved prescription and OTC drugs can be found in the PDR.
_____8. A pharmacologist dispenses drugs at a pharmacy.
_____9. Schedule V drugs are considered illegal for human consumption.
_____10. A doctor must be registered with the DEA to be able to prescribe controlled
substances.
Check your answers with those on page 145.
11
UNDERSTANDING DRUG USE
Health care professionals must have a complete and
thorough working knowledge of drugs, including
Drug actions on the body
Precautions and contraindications of drug use
Reasons that physicians order specific drugs
Categories of medications as related to therapeutic
effects on body systems
By understanding how patients respond to medication,
health care professionals can
Explain possible drug interactions with other medica-
tions or food
Educate patients to ensure compliance and
understanding
Answer patients questions about possible reactions
Explain undesired effects and interactions
Indications for and Uses
of Medications
Indications are reasons to use a particular drug to meet a
certain need. When a patient presents with specific signs and
symptoms, these may become indications for treatment.
The following are traditional reasons for prescribing or using
medications:
Relieve symptoms (therapeutic medications)
Pinpoint disease through diagnostic testing (diagnostic
medications)
Replace missing chemicals in the patient (replacement
medications)
Avoid deficiencies or reinforce body chemicals
(supplemental medications)
12
Prevent or lessen the severity of a disease (preventative
or prophylactic medications)
Reduce symptoms (palliative medications)
Kill or remove the causative agent of a disease (curative
or healing medications)
Maintain health (maintenance medications)
Maintain the body in homeostasis until a disease process
is resolved (supportive medications)
Mechanisms of Drug Interactions
A drug interaction is the combined effect of medications taken
together. Most commonly, there are drug-drug interactions,
but interactions can also take place between drugs and food.
Precautions and Contraindications to Medication
Use in Certain Populations
A contraindication is a condition in which the use of a specific
medication should be avoided. For example, a previous aller-
gic reaction to a drug is a contraindication for future use.
Because of their sensitive nature, the following groups should
be monitored closely for contraindications:
Pregnant women
Lactating women
Children
Geriatric population
When people age, their metabolic and excretory functions
naturally slow down. Because the elderly cant process and
eliminate drugs at an ideal rate, theyre at increased risk for
overdose. Drugs tend to accumulate in the elderly; the cumu-
lative effect is more likely to occur in debilitated patients or
those with chronic medical conditions. Compliance is another
issue with the elderly. As the elderly become more forgetful,
medication compliance decreases.
13
Interpreting and Documenting
Medication Orders
Prescription versus Medication Order
One of the roles of a health care provider or an allied health
professional is to read, interpret, and document medication
orders. Dont confuse a prescription with a medication order.
The word prescription comes from the Latin praescriptus,
meaning to write before. A prescription is a written order for
dispensing or administering medications. Prescriptions are
usually written by providers such as physicians, dentists,
and other licensed health care professionals as allowed by
law. A medication order, on the other hand, is a written or
verbal order issued by a licensed health care professional for
the administration of a medication in a health care setting.
Latin abbreviations are frequently used in prescription writ-
ing. Figure 4 includes common Latin abbreviations with the
definitions of terms used, usually in the directions section of
the prescription. By using these abbreviations, the prescriber
is able to write long sentences very quickly. The pharmacy
technician, however, has to rewrite the abbreviated sentence
into a complete English sentence and place it on the label for
the patient to understand. Heres an example. The prescriber
writes the sentence 1 tab q.i.d. a.c. and h.s. for the Sig.
portion on the prescription. The pharmacy technician would
type the corresponding English translation on the label that
would read, Take one tablet four times a day, before each
meal and at bedtime. From this example, you can see how
its easy for the prescriber to use the abbreviation. It effec-
tively conveys these exact directions to the patient through
the English translation. There are also abbreviations that
indicate the route of administration, as listed in Figure 5.
Orders for Administering Medications
Verbal orders are medication orders that the physician relays
out loud (in person or over the phone) to an allied health pro-
fessional. In some cases, medication orders are the standing
orders that are used for specific instances.
14
Latin Abbreviation English Abbreviation Written
a.c. (ante cibum) before meals Take one tablet a.c.
b.i.d. (bis in die) twice daily Take medicine b.i.d.
c (cum) with take c water
cap (capsula) capsule 2 caps at once
disp. (dispensa) dispense disp. 20 tablets
h.s. (hora somni)* at bedtime Take medicine h.s.
M. (misce) mix M. and ft. with water
n.r. (non rep.) do not refill Dispense medicine n.r.
p.c. (post cibum) after meals Take one tablet p.c.
p.r.n. (pro re nata) as needed Take one tablet p.r.n.
q. (quaque)* every Take medicine q. day
q.o.d. (quaque alternis die)* every other day Take one capsule q.o.d.
q.a.m. (no Latin equivalent) every morning Take medicine q.a.m.
(no Latin equivalent)* every day Take medicine daily
q.h. (quaque hora) every hour Check pulse q.h.
q.i.d. (quater in die) four times daily Take medicine q.i.d.
(no Latin equivalent) every other day Take medicine every other day
q.p.m. (no Latin equivalent) every evening Take medicine q.p.m.
q.s. (quantum satis) sufficient quantity Make q.s. to fill 4 ounce bottle
q.2.h. (quaque secunda hora) every 2 hours One teaspoonful q.2.h.
q.3.h. (quaque tertia hora) every 3 hours One teaspoonful q.3.h.
q.4.h. (quaque quarta hora) every 4 hours One teaspoonful q.4.h.
Sig. (signa) label (you write) Sig.: Take medicine as directed.
ss (semis)* one-half Take ss teaspoonful of medicine
daily
stat (statim) at once Two tablets stat
tab (tabella) tablet dispense 24 tabs
t.i.d. (ter in die) three times daily Take medicine t.i.d.
*These abbreviations are on the Do Not Use list posted by JCAHO and ISMP. Please refer to the Web site
for further updates.
FIGURE 4Latin Abbreviations and English Translations
15
Route Abbreviation
buccal buc
capsule cap
dermal D
drop gtt
elixir elix
hypodermic hypo, h, H, (h)
intradermal ID
intramuscular IM
intravenous IV
intravenous push or
intravenous pyelogram IVP
intravenous piggyback IVPB
ointment ung
ophthalmic O.D. (right eye)
O.L. or O.S. (left eye)
O.U. (each eye)
oral PO, p.o., O., o, or per os
otic A.D. (right ear)
A.S. (left ear)
A.U. (both ears)
rectal p.r., r, R
subcutaneous SC, sub-Q, SQ, subcu
sublingual SL, subling, or subl
suppository supp
suspension susp
tablet tab
topical T
vaginal p.v.
FIGURE 5Abbreviations for
Routes of Administration
16
Documentation of Medical Orders
The patients medical record is considered a legal document.
Therefore, every aspect of the patients care, including med-
ication and refill orders, should be documented. The following
medical order information should be documented in the
patients medical record:
Date, time, and name of medication
Strength and amount of medication
Directions for medication use
Sample medications given
Medications and patient education
Patients should be reminded to bring all medications in their
original bottles to every appointment. This includes all pre-
scription medication, over-the-counter medication, and all
vitamin and herbal supplements.
Patient education should include not only prescription med-
ication, but also over-the-counter medication, as well as
vitamin and herbal supplements. Patients tend to be more
compliant when they have an increased understanding of
medications prescribed. Its imperative that all medication be
included in the medical record. Failure to include this infor-
mation in the medical record could lead to potential drug
interactions.
Interpreting Drug Labels
As you can imagine, health care professionals must be able
to read and understand medication labels before administering
drugs to patients. If a health care professional or patient
cant read and understand a label, the result could be inap-
propriate dosing, administration, or consumption. These
results could be fatal.
17
Identifying Generic and Trade Names
Brand name or trade name drugs are proprietary drugs that
have a registered trademark. Brand name drugs are sold
through a specific pharmaceutical manufacturer, which is
generally the sole source of the product. Lipitor
, Nexium
,
and Glucophage
are examples of brand names.

Generic drugs are made with the same ingredients and same
dosage as a brand name drug; however, theyre not protected
by a trademark. The generic drug is considered to be equiva-
lent to the brand name drug, but its sold under its generic,
or chemical, name. A generic name is the drugs official
name, which is found in the United States Pharmacopoeia/
National Formulary (USP/NF). The generic names of the brand
name drugs listed above are, respectively, atorvastatin,
esomeprazole, and metformin. Both brand name and generic
drugs are regulated by the FDA.
You may be wondering if generic drugs are as effective as
brand name drugs. Generic drugs are the same as brand
name drugs in
Safety
Strength
Quality
Dosage
Function
Generic drugs use the same active ingredients as brand
name drugs, so they have the same benefits and risks. The
FDA requires generic drugs to be the same quality, strength,
purity, and stability as brand name drugs.
Parts of a Medication Label
Medication labels contain important information to help
health care professionals correctly administer medication to
patients (Figure 6). Labels also help prevent drug interactions
and other drug-related problems. Failure to understand med-
ication labels may lead to mistakes and may cause serious
health-related consequences.
18
Measurement Systems and Their
Equivalents
When dealing with medications, sometimes it may be neces-
sary to convert from one system to another to dispense or
administer the proper amounts of substances. Therefore, it
helps to be efficient with conversions. Several different meas-
urement systems are used in pharmacology today:
Metric system
Apothecary system
Household system
Lets take a closer look at each system.
Metric System
The metric system is a system of decimal measurement based
on three basic units of measure:
Meter
FIGURE 6A Prescription
Medication Label
19
Liter
Gram
The basic unit of length measurement in the metric system is
the meter (abbreviated m). A meter is equal to 39.37 inches.
Because a meter is so large, subdivisions of a meter, such as
the centimeter, are used in medicine.
The basic unit of volume measurement in the metric system
is the liter (abbreviated L). One liter is slightly more than
32 ounces. Liquid medications are usually expressed in
subdivisions of a liter, such as the milliliter and the cubic
centimeter.
The basic unit of weight measurement in the metric system
is the gram (abbreviated g). Conversion subdivisions within
the gram include the kilogram, the milligram, and the
microgram.
The Apothecary System
Although fast becoming obsolete due to the metric system,
the apothecary system is occasionally used today for weigh-
ing and calculating drugs, and therefore, should be taken
into consideration. The apothecary system has two divisions
of measurement:
Weight
Volume
The basic unit of weight is the grain (gr). The basic unit of
volume is the minim (min). Measurements in the apothecary
system are expressed in fractions whenever necessary.
Household Measurement System
The household system of measuring uses basic systems of
measurement that can be found around the house, including
Droppers
Teaspoons
Tablespoons
20
Cups
Pints
Quarts
Gallons
This system generally isnt recommended for use in a medical
facility because of the varying sizes of devices used and the
fear that the dosages wouldnt be the same.
Converting between Measurement Systems
Time conversions. Health care professionals must often
convert from one measurement system into another because
theres currently no worldwide standard.
There are two commonly used standards for time:
12-hour clock
24-hour clock
The 12-hour clock is divided into two periods of time: A.M. and
P.M. Each period consists of 12 hours numbered 1 through
12. Time periods run from 12:00 to 11:59. Twelve oclock can
be either noon or midnight. The 12-hour clock is dominant in
a few countries, particularly the United States and Canada.
The 24-hour clock is also known as the International Standard
ISO 8601. It runs from midnight to midnight and is divided
into 24 hours, numbered from 00 to 23. The 24-hour clock
doesnt use the A.M. and P.M. notations. For example, 4 A.M. is
0400 on the 24-hour clock. In addition, midnight is 0000.
The 24-hour clock is standard all over the world. In the
United States and Canada, this time is commonly referred to
as military time. Refer to Figure 7 for conversions between the
12-hour clock and 24-hour clock.
In the medical field, the 24-hour clock is often used because
it reduces the chance of human error. For example, a health
care provider may document 7:00 in the patients medical
record, but forget to add A.M. or P.M. However, if the health
care provider documents 1900 instead, theres no confusion;
the time would be 7:00 in the evening.
21
12-Hour Clock 24-Hour Clock
12 midnight 0000
1 AM 0100
2 AM 0200
3 AM 0300
4 AM 0400
5 AM 0500
6 AM 0600
7 AM 0700
8 AM 0800
9 AM 0900
10 AM 1000
11 AM 1100
12 noon 1200
1 PM 1300
2 PM 1400
3 PM 1500
4 PM 1600
5 PM 1700
6 PM 1800
7 PM 1900
8 PM 2000
9 PM 2100
10 PM 2200
11 PM 2300
FIGURE 7Time Conversions
22
Temperature conversions. The two temperature scales are
Celsius
Fahrenheit
Both scales are measured in degrees (C and F).
The Celsius scale is commonly referred to as the centigrade
scale. Some common temperatures of the Celsius scale are
0C, which is the freezing point of water, and 100C, which is
the boiling point of water.
In the Fahrenheit scale, the freezing point of water is 32F
and the boiling point of water is 212F.
To convert from Fahrenheit to Celsius, use either of the two
following formulas:
C =
5
/9 (F 32)
C = (F 32) 1.8
To convert from Celsius to Fahrenheit, use either of the two
following formulas:
F = (
9
/5 C) + 32
F = 1.8 (C) + 32
The decimal 1.8 is equivalent to
9
/5. It doesnt matter which
of the two formulas is used for each scale because both for-
mulas will produce the same result. Feel free to use the
formula with which youre more comfortable.
23
Self-Check 2
Questions 110: Indicate whether each of the following statements is True or False.
______ 1. Both brand name and generic drugs are regulated by the FDA.
______ 2. The time 2005 is an example of military time.
______ 3. 25C is equal to 57F.
______ 4. The units of measure in the apothecary system are the meter, liter, and gram.
______ 5. The abbreviation gtt means ointment.
______ 6. The combined effect of drugs administered together is a drug interaction.
______ 7. A medication order is another name for a prescription.
______ 8. The elderly experience more drug-related incidents than other age groups because of
their high rate of medication use.
______ 9. The abbreviation q.i.d. means every hour.
______ 10. Lack of communication can lead to noncompliance with treatment.
24
UNDERSTANDING
PRESCRIPTIONS
Parts of a Prescription
A prescription is a written order from a prescriber. It tells the
pharmacist what drug to give to a patient. The writing on the
prescription must provide the following information to the
pharmacist with complete accuracy:
The name of the drug to dispense
The strength of the drug to dispense
The quantity of the drug to dispense
The name of the patient to whom the drug is to be given
Exact directions for the patient on how to take the drug
In the past, prescriptions were written on standard-sized
pieces of paper that measured 4
1
/
2 inches by 5
1
/
2 inches.
Today, prescriptions may still be written on paper and given
to the patient, but they can also be e-mailed or faxed directly
from the prescribers office to a pharmacys computer system.
E-mailing or faxing prescriptions can help to reduce prescrip-
tion errors.
Today, drugs are manufactured under very strict conditions
in a laboratory, and most arrive at the pharmacy in a ready-
to-dispense form (capsules, tablets, syrups, and so on). Many
years ago, before the development of modern drugs, a pre-
scription order would include complex instructions to the
pharmacist, telling him or her exactly how to make and com-
pound a medicinal preparation using many active
ingredients. The pharmacist would grind and mix the ingredi-
ents together by hand as instructed, and then make tablets,
solutions, or lotions as required. The prescription instruc-
tions were similar to a cooks recipe that describes how to
make a pie or cake. You can imagine how time-consuming
this process was, and how impossible it would be to fill hun-
dreds of prescriptions a day using these methods! Eventually,
to meet the increasing demand for standardized drugs, phar-
25
maceutical manufacturers began to produce medications in
large quantities in factories, and the old-fashioned recipe
process was abandoned. There are still some prescriptions
today that will need to be specially prepared or compounded
by the pharmacist. However, the vast majority of todays pre-
scriptions are for drugs that are delivered to the pharmacy in
a ready-to-dispense form.
So, today, if a prescriber wants to request a mixture of three
different antimicrobials in an ointment to treat skin infec-
tions and redness, he or she can simply prescribe a product
called Neosporin ointment. This ointment is fully prepared
and packaged by the manufacturer, with no further prepara-
tion necessary by the pharmacist. The pharmacist merely
generates a label of directions, affixes it to the tube of oint-
ment, and gives it to the patient. In contrast, many years
ago, the prescription order for this same medicine would have
included a complex set of directions on how to mix the three
antimicrobials into an ointment base.
Physicians, of course, are the largest group of professionals
authorized to write prescriptions. Physicians are taught
how to write prescriptions as students in medical school.
Theyre taught that a prescription order should be written
legibly. We know from experience, however, that many physi-
cians dont write very legible prescriptions! Since prescription
orders are considered medical-legal documents, prescribers
are also taught to write them in ink. Writing prescriptions
in ink is required for Schedule II controlled substances.
The Prescription Blank
Figure 8 shows what a typical prescription blank looks like
before any prescription is written.
Its convenient and the accepted form to have the prescribers
name, address, and telephone number preprinted on the
form. In this case, the name of the medical group is shown
rather than the individual physician. If the physician is in a
solo practice, then the physicians name would be on the
form. A second type of blank form is shown in Figure 9.
26
Figure 9 also has a space for the DEA number, or the Drug
Enforcement Agency number, if the pharmacist requests it
from the prescriber. The statement Not For Controlled
Substances protects these blanks from illegal ordering of
abused drugs.
FOUR SEASONS MEDICAL GROUP
Professional Building
100 East South Street, Suite 200
Scranton, PA 18515
PH: (111) 333-2211
Name ______________________ Date ________________
Address ____________________
Signature ______________
Repeat # ________ DEA No. ________________________
FIGURE 8A Blank
Prescription
University of Pharmacy
Medical Group
Name ______________________ Date ________________
Address ____________________
NOT FOR CONTROLLED SUBSTANCES
DEA Number ____ Signature ______________________
Repeat # ________ Printed Signature ________________
FIGURE 9A Blank
Prescription with Space
for the DEA Number and
the Statement Not For
Controlled Substances
University of Pharmacy Professional Building
567 W. Market St.
Scranton, PA 18515
PH: (111) 555-1234
27
Figure 10 shows a typical blank prescription form from a solo
practitioner. This prescriber happens to be a dentist. The
initials D.M.D. stand for Doctor of Dental Medicine. Note the
line for the address under the line for the patients name. A
space for age is also indicated. Refills are denoted by printed
numerals at the bottom left. The prescriber circles the num-
ber of refills desired. A line for the DEA number is included
at the bottom right.
The Components of a Prescription
A typical prescription and its components are shown in
Figure 11. Traditionally, the prescription order follows a
definite pattern to simplify its interpretation. Often, only
one prescription will be written on each blank, but this isnt
always the case.
The boldface numbers in the prescription in Figure 11 indi-
cate the following parts of the prescription:
1. The name and address of the patient, and the date
2. The symbol Rx
3. The name of the medicine, its dose form, and the
strength of the medicine
James Jones, D.M.D.
120 Main Street
Scranton, PA 18515
PH: (111) 555-1234
For ________________________ Age ________________
Address ____________________ Date ________________
0 1 2 3 Signature
DEA Number
FIGURE 10A Blank
Prescription Form from
a Solo Practitioner
28
4. Directions to the pharmacist
5. Directions to the patient
6. The prescribers signature
7. Refill information
Name and date. The name is necessary in order to avoid
giving medications to someone else. Also, its important for
the pharmacy to keep a record of the patient, his or her
address, and the medicine. This information establishes a
patient drug profile to monitor the prescribed doses, patient
compliance, and potential interactions with other drugs taken
at the same time. Prescription orders for Schedule II drugs
must contain the full name and address of the patient.
Most prescribers dont put the address of the patient on
prescriptions for nonscheduled drugs. Nonscheduled drugs
are drugs that arent federally classified as potentially
abusive. Its good practice to verify the name of the patient
written on the prescription to ensure that the right patient
is getting the right medication. This verification can be made
either with the patient directly, or by the person handing the
Scranton, PA 18515
PH: (111) 333-2211
Name ______________________ Date ________________
Address____________________________________________
3 Prozac Capsules 20 mg
4 Dispense #30
5 Sig.: one capsule each morning
Signature ________________________
Repeat # ________Printed Signature __________________
FIGURE 11A Prescription
with Its Components
Joe Fleming
North Street, Scranton, PA 18512
Sept. 4, 2008
1
2
6
Jonas Jones, M.D.
1
Jonas Jones, M.D.
7
29
prescription to the pharmacist. For prescriptions written by
a veterinarian, its traditional to put the name of the animal
first, followed by the last name of the owner. Instead of Gus
the Dog, the prescription name would be written as Gus
Wynn. Instead of Patches the Cat, the name written would
be Patches Wynn. Note that the name of an animal should
always be written in quotation marks.
The date when the prescription order is written is important.
Federal law requires that orders for drugs listed in Schedules
II, III, and IV of the Controlled Substances Act of 1970 be
dated. Orders for substances in Schedules III, IV, and V
cant be filled or refilled more than six months after date of
issuance. They may be refilled five times within the six
months. Schedule II drugs cant be refilled.
The symbol Rx. The symbol Rx is an abbreviation for the
word recipe, which is Latin for take thou. Note that this
symbol is always preprinted on the prescription blank and
isnt written in by the prescriber.
Name of the medicine, its dose form, and strength of the
medicine. Drugs are prescribed either by their generic
name (nonproprietary name) or their manufacturers brand
name (proprietary name). Almost all states have laws allowing
the pharmacist to substitute the product of one company for
the same formulation from a different manufacturer. Such
laws also indicate methods for the prescriber to prevent this
substitution. Most of the laws are written so the pharmacist
must dispense a generic equivalent, if available, of a brand
name drug unless the prescriber indicates that the brand
name is necessary for a medical purpose.
Note that for newly approved brand name drugs, no generic
equivalent is available. The law allows the manufacturer to
have exclusive marketing rights to the product for approxi-
mately 10 years. Arguments in favor of substitution with
generic drugs are based on eliminating duplication of names
for drug products, and on the possibility of an economic
benefit to the patient. A generic drug may be the therapeutic
equivalent of a brand name drug. A therapeutic equivalent is
a generic drug that provides the same therapeutic effect as
another comparable drug when administered in the same
amount. Arguments against substitution are based on the
30
possibility of therapeutic inequivalence with some generic
products. To ease these concerns, the Food and Drug
Administration has prepared a publication that identifies
currently marketed prescription drug products and evalua-
tions of the therapeutic equivalence for each product. Its
hoped that this information will minimize the uncertainty
with prescribing and dispensing generic drugs. Documented
cases of nonequivalence between the generic form and the
brand name for the same drug are very uncommon.
Certain patients do exhibit changes in response to a drug
when theyre switched from one brand to another. Such
changes are usually unexplainable, and can also be observed
in patients taking very potent drugs in which a small change
in drug concentration may lead to some additional unwanted
effects. In these cases, the prescriber prevents substitution
by writing dispense as written, on the prescription order or
by telling the pharmacist that only the product requested is
to be dispensed.
In Figure 11, the drug named in the sample prescription is
Prozac, which is the brand name for the drug fluoxetine. The
brand name is assigned by the manufacturer, Eli Lilly.
The dose form thats requested on the sample prescription is
the capsule. For many drugs, more than one dose form may
be available (such as tablets, capsules, liquids, and even
chewable tablets), and the prescriber must make it clear
which one is requested. Its good procedure to indicate the
dose form even though only one may be available.
The strength indicated in the sample prescription is 20 mg,
or 20 milligrams. Therefore, the prescriber is requesting
20-milligram capsules of Prozac. Most drugs are available
in more than one strength, and its extremely important for
the prescriber to indicate which strength of medication the
patient should have.
Directions to the pharmacist. Prescription orders for a
single drug usually consist of directions such as dispense
24 tablets, dispense 4 ounces, dispense 200 ml, dispense a
15-gram tube of ointment, and so forth. The word dispense
is often abbreviated as disp. In our example, the directions
on this prescription to the pharmacist state to dispense 30
capsules. Although it reads dispense #30, and the word
31
capsule is missing, the dosage form is a capsule. Therefore,
capsules are dispensed. To follow the directions on the sam-
ple prescription, the pharmacist or pharmacy technician
Counts out 30 capsules using the counting tray and
spatula
Places them in an appropriate container
Places an appropriate label on the container
The pharmacy technician would have the pharmacist
check the prescription and label for accuracy
Gives them to the patient
This service is in return for a fee that includes a charge for
the medicine and a charge for the dispensing. In the case
of prescription orders for medicines to be prepared, a short
sentence is used for directions to the pharmacist such as
make a solution or mix and place into 10 gelatin capsules
or mix as ointment and dispense in ointment tube.
Directions to the patient. This section starts with the word
Sig. Sig. is the Latin abbreviation for Signa, meaning
you write. The Sig. is the instructions typed on the label
of the dispensed medications that instruct the patient how to
take the medicine. These instructions should be written in
English. However, most prescribers continue to use Latin
abbreviations for the sake of tradition, shortness, and speed.
The dispenser of the medication must type on the label the
exact directions written by the prescriber. If theyre written in
Latin abbreviations, the corresponding English translation
must be typed onto the label. Our example instructs the
patient to take one capsule each morning. Other types of
Sigs read take as directed, take as necessary, and take
every 4 hours. The directions to the patient may also include
a reminder of the intended purpose of the medicine by
including phrases such as for relief of pain, for relief of
headache,or to relieve itching. Also common is the direc-
tion take 3x a day, which translates to take three times a
day. The x stands for times.
32
Prescribers signature. The prescription order is completed
by the prescriber signing the bottom of the blank along with
the professional degree following the signature. Note in our
example that Dr. Jones places the M.D. after the signature.
Also, note the line placed for the printed signature. For
difficult-to-read written signatures, the pharmacist will know
the name of the prescriber. Federal law requires that the
prescribers address and DEA registry number also appear on
every prescription order for controlled drugs and that the
order be signed with ink.
Refill information. According to the Durham-Humphrey
Amendment to the Food, Drug, and Cosmetic Act, prescrip-
tion orders for drugs that bear the legend Federal law
prohibits dispensing without a prescription may not be
refilled without the consent of the prescriber. Under the
Controlled Substances Act of 1970, prescription orders for
Schedule III, Schedule IV, and V drugs cant be refilled more
than five times, and the prescription order is invalid six
months from the date of issue. These restrictions are
intended to control the overuse and abuse of prescription
medications. For these reasons, the prescriber should indi-
cate the number of refills on each original prescription order,
regardless of whether or not its for controlled substances.
This information may be indicated by instruction to refill a
certain number of times or not to refill at all. Schedule II
substances cant be refilled. The abbreviation non rep. may
be used for no refills allowed.
Types of Prescriptions
Prescriptions from Refills
Prescriptions may be filled upon the request of the patient if
refills were indicated on the original written prescription.
Over half of the prescriptions filled on a daily basis are refills
of an original prescription. The patient will provide the phar-
macy with the prescription number (label number) of the
prescription to be refilled. This number was stamped on the
original prescription when dispensed and is used as a filing
number for future reference. The patient will either call in the
33
number over the telephone or bring the empty prescription
container to the pharmacy. In some cases, the doctors office
will call with the prescription number to request the refill.
Once the prescription number is known, the prescription can
be identified from the files and the medicine is dispensed as
instructed on the original prescription.
When the refill is dispensed, the medicine is labeled with one
less refill remaining. For example, if the original prescription
was written for a medicine with two refills, then 2 refills
remaining is typed on the label when the prescription is
filled for the first time. Each time a patient refills the pre-
scription, a new label is typed. On each new label, the
amount of refills remaining must be subtracted by one. A
sample label shown in Figure 12 illustrates where the pre-
scription number is on the label and the indication for the
number of refills.
Springs Pharmacy
201 South Street
Scranton, PA 18512
PH: (111) 555-1234
# 309187 Date
Richard Wynn
Take 1 tablet every day.
Procardia 30 mg tab
1 refill
FIGURE 12Example
Pharmacy Label
08/30/08
Dr. Smith
Prescription number
Refills remaining
34
Prescriptions from Telephone Orders
New prescriptions can be called into a pharmacy over the
telephone by the prescriber. The pharmacist transfers the
telephone order onto a prescription blank. The prescription is
dispensed as if it were the original written prescription. Lets
look at some example telephone orders.
Sample Telephone Order 1
Imagine that a doctors office places the following call to a
pharmacy:
This is Doctor Smiths office from Four Seasons Medical
Group. Prescription for Tom Jones, Penicillin VK tablets,
250 milligrams. Dispense number 40. Directions to the
patient are to take two tablets at once, then one tablet every
six hours until all taken. No refills.
The pharmacy may have printed forms for the Four Seasons
Medical Group. If not, the pharmacist would fill in the name
of the group and the doctors name on a blank prescription
form. Figure 13 shows the prescription that was written from
this telephone order.
Scranton, PA 18515
PH: (111) 333-2211
Name ______________________ Date ________________
Address____________________________________________
Penicillin VK 250 mg
Disp. #40
Sig.: 2 tabs immediately, then 1 tab
every six hours until gone.
Signature ______________________
FIGURE 13Written
Prescription from
Telephone Order 1
Abe St., Scranton, PA 18512
Dr. Smith
Dr. Smith 0
35
Lets examine another call:
This is Dr. Mel Williams. Prescription for the Jenkins child,
Julie, Entex liquid, dispense six ounces. Directions to the
patient are to take one teaspoonful every six hours for chest
congestion. One refill if necessary.
Figure 14 shows the prescription written for this order.
Lets examine another call:
This is Dr. Lillian Adams. Prescription for Sammy Jones,
dispense one Ventolin inhaler with directions to inhale three
to four times daily for shortness of breath. Two refills.
Figure 15 shows the prescription written for this order.
Scranton, PA 18515
PH: (111) 333-2211
Name ______________________ Date ________________
Address____________________________________________
Entex Liquid six ounces
Sig.: 1 tsp. every six hours
for chest congestion
Signature ______________________
FIGURE 14Written
Prescription from
Telephone Order 2
10th Ave., Scranton, PA 18515
Mel Williams, M.D.
Mel Williams, M.D. 1
Julie Jenkins 09/6/08
36
Hospital Medication Orders
Doctors can order medications for patients while theyre in
the hospital. If a doctor orders a medication in a hospital,
its known as a medication order or physicians order. Its
not called a prescription as in the community pharmacy.
Many hospitals now use computerized systems to track all
physician orders for each patient. The physician can enter
his or her orders directly into the system used by the hospital.
However, there are still many hospitals that use a paper-
based system to send medication orders to the pharmacy
department.
The medication order essentially starts with the blank form,
called the physicians order form, for that particular institu-
tion. Each institution (hospital) has its own medication order
form. A sample form is shown in Figure 16.
This medication order form is an official form for that partic-
ular hospital and has the hospital name printed on the top of
the form. The order will be stamped with the patients full
name, a hospital identification number assigned to that
patient, the patients room number, the doctor who admitted
the patient to the hospital, and the admission date.
Scranton, PA 18515
PH: (111) 333-2211
Name ______________________ Date ________________
Address____________________________________________
Ventolin Inhaler #1
Sig.: Inhale 3-4 times a day
for shortness of breath.
Signature ______________________
FIGURE 15Written
Prescription from
Telephone Order 3
Box 12, Scranton, PA 18515
Lillian Adams, M.D.
Lillian Adams, M.D.
2
Sammy Jones 09/6/08
37
FIGURE 16Physicians Order Form (Physicians Order Form courtesy of Mercy Hospital, Scranton, PA)
38
When the doctor visits the patient in the room, any medica-
tion the patient may need for therapy will be requested
through the medication order system. Medication information
is written on the form in the same way that information is
written on a prescription. This information includes the drug
name, dose form, strength of the medication, number of
doses to be dispensed, and the directions for taking the med-
ication. Additional information not found on a prescription
may be written on a medication order, including items such
as patients diet, blood tests, and urine tests. If the order
contains more information than simply the medication, then
its a physicians order and not simply a medication order.
After the physician sees the patient and completes the order,
its checked by a nurse or a ward clerk at the nurses station.
The nurses station is a desk area on the floor close to the
patient rooms. The order is then sent to the pharmacy and
other departments as needed.
The pharmacy fills the medications written on the physicians
order according to the instructions requested by the physi-
cian. When the medication order is filled, no more than 24
hours worth of medication is delivered to any patient. For
example, instead of a supply of 36 tablets of penicillin in a
vial, as many prepackaged unit-dose penicillin tablets as the
patient needs for one day would be provided. If the patient
doesnt use all the medication, it can be returned to the phar-
macy and used for another patient. Since these unit-dose
medication preparations are individually sealed, no contami-
nation will occur from any given patient.
Introduction to Drug Monographs/
Package Inserts
Each time a new drug package is opened in the pharmacy
for dispensing, all the information ever collected about that
particular drug is available. This information is in the form
of a monograph, which youll much more about shortly. This
monograph is inserted into the drug package as a package
insert. In most cases, this small folded informational sheet is
either ignored or overlooked, even though it was placed in the
drug package purposely to serve as an official source of drug
39
information. This study unit takes you on a very important
tour of this little packet of facts to show you how this infor-
mation is used in drug dispensing.
This section describes a drug monograph and how the
monograph is used as a package insert in the drug product.
Examples of some typical package inserts are provided for
you to review. Explanations of each section of information
included in the drug monograph/package insert are provided
in easy-to-understand language so that you can appreciate
the value and importance of this information source.
What Is a Drug Monograph?
A drug monograph is a concise collection of information
about a given drug thats required by the Food and Drug
Administration (FDA) to describe the characteristics of the
drug. Its usually a printed document containing detailed
information that has been reviewed and approved by the FDA
for accuracy and detail, and it describes all aspects of the
use of the drug for medical purposes. The information in the
drug monograph has been derived from the multitude of data
submitted in the New Drug Application (NDA) to the FDA and
has been transformed into an organized, concise, and official
description of the actions of the drug. The monograph is filed
with the FDA as the official information that must, by law,
accompany the drug in either the original form or in an
edited form in all advertising, promotion, and descriptions of
the drug. It is, in a sense, a legally binding document that
can be used to describe the actions of the drug if questions
concerning these actions arise. The drug monograph is filed
with the FDA, and a copy can be obtained by anyone upon
request to the FDA.
The drug monograph or its edited version can be found in
many sources of drug information, including the insert that
accompanies a drug package as distributed to the pharmacy,
the Physicians Desk Reference (PDR), and other official and
nonofficial compendia of drug information. Drug monographs
that accompany the promotional literature of a drug present
a great deal of information in a very concise manner.
40
What Is a Package Insert?
A package insert is a copy of a drug monograph that accom-
panies the drug in its package when distributed for sale and
use. Each new drug package opened for dispensing in the
pharmacy contains the package insert for that drug. If the
medicine is packaged in a box or plastic container, the pack-
age insert is folded and placed inside the box. If the medicine
is available as pills or liquid in a bottle, the insert is affixed
with some type of adhesive to the outside of the bottle.
Drug monographs accompany drugs when theyre shipped
throughout the country to pharmacies and other dispen-
saries. Once the monograph is folded and placed into the
drug package, it then becomes known as the package insert.
Because the package insert is the drug monograph, its con-
cise, contains a great deal of information, and takes up a
very small space. The package insert is affixed to the outside
of the medication bottle in its original configuration. The orig-
inal packet takes up a space of 1
1
/
2 inches by 2
1
/
2 inches. If
the insert is unfolded from left to right, it opens to a final size
of 12 inches by 18 inches. Since both sides of the 12-by-
18inch paper are filled with type, the entire package insert
holds about 32,400 wordsa lot of information!
Types of Package Inserts
Currently, there are two distinct types of package inserts
that can be found in the pharmacy. The reason for this is
that in January, 2006, for the first time in more than 25 years,
the FDA announced a revised format for the content and lay-
out of the package insert. Many of these changes were made
with practitioner input to reduce medication errors, provide
proper risk management information, and provide the most
up-to-date data in an easier-to-read and navigate format.
This new format also makes information easier to access in
electronic format. This final rule went into effect on June 30,
2006.
The products that must conform to the final rule include
Prescription drugs and biologics submitted on and after
June 30, 2006
41
Any drug or biologic that was approved five years prior to
June 30, 2006. (The FDA has provided an implementa-
tion schedule to give manufacturers time to conform.)
Drugs or biologics that were approved prior to June 30,
2001, that experience a major labeling change such as
new indication, new dosage regimen, or new route of
administration
Any drug or biologic that was approved prior to June 30,
2001, that doesnt experience any major labeling change may
submit the revised format on a voluntary basis. Since there
are many drugs that arent required to follow this revised for-
mat, well present both types of package inserts in this study
unit. For the sake of simplicity, well refer to drugs that arent
required to use the revised format as having the older-style
package insert.
Examples of Package Inserts
Package inserts come in various sizes depending on how they
accompany the medicine and the size of the medicine bottle
or box. Imagine a small ointment tube in a box into which
an insert must be placed. In this case, the insert is probably
folded many times and printed in very small type. A large
box of medicine, however, probably contains a larger printed
insert.
These inserts change shape and size frequently, but an
online version of this information is almost always available.
42
NOTES
43
Drug Nomenclature
Most drugs are referred to by several names:
Generic
Chemical
Brand
Popular
The chemical name is usually a very long name of the chemi-
cal composition of the drug. It can be found in the package
insert. It isnt often used in the dispensing process, but its
important to the FDA and the offices that register the patent
on the drug. Its also important to chemists and other scien-
tists working in the field of pharmaceuticals.
The popular name is usually nothing more than an abbrevi-
ated version of the generic or chemical name. For example,
the cancer-treating drug whose generic name is etoposide
and whose brand name is VePesid is often referred to by its
popular name, VP-16, the name researchers used in its
development.
For safety reasons, the proper way to express the name of
a medication in the pharmacy and medical literature is by
the generic name. However, patients are often more apt to
recognize the brand name of the drug. Fortunately, in the
United States, the NDC is indispensable when trying to
identify each individual drug, regardless of which name is
being used to describe the drug.
44
Generic Products
Many shoppers think that generic grocery items are of an
inferior quality to their brand-name counterparts. This may
be the case in the food industry, but the manufacturers of
generic products in the drug industry must maintain the
same standards of purity and content that the innovator or
original manufacturer did when the product was first
approved by the FDA. All drugs are tested for purity and
accuracy of the dosage form. For example, if its a solid
dosage form like a capsule, it must dissolve in a certain time.
Substitution of a generic equivalent often saves money for the
consumer.
Patents
The concept of a patent in the drug industry is very impor-
tant to continued production and discovery of new products.
Manufacturers spend a portion of income on research. The
goal of the research is to produce new medications to be sold
while theres no competition. A patent is assigned to a prod-
uct when its first discovered. The time from discovery to
marketing may be up to 10 years. In the United States, the
life of a patent is 17 years. The patent allows the manufac-
turer to produce and market its product exclusively, without
competition, until the patent expires. After the patent expires,
other manufacturers can submit a request to the FDA for
approval of an equivalent product. This product is called a
generic equivalent, or an equal product. When a brand-name
product has approved generic equivalents, competition drives
the prices down. The result is less-expensive drugs for the
consumer.
Drug Manufacturers
The number of drugs and drug manufacturers in both the
United States and abroad is staggering. Drug sales total
around 300 billion dollars, with the sale of generics and bio-
logics rising rapidly. (Biologics are medicinal products from
natural sources and include a growing range of products that
include vaccines and blood components.) As you review the
45
top 200 drugs, you may recognize familiar names of large
drug manufacturers, including Pfizer, Bristol-Myers Squibb,
GlaxoSmithKline, and Sanofi. You might have guessed from
the names listed here that many pharmaceutical and biotech
companies have merged over the years. This change is con-
stant. Take time to visit the Web sites of the major drug
manufacturers of the top 200 drugs. Go to the About page of
each company for an overview of the key products, recent
yearly revenues, and dollars spent on research and develop-
ment (R & D). Youll see that many large pharmaceutical
companies make both brand-name and generic products, as
well as consumer healthcare products (including over-the-
counter medications). Many large drug manufacturers also
have a line of animal health products. Though its not neces-
sary to know which manufacturer produced each medication
thats handled in the pharmacy, a good overview of the
industry is helpful.
Administration of Drugs
Medication comes in a wide variety of forms that are adminis-
tered in different ways. There are pills, injections, ointments,
elixirs, suppositories, inhalers, and the list goes on. Some
drugs reach their destination by only one route. Others may
travel by a variety of ways, and the physician will choose one
route over the others based on speed, cost, safety, and local
versus systemic effects. In drug references, this information
will usually be listed under the heading How Supplied.
Refer back to Figure 5 for a list of abbreviations for common
routes of administration.
Routes of Administration
These are GI-tract routes of drug administration:
Oral (PO, or per os [Latin for by mouth])the easiest,
safest, cheapest, but slowest way of supplying a drug to
body cells (Figure 17). The medication is swallowed so it
will be absorbed into the bloodstream via the mucosa
(lining) of the stomach and intestine. Oral drugs include
tablets, enteric-coated tablets (coated to ensure absorp-
tion by the intestine rather than the stomach), capsules,
46
timed-release (or sustained-release) capsules, lozenges
(or troches), suspensions (drugs suspended in liquid),
emulsions (containing fats), elixirs (containing alcohol),
syrups (sweetened), and solutions.
Nasogastric (NG) tubea tube inserted through the nos-
tril and passed through the esophagus into the stomach
for feedings and medications
Rectal (R)a slow and irregular route of absorption, but
valuable in a patient who is vomiting or cant swallow.
Rectal medications include suppositories and enema
solutions.
Any route other than the GI tract is called parenteral.
(However, the term is often used to mean injection with a
needle and syringe, so keep that in mind.) Parenteral
routes are used when the patient can take nothing by
mouth (NPO), or when the drug simply isnt suitable for
GI routes. Parenteral routes include
Topical (T)placing the drug directly on the skin or
mucous membrane, often for a local
effect; dermal (D) and mucosal routes,
respectively (Figure 18). Topical med-
ications come in the form of creams,
liniments (oily liquid preparations),
lotions, ointments, liquids, and pow-
ders. Examples include insertion of
vaginal creams and douches, irriga-
tion of the bladder with water that
contains drugs, and transdermal
delivery via medicated dermal
patches. The nose, eyes, and ears
may all be treated with the instillation
of drops. Sublingual (SL) medications
are tablets placed under the tongue
to be dissolved in saliva and absorbed
by mucous membranes of the mouth,
not swallowed; the most obvious
FIGURE 17Oral Drug Forms
47
example is nitroglycerin taken to fend off attacks of
angina pectoris. Similarly, buccal medications are placed
against the cheek for absorption.
Inhalationvapors or gases taken into the bloodstream
via the lungs. Sprays, mists, powders, or steam may be
breathed in via inhalers, nebulizers (devices for throwing
spray), atomizers, and other devices. Asthmatic persons
often use aerosols to control symptoms. Many anesthet-
ics are also inhaled.
Injectionby means of a hollow needle and syringe. This
is the fastest way of getting drugs into the bloodstream,
but potentially the most dangerous. It requires special
training for proper administration. An injectable drug
may be either a solution or a powder that has been
mixed in a solution (reconstitution).
FIGURE 18Topical Drug Forms
Topical
Buccal
Sublingual
Vaginal
Transdermal
48
There are many methods of injection (Figure 19):
Intravenous (IV), into a vein (the very fastest route)
Intramuscular (IM), into a muscle (the next fastest)
Subcutaneous (SC) (or hypodermic), into the fatty tissue
layer under the skin
Intradermal (ID), within the layers of the skin
IV, IM, SC, and ID injections may be administered by trained
personnel such as nurses, lab technicians, and medical
assistants. Other injections are highly specialized and usually
performed by a physician:
Intracardiac, directly into the heart
Intracavitary, directly into a body cavity
Intraspinal, into the subarachnoid space
Intrathecal, into the space underlying membranes around
spinal cord and brain
Intracapsular, into the capsule of a joint
49
FIGURE 19Forms of Drug Injection
50
Dosage
Besides its properties of absorption, distribution, metabolism,
excretion, and interaction with other medications, a drugs
action and effect on the body is influenced by the patients
age, weight, gender, and genes. The bodies of the very young
and the very old dont respond in exactly the same ways as
average adults. Drugs distribute differently in bodies that
are very lean or very high in fat content. The physician will
take these variables into account when prescribing dosages
(Figure 20).
Therefore, even dosage has its own list of terminology:
Minimum doseany less wouldnt do any good
Maximum doseany more would be toxic
Loading dosean initial high dose to load up the
bloodstream with the drug
Maintenance dosekeeps drug level steady
Lethal dosedeadly
Usual dosecustomary dose for body weight
FIGURE 20A physician will deter-
mine dosage based on variables such
as weight, age, gender, and genes.
51
And lets not overlook the power of positive thinking! Having
a healthy attitude about a drugs potential action tends to
have a synergystic effect. In fact, scientific studies have
shown that sometimes a positive physical response can be all
in the mind. Patients in experiments have reported feeling
better after being given a placebo, a substance that looks like
a medication but doesnt contain any active drug. And simi-
larly to this positive placebo effect, pessimism can diminish
the effectiveness of a drug.
Medication Administration
An important factor of pharmacology is safely administering
medications. One way the medical industry insures safety is
through quality assurance, which is a program that estab-
lishes standards of excellence and ensures that practices
adapt to those standards.
OSHA Standards in Medication Administration
The Occupational Safety and Health Administration (OSHA)
is a federal agency that publishes and enforces safety and
health regulations for most businesses and industries in the
United States. OSHA is part of the Department of Labor. In
July 1992, OSHA began enforcing workplace controls for
dealing with bloodborne pathogens. Each facility must have a
plan of controls that includes
Mandatory education
Measures to reduce the possibility of disease exposure
Drug Classifications
Many drug references organize drug listings by classifications
and subclassifications; therefore, a solid understanding of
drug classes will make looking up unfamiliar generic and
brand names faster and more efficient. Remember, though,
that medications may have several different effects and,
therefore, belong under more than one classification. For
instance, you might take an aspirin for one of several rea-
sonsto ease a headache, to lower a fever, or to reduce
inflammation. Some references may cross-list a drug under
52
more than one classification. Drug classifications are used
very frequently in medical settingsin fact, youll probably
understand many of them without our definitions, probably
from personal experience. Well go over some general ones
here, and then well add more as they pertain to the body
systems well be studying.
Analgesics and Narcotics
ALGESI/O means pain, and AN- means without, and
analgesics are drugs that relieve pain. Mild analgesics such
as aspirin will relieve moderate pain quite wellheadaches,
sore muscles, toothaches, etc.and arent dangerous if used
according to directions. Here are the most common generic
analgesics, with examples of brand names. Youll recognize
most of them as over-the-counter medications:
acetylsalicylic acid (aspirin)Bayer, Ascriptin,
Bufferin
acetaminophenTylenol
ibuprofenAdvil, Medipren, Motrin
Aspirin and ibuprofen are also antipyretics because they
lower fevers and anti-inflammatory agents (or antiarthritics)
because they reduce swelling and inflammation. Other anti-
inflammatory agents most commonly prescribed to treat
arthritis include
indomethacinIndocin
fenoprofen calciumNalfon
naproxenNaprosyn
A subclassification of analgesics is narcotics. These potent
drugs not only relieve painthey almost relieve conscious-
ness; they can put the patient in a stupor. Because they can
be habit forming, narcotics are used only to relieve severe
pain. Here are some examples:
morphine sulfate
codeine phosphate
oxycodone HClPercodan
53
oxycodone with TylenolPercocet
Heres a reminder: its important to keep the differences
between generic and brand names straight in your mind, and
one way of doing that is to remember that in our examples,
as in other medical documents, brand names are capitalized
but generic names arent.
Anesthetics
If youve ever had a shot of Novocain to kill the pain of a
dentists drilling, youve been under the influence of a local
anesthetic, an agent that reduces or eliminates sensation in a
limited region of the body. Other common examples are the
following:
hydrocortisone acetateOrabase
lidocaineXylocaine
A general anesthetic eliminates sensation in the whole body
and induces a state of unconsciousness. Here are some
examples:
halothaneFluothane
nitrous oxide
thiopentalPentothal
Antibiotics
Who today would fear imminent death at the onset of a bad
cough with a high fever? The minute we suspect pneumonia
(or some lesser infection) has invaded our bodies, we can
take powerful doses of penicillin or another antibiotic to stop
the growth of whatever bacteria, fungi, or parasites are
responsible for the disease. Until 1945, when penicillin
became available for general use, infections werent so easy to
fight off and were often life-threatening. Since then, pharma-
cologists have developed many other antibiotics to fight a
broad spectrum of microorganisms.
54
Youre probably familiar with many of these examples:
penicillin VPen-Vee K, V-Cillin K
benzathine penicillin GBicillin
procaine penicillin GWycillin, Duracillin
ampicillinAmcill, Omnipen
amoxicillinAmoxil
tetracycline HClAchromycin V, Sumycin
doxycycline
erythromycinE-mycin, Erythrocin, Ilosone,
Pediamycin
cephalexinKeflex, Keflin
gentamicin sulfateGaramycin
Some antibiotics are especially effective against viral infec-
tions such as herpes and are sometimes referred to as
antivirals:
ganciclovirCytovene
acyclovirZovirax
zidovudine, AZTRetrovir
An antibiotic is the primary antitubercular agent, prescribed
to control tuberculosis:
isoniazidINH
You may have heard of sulfa drugs, or sulfonamides, a form
of antibiotic drug very effective against urinary tract and GI
infections. These antibiotics have been prescribed since the
1930s, but care must be taken as many patients experience
allergic reactions to sulfa drugs. Sulfa drugs include:
sulfasalazineAzulfidine
sulfisoxazoleGantrisin
trimethoprim sulfamethoxazoleBactrim, Septra
55
Drug Action and Effect
How do drugs do what they do? And how does the body react
to the presence of drugs? These are big questions for phar-
macologists. And the answers arent just fascinatingtheyre
also good to know. All drugs cause changes in cells, and this
is called drug action. This action in turn causes some physio-
logical change in the body, or effect. Depending on the drugs
action, the effect may be systemic, throughout the body, or
local, limited to the area where administered.
Drug Processing
Before its action can take effect, a drug has to get where its
going. Once the drug is administered, its first phase of the
journey through the body is absorption, or getting into the
bloodstream. The route of administration affects the speed of
absorption, as do many other variables. For instance, an oral
drug taken on an empty stomach will be absorbed more
quickly than when taken with food. Then again, some drugs
can damage an empty stomach and should be taken with
food or large amounts of liquid. Thats just one reason why
its always important to read labels!
Drugs have a target substance, called a receptor. The recep-
tor might be a particular chemical that will react with the
drug to speed up or slow down normal cell processes. The
drug reaches the receptor by a process called distribution, in
which the drug moves from the bloodstream across cell mem-
branes. Some substances are allowed transport across cell
membranes while others are not. Some drugs have selective
distribution; they go only to specialized tissues that attract
them. This is an important consideration for pharmacologists
studying the action of a particular drug.
You may already know about metabolism, and drugs nor-
mally undergo this cellular activity, toojust like our food.
The drug might depress the cells processes, stimulate the
cells processes, destroy the cell or certain parts of the cell, or
replace a substance in the cell that the body hasnt produced
on its own (as with hormone replacement therapy).
56
The final phase of the drugs medicinal journey is excretion,
the elimination of the waste products of drug metabolism.
Most drugs leave via the kidneys, though some may be
exhaled or perspired out of the body. Even the excretion of a
drug can be a factor in its proper use. In patients with kidney
problems, certain drugs can be contraindicated, or considered
dangerous and ill advised, because of the renal condition.
Reactions and Interactions
Once a drug has entered the body and begun its action, there
are many possible effects a physician will monitor. Some con-
cern the effectiveness of the drug over time. Others concern
the effects of drug interaction, or using two or more drugs
simultaneously.
Dependencypsychological and physical need for a
drug resulting in withdrawal symptoms when the drug
is absent
Tolerancethe more a drug is given, the weaker the
effect of the drug. The dose must be increased to main-
tain the desired effect.
Cumulative actionthe more a drug is given, the stronger
its toxic effect on tissue. The dose may have to be
reduced to limit damage to the body.
Additive actiontwo or more drugs act together without
diminishing or increasing the effects of each other.
Synergismtwo drugs act together to surpass the addi-
tive effect of the individual drugs. The whole is greater
than the sum of its parts.
Potentiationone drug prolongs or intensifies the effect of
another drug.
Antagonismtwo drugs decrease or cancel out the effec-
tiveness of one another.
Idiosyncrasyany unexpected effect. An example of an
idiosyncrasy is anaphylaxis, a severe and potentially
fatal allergic reaction to a drug. Immune responses of
milder degrees are termed hypersensitivity.
57
Toxicitya harmful or fatal effect from exposure to either
a poison or a dangerous amount of a drug thats safe in
smaller amounts.
Teratogenic effectphysical defects in a fetus caused by
a drug taken during pregnancy.
Iatrogenic disorderspathology produced from drug
treatment.
The combined effects of medications, or drug interactions, can
be either desirable or undesirable. Thus you may hear about
desirable synergism or undesirable synergism, desirable
potentiation or undesirable potentiation, and so on.
Therapeutic drugs also have effects that are normal and
expected but not quite what the doctor ordered. That is, they
arent part of the therapeutic plan; they just happen. Theyre
side effects, and they range from unnoticeable to mildly
unpleasant to inconvenient to dangerous. Side effects of drug
therapy often resemble symptoms of pathology. You may
already be familiar with many of these terms (Table 1).
58
Table 1
SOME DRUG THERAPY SIDE EFFECTS
Anorexia (diminished appetite) Impotence
Anxiety Insomnia
Blurred vision Irritability
Breast tenderness Itching
Bruising Lightheadedness
Burning sensation Low blood pressure
Chest pains Menstrual irregularities
Confusion Nasal congestion
Constipation Nausea
Cramps Nervousness
Depression Palpitations
Diarrhea Rash
Dizziness Restlessness
Drowsiness Sweating
Dry mouth/nose/skin Tingling
Dyspnea (difficulty breathing) Tinnitus (ringing in ears)
Edema Tremors
Fatigue Twitching
Fever Urinary frequency
Flushing Urine discoloration
Headache Urine retention
Heartburn Vaginal discharge
Hiccups Weakness
Hives Weight gain
59
Self-Check 3
Questions 110: Match the term on the left with its definition on the right. Indicate your
choices in the spaces provided.
______ 1. Potentiation
______ 2. Teratogenic effect
______ 3. Package insert
______ 4. OSHA
______ 5. Placebo effect
______ 6. Sulfonamides
______ 7. Subcutaneous
______ 8. Analgesics
______ 9. Physicians order
______ 10. Distribution
a. Method of injecting drugs into the fatty tissue
layer under the skin
b. Experience of feeling better after taking a sub-
stance that doesnt contain any active drug
c. Drugs that relieve pain
d. Physical defects in a fetus caused by a drug
taken during pregnancy
e. Medications ordered by a doctor for a patient
in the hospital
f. One drug prolongs or intensifies the effect of
another drug
g. Copy of a drug monograph that accompanies a
drug when distributed for sale
h. The process where a drug moves from the
bloodstream across cell membranes
i. A type of antibiotic thats effective against GI
infections
j. Federal agency that publishes and enforces
safety and health regulations
60
DRUG CLASSIFICATIONS
ACCORDING TO BODY SYSTEM
Integumentary System
Anti-infectives (antibacterials and antifungals) are applied
either topically (on the surface area of the skin) or systemi-
cally to eliminate epidermal infections. Anti-inflammatory
drugs (topical corticosteroids) are applied topically to relieve
three common symptoms of skin disorders: pruritis (itching),
vasodilation (dilation of a blood vessel), and inflammation.
Antipruritics prevent or relieve itching. Antiseptics are topi-
cally applied compounds or agents that destroy bacteria.
They prevent the development of infections in cuts, scratches,
and surgical incisions.
Keratolytics destroy and soften the outer layer of the skin so
that its sloughed off (shed). Strong keratolytics are effective
for removing warts and corns. Milder preparations are used
to promote the shedding of scales and crusts in eczema, pso-
riasis, and seborrheic dermatitis. Very weak keratolytics act
as tonics that speed up the healing process.
Parasiticides, as the name suggests, kill insect parasites that
infest the skin. Scabicides kill mites that cause scabies.
Pediculocides kill lice that cause pediculosis.
Protectives and astringents are used to cover, cool, dry, or
soothe inflamed skin. Protectives dont penetrate the skin or
soften it, but form a long-lasting film. This film protects the
skin from air, water, and clothing during the natural healing
process. Astringents shrink the blood vessels locally (in one
spot), dry up secretions from seeping lesions, and lessen the
sensitivity of the skin.
Topical anesthetics are prescribed for pain on skin surfaces
or mucous membranes caused by wounds, hemorrhoids, or
sunburns. These topical anesthetics relieve pain and itching
by numbing the skin layers and mucous membranes. Theyre
applied directly to the painful areas by means of sprays,
creams, gargles, suppositories, and other preparations.
61
Common Types of Anti-Infectives
The anti-infective drugs are a diverse group of drugs that are
used to kill or slow the growth of the many pathogens that
can invade the body and cause infection. The anti-infectives
include antibiotics, antivirals, antifungals, and antiprotozoans.
These four groups of anti-infectives are further subdivided
based on several criteria, including chemical structure
(penicillins and aminoglycosides); what kind of organisms
they inhibit or kill (anaerobes, broad spectrum, narrow
spectrum); and disease states theyre used for (HIV/AIDS,
tuberculosis). Anti-infectives are available in a variety of
ways, including oral dosage forms (tablets, capsules, suspen-
sions), injectable forms (for IM or IV use), topical forms
(creams, lotions, ointments), otic forms (ear drops), and
ophthalmic forms (drops and ointments).
Antibiotic use. The antibiotics, or antibacterials, are a class
of drugs that inhibit the growth of or kill bacteria. These
drugs are effective only against bacteria, not viruses. Some of
these drugs are very powerful, and should be used only when
theyre needed. Many people think that anytime they get a
cold, they need an antibiotic. This isnt true and actually can
lead to antibiotic resistance. Antibiotic resistance occurs
when the antibiotic is no longer able to kill or slow down the
growth of an organism. In other words, the organism has now
found a way around the effects of the antibiotic, and has, in
essence, grown stronger than the drug that once was able to
kill it. This happens when antibiotics are misused (such as
when theyre prescribed when theyre not needed) and when
people dont finish the full course of their antibiotic.
If patients dont finish a full course of antibiotic, theyre only
killing the weakest of the bacteria infecting them. The stronger
organisms are left to multiply and grow. These stronger
organisms can now reinfect the person, or be passed on to
other people. Two extreme examples of this are when people
become infected with MRSA (methicillin-resistant staph
aureus) and VRE (vancomycin-resistant enterococcus). MRSA
and VRE are sometimes called super bugs because there
arent many drugs available to kill them, and people who
are infected with them become very sick and can even die.
Treatment involves hospitalization with isolation, intravenous
antibiotics, and sometimes surgery.
62
Antibiotic resistance is a very serious issue, and there are
important points to remember:
An antibiotic isnt necessary or indicated every time a
person gets sick. A prescriber shouldnt be pressured
into prescribing antibiotics. The prescriber should be the
judge of what treatment is appropriate.
Antibiotics are useless against colds or the flu and can
actually do more harm than good.
Its very important to take the full course of antibiotics
prescribed. A patient may feel better after a few days,
but must take all of the medication to completely kill
the bacteria. There should never be leftover antibiotics.
If the prescriber changes an antibiotic therapy, the
patient should dispose of the remaining drug properly.
It shouldnt be saved just in case the patient gets ill in
the future. He or she should be examined properly to see
if an antibiotic is necessary at that time.
Antibiotics shouldnt be shared or given to others. Others
may have the same symptoms, but its important that they
be examined properly to see if an antibiotic is necessary
for them.
Its important to understand antibiotic resistance and the steps
we can all take to try to prevent it.
The major classes of antibiotics that well discuss are
Penicillins
Cephalosporins
Macrolides
Tetracyclines
Aminoglycosides
Well also present other antibiotics that dont fit in these
major classes but are important drugs, nonetheless.
63
Penicillins. These drugs were discovered in a mold of the
genus Penicillum notatum by Sir Alexander Fleming in 1928.
The penicillins are also called beta-lactams because the
chemical structure of all penicillins contains a beta-lactam
ring, as shown in Figure 21.
Penicillin was found to be very effective in eradicating
pathogenic organisms that cause serious and sometimes
life-threatening infections. Since the discovery of the original
penicillin, many derivatives have been made from the natu-
ral products found in the penicillum mold. The pencillin
family is divided into the original penicillins, penicillinase-
resistant penicillins, aminopenicillins, and extended-spectrum
penicillins. Figure 22 shows these divisions and lists some
examples.
The spectrum of activity of an antibiotic indicates the range
of organisms that are susceptible to the antimicrobial effects
of the antibiotic. A narrow range usually indicates effects
against gram-positive bacteria only. A broad range usually
indicates effects against gram-positive and gram-negative
bacteria. The penicillinase-resistant penicillins are so called
because they resist an enzyme secreted by bacteria called
penicillinase. Penicillinase is an enzyme that can ordinarily
destroy the penicillin molecule, rendering it ineffective. The
extended-spectrum penicillins are so called because they
eradicate a broad range of pathogenic bacteria.
FIGURE 21The Beta-
Lactam Ring of Penicillin
64
Several penicillin-containing products combine a penicillin
with either potassium clavulanate, sulbactam, or tazobactam.
These compounds inhibit penicillinase and protect the peni-
cillin from breakdown by the penicillinase enzyme. They also
extend the antimicrobial spectrum of the penicillin to include
bacteria that would normally be resistant to the penicillin.
Cephalosporins. The cephalosporin group of antibiotics is
pharmacologically and chemically related to the penicillins.
Like the penicillins, the cephalosporins also contain a beta-
lactam ring (Figure 23). The cephalosporins are classified into
four different generations. Each generation differs from the
others in its position on the spectrum of antimicrobial activ-
ity and the cost of the medication.
First-generation cephalosporins are active against gram-
positive organisms and against some gram-negative organisms.
Second-generation agents have a broader spectrum of activity
CATEGORIES OF PENICILLINS
Drug Name Brand Name Classification Route
penicillin G Bicillin C-R, Pfizerpen Natural penicillin IM, IV
penicillin V Pen-Vee K, Veetids, V-Cillin-K Natural penicillin Oral
dicloxacillin N/A Penicillinase-
resistant Oral
naficillin N/A Penicillinase-
resistant IV
amoxicillin Amoxil, Trimox Aminopenicillin Oral
amoxicillin/ Augmentin Aminopenicillin Oral
clavulanate potassium
ampicillin Principen Aminopenicillin Oral, IM, IV
ampicillin/ Unasyn Aminopenicillin IM, IV
sulbactam
piperacillin/ Zosyn Extended-spectrum IV
tazobactam
ticarcillin/clavulanate Timentin Extended-spectrum IV
FIGURE 22Categories of Penicillins
65
against gram-negative organisms, and third- and fourth-
generation drugs have an even broader spectrum of activity
against gram-negative organisms. The cost of the drugs
significantly increases with each generation. Figure 24 sum-
marizes the four generations of cephalosporin antibiotics.
Tetracyclines, macrolides, and aminoglycosides. Refer to
Figure 25, which lists the specific drugs within three classes
of antibiotics: tetracyclines, macrolides, and aminoglycosides.
The tetracyclines are a series of chemically related compounds
used to treat a broad spectrum of infections. Tetracyclines
are bacteriostatic, meaning that while they dont kill bacteria
outright, they prevent the growth of the bacteria. In addition
to treating active infections, tetracycline antibiotics are often
used long term by patients who suffer from severe acne.
The erythromycins are known as macrolide antibiotics since
theyre chemically composed of a large molecule. Theyre
effective in treating infections that are susceptible to peni-
cillins since they have similar spectrums of action. The
macrolides are often the drugs of choice for people who are
allergic to penicillin. A newer class of drugs, the ketolides, are
structurally similar to the macrolides. Ketek (telithromycin) is
a ketolide.
The aminoglycosides are a series of compounds that share
similar chemical and pharmacological properties. Amino-
glycosides have a broad spectrum of activity. Aminoglycosides
are associated with significant otoxicity and nephrotoxicity,
meaning that they can cause damage to hearing (including
deafness) and damage to the kidneys. Patients on amino-
glycosides must be monitored to be sure that drug levels are
in a safe range.
FIGURE 23The Beta-Lactam
Ring of Cephalosporin
66
CATEGORIES OF CEPHALOSPORINS
FIRST-GENERATION CEPHALOSPORINS
Drug Route Brand Name
cephalexin Oral Keflex, Keftab
cefadroxil monohydrate Oral Duricef
cefazolin IM, IV Ancef, Kefzol
SECOND-GENERATION CEPHALOSPORINS
cefaclor Oral Ceclor, Keflor
cefpodoxime proxetil Oral Vantin
cefprozil Oral Cefzil
cefuroxime sodium Oral, IM, IV Ceftin, Kefurox, Zinacef
loracarbef Oral Lorabid
THIRD-GENERATION CEPHALOSPORINS
cefixime Oral Suprax
cefoperazone sodium IM, IV Cefobid
ceftriaxone sodium IM, IV Rocephin
cefotaxime sodium IM, IV Claforan
FOURTH-GENERATION CEPHALOSPORINS
cefepime hydrochloride IV Maxipime
FIGURE 24The Cephalosporin Family
67
CATEGORIES OF ANTIBIOTICS: TETRACYCLINES,
MACROLIDES, AND AMINOGLYCOSIDES
TETRACYCLINES
demeclocycline hydrochloride Oral Declomycin
doxycycline hyclate Oral, IV Doryx, Vibramycin
minocycline hydrochloride Oral, IV Minocin
tetracycline hydrochloride Oral Sumycin
MACROLIDES
azithromycin Oral, IV Zithromax, Z-Pak
clarithromycin Oral Biaxin
erythromycin base Oral Ery-Tab, ERYC
erythromycin estolate Oral Ilosene
erythromycin ethylsuccinate Oral E.E.S., EryPed
erythromycin stearate Oral Erythrocin Stearate
AMINOGLYCOSIDES
amikacin sulfate IM, IV Amikin
gentamicin sulfate IM, IV, intrathecal Garamycin
kanamycin sulfate Oral, IM, IV,
intraperitoneal, inhalation Kantrex
neomycin sulfate Oral Mycifradin
streptomycin sulfate IM Streptomycin
tobramycin sulfate IM, IV Nebcin, Tobi
paromomycin sulfate Oral Humatin
FIGURE 25Other Important Antibiotic Families
68
Additional Anti-infectives
Our study of anti-infectives continues with the anaerobic,
quinolone, and carbapenem anitbacterials, as well as other
miscellaneous antibacterials. In addition, well look at the
sulfa-type antibacterials, antitubercular agents, antifungals,
antivirals, antiretroviral agents, antimalarial drugs, and
drugs used to treat trichomonas and intestinal parasites.
Refer to Figures 26, 27, and 28 as you learn about these
important anti-infectives.
Anaerobic antibacterials. Anaerobic antibacterials are
useful in the treatment of infections caused by anaerobic
organisms. Clindamycin, whose brand name is Cleocin, is
effective in the treatment of infections that resist other anti-
biotics such as erythromycins and penicillins. Metronidazole
(Flagyl) is an agent that has long been used to treat proto-
zoal infections such as trichomonas infections. Its also
useful in the treatment of serious anaerobic infections.
Quinolone antibacterials. The quinolone antibacterials are
extremely effective broad-spectrum antibacterials that are
used to treat infections that dont respond to other anti-
bacterials or antibiotics. Most of the oral quinolones can bind
to calcium or magnesium, so its important to tell patients to
separate these drugs from vitamins, antacids, and foods that
contain calcium.
Carbapenem antibacterials. The carbapenem antibacterials
are related to penicillins in that they also contain a beta-lac-
tam ring. These drugs have a broad spectrum and are often
used as the antibiotics of last resort in very serious infections
where other antibiotics have failed. Patients on carbapen-
ems are usually in a hospital or other skilled care facility.
Miscellaneous antibacterials. Aztreonam (Azactam) is use-
ful in the treatment of serious gram-negative infections.
Chloram-phenicol is reserved for very limited use such as
typhoid fever. Vancomycin is a powerful agent usually
reserved as a last line of defense when all other antibacterials
or antibiotics have failed. Tigecycline is related to the tetracy-
clines and is reserved for more serious infections.
Nitrofurantoin is specifically used to treat urinary tract infec-
tions.
69
ANTIBACTERIAL DRUGS
ANAEROBIC ANTIBACTERIALS
clindamycin HCl Oral Cleocin HCl
metronidazole HCl Oral, IV Flagyl, Protostat
QUINOLONE ANTIBACTERIALS
ciprofloxacin HCl Oral, IV Cipro, Proquin XR
norfloxacin Oral Noroxin
ofloxacin Oral, IV Floxin
levofloxacin Oral, IV Levaquin
moxifloxacin Oral, IV Avelox
CARBAPENEM ANTIBACTERIALS
meropenem IV Merrem IV
imipenem/cilastatin IM, IV Primaxin, Tienam
ertapenem IM, IV Invanz
doripenem IV Doribax
MISCELLANEOUS ANTIBACTERIALS
aztreonam IM, IV Azactam
chloramphenicol IV Chloromycetin
vancomycin Oral, IV Vancocin
tigecycline IV Tygacil
nitrofurantoin Oral Macrobid,
Macrodantin
rifampin Oral Rifadin, Rimactane
FIGURE 26Important
Antibacterial Drugs
70
Antitubercular drugs. Antitubercular drugs are specifically
used to treat tuberculosis, a highly contagious disease caused
by a specific bacterium that thrives inside the lungs. Some
typical antitubercular drugs include isoniazid (also known as
INH) and rifampin.
Antifungals. Fungal infections differ from bacterial infections
in that theyre more difficult to eradicate. Specific drugs are
required to effectively cure fungal infections. Since many
fungal infections are on the skin, several antifungals are
available in topical forms (creams, ointments, lotions,
shampoo). This allows the drug to be applied directly to the
site of infection.
Antivirals. Viruses are responsible for many infections
ranging from the common cold to acquired immunodeficiency
syndrome (AIDS). Some drugs specifically treat viral infections.
Amantadine and oseltamivir phosphate (Tamiflu) are used to
treat influenza. Acyclovir (Zovirax), famciclovir (Famvir), and
valacyclovir (Valtrex) are used to treat infections caused by
the herpes virus, including genital herpes, oral herpes (cold
sores), and herpes zoster (shingles).
Antiretroviral agents. Antiretroviral agents are specifically
used to treat HIV (human immunodeficiency virus). This is
the virus responsible for causing AIDS. The drugs listed are a
very small sample of the many treatment options that are
available to treat HIV. HIV therapy is constantly evolving and
treatment constantly changes to respond to how the virus
changes in the body. There are many drugs available that are
combinations of medication to try to cut down on the number
of pills the patient has to take in a day. Some of these drugs
are very toxic, and many of them have black-box warnings.
Antimalarials. Malaria is caused by a parasitic organism
that infects the blood and specific organs such as the liver.
The following drugs are used to eradicate the malarial para-
site: chloroquine (Aralen), pyrimethamine (Daraprim),
quinacrine (Atabrine), and quinine.
71
Antiparasitic drugs. Metronidazole is the most effective
drug in the treatment of trichomoniasis, primarily a parasitic
disease of the vagina. Helminthiasis, an infestation of para-
sitic worms that infect the gastrointestinal (GI) tract, is
believed to be the most common form of parasitic disease
that affects humans. Anthelmintic drugs are useful for era-
diticating the worms that cause helminthiasis. Antiparasitic
drugs include praziquantel (Biltricide), pyrantel pamoate
(Antiminth), thiabendazole (Mintezol), and mebendazole
(Ovex, Vermox, Antiox and Pripsen).
ANTI-INFECTIVE DRUGS
ANTITUBERCULAR DRUGS
Drug Brand Name
aminosalicylate sodium Sodium P.A.S.
capreomycin sulfate Capastat Sulfate,
Capreomycin (IM)
cycloserine Seromycin
ethambutol Myambutol
isoniazid Nydrazid
rifabutin Mycobutin
rifampin Rimactane, Rifadin
ANTIFUNGALS
Drug Brand Name
nystatin Mycostatin
miconazole Monistat
ketoconazole Nizoral
fluconazole Diflucan
itraconazole Sporanox
griseofulvin Fulvicin
ANTIVIRALS
Drug Brand Name
amantadine Symmetrel
acyclovir Zovirax
zidovudine Retrovir, AZT
didanosine Videx
stavudine Zerit
oseltamivir Tamiflu
famciclovir Famvir
valacyclovir Valtrex
FIGURE 27Anti-infective
Drugs Used to Treat
Various Conditions
72
Sulfa drugs. The sulfa drugs (or sulfa-type antibacterials)
get their name from the fact that theyre all derivatives of
sulfanilamide, an antibacterial that was first used in the
1930s. The molecule contains the sulfur atom, hence the
name sulfa drugs. Sulfa drugs are most effective in the
treatment of genitourinary tract infections and cystitis
conditions. Vancomycin is also often used to treat MRSA
(methicillin-resistant staph aureus) infections.
Corticosteroid Preparations
Corticosteroids are powerful anti-inflammatory agents used
to treat a variety of diseases associated with inflammation.
A wide variety of corticosteroids on the market are used as
inhalants, intranasal applications, tablets to be taken orally,
and topical creams and ointments to be applied locally.
Figure 29 lists these product forms and the representative
corticosteroids within each product category.
Corticosteroids promptly relieve symptoms associated with
many allergic conditions, including bronchial asthma, allergic
rhinitis, hay fever, reactions to drugs, and allergic dermatitis.
The inhalant and intranasal products are useful in treating
and controlling bronchial asthma, allergic rhinitis, and hay
fever.
Anti-inflammatory medications used in asthma inhalers help
prevent asthma attacks by reducing swelling and mucus pro-
duction in the airways. Popular corticosteroids delivered
through an inhaler include Advair, Aerobid, Azmacort,
SULFA-TYPE ANTIBACTERIALS
sulfadiazine Oral Sulfadiazine
sulfamethizole Oral Thiosulfil Forte
sulfasalazine Oral Azulfidine
sulfisoxazole Oral Gantrisin
sulfamethoxazole Gantanol
sulfamethoxazole w/ Oral Bactrim, Septra
trimethoprim
FIGURE 28Important
Sulfa-Type Drugs
73
CORTICOSTEROID PREPARATIONS
INHALANTS
Drug Brand Name
beclomethasone QVAR
fluticasone Advair, Flovent
flunisolide Aerobid
INTRANASAL
Drug Brand Name
fluticasone Flonase
budesonide Rhinocort
beclomethasone Beconase, Vancenase
TABLETS TAKEN ORALLY
Drug Brand Name
methylprednisolone Medrol
prednisone Deltasone
prednisolone Prelone
dexamethasone Decadron
betamethasone Celestone tablets
TOPICALS (CREAMS AND OINTMENTS)
Low Potency
Drug Brand Name
alclometasone Aclovate
dexamethasone Decadron
Medium Potency
Drug Brand Name
betamethasone Diprosone, Diprolene
Valisone
fluocinolone Synalar
fluticasone Cutivate
High Potency
Drug Brand Name
fluocinonide Lidex
triamcinolone Aristocort
halcinonide Halog
Very High Potency
Drug Brand Name
clobetasol Temovate
halobetasol Ultravate
FIGURE 29Corticosteroid
Anti-inflammatories
74
Flovent, Pulmicort, QVAR, and Symbicort. Though not as
effective as the inhaled cortico-steroids, Intal and Tilade,
which are mast cell stabilizers, are also used to prevent
allergic reaction and provide asthma relief.
The topical corticosteroid products relieve many allergic and
inflammatory symptoms associated with dermatologic disor-
ders. The topicals are divided into four degrees of potency:
low, medium, high, and very high.
For several chronic conditions such as rheumatoid arthritis,
systemic cortiosteroids are taken in the form of tablets and
are generally used only after initial therapy with noncortico-
steroid agents.
Topicals
Eyedrops and eyewashes. Eyedrops are most commonly
used to treat irritation and dryness of the eye. Eyewashes are
used to flush and bathe the eye, usually to remove foreign
particles or chemical irritants. Well discuss eyedrops and
eyewashes in more detail when we cover drugs related to the
sensory system.
Sunburn preparations. Sunburn is caused by an abun-
dance of ultraviolet rays hitting the skin. Mild sunburn is
tender to the touch, and the patient may complain of a hot,
tight feeling to the skin. A patient with more severe sunburn
may experience intense pain, inability to tolerate contact with
clothing, and symptoms of fever and chills (Figure 30).
Local anesthetics are useful in relieving the pain associated
with sunburn. Protectants are often included with the anes-
thetic to provide additional relief for the burning sensation.
These protectants include cocoa butter, glycerin, shark liver
oil, and petrolatum (petroleum jelly).
75
Sunscreen lotions and creams. The uses of sunscreens
(suntan lotions) are to prevent sunburn and aid in the
development of a suntan. They also protect exposed areas of
the body in susceptible individuals from the long-term haz-
ards of skin cancer and premature aging. An important
measure of sunscreens is the SPF factor (sun protection fac-
tor). The SPF factor is a number ranging from 1 to 50. The
higher the number, the greater the protection from the suns
rays. For example, an individual who always burns and never
easily tans would require an SPF factor of 15 or more. The
Skin Cancer Foundation recommends using a product with an
SPF factor of 15 or more before every exposure to the sun.
Many individuals sometimes burn and tan gradually.
FIGURE 30There are several
products on the market that
contain a local anesthetic to
reduce the pain associated
with sunburn.
76
There are three types of sunscreens:
Sunscreensunburn preventive agents
Sunscreensuntanning agents
Sunscreenopaque sunblock agents
Most of the products on the market contain a combination of
the first two types of agents. The opaque sunblock agents are
visible when applied to the skin. Theyre used by people who
cant tolerate any exposure to the sun. Zinc oxide ointment is
the favored sunblock. More than 20 chemical agents have
been proven to be effective as sunscreens and sunblocks.
These chemicals include aminobenzoic acid, ethylhexyl
paramethoxy cinnamate, and methyl anthranilate. The com-
mercial products all contain one of these agents, or a
combination of several agents.
External analgesics. These topically applied agents have
analgesic, anesthetic, and anti-itching effects (counterirritant
effects). The first two effects result in the depression of the
skin receptors for pain, itching, and burning. They also
reduce these symptoms caused by burns, cuts, abrasions,
insect bites, and skin lesions. Topical analgesics and anes-
thetics include benzocaine, tetracaine, dibucaine, lidocaine,
benzyl alcohol, and dyclonine hydrochloride. Topical anti-
itching agents include diphenhydramine and tripelennamine.
Topical hydrocortisone is an effective alternative to the anes-
thetics such as benzocaine and diphenhydramine.
Counterirritant effects, the third type of analgesic effects, are
the mainstays of these external products. These products are
applied locally to produce a mild, local, inflammatory reaction
with the objective of providing relief in another site, usually
next to or underlying the skin surface being treated. The
counterirritant drug is usually applied to the skin where pain
is experienced.
The counterirritants that are components of commercial anal-
gesic rubs are
Eucalyptus oil
Methyl salicylate
Turpentine oil
77
Menthol
Camphor
Capsicum preparations
There are several agents available to treat and help heal cold
sores. If you look at the active ingredients, many of these
preparations contain an astringent, or drying agent (benzyl
alcohol, zinc sulfate); a protectant (dimethicone); a counter-
irritant to help with itching (menthol, camphor, phenol); and
a topical anesthetic to help numb the area (benzocaine,
dyclonine, dibucaine). One product, however, is different.
Docosanol (Abreva) is the only product that has antiviral
properties, thus it helps to shorten the severity and duration
of cold sores.
Topical anti-infectives. These products are used to coun-
teract local infection of the skin; their active ingredients are
antibacterial or antifungal drugs. Most bacterial infections
occur as localized skin infections and are caused by staphlo-
coccus strains of organisms. Additional types of bacteria-
causing skin infections are gram-negative anaerobes, which
are microorganisms that wont grow in the presence of oxygen.
Fungal organisms arent the same as bacterial organisms,
and fungi cause longer infections that are sometimes more
difficult to eliminate. Antibacterial components of these prod-
ucts include bacitracin, polymyxin B sulfate, and neomycin.
The antifungal components of these topicals include unde-
cylenic acid and miconazole. The antiviral docosanol is a
component in the cold sore medication Abreva.
There are also many topical products available for the treat-
ment of vaginal yeast infections. The active ingredients in
these preparations are antifungals, and are avaliable as
creams and vaginal suppositories for internal use. Many of
these also come with a small tube of cream for external use
for relief of itching and discomfort. There are seven-day,
three-day, and one-day regimens available. Some active
ingredients include miconazole, butoconazole, clotrimazole,
and tioconazole.
Corticosteroid topicals. Topical corticosteroids are avail-
able over the counter to treat atopic dermatitis and contact
dermatitis. Atopic dermatitis is one of the most common skin
78
disorders seen in children and young adults. Symptoms of
atopic dermatitis are scaling of the skin, reddening and weep-
ing of the skin, and serious itching. The cause is unknown.
Contact dermatitis is a condition in which all the above skin
symptoms occur because of contact with an offending sub-
stance such as poison ivy, soap powders, or latex gloves.
Hydrocortisone creams and ointments are effective in treating
these two types of dermatitis.
The principal use of hydrocortisone is to relieve itching, This
action results from its anti-inflammatory nature. The official
indication for topical hydrocortisone is temporary relief of
itching associated with minor skin irritations, inflammation,
and rashes due to dermatitis, insect bites, poison ivy, poi-
son oak, soaps, detergents, cosmetics, and jewelry. Its also
indicated for external genital, feminine, and anal itching.
Hydrocortisone is a steroid that will act to prevent further
inflammation but wont reverse existing inflammation. The
effective concentration of hydrocortisone for treatment of der-
matitis is 0.25 to 0.5 percent cream.
Hydrocortisone should be applied sparingly three to four
times daily. The term sparingly is used to describe an appli-
cation of very small amounts. Its important to note that
patients will tend to apply large amounts of hydrocortisone,
assuming that more is better. This practice isnt true, and
much of the cream goes to waste. The pharmacist should
instruct the patient to apply a thin film to the area and mas-
sage it into the skin thoroughly.
Musculoskeletal System
Muscle relaxants relieve pain and stiffness of skeletal mus-
cles; theyre used extensively for orthopedic disorders,
injuries, and back pain. Actually, these drugs are various
types of sedatives and tranquilizers that affect the central
nervous system rather than directly relaxing the muscles.
Skeletal muscle relaxants are drugs used to overcome painful
muscle spasms in the skeletal muscle network. This group of
drugs is tremendously effective in treating conditions such as
lower back muscle pain, pulled hamstring muscles, abdominal
muscle spasms, and quadriceps muscle spasms. In addition,
79
when taken with the anti-inflammatory analgesics, skeletal
muscle relaxants effectively relieve the associated pain and
inflammation.
Muscles become sore, inflamed, and spastic through overuse,
and this results in pain and tenderness. Spasticity specifically
occurs as a result of muscular cramps in well-conditioned
athletes and normal individuals for no apparent reason. At
any time, muscle spasticity affects approximately six million
people in the United States. Skeletal muscle relaxants
are classified in two categoriesnonbenzodiazepines and
benzodiazepines. Representative drugs within each category
are listed in Figure 31. Cyclobenzaprine (Flexeril) and
methocarbamol (Robaxin) are two of the more popular muscle
relaxants. Diazepam (Valium) is the benzodiazepine most
often used to achieve muscle relaxation. This drug is pre-
ferred over the others if the patient experiences an anxiety
that requires the tranquilizing actions of a benzodiazepine.
SKELETAL MUSCLE RELAXANTS
NONBENZODIAZEPINES
Drug Brand Name
metaxalone Skelaxin
carisoprodol Soma
cyclobenzaprine Flexeril
methocarbamol Robaxin
orphenadrine Norflex
chlorzoxazone Parafon Forte
BENZODIAZEPINES
Drug Brand Name
diazepam Valium
tetrazepam Clinoxan, Myolastan
FIGURE 31The Family
of Muscle Relaxants
80
Cardiovascular System
A variety of subclassifications apply to drugs that act on the
heart and blood vessels. The term tonic refers to a tone, and
cardiotonics are drugs that restore the heartbeat to its normal
force and efficiency.
Remember what cardiac arrhythmias are? Antiarrhythmic
drugs are given to correct variations from normal heart
rhythms. Some work as beta-blockers, that is, blocking the
action of epinephrine that may be overexciting the heart and
blood vessels. Others are calcium-channel blockers, which
block entrance of calcium into cells.
As you may know, high blood pressure is called the silent
killer. But if its detected and brought under control by
lifestyle changes and drug therapy, the hypertensive individ-
ual can live a long and healthy life. Beta-blockers and
calcium-channel blockers also act as antihypertensives.
Diuretics are antihypertensives because they cause the kid-
neys to excrete more urine from the body, resulting in a lower
volume of blood in the body and less pressure on the blood
vessels.
Vasodilators act as antihypertensives by widening blood ves-
sel walls, allowing blood through without needing excessive
pressure. Vasodilators are also effective against angina
attacks, as are beta-blockers and calcium-channel blockers.
In contrast, vasoconstrictors narrow the blood vessels and
raise blood pressure. Obviously, this wouldnt be desirable in
most cardiovascular diseases. But its sometimes necessary
to get blood moving during cardiac or respiratory failure. And
since the bronchial tubes will dilate to bring in more oxygen
when the blood supply is low, vasoconstrictors are effective in
the treatment of bronchial asthma.
Of course, atherosclerosis is a factor in many cardiovascular
diseases, and cholesterol contributes to atherosclerosis, so
cholesterol-lowering drugs are important, too. They work by
reducing the livers fat-production capacity and increasing
the amount of cholesterol eliminated in feces.
81
Anticoagulants may be used to break up clots formed within
blood vessels; thus, they are effective for patients with throm-
bosis and/or embolism. Also, anticoagulants can prevent clot
formation in susceptible patients and in donated blood thats
being stored for transfusions. A natural anticoagulant pro-
duced by the liver and white blood cells is heparin. If the
patient receives an overdose of anticoagulant or has a clot-
ting deficiency, a coagulant will be given to promote normal
blood clotting. Anemic patients may be given hematinics to
improve the quality of blood.
Antihypertensives
High blood pressure, or hypertension, affects millions of people
in the United States. No one knows what causes most forms
of high blood pressure. Its known, however, that if left
untreated, high blood pressure leads to additional cardio-
vascular diseases such as stroke, renal failure, and heart
failure. Its imperative to return high blood pressure to a
normal level. High blood pressure can sometimes be lowered
through weight loss, exercise, and reduction of salt intake.
Often, however, drugs must be used to lower high blood
pressure. Because there are many hypertensive individuals,
blood pressure medicines are dispensed frequently.
Antihypertensive drugs work in several ways to lower high
blood pressure. They dilate (open up) the arteries, which
results in a lowering of the blood pressure. This occurs
because arteries are often constricted, causing the pressure
inside them to rise. Antihypertensives open up the constricted
arteries, thus decreasing the pressure within the arteries.
The drugs that dilate constricted arteries are angiotensin-
converting enzyme (ACE) inhibitors, angiotensin II receptor
blockers (ARBs), calcium channel blockers (CCBs), and others
such as alpha 1 receptor blockers.
Secondly, some antihypertensives act on the heart to reduce
the amount of blood volume thats pumped into the arteries.
Less fluid volume within the arteries usually results in less
pressure within the cardiovascular system. Drugs that act on
the heart to reduce blood outflow are called beta adrenergic
blocking agents (beta blockers).
82
Other drugs, called diuretics, help to reduce blood pressure
by decreasing the volume of fluid in the plasma. These drugs
are often combined with antihypertensives to increase the
antihypertensive effect. Refer to Figure 32 as we take a brief
look at the various categories of blood pressure medications.
BLOOD PRESSURE MEDICATIONS
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
Drug Brand Name
enalapril Vasotec
lisinopril Prinivil, Zestril
benazepril Lotensin
ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs)
Drug Brand Name
candesartan Atacand
eprosartan Tevetan
irbesartan Avapro
telmisartan Micardis
valsartan Diovan
losartan Cozaar
CALCIUM-CHANNEL BLOCKERS (CCBs)
Drug Brand Name
nifedipine Adalat, Procardia
diltiazem Cardizem, Tiazac
amlodipine Norvasc
BETA BLOCKERS
Drug Brand Name
atenolol Tenormin
metoprolol Lopressor, Toprol
propranolol Inderal
MISCELLANEOUS
Drug Brand Name
prazosin Minipress, Vasoflex
doxazosin Cardura
FIGURE 32Categories of
Blood Pressure Medications
83
Angiotensin-converting enzyme (ACE) inhibitors. ACE is
present in the blood. Ordinarily, it causes production of a
very powerful constricting substance that contributes to high
blood pressure. ACE inhibitors block the actions of this
enzyme, causing dilation of the blood vessels and reduction
of blood pressure.
These drugs have a beneficial effect on the kidneys and are
very effective in the treatment of hypertension. One of the
more annoying side effects of ACE inhibitors is a dry cough.
The names of ACE inhibitors end in pril. For example,
enalapril, lisinopril, and benazepril are the generic names for
three popular ACE inhibitors.
Related to the ACE inhibitors are the angiotensin-2 receptor
blockers, or ARBs. ARBs prevent angiotensin-2 from binding
to receptors, and therefore reduce blood pressure by prevent-
ing vasoconstriction. Although its possible, ARBs arent as
likely to produce the dry cough that many ACE-inhibitors do.
Popular drugs in this class include Diovan (valsartan),
Avapro (irbesartan), and Cozaar (losartan). Notice that the
generic names of all of the ARBs end in sartan.
Calcium-channel blockers (CCBs). These drugs lower blood
pressure by causing constricted blood vessels to dilate. These
drugs cause dilation by blocking the uptake of calcium
through channels in cell membranes. The smooth muscle
cells that line the arteries utilize calcium to cause tightening
within the blood vessels. The blockade of calcium by CCBs
eases this tightening effect and leads to dilated blood vessels
and lower blood pressure. Three popular CCBs used to treat
hypertension are nifedipine (Procardia), diltiazem (Cardizem),
and amlodipine (Norvasc).
Beta adrenergic receptor blockers. These drugs work in
the heart to force large volumes of blood into circulation. The
blockade of these receptors by beta-blocking drugs prevents
the outflow of large volumes of blood, and blood pressure is
reduced. The names of beta adrenergic receptor blockers end
in olol. Three popular beta blockers are atenolol, metoprolol,
and propranolol.
84
Other antihypertensives. There are other ways to cause
dilation of the arteries. Drugs that dont fit into the previous
categories are found in the alpha-blocker class of antihyper-
tensives. Two popular drugs in this category are prazosin
(Minipress, Vasoflex) and doxazosin (Cardura). They block
alpha receptors within the arterioles to cause vasodilation, or
widening of the blood vessels. In addition to reducing blood
pressure, these drugs are often used to treat problems asso-
ciated with an enlarged prostate (Figure 33).
Antilipemics
Antilipemics are cholesterol-lowering drugs. Cholesterol is
believed to contribute to atherosclerosis, a condition where
plaque builds up in the arteries. Atherosclerosis is related to
many heart problems and thus these drugs are important for
managing heart health. Well discuss antilipemics in more
detail later in this study unit.
FIGURE 33An enlarged
prostate is one of the
most common health
problems in older men.
85
Heart Medicines and Anticoagulants
Heart medicines work on the heart to overcome congestive
heart failure, to reverse arrhythmias (irregular heartbeats),
and to prevent angina (severe chest pain) attacks. This cate-
gory also includes the anticoagulants because they prevent
strokes and heart attacks in survivors of these two condi-
tions. Cardiac glycosides are drugs that overcome congestive
heart failure. Drugs that reverse arrhythmias are called
antiarrhythmics, and drugs that prevent angina are called
antianginals. The anticoagulant class of heart medicines is
often referred to as blood thinners. Refer to Figure 34 as you
learn about various heart medications.
HEART MEDICINES
CARDIAC GLYCOSIDES
Drug Brand Name
digitoxin Crystodigin
digoxin Lanoxin
ANTIARRHYTHMICS
Drug Brand Name
amiodarone Cordarone
quinidine Cardioquin,
Quinidex
verapamil Calan, Isoptin
digoxin Lanoxin
propafenone Rythmol
sotalol Betapace
acebutolol Sectral
propranolol Inderal
ANTIANGINALS
Drug Brand Name
isosorbide dinitrate Isordil, Sorbitrate
isosorbide mononitrate Imdur, ISMO
nitroglycerin Nitrostat
propanolol Inderal
bepridil Vascor
nifedipine Adalat, Procardia
ANTICOAGULANTS
Drug Brand Name
warfarin Coumadin
heparin Hep-Lock,
Liquaemin
enoxaparin Lovenox
FIGURE 34Categories of
Heart Medicines
86
Cardiac glycosides. This collective term describes the fam-
ily of digitalis drugs that comes from the Digitalis lanata or
Digitalis purpura plants. These drugs specifically treat a fail-
ure of the heart known as congestive heart failure. Congestive
heart failure results from a weakened heart that loses the
force of muscle contraction. As a result, the blood isnt
pumped adequately through the circulatory system and the
venous blood doesnt effectively return to the heart from
peripheral circulation or from the lungs. The lack of venous
return results in the collection of fluids in the tissues and
lungs, which causes peripheral and pulmonary edema. The
digitalis family of drugs increases the pumping action of the
heart and is one of the primary treatments for congestive
heart failure. Digitoxin and digoxin are the two cardiac gly-
coside drugs that are dispensed for patients with a history of
congestive heart failure. These drugs are often referred to as
cardiotonics.
Antiarrhythmics. Theres a diverse group of drugs that
reverses the disorderly pattern of heartbeats. As long as the
patient takes the drug, an orderly beating pattern is main-
tained. Cardiac arrhythmias are disorders of electrical impulse
conduction throughout the heart. The beating of the heart is
initiated and stimulated by electrical impulses from the
sinoatrial node, which is located in the muscle of the right
atrium. This node is known as a natural pacemaker.
Electrical impulses ordinarily occur in the heart muscle to
allow for a smooth pattern of heartbeats.
When the electrical conduction becomes disorderly, the
normal beating pattern is lost and heart rhythm changes.
The following drugs are commonly used to treat arrhythmias:
quinidine, verapamil (Calan), digoxin, propafenone (Rythmol),
sotalol (Betapace), and acebutolol (Sectral). The many drugs
that are used to manage and correct arrhythmia do so by
several different complicated mechanisms.
Antianginals. Nitrates such as nitroglycerin dilate the coro-
nary blood vessels to allow for adequate oxygen flow to the
heart muscle. Such dilation is necessary in conditions of car-
diac oxygen deprivation, which results in angina. Angina
refers to a syndrome of the heart called angina pectoris. This
syndrome is characterized by an intense pain in the heart
87
region thats caused by a lack of oxygen in the heart muscle.
Angina is an imbalance between oxygen demand and oxygen
supply in the heart muscle. The classic symptoms of an
angina attack are tightness of the chest, excruciating pain in
the chest, shortness of breath, and the radiation of pain
down the left arm.
Angina isnt the same as the classical heart attack, known as
myocardial infarction. Angina is characterized by a lack of
oxygen in the heart muscle (ischemia), which occurs because
the diseased coronary arteries cant deliver enough oxygen to
meet the demand. Some angina attacks occur at rest and
arent associated with an increased myocardial demand. The
pain associated with this form of angina is believed to be
caused by reductions in oxygen supply due to coronary artery
spasm and coronary artery occlusion (Figure 35).
Nitroglycerin is the most commonly used drug for treatment of
angina. Its often prescribed in pill form and is placed under
the tongue for rapid effect during an angina attack. When
exposed to air and light, nitroglycerin degrades. This led to
the development of a nitro spray, which is contained in an
airtight cylinder until its sprayed under the tongue. Nitro-
glycerin is also prescribed in the form of a skin patch thats
worn to prevent a future angina attack. Other nitrates that
are prescribed to prevent angina attacks include isosorbide
dinitrate and isosorbide mononitrate.
FIGURE 35Patients
being treated for
myocardial infarction are
often given nitroglycerin,
which temporarily opens
arterial blood vessels,
improving blood flow to
and from the heart.
88
Other drugs that cause dilation of the coronary blood vessels
for the treatment of angina are bepridil (Vascor) and nifedipine
(Procardia), both of which are calcium-channel blockers. Beta
adrenergic receptor blockers, such as propranolol, are also
used to treat angina because they decrease the workload of
the heart.
Anticoagulants. These drugs reduce the bloods ability to
clot. These drugs are useful in treating conditions associated
with clot formation such as stroke and heart attack. By
reducing the bloods ability to clot, these drugs prevent the
likelihood of further strokes and heart attacks. Warfarin
(Coumadin) is an important oral drug in this class. Two of
the more common injectable anticoagulants include heparin
and Lovenox.
Diuretics
Diuretics are medicines that promote the excretion of sodium
along with large amounts of water from the kidneys. Medical
conditions in which the accumulation of water is harmful are
treated with diuretics. These conditions include high blood
pressure, congestive heart failure, and obesity. Diuretic drugs
are categorized according to their mechanisms of excreting
sodium and water. These categories are thiazide diuretics,
carbonic anhydrase inhibitors, loop diuretics, and potassium-
sparing diuretics. The relationship between these four groups
of diuretics and their mechanisms of effect are illustrated in
Figure 36.
Thiazides. The thiazide diuretics are so called because of
the chemical nature of their molecules. They contain a sulfur
atom thats identified in chemistry as thia. Thus, thiazide
means sulfur-containing molecule. The thiazides promote
the excretion of the sodium atom from the kidney. The
sodium atom in turn carries large amounts of water with it,
and volumes of water are effectively released from the body.
Many patients who are on thiazide diuretics will also be on
potassium supplements, since the body tends to excrete
potassium along with sodium. Any drug name ending in thi-
azide is a thiazide diuretic. There are also thazide-like drugs
that, though chemically different than thiazides, are similar
in action, such as chlorthalidone. Thiazides are the most
89
widely used diuretic agents, and the drug hydrochlorothiazide
(HCTZ) is the most popular thiazide. Other common thiazides
include Indapamide (Lozol), and metolazone (Zaroxolyn).
Carbonic anhydrase inhibitors. Carbonic anhydrase is an
enzyme involved in the normal kidney function of urine forma-
tion and water retention. Inhibition of this enzyme results in
more water excretion than retention. Thus, diuresis occurs
with these drugs. Acetazolamide (Diamox) is the most com-
mon carbonic anhydrase inhibitor. Although these drugs are
classified as a type of diuretic, theyre more commonly used in
the treatment of glaucoma.
DIURETICS
THIAZIDES
Drug Brand Name
hydrochlorothiazide (HCTZ) Esidrix, Maxzide
HydroDIURIL
Indapamide Lozol
metolazone Zaroxolyn
chlorothiazide Diuril
CARBONIC ANHYDRASE INHIBITORS
Drug Brand Name
acetazolamide Diamox
LOOP DIURETICS
Drug Brand Name
furosemide Lasix
torsemide Demadex
bumetanide Bumex
POTASSIUM-SPARING DIURETICS
Drug Brand Name
triamterene with
hydrochlorothiazide Dyazide
amiloride Midamor
spironolactone Aldactone
FIGURE 36Categories
of Diuretics
90
Loop diuretics. The nephron is the functional unit of the
kidney where urine formation occurs. The portion of the
nephron thats shaped like a loop is called the loop of Henle.
This portion of the nephron contains the greatest concentra-
tion of urine. Actions at the loop by the group of drugs called
loop diuretics allow for the formation of large amounts of
urine. Therefore, large amounts of water are excreted. As
with the thiazides, patients on loop diuretics will also likely
be on potassium supplementation since potassium gets lost to
the urine along with sodium. Loop diuretics are the most
effective diuretics and are used when the passage of large
amounts of water is desired. Furosemide (Lasix) is the most
popular loop diuretic. Other useful loop diuretics are
torsemide (Demadex) and bumetanide (Bumex).
Potassium-sparing diuretics. The previously mentioned
diuretics not only excrete sodium and water, but they pull
potassium along with it. Loss of potassium is dangerous in
some patients, particularly if they have heart problems. Many
patients who take these diuretics also take extra potassium
in the form of supplemental tablets or in potassium-rich food
such as bananas. Potassium-sparing diuretics keep potassium
within the body so that the patient doesnt need potassium
supplements. Potassium-sparing diuretics arent as effective
as thiazides and loop diuretics, but some products combine
potassium-sparing diuretics and thiazides to improve efficacy
such as triamterene with hydrochlorothiazide (Dyazide). Other
potassium-sparing diuretics are amiloride (Midamor) and
spironolactone (Aldactone).
Respiratory System
Respiratory drugs are primarily used for opening bronchial
tubes and reversing the effects of histamines, which cause
the respiratory system to become inflamed. Antihistamines
oppose the action of histamine. Antitussives prevent or relieve
coughing, usually by acting on the medullary center of the
brain to inhibit the cough reflex. Decongestants reduce the
swelling of mucous membranes in nasal passages. Another
type of drug, expectorants, thins mucus secretions, allowing
them to drain or be more easily expelled from the system.
91
A major health care problem in the United States is the inap-
propriate use of antibiotics for respiratory conditions. Many
of the aforementioned diseases are viral in nature; they dont
respond to antibiotics. Only bacterial infections respond to
antibiotics. For example, someone with nasal drainage and
cough is likely to have a viral infection. But some clinicians
nevertheless prescribe antibiotics. Part of the problem is that
medical professionals face great public pressure to prescribe
antibiotics. When people see a doctor for an illness, they gen-
erally want a prescription medication that will cure it. This
pressure may influence some doctors to prescribe antibiotics
for viral illnesses. The other contributing factor is that some
viral infections are difficult to distinguish from bacterial
infections.
Prescribing antibiotics for these viral infections can lead to
several problems. First, the antibiotics are costly. Second,
they can cause significant side effects, such as rash, edema,
diarrhea, and yeast infection. The most serious problem is
that this practice encourages the emergence of antibiotic-
resistant bacteria. These bacteria arent affected by the usual
antibiotics. Infections caused by such antibiotic-resistant
bacteria are difficult to eradicate. A person who has been
exposed to multiple regimens of antibiotics can easily develop
a resistant infection. The most effective method of battling
this problem is the appropriate use of antibiotics. This means
that viral illnesses shouldnt be treated with antibiotics.
Instead, viral rhinitis, sinusitis, or bronchitis can be treated
with other medications, such as decongestants, bronchodila-
tors, and inhaled corticosteroids.
Antihistamines
Antihistamines work against histamine, which causes the
mucous membranes to become inflamed and produce fluid,
particularly in conditions of nasal and seasonal allergies.
This effect of histamine results from its action on specific
cell sites called histamine type 1 (H
1
) receptors. Histamine
also causes excess secretion of stomach acid and is partly
responsible for the secretion of stomach acid in conditions of
excess gastric acidity or heartburn. This effect of histamine
results from its action on specific cell sites in the stomach
92
called histamine type 2 (H
2
) receptors. Antihistamines can
block the actions of histamine at either the H
1
receptor sites
or the H
2
receptor sites. Blocking the H
1
receptor sites results
in the reduction and virtual elimination of allergy symptoms
associated with rhinitis. Blocking the H
2
receptor sites
results in decreased stomach acid production. Antihistamines
are subdivided into H
1
blockers and H
2
blockers. The H
1
blockers are used to treat allergy symptoms, and the H
2
blockers are used to treat gastric hyperacidity. The H
1
block-
ers are further subdivided into antihistamines that produce
sedation and drowsiness as a side effect, and antihistamines
that are nonsedating. Figure 37 lists the representative drugs
within the three subcategories of antihistamines. Many antihis-
tamines can now be purchased without a prescription.
Bronchodilators
Bronchodilators open up the airway passages to allow for bet-
ter air intake in conditions of asthma. Bronchodilators are
administered as inhalants dispensed from pressurized hand-
held containers and orally in the form of tablets and liquids.
Asthma inhalers can deliver medicine via metered-dose
inhalers (MDIs) and dry-powder inhalers (DPIs). These drugs
are also available in nebulizer solutions that are delivered via
a nebulizer, which is a breathing machine that changes the
medication from a liquid to a mist for inhalation.
ANTIHISTAMINESH
1
BLOCKERS
H
1
BLOCKERS (SEDATING)
Drug Brand Name
chlorpheniramine Chlor-Trimetron
diphenhydramine Benadryl
H
1
BLOCKERS (NONSEDATING)
Drug Brand Name
loratadine Claritin, Alavert
certirizine Zyrtec
fexofenadine Allegra
FIGURE 37The Family
of Antihistamines
93
Bronchial asthma is a chronic condition that results in
wheezing and difficulty in breathing. Asthma is caused by a
partial obstruction of the bronchi and bronchioles due to the
contraction of the muscles in the bronchial walls. When the
bronchi become blocked, the mucous membranes become
swollen with fluid. Stale air then becomes trapped, and the
amount of new air that can enter the lungs becomes limited,
resulting in a characteristic wheezing sound.
In people suffering from bronchial asthma, a genetic factor
predisposes them to be hypersensitive to certain allergens.
These allergens include dust, pollens, animal dander, and
some foods. Attacks can even stem from infections, certain
drugs, vigorous exercise, and stress. Asthma is most common
in school-aged children, many of whom outgrow the disease.
Only two to three percent of the adult population has asthma,
for which theres no cure. Drugs that cause dilation of the
bronchi and bronchioles have been found to be effective in
reducing the symptoms of an asthmatic attack. The drugs
open the passages to allow for optimal air intake and breathing.
Inhalants act immediately to open the bronchi and bronchioles
because theyre administered directly to the bronchiolar site.
Representative inhalants and oral bronchodilators are listed
in Figure 38. The oral drugs are used to provide a constant
blood level of drug that maintains an intact open airway. An
open airway reduces the chances of an asthmatic attack. The
asthmatic patient will often take a theophylline medication
for long-term relief and have an inhalant handy for use in
case of a breakthrough asthmatic attack.
Cough, Cold, and Allergy Products
Antitussives and expectorants. A cough is usually associ-
ated with the common cold and is classified as productive or
nonproductive. A productive cough removes secretions and
phlegm from the lower respiratory tract. A nonproductive
cough is a dry cough in which secretions or phlegm isnt
present. OTC medicines used to stop coughs are called cough
suppressants.
94
The medical term for cough suppressants is antitussives.
Cough suppressants are taken by consumers when theres a
need to stop a persistent cough. The two cough suppressants
found in commercial products are codeine and dextromethor-
phan. Codeine is the most effective antitussive agent, to which
all antitussives are compared. Codeine cough medicines are
available by prescription only because of their narcotic content.
Dextromethorphan is the non-narcotic anticough medication
used in OTC cough medicines. Dextromethorphan affects the
cough center in the medulla, increasing the threshold at
which were stimulated to cough, which in turn makes us
cough less.
Expectorants act to decrease the viscosity (thickness) of the
sputum (saliva and respiratory discharge) in coughing condi-
tions. This action promotes ease of expectoration (the discharge
of matter from the throat). The most popular expectorant is
guaifenesin, which is also known as glyceryl guaiacolate.
Although not federally mandated, many retailers have
restricted the sale of products containing dextromethorphan
to persons over the age of 18 because dextromethorphan has
become a drug of abuse among the adolescent population. At
very high doses, dextromethorphan can cause euphoria and
hallucinations. These high doses are very dangerous and can
BRONCHODILATORS
INHALANTS
Drug Brand Name
levalbuterol Xopenex
albuterol Ventolin, Proventil
salmeterol Serevent
formoterol Foradil
TABLETS/LIQUIDS TAKEN ORALLY
Drug Brand Name
theophylline/aminophylline Elixophyllin, Quibron,
Slo-Bid, Theo-Dur,
terbutaline Brethaire, Brethine
albuterol Proventil
FIGURE 38Some
Inhalants and Oral
Drugs to Treat Asthma
95
cause death, especially since dextromethorphan is commonly
combined with other active ingredients that can also become
toxic at high doses.
Decongestants. The common cold, more than any other ill-
ness, is the reason time is lost from work and school. The
common cold is the most prevalent illness in the winter
months and accounts for one-half of all absences in the
workplace. The public buys hundreds of millions of dollars
of OTC cough and cold preparations each year. Children 1 to
5 years old are the most susceptible to the common cold and
may average up to 12 episodes per year. Individuals 25 to 30
years old average about six respiratory illnesses per year.
Viruses cause the common cold. Symptoms include fluid
accumulation in the nose and sinuses, profuse watery
discharge from the nose (rhinorrhea), sneezing, and fever.
Sneezing is caused by a combination of nasal irritation,
discharge, and congestion. It subsides when the secretions
clear. There are no curative remedies for the common cold,
and self-medication is intended to provide relief from the
symptoms of this ailment (Figure 39.
The major drug class used to treat colds is decongestants.
Decongestants are drugs that cause constriction of the blood
vessels in the nose. This action results in reduction of nasal
discharge as a result of vessel constriction. The drugs are
called sympathomimetic amines and are used either as nasal
sprays, tablets, or liquids.
Nasal decongestants are sprayed into the nose to cause con-
striction of the dilated blood vessels that produce congestion.
The constriction results in shrinkage of the swollen vessels and
the mucous membranes. This medication promotes drainage
and relieves stuffiness. Intranasal application of decongestants
provides prompt relief of nasal congestion. Shrinkage of the
mucous membranes not only makes breathing easier, but also
permits the sinus cavities to drain.
The following nasal decongestant agents are used in most com-
mercial products:
Naphazoline (in Privine and others)This product is a
potent vasoconstrictor that has a duration of about six
hours.
96
Phenylephrine (in Neo-Synephrine and others)This
drug is commonly applied as two or three drops or as a
spray every four hours.
Oxymetazoline and xylometazoline (in Afrin and others)
These are longer-acting agents having a decongestant
effect of five to six hours.
Oral decongestants are swallowed as pills to provide systemic
relief of nasal congestion. One of the most widely used sys-
temic decongestants available in commercial products is
pseudoephedrine. When taken orally, this drug is a very effec-
tive vasoconstrictor. However, the sale of pseudoephedrine is
restricted due to the Methamphetamine Anti-Proliferation Act.
Pseudoephedrine is one of the ingredients used in meth labs.
In an effort to combat methamphetamine use, this act
requires that sales of pseudoephedrine products be tracked,
either electronically or in a written log.
FIGURE 39There are many
medications available to lessen
the symptoms associated with
colds and flu.
97
In many states, pseudoephedrine products are kept behind
the pharmacy counter and customers must present a valid
photo ID to buy them. There are also restrictions on the
maximum amount of pseudoephedrine that can be sold to a
person.
Phenylephrine is an oral decongestant thats used in many
products in place of pseudoephedrine. It may not be as
effective as pseudoephedrine, but many manufacturers have
reformulated their products that once contained pseudo-
ephedrine to now contain phenylephrine so that they can be
kept in the aisle and not behind the pharmacy counter.
Allergy medications. Mold spores and plant pollens that
depend on the wind for cross-pollination are the agents
responsible for seasonal allergies. Some common pollens that
cause many seasonal allergies are ragweed, grass, and tree
pollens. The main symptoms of seasonal allergies are swelling
(edema) of the nasal mucosa, sneezing, nasal itching, and
nasal congestion.
Histamine, as mentioned earlier, is the causative agent that
contributes to cold and allergy symptoms, and antihistamines
are drugs that block the effects of histamine in the tissues.
Blockage of the histamine effects by antihistamine drugs
reduces these symptoms. These chemical agents act by
blocking histamine at receptor sites. Theyre most effective in
controlling allergic rhinitis. The most common antihistamines
found in commercial products are diphenhydramine, phenyl-
toloxamine, doxylamine, and chlorpheniramine.
Two types of antihistamines are available for allergies: first-
generation (sedating) antihistamines and second-generation
(nonsedating) antihistamines. The first-generation antihista-
mines are effective at controlling cold and allergy symptoms,
but they can cause drowsiness. The second-generation anti-
histamines have the advantage of not causing drowsiness.
However, for some types of allergic reactions, the first-genera-
tion antihistamines are more effective. Loratadine is a
second-generation antihistamine thats available over the
counter. Many second-generation antihistamines are avail-
able by prescription only.
98
Gastrointestinal System
You probably have some gastrointestinal drugs in your medi-
cine cabinet. Many of them are OTC preparations designed to
relieve symptoms such as indigestion, nausea, and diarrhea.
Antacids are medications that neutralize the hydrochloric
acid that causes heartburn and pain from uclers, esophagi-
tis, or other stomach problems.
There are antiulceratives that go beyond neutralizing stomach
acid; they decrease the amount of acid secreted. Drugs called
cathartics relieve constipation and may also be given to stim-
ulate defecation for diagnostic or operative purposes. The
term laxative refers to mild cathartics; purgative refers to
strong cathartics. Antidiarrheals stop diarrhea.
In addition, there are antiemetics, drugs that inhibit or stop
nausea and vomiting. These drugs are also used to counter-
act dizziness, motion sickness, and inflammation of the inner
ear. In contrast, its occasionally necessary to ingest a drug
that will induce vomiting, or an emetic drug. If a patient has
been affected by a poison that shouldnt or cant be purged
with an emetic drug, as with the case of snake bites, for
instance, it will be necessary to administer an antidote, an
agent that counteracts the poison.
In addition to the previously mentioned H
2
blockers for heart-
burn, the proton-pump inhibitors are widely used to treat
GERD, or gastroesophageal reflux disease (Figure 41). These
drugs prevent the stomach from making acid by turning off the
pumps in the stomach that are needed to produce acid.
This gives the tissue lining the stomach and esophagus time
to heal from erosion that too much acid can cause.
Antacids
Many gastrointestinal disorders are due to the formation of
excess stomach acid. Excess acid contributes to heartburn or
dyspepsia, indigestion, burning sensations in the stomach,
and peptic ulcers. One sure way to reduce these effects is to
reduce the excess stomach acid. There are three ways to
reduce the effects of excess stomach acid:
Antacids
99
Drugs referred to as H
2
receptor antagonists
Proton-pump inhibitors
Antacids are compounds that work by neutralizing the gastric
acid in the stomach.
The fluid volume remains the same, but the acid content
now becomes more neutral. Its important to note that these
compounds dont reduce the volume of acid secretion in the
stomach. Each antacid compound is a chemical that converts
the hydrochloric acid in the stomach to water and a harmless
salt. Antacid preparations all contain one or more of the
following active compounds that neutralize stomach acid:
calcium carbonate, aluminum hydroxide, magnesium oxide
or hydroxide, or magnesium trisilicate.
There are about 75 different antacid products sold in drug-
stores. Antacids are available as liquid suspensions, tablets,
quick-dissolving tablets, and chewables. Some products con-
tain a combination of ingredients. If the patient takes the
product, the acid will be neutralized in the stomach.
The H
2
receptor antagonists block specific receptors in the
gastrointestinal tract from the actions of histamine. Usually,
histamine is one of the culprits secreting stomach acid, and if
its actions are blocked, less stomach acid is secreted. These
DRUGS USED TO TREAT GERD
H
2
BLOCKERS
Drug Brand Name
cimetidine Tagamet
famotidine Pepcid
nizatidine Axid
ranitidine Zantac
PROTON-PUMP INHIBITORS
Drug Brand Name
omeprazole Prilosec
lansoprazole Prevacid
pantoprazole Protonix
esomeprazole Nexium
rabeprazole Aciphex
FIGURE 40Drugs Used
to Treat GERD
100
drugs dont neutralize the acid, but they reduce its secretion.
Currently, four H
2
receptor antagonist drugs are sold over the
counter: Tagamet HB, Zantac 75, Pepcid AC, and Axid.
H
2
receptor antagonists are some of the most popular drugs
ever discovered. These drugs have been widely prescribed.
Two drugs known as Zantac (ranitidine) and Tagamet (cimeti-
dine) have been two of the most widely prescribed drugs in
the world. In the early 1990s, these drugs were given
approval by the FDA for sale without a prescription. Soon
after, Pepcid and Axid were made available over the counter.
The original OTC forms of these agents have exactly half the
amount of active drug that the prescription product contains.
As a result, suffixes have been added to their names to iden-
tify the lower concentration. OTC Zantac is called Zantac 75
because it contains 75 mg of drug instead of the full 150 mg
prescription strength. OTC Tagamet is called Tagamet HB
(HB for heartburn). OTC Pepcid is called Pepcid AC (AC for
acid control). Table 2 lists these products by both prescrip-
tion and OTC.
Since these drugs first became available over the counter,
different forms have been made available. For example,
Zantac is now also available as 150-milligram tablets. Pepcid
Table 2
H
2
RECEPTOR ANTAGONISTS FOR
STOMACH ACID REDUCTION
Drug Name OTC Product Name Rx Product Name
Cimetidine Tagamet HB Tagamet
Ranitidine Zantac 75 Zantac
Famotidine Pepcid AC Pepcid
Nizatidine
Axid AR,
Axid Pulvules
Axid
101
Complete combines famotidine with an antacid. In addition,
Prilosec OTC (omeprazole), which is a proton-pump inhibitor,
is available over the counter to treat heartburn.
Antidiarrheals
Acute diarrhea is characterized by sudden onset of frequent,
liquid stools accompanied by weakness, flatulence (gas), and
pain. The changes in the origin of diarrhea make identifica-
tion of the cause very difficult. The etiology (causes) of
diarrhea can be infectious, psychogenic, allergenic, surgical,
neurogenic, or dietary.
For years, opiate drugs were the mainstay in the treatment of
diarrhea. The opiate-containing products contain paregoric.
Paregoric is either a liquid form of opium or diphenoxylate
(Lomotil), a distant relative of opium. Because of the abuse
potential of paregoric and Lomotil, they can no longer be sold
without a prescription and are rarely prescribed. Because of
their morphine content, paregoric-containing products exert a
direct effect on the muscles. This effect inhibits propulsive
movements in the small intestine and colon. Thus, movement
decreases, and the passage of intestinal contents slows. The
result is absorption of water and electrolytes. A paregoric-like
agent that can be bought without a prescription is a drug
called loperamide (Imodium). This opiate-like drug lacks any
abuse potential because it doesnt enter the brain through the
blood. It merely stays in the gastrointestinal tract to slow peri-
stalsis (contractions). Loperamide is sold as a single agent in
liquid or in capsule form.
Pepto-Bismol (bismuth subsalicylate), with its antisecretory and
antimicrobial properties, is also used for diarrhea.
Laxatives
Constipation is generally defined as a decrease in frequency of
fecal elimination characterized by difficult passages of hard,
dry stools. It usually results from abnormally slow movement
of feces through the colon. This slow movement results in
feces accumulation in the colon. There are many ways to pro-
mote bowel activity in patients with constipation, and many
102
different types of laxative products exist. Laxative drugs are
classified as gastrointestinal stimulants, bulk-forming agents,
emollients and lubricants, and saline-type agents.
Stimulant laxatives are powerful agents that increase the
propulsive peristaltic activity in the intestine by local irritation
of the mucosa or by more selective action on the innervation
(nerve supply) to the intestine. These agents may cause
severe cramping and should be used with caution. The three
most well-known stimulant substances contained in various
laxative products are bisacodyl (Dulcolax), sennoside (stimu-
lant), and castor oil.
Bulk-forming laxatives are substances such as psyllium,
methylcellulose, polycarbophil, and polyethelene glycol. These
laxatives are all semisynthetic polysaccharides and cellulose
derivatives that dissolve or swell in the intestinal fluid,
thereby retaining water. This action forms an emollient gel
that allows the passage of the intestinal contents. At the
same time, these substances stimulate peristalsis. They
have a relatively slow onset of action, and may require up to
three days to work for many individuals. An example of a
bulk-forming laxative is senna, which is marketed as Ex-Lax,
Senocot, Senolax, and several other brand names.
Emollients and lubricants act to either increase the wetting
efficiency of intestinal fluid to soften fecal mass, or to soften
the fecal contents by coating the contents with oil to retain
fecal water in the colon. The emollients are also known as
stool softeners. Docusate, also known as dioctyl sodium
sulfosuccinate, is a drug thats administered orally. It effec-
tively softens fecal mass for ease of evacuation. Mineral oil is
a lubricant-type laxative.
The saline-type laxatives are the magnesium-type salts such
as citrate of magnesia and a salt called sodium phosphate, as
in a Fleet enema. Also available in an oral form, these salts,
when present in the colon, act to attract water from body tis-
sues into the colon to result in increased colon mobility and
evacuation. These saline laxatives are extremely effective and
are usually reserved for acute evacuation of the bowel before
endoscopic examinations.
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Antigas Agents
Simethicone is an oral antigas agent. It works by dispersing
and preventing the formation of mucus-surrounded gas
pockets in the GI tract. It also changes the surface tension of
gas bubbles, enabling them to coalesce, so gas can be freed
and eliminated more easily. Simethicone is available either by
itself, or in combination with either antacids or laxatives.
Hemorrhoidal Agents
Hemorrhoids, which are swollen, inflamed veins around the
anus, are very common in the population. Some symptoms
of hemorrhoids are inflammation, itching, and swelling.
Products are available in a variety of forms, such as creams,
gels, ointments, foams, suppositories, and medicated wipes.
These products may have a single active ingredient, or sev-
eral. One of the products thats used to treat hemorrhoids is
hydrocortisone. Hydrocortisone is a steroid thats used to
reduce inflammation, itching, and swelling. Local anesthetics,
such as benzocaine or pramoxine, are also used in hemor-
rhoidal preparations. These agents help to relieve pain,
itching, and irritation. Vasoconstrictors, such as phenyle-
phrine, help to decrease swelling of inflamed tissues. Witch
hazel and zinc oxide are classified as astringents. These help
to protect underlying tissue along with lessening mucus and
other secretions.
Sensory System
Many drugs prescribed for problems with the special sense
organs fall into one of the general classes described below.
General Classes
Antibiotics treat infections caused by bacteria.
Otics treat ear problems. These drugs are in the form of
drops that are instilled directly into the ear.
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Antihistamines inhibit the body from releasing histamines,
which are a reaction to an allergen. Antihistamines are used
when the body produces too much histamine, causing over-
sensitivity to an allergen.
Corticosteroids are used in the treatment of many diseases
and replace or enhance the steroids that are normally pro-
duced by your own body.
Eyedrops and Eyewashes
Therapeutic agents contained in OTC eye products include
decongestant-vasoconstrictors and artificial tears. Decongestant-
vasoconstrictors are effective in the treatment of eye allergies
and provide relief of redness caused by minor eye irritation.
Redness in the eye usually disappears immediately after
placing a few drops of decongestant-vasoconstrictors in an
eye with constricted blood vessels. Artificial tears are also
known as demulcents, and are dropped into the eye to lubri-
cate the mucous membrane surfaces and relieve dryness and
irritation. Eyewashes contain no active ingredient and are
intended for bathing and flushing the eye to remove loose
foreign material and chlorinated water.
There are also ophthalmic decongestant/antihistamine
combination products available. These agents are used to
relieve redness, itching, and tearing that are associated
with allergies. With all ophthalmic products, its important to
check the active ingredients. For example, presently Visine
contains a decongestant, Visine-A contains a decongestant
and antihistamine, and Visine Allergy Relief contains just a
decongestant. However, active ingredients of over-the-counter
products can change without notice.
Nervous System
Most drugs prescribed to treat symptoms and disorders of
the nervous system fall into one of the basic categories.
Basic Categories
Analgesics inhibit the passage of pain impulses.
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Seizures that result from overstimulation of nerve cells in the
brain can often be controlled with anticonvulsants.
Everyone gets depressed once in a while, and the normal
mood swings of everyday life arent cause for medication. In
profound depression, however, patients will suffer a chronic
inability to be active, think clearly, eat normally, and sleep
soundly. Drug therapy with antidepressants may be used
along with intensive psychotherapy to help such patients
function normally again.
Opiates are sedative narcotics that contain opium or its
derivatives.
Drugs that act on the brain to speed up the heart and respi-
ratory system are called stimulants. Stimulants arent given
to counteract psychological depression; rather, the medically
proper usage is to resuscitate patients whose cardiovascular
and respiratory systems are depressedas in cases of shock.
Stimulants are among the drugs most often abused, and
some of them (the more potent amphetamines) are controlled
substances. But one stimulantcaffeineis the everyday
drug in coffee, tea, and soda.
When a patient is at the opposite extremevery nervous and
excitedthe condition may be treated with sedatives that
depress the central nervous system. Hypnotics are sedatives
that relax the body to the point of sleep and are sometimes
called sleeping pills.
Barbiturates are sedative-hypnotics that can become habit
forming.
Tranquilizers are used to calm down patients who are very
anxious. Milder drugs, called minor transquilizers have
antianxiety properties.
Central Nervous System (CNS) Drugs
Central nervous system (CNS) drugs are those categories of
drugs used to treat illnesses of the brain. CNS drugs are also
those drugs that cause a direct effect within the brain such as
sedation, tranquilization, or appetite suppression. Psychiatric
drugs have their own classification. The specific categories of
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CNS drugs are shown in Figure 41. They include anticonvul-
sant drugs, antiemetic drugs, antimigraine drugs, antianxiety
drugs, antiparkinson drugs, hypnotic drugs, CNS stimulants,
and drugs to treat Alzheimers.
CENTRAL NERVOUS SYSTEM (CNS) DRUGS
ANTICONVULSANT DRUGS
Drug Brand Name
phenytoin Dilantin
phenobarbital Phenobarbital
carbamazepine Tegretol
gabapentin Neurontin
divalproex sodium Depakote
lamotrigine Lamictal
topiramate Topamax
tiagabine Gabitril
levetiracetam Keppra
ANTIEMETIC DRUGS
Drug Brand Name
prochlorperazine Compazine, Buccastem,
Stemetil, Phenotil
ondansetron Zofran
metoclopramide Reglan
granisetron Kytril
dimenhydrinate Dramamine
ANTIMIGRAINE DRUGS
Drug Brand Name
sumatriptan Imitrex, Imigran
methysergide Sansert, Deseril
ergotamine Ergostat, Ergomar
ergotamine w/caffeine Cafergot
eletriptan Relpax
rizatriptan Maxalt
zolmitriptan Zomig
(Continued)
FIGURE 41Categories
of Central Nervous
System (CNS) Drugs
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CENTRAL NERVOUS SYSTEM (CNS) DRUGS
ANTIPARKINSON DRUGS
Drug Brand Name
trihexyphenidyl Artane
levodopa Larodopa
carbidopa-levodopa Sinemet
entacapone Comtan
selegiline Eldepryl
ropinirole Requip
pramipexole Mirapex
ANTIANXIETY DRUGS
Drug Brand Name
diazepam Valium
oxazepam Serax
lorazepam Ativan
buspirone BuSpar
alprazolam Xanax
SEDATIVE/HYPNOTIC DRUGS
Drug Brand Name
flurazepam Dalmane
triazolam Halcion
zolpidem Ambien
eszopiclone Lunesta
zaleplon Sonata
chloral hydrate Noctec, Somnote
temazepam Restoril
CNS STIMULANT DRUGS
Drug Brand Name
dexmethylphenidate Focalin
dextroamphetamine Dexedrine
methylphenidate Ritalin
ALZHEIMERS AGENTS
Drug Brand Name
donepezil Aricept
rivastigmine Exelon
galantamine Razadyne
memantine Namenda
FIGURE 41Continued
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Anticonvulsant drugs. The anticonvulsants are referred to as
seizure medications because theyre used to prevent epileptic
seizures. Approximately one to four percent of the population
has some form of epilepsy, and many anticonvulsant drugs
are effective in preventing seizures in these individuals. Since
there are many different types of epilepsies, many different
types of drugs used to treat epileptic patients. Interestingly,
many anticonvulsants are also used to treat other conditions,
such as nerve pain, bipolar disorder, and prevention of
migraine headaches.
Antiemetic drugs. Emesis is the act of vomiting, and
antiemetic drugs are used to prevent vomiting or to stop
ongoing vomiting. Vomiting is mediated through the CNS by
way of peripheral inputs such as nausea in the stomach or
imbalance within the inner ear during seasickness. Zones
within the medullary portion of the brain, the chemoreceptor
trigger zone and the vomiting zone, initiate the vomiting
response to move stomach contents up the esophagus to be
expelled. Nausea and vomiting are very unpleasant experiences,
and some of these drugs can alleviate much of the unpleasant-
ness. Theyre variably effective; their effectiveness depends on
the nature of the vomiting stimulus. For example, emesis
due to food poisoning will be treated differently than emesis
due to chemotherapy.
Some of these drugs are available in different forms, such as
suppositories, injectables, and oral-disintegrating tablets. This
is because it can be difficult for patients who are suffering
from nausea and vomiting to swallow a pill.
Antimigraine drugs. Methysergide (Sansert) and ergota-
mine (Ergostat, Ergomar, Cafergot) are members of the ergot
group of drugs, which have been used for over a century to
treat migraines. Sumatriptan, eletriptan, and rizatriptan are
antimigraine agents that all effect serotonin. Sometimes
theyre called triptans because of their names. These drugs
are available in various dosage forms, such as injectable,
nasal spray, and disintegrating tablets, since migraine
sufferers are often very nauseous.
Antiparkinson drugs. Parkinsons disease is a CNS disorder
characterized by muscle tremor, rigidity, and lack of smooth
motor movement. Research has determined that patients with
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this disease have excessive amounts of acetylcholine and
deficient amounts of a transmitter called dopamine. Drug
therapy focuses on correcting the imbalance of transmitters.
Antianxiety drugs. Nervousness and anxiety are disorders
characterized by fears, worry, and muscular tension. Anti-
anxiety drugs act as tranquilizers to reduce these symptoms,
making the anxious person feel relaxed and somewhat care-
free. Most tranquilizers fall into the benzodiazepine class of
drugs, which are named after their chemical structure. The
benzodiazepines are also known as the Valium family of
drugs because Valium was one of the first benzodiazepines to
be used as a tranquilizer. In general, any drug name ending
in azepam is a member of the Valium family of drugs. These
habit-forming drugs cause physical and chemical dependence
and are controlled substances.
Hypnotic drugs. Hypnotic drugs (sleeping pills) are used to
induce sleep. Most of these drugs are controlled substances
and can be habit forming.
CNS stimulant drugs. Central nervous stimulant drugs are
used in disease states where patients have difficulty focusing
and paying attention, such as attention deficit hyperactivity
disorder, or ADHD. These drugs are also used for treating
narcolepsy, which is a disorder that affects the control of
sleep and wakefulness. In narcolepsy, patients experience
uncontrollable episodes of falling asleep during the day. The
CNS stimulant drugs work by altering the levels of various
neurotransmitters in the brain. Most of these drugs are
controlled substances and can be abused.
Alzheimers agents. Alzheimers disease is a type of dementia
that mostly affects the elderly. In this disease, plaques form
in the brain and cause death of brain cells. There is no cure,
but current treatment is aimed at maintaining a high level of
chemical messengers in the brain.
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Endocrine System
Endocrine Drugs
Anabolic steroids. The term anabolic refers to the building
stage of body metabolism, and anabolic steroids are drugs
made from testosterone. When used clinically, these drugs
are an invaluable aid in the growth and repair of body tissues
during debilitating illness or recovery from injury or surgery.
These same qualities have helped many body builders and
athletes develop unnatural muscle mass and strength. Even
though temporary steroid treatment during healing is safe,
taking steroids regularly for no clinical reason is dangerous.
It sends the endocrine glands false signals, and the natural
negative feedback loop is broken. Ultimately the abuse of
steroids will lead to damage of body tissues, sterility, mental
imbalance, and other negative side effects.
Hormone replacement. Hormone replacement therapy can
counteract the negative effects of a malfunctioning endocrine
gland. Hormones are useful for other reasons, too. Male
androgens can be given to treat breast cancer in women. On
the other hand, female estrogens can be given to treat
prostate cancer in men. Female hormones, including both
estrogens and progestins (progesterone), are given to many
postmenopausal women.
And finally, adrenal corticosteroids or glucocorticoids, are
important hormones used to treat a variety of diseases
arthritis, allergic conditions, respiratory disorders, blood
ailments, GI complaints, cancer, and other pathologies.
Antidiabetics
Treatment of diabetes depends on whether the patient has
type 1 or type 2 diabetes. In patients with type 1, or insulin-
dependent diabetes mellitus, the body doesnt produce any
insulin, so the only way to treat the disease is with daily
insulin injections. Insulin preparations come in three forms:
1. Rapid acting
2. Intermediate acting
3. Long acting
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In type 2, or non-insulin-dependent diabetes mellitus, either
the body isnt making enough insulin or the insulin thats
made by the body isnt being used by the cells properly. For
patients with type 2 diabetes, there are many pharmacother-
apies available. These drugs stimulate the pancreatic islets to
secrete insulin.The oral antidiabetic medications that are
available can be divided in several groups: sulfonylureas,
alpha-glucosidase inhibitors, biguanides, meglitinides, and
thiazolidinediones. Patients with type 2 diabetes may be on a
combination of these medications with or without insulin.
Well also discuss some miscellaneous agents that are used
to help manage diabetes. Refer to Figure 42.
Insulin. Insulin is a hormone that cant be taken orally since
the stomach acid would destroy its preparation. Therefore, it
needs to be taken by either subcutaneous injection or by oral
inhalation. The different forms of insulin differ according to
their onset time and duration of action. Some patients are on
more than one type of insulin, depending on the level of con-
trol needed. Most patients use insulin by injection since the
oral inhaled form can be used only in specific patients.
INSULIN
Drug Brand Name
Rapid-acting insulin (duration 35 hrs)
insulin lispro Humalog
insulin aspart NovoLog
insulin glulisine Apidra
Short-acting insulin (duration 610 hrs)
insulin regular Humulin R, Novolin R
Intermediate-acting insulin (duration 1624 hrs)
insulin isophane (NPH) Humulin N, Novolin N
Long-acting insulin (duration 24 hours)
insulin glargine Lantus
insulin detemir Levemir
(Continued)
FIGURE 42Drugs Used
to Treat Diabetes
112
Sulfonylurea. Sulfonylureas are oral antidiabetic meds that
increase insulin release from the pancreas. The sulfonylureas
are the oldest class of oral antidiabetics and can potentially
make the blood sugar level drop too low, a condition known
as hypoglycemia.
Alpha-glucosidase inhibitors. The alpha-glucosidase
inhibitors delay the conversion of complex carbohydrates to
glucose. For this reason, they must be taken at the start of
meals. These drugs dont affect the release or use of insulin.
Biguanides. Biguanides control diabetes by decreasing the
production of glucose in the liver, decreasing glucose absorp-
tion from the intestines, and increasing insulin sensitivity
ORAL DRUGS USED TO TREAT DIABETES
SULFONYLUREAS
Drug Brand Name
glimipiride Amaryl
chlorpropamide Diabinese
glipizide Glucotrol
glyburide Diabeta, Glynase
Glycron, Micronase
ALPHA-GLUCOSIDASE INHIBITORS
Drug Brand Name
acarbose Precose
miglitol Glyset
BIGUANIDES
Drug Brand Name
metformin hydrochloride Glucophage, Riomet,
Fortamet
MEGLITINIDES
Drug Brand Name
repaglinide Prandin
nateglinide Starlix
THIAZOLIDINEDIONES
Drug Brand Name
rosiglitazone Avandia
pioglitazone Actos
FIGURE 42Continued
113
(the way cells in the body use insulin). The main advantages
of these drugs are that they usually dont cause weight gain
(and may even promote weight loss) and theyre unlikely to
cause hypoglycemia.
Meglitinides. The meglitinides help to control diabetes by
stimulating insulin production. These drugs may be used
alone or in combination with other drugs.
Thiazolidinediones. The thiazolidinediones help to control
high blood sugar by reducing glucose production in the liver
and by increasing insulin-dependent glucose uptake in muscle
cells. These drugs dont affect the production of insulin.
Miscellaneous. There are two injectable drugs, which mimic
chemicals that are produced by the body, that are used in
the management of diabetes. One of them, pramlintide
acetate (Symlin) is used in both type 1 and type 2 diabetics.
The other, exenatide (Byetta) is used only in type 2 diabetics.
Another drug, sitagliptin phosphate (Januvia) is an oral
medication thats part of a new class, known as dipeptidyl
peptidase-4 inhibitors. This drug, which is only used in type 2
diabetics, helps to increase the release and synthesis of
insulin and lower levels of glucagon.
Thyroid Products
Thyroid products are drugs used to treat conditions of
diminished thyroid hormone output (hypothyroidism) and
excess thyroid hormone output (hyperthyroidism). Thyroid
replacement drugs are used to treat hypothyroidism and are
essentially either natural thyroid hormone obtained from pigs
or cattle, or synthetic hormone produced in the laboratory.
Examples of synthetic hormones are levothyroxine (Synthroid)
and liothyronine (Cytomel). These thyroid drugs act as a
replacement for missing thyroid hormones. Refer to Figure 43.
Antithyroid drugs work by preventing the manufacture of the
thyroid hormone within the gland itself. As a result, excess
hormone isnt produced, and the symptoms resulting from
overproduction of the hormone are decreased. There are
only two antithyroid drugs that are marketed to treat hyper-
thyroidismpropylthiouracil and methimazole (Tapazole).
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Oral Contraceptives
In combination, estrogen and progesterone hormones make
effective contraceptives and are the two ingredients of the
birth control pills dispensed in the pharmacy. The combina-
tion of estrogen and progesterone seems to be more effective
in preventing pregnancy than either hormone alone when
taken in pill form. Figure 44 lists the synthetic estrogens and
progesterones used in oral contraceptive products.
The estrogen component of the oral contraceptives suppresses
the release of follicle-stimulating hormone (FSH) from the
anterior pituitary gland. As a result, FSH-induced ovulation
is prevented, and ovulation doesnt occur. The progesterone
component suppresses the release of luteinizing hormone (LH)
from the pituitary. It also reduces fertility by altering the
nature of the endometrial lining of the uterus. These actions
impair the normal transport of sperm and ova and may
prevent a fertilized ovum from properly implanting on the
endometrial surface.
The combined estrogen-progestin pills are available in many
regimens and strengths. There are monophasic, biphasic, and
triphasic regimens available. In addition, there are extended-
cycle regimens and continuous regimens that reduce the
number of menstrual periods a woman will get in a year. Oral
contraceptives are also available as a progestin-only pill (POP).
DRUGS USED TO THYROID CONDITIONS
Thyroid Replacement Agents
Drug Brand Name
levothyroxine sodium Synthroid, Levoxyl,
Levothroid, Unithroid
liothyronine Cytomel
liotrix Thyrolar
Antithyroid Agents
Drug Brand Name
propylthiouracil tablets propylthiouracil
methimazole tablets Tapazole
FIGURE 43Thyroid Agents
115
Also, there are alternatives to oral contraceptives in the form of
an injectable medroxyprogesterone (Depo-Provera, Provera,
and Cycrin), a combined hormonal patch (Ortho Evra) and a
vaginal ring (Nuvaring).
Urinary/Excretory System
There are many different antibiotics and antimicrobials that
are used for treatment of the many infections that can occur
in the urinary system.
Anticholinergics are drugs used to treat urinary system prob-
lems, such as overactive bladder, by blocking the nerves that
are causing excessive contractions.
Anesthetics are used to control symptoms such as pain and
burning caused by urinary tract infections.
Antispasmodics are drugs that reduce muscle spasms in the
urinary system, also mainly used to reduce overactive blad-
der symptoms.
Many drugs used to treat renal failure are those used to treat
high blood pressure, since so much blood is sent under high
pressure to the kidneys. Disease in one system is often
related to disease in the other. Patients with liver failure also
have to be careful of any kinds of medicines being taken for
other disease processes since the kidneys filter many of the
drugs that go through our bodies.
ORAL CONTRACEPTIVES
Estrogen Progesterone
Component Component
ethinyl estradiol norethindrone
mestranol levonorgestrel
norgestrel
norgestimate
ethynodiol diacetate
desogestrel
FIGURE 44Oral
Contraceptives
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Reproductive System
The reproductive system is the only area of the body where
so much money and effort is spent in preventing the system
from working! A large number of drugs and devices used in
this system are for contraception, the prevention of pregnancy
(CONTRA- means against,``` -CEPTION means concep-
tion). Devices include a bowl-shaped rubber device placed
over the cervix called a diaphragm that prevents the passage
of sperm into the uterus. Its usually used along with a sper-
micide ointment (an agent lethal to sperm). Another uterine
contraceptive device is the intrauterine device (IUD), an object
inserted inside the uterus to prevent any embryo from
implanting itself. The IUD must be inserted by a physician.
The easiest and oldest form of contraception is the condom, a
device currently made of latex that covers the male penis and
prevents ejaculate from entering the vagina. The added bonus
for condom use is that its the best known protection against
STDs besides abstinence.
Synthetic hormones, gonadotropins, are used frequently in
this system. Sometimes the drugs contain the hormones, and
sometimes they stimulate production of the natural hormone.
There are drugs that contain hormones that prevent preg-
nancy (estrogen and progestin), drugs that cause ovulation
(by stimulating production of LSH), and hormones that help
induce labor (synthetic oxytocin).
There are also drugs that suppress gonadotropin release in
cases where the hormones may be causing an abnormality or
allowing abnormal cells to increase at a faster rate than
usual.
The symptoms of menopause can be treated with hormonal
replacement therapy (HRT). This is low-dose estrogen with or
without progesterone, and it takes the place of the hormones
that are lost when the ovaries stop functioning. HRT may
also prevent or slow down the progression of osteoporosis, a
common side effect of menopause.
Tocolytics are drugs used to relax the uterus and prevent pre-
mature birth.
117
This system is susceptible to infection because its exposed to
other humans during sexual intercourse, and bodily fluids
are exchanged. Its an entry point to the body for females,
and the environment is warm and moist, providing an ideal
place for bacteria to grow. For this reason, antibiotics and
antifungals are a large part of the arsenal of treatment for
dysfunction in the reproductive system.
Oral drugs known as phosphodiesterase type 5 (PDE5)
inhibitors and devices known as penile implants are used to
treat erectile dysfunction. PDE5 inhibitors increase vasodila-
tion and penile erection. Penile implants are available in an
inflatable type that can be pumped up to create an erection
and then deflated. There are also semirigid implants that are
always somewhat firm. Besides ED, implants can be used to
treat some cases of Peyronies disease, a connective-tissue
disorder in which plaque forms on the penis.
Lymphatic System
Though theres no cure for AIDS, the antiretroviral drugs
azidothymidine (AZT) and dideoxyinosine (ddI) do prolong
healthy life by inhibiting the reproduction of HIV within
infected cells.
Immunotherapy comprises a number of different therapies,
depending on what process is being treated. Immunotherapy
is being used to treat everything from allergies to asthma to
cancer.
Some drugs are being used to promote an immune response
to cancer cells. Current investigation involves a therapeutic
vaccine form. A vaccine is an introduction of diseased micro-
organisms (either killed or attenuated) into the body with the
intent of provoking the immune system to produce antibodies
against it. When the microorganism then appears in the body
in a live form, it will be recognized by the antibodies, and the
lymphocytes will work faster to kill the abnormal cells.
Chemotherapy agents are used to treat cancers within the
lymphatic system.
++99999999999999999999999+
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Anesthesia
Many of the medications used by surgeons are for fighting
infections and for preventing pain.
Antibiotics are used often to prevent infection as well as to
treat infections that occur either before or after the surgery.
Analgesics are used to deal with pain after surgery. These
can be mild analgesics for small surgeries, or very powerful
narcotics for major postsurgical pain. Although oral medica-
tion is often used, some postsurgical pain is so intense that
the medication is administered intravenously.
Anesthesia is usually the first medicine people think of when
they think about surgery. Indeed, anesthesia is a large part
of what makes surgery less painful these days, as well as
what enables surgeons to perform advanced techniques.
There are four general types of anesthesia:
1. Topical anesthetics are used on the surface of the skin
or other tissue. They numb the tissue to which theyre
directly applied.
2. Local anesthesia is for anesthetizing a small part of the
body. Its often injected into the area and affects only
that area.
3. Regional anesthesia works in a similar way to local anes-
thesia, but it affects a larger part of the body.
4. General anesthesia renders the patient completely
unconscious, allowing surgeons to work on any part of
the body without patient awareness.
The mode of induction (how the anesthesia is administered) is
important and differs depending on the type of anesthesia.
General anesthesia is usually administered by endobronchial,
endotracheal, inhalation, insufflation (breathing into), or
intravenous modes. The intravenous method is for use with
a liquid anesthetic that can be attached to an intravenous
pump. The other methods are used with gas and indicate
where the gas is directed to provide the best results.
Regional anesthesia is often administered by block, some-
times called a nerve block. The anesthetic is injected along a
nerve path to stop nerve impulses in that area.
119
Local anesthetic is administered by infiltration, which means
that the anesthetic is injected into the tissue of the area that
needs to be anesthetized.
As we discussed, topical anesthetic is applied directly to the
affected tissue.
Genetic Engineering
Genetic engineering is the purposeful manipulation of genetic
material to alter the genetic makeup of an individual. This
powerful technology has the potential to bring great benefit or
harm to this world. Many ethical questions surround the
proper use of genetic engineering. Although it may promise to
cure many diseases, the ultimate outcomes of genetic engi-
neering have yet to be seen.
Gene therapy is the technique of treating genetic diseases.
Its made possible by the advances in the past half century.
There are four ways that gene therapy works:
1. A normal gene is inserted into the genome that will
replace the damaged one.
2. A normal gene is swapped out for a specific abnormal
gene.
3. An abnormal gene is repaired by reverse mutation.
4. The gene can be activated or deactivated.
The first scenario, replacing a damaged gene with a normal
one, is most common. To do that, however, there has to be
some method of delivering the new gene. The delivery is done
by a molecule called a vector. Scientists have recruited an
unlikely suspect for this jobviruses.
Viruses are capable of encapsulating disease and depositing
it into cells. Scientists have taken advantage of this capability
to remove the damaging portions of the molecules, introduce
the genes they wish to insert, and let the viruses go!
There are also experiments now with inserting a 47th chro-
mosome into cells that would be able to exist without causing
problems and act as a permanent vector.
We are on the verge of even more discoveries where genes are
concerned. This is a field worth keeping an eye on!
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Antineoplastic Agents
A neoplasm, or tumor, is an abnormal growth of tissue within
the body. Antineoplastic agents are drugs that treat tumors or
cancer. These agents work by traveling through the body and
destroying cancer cells.
Examples of antineoplastic agents include
Methotrexate
Fluorouracil
Doxorubicin
Paclitaxel
Cyclophosphamide
Side effects usually occur with antineoplastic agents because
the agents destroy some healthy body cells along with the
cancerous cells. Side effects of antineoplastic agents include
Mouth sores
Alopecia (hair loss)
Nausea
Lowering of blood counts
Patient education can help lower some of the side effects.
Immunity/Vaccines
When a person becomes sick, his or her body isnt functioning
normally or at its full potential. Our bodys immune system
helps to fight against illness and disease with its collection
of organisms that kill pathogens. Immunity can be created
naturally by a reaction within the body through antibodies or
by a secondary reaction delivered through an immunization.
To help strengthen the immune system, the medical industry
has created acquired immunities through immunizations.
Immunizations are also called vaccinations or inoculations.
121
Types of Immunity
Natural immunity, which is present at birth, is a resistance to
disease and organisms invading ones body. Natural immu-
nity works to prevent entry of microorganisms into tissues. If
these microorganisms gain entry, natural immunity works to
eliminate them prior to the occurrence of disease.
Natural immunity
Is present at birth
Is nonspecific in that it acts on many organisms and
doesnt show specificity
Doesnt become more effective with subsequent exposure
to the same organisms
Acquired immunity occurs in response to infection that has
invaded the body. This type of immunity is also known as
adaptive immunity because the immune system must adapt
itself to previously unknown organisms. Once an individual
has recovered from certain infections, he or she will never
again develop an infection by that same organism. However,
individuals can become infected with similar microorganisms,
and must protect themselves through immunity.
Active immunity is the development of antibodies in response
to stimulation by an antigen. Antigens are introduced or
formed by the body to help create specific antibodies.
Passive immunity is acquired from injections or by passing
antibodies from one immune person to another. Once formed,
these antibodies can be removed from the host and trans-
ferred into a recipient, providing the recipient with immediate
passive immunity.
Vaccines
Vaccines are preparations of viruses, either alive or in an
attenuated dormant stage, that are injected into the host
to stimulate the bodys immune system to repel any further
invasion of the specific virus. Thus, influenza vaccine will
repel any further influenza viruses during the protective
period of vaccination. Specific illnesses that are prevented
122
by vaccine administration are measles, mumps, hepatitis,
influenza, rabies, tetanus, pertussis, polio, and rubella
(German measles).
Vaccination against diseases has become a bit controversial
as more vaccines have been added to the mandatory list of
childhood vaccinations. Several vaccines have been recom-
bined in an effort to lessen any side effects. The timing of
vaccinations has also been scrutinized. Typical childhood
vaccines are listed in Figure 45.
Psychiatric Drugs
Mental illness takes many forms. Therefore, many different
types of drugs and drug categories are associated with its
treatment. Psychosis, depression, and manic depression are
the three major forms of mental illness, and theyre treated
with antipsychotics, antidepressants, and antimanic drugs,
respectively. Refer to Figure 46 as you learn about these
three classes of drugs.
Antipsychotic Drugs
Psychosis is defined as any major mental disorder of organic
or emotional origin marked by derangement of personality and
loss of contact with reality, with delusions and hallucinations
and often with incoherent speech, disorganized and agitated
behavior, and delusions. This includes disorders such as
VACCINES
diphtheria tetanus pertussis
measles mumps rubella
polio HIV hepatitis B
varicella influenza hepatitis A
rotavirus pneumococcal
FIGURE 45Common
Vaccines Used in Humans
123
schizophrenia and dementia. There are several antipsychotic
drugs. The newer, atypical antipsychotics usually have less
serious side effects and more convenient dosing than the
other categories of drugs, but all of these drugs are widely
used. Occasionally, patients have to take combinations of
these drugs to achieve control over the psychosis. All of these
drugs affect neurotransmitters in the brain.
PSYCHIATRIC DRUGS
ANTIPSYCHOTICS
Drug Brand Name
chlorpromazine Thorazine
thioridazine Mellaril
fluphenazine Prolixin
haloperidol Haldol
droperidol Dropletan, Inapsine
azaperone Stresnil, Fluoperidol
thiothixene Navane
trifluoperazine Stelazine
perphenazine Trilafon, Etrafon
ATYPICAL ANTIPSYCHOTICS
Drug Brand Name
olanzapine Zyprexa
quetiapine Seroquel
risperidone Risperdal
ziprasidone Geodon, Zeldox
aripiprazole Abilify
clozapine Clozaril, Leponex
(Continued)
FIGURE 46Representative
Antipsychotic Drugs
124
PSYCHIATRIC DRUGS
ANTIDEPRESSANTS
Tricyclics
Drug Brand Name
amitriptyline Elavil
nortriptyline Aventyl, Pamelor
imipramine Trofanil
desipramine Norpramin, Pertofrane
Serotonin Reuptake Inhibitors
Drug Brand Name
fluoxetine Prozac
fluvoxamine Luvox
paroxetine Paxil
sertraline Zoloft
citalopram Celexa
escitalopram Lexapro
Monoamine Oxidase Inhibitors
Drug Brand Name
isocarboxazid Marplan
phenelizine Nardil
tranylcypromine Parnate
ANTIMANIC DRUGS
Drug Brand Name
lithium Eskalith
clonazepam Klonapin
carbamazepine Tegretol
OTHER ANTIDEPRESSANT DRUGS
Drug Brand Name
venlafaxine Effexor
mirtazapine Remeron
duloxetine Cymbalta
bupropion Wellbutrin
trazodone Desyrel
FIGURE 46Continued
125
Antidepressant Drugs
Antidepressant drugs are used to improve the mood of indi-
viduals who show signs of depression. They improve the
mood by increasing certain chemicals in the brain that
become deficient during bouts of depression. The two major
groups of antidepressants are the tricyclics and the selective
serotonin reuptake inhibitors (SSRIs). The tricyclic drugs are
so named because their chemical formula consists of three
chemical ring structures. The selective serotonin reuptake
inhibitors are so named because they block the reuptake of the
transmitter called serotonin into the nerve cells. This block-
ing action allows the level of serotonin to increase outside
the nerve, thus relieving depression. A third minor group of
antidepressants is called the monoamine oxidase inhibitors
(MAO inhibitors). The monoamine oxidase inhibitors are a very
select and powerful group of drugs reserved for limited use in
the treatment of severe forms of depression. The use of MAO
inhibitors is limited by the many drug and food restrictions
that have to be followed while taking the drug. There are
several other antidepressants available that dont fit into
these three groups. These drugs affect the concentrations of
various neruotransmitters in the brain. As with the antipsy-
chotics, combinations of these drugs may have to be taken to
gain control over depression. Interestingly, some antidepres-
sants are also used for various types of nerve pain.
Antimanic Drugs
Lithium effectively treats manic depression. Researchers arent
sure how lithium works, but it seems to level out the manic
and depressed phases of this disorder. Lithium is available
as lithium carbonate salt and lithium citrate salt. Lamotrigine
(Lamictal) is another drug used to treat manic depression,
or bipolar disorder. Divalproex sodium (Depakote) is also
used to control mania associated with bipolar disorder. Many
of the newer anticonvulsants are also used to stabilize mood
in bipolar disorder, especially in the manic phase.
126
Antilipemic Drugs
Antilipemic drugs are used to lower the cholesterol levels in
the blood. The reduction of blood cholesterol is thought to be
helpful in the management of atherosclerosis, hardening of
the blood vessels (arteries) caused by fatty deposits. These
drugs are subdivided into two groups. One group is called the
HMG-CoA reductase inhibitors, and the other is a group of
miscellaneous agents that lower blood cholesterol through
various mechanisms. Refer to Figure 47 as you learn more
about these antilipemic drugs.
HMG-CoA Reductase Inhibitors
Hydroxymethylglutaryl-coenzyme A reductase (HMG-CoA
reductase) inhibitors are cholesterol-lowering drugs. HMG-CoA
reductase is an enzyme thats responsible for the formation
of cholesterol in the liver. Inhibition of this enzyme blocks
the formation of cholesterol. Note that, though their brand
names differ, their generic names all end in statin, and
theyre collectively often referred to as statins. There has been
intense development of drugs in this category because of the
high cholesterol content in todays diets.
Other Antilipemic Drugs
Some antilipemic drugs work by various mechanisms to
lower blood cholesterol. The one thing they have in common
is that they dont affect HMG-CoA reductase. Cholestyramine
resin gets rid of bile acids in the gastrointestinal tract and
indirectly removes cholesterol from the liver to be excreted
in the feces. The other agents listed help to reduce overall
cholesterol and triglycerides by various mechanisms, and are
often given in combination with statins.
127
Vitamins, Minerals, and Herbals
There are thousands of multiple vitamin preparations in
pharmacies today. The typical vitamin product contains a
mixture of fat-soluble vitamins, water-soluble vitamins,
minerals, and trace elements, also known as microminerals.
Multiple-vitamin products are indicated as supplements to be
used as adjuncts (in combination) with a regular diet.
Vitamins should never be used as a substitute for food. Many
health professionals argue that vitamin supplements are
unnecessary and that megavitamin therapy (ingestion of large
amounts of vitamins to ward off colds, flu, cancer, etc.) could
be dangerous. Other professionals claim that everyone would
benefit from supplements, and megavitamins are the answer
to most health problems. The correct use of vitamins, however,
is between these two extremes. The Recommended Dietary
Allowances (RDAs) are listed by governmental agencies for
essential nutrients based on age, gender, height, and weight.
The body produces enough of many nutrients to keep itself
functioning well. These types of nutrients are referred to as
conditionally essential nutrients. Other necessary nutrients
ANTILIPEMIC DRUGS
HMG-CoA REDUCTASE INHIBITORS
Drug Brand Name
atorvastatin Lipitor
fluvastatin Lescol
lovastatin Mevacor
pravastatin Pravachol
simvastatin Zocor
rosuvastatin Crestor
OTHER ANTILIPEMIC DRUGS
Drug Brand Name
cholestyramine resin Questran
fenofibrate Tricor
gemfibrozil Lopid
niacin Niaspan
ezetimibe Zetia
FIGURE 47Drugs That
Lower Cholesterol
128
are referred to as essential nutrients. These are needed to
maintain proper function of the body as well. Essential
nutrients are synthesized by the body but must also be
obtained through a balanced diet to maintain adequate levels
necessary for a healthy body.
The following sections include brief descriptions of the vitamin
and mineral components found in commercial multiple-
vitamin products. Vitamins are small amounts of chemical
components of foods that are essential to the human body.
They allow the body to perform metabolic reactions that
break down food and maintain life. Vitamins fall in two major
subgroups:
Fat-soluble vitamins
Water-soluble vitamins
An additional function of certain vitamins is against the action
of free radicals in the body. Free radicals are unstable atoms
that need an additional electron to become stable. Normally,
the body can handle free radicals, but if they become too
numerous, cell damage can occur. Free-radical damage,
which is due to several factors, including pollution, radiation,
cigarette smoke, and herbicides, accumulates with age. Some
vitamins protect cells from this damaging oxidation process
by providing one of their own electrons to the free radical,
thus alleviating the free radicals need to steal an electron
from another source. These vitamins are called antioxidants.
Vitamins C is the most abundant water-soluble antioxidant
in the body. Fat-soluble vitamin E combines with free radicals
caused by pollution and cigarette smoke (Figure 48).
Fat-Soluble Vitamins
The four fat-soluble vitamins are A, D, E, and K. ADEK is an
acronym for remembering the letters of the four fat-soluble
vitamins. Theyre called fat-soluble vitamins because all are
absorbed from the diet in association with fats.
Vitamin A. Vitamin A, also known as retinol, helps to
maintain healthy skin and mucus linings, strengthens the
immune system, and helps vision in dim light. Vitamin A
is found in fatty foods such as butter, cream, eggs, milk,
129
cheese, and yogurt. Its also found in oily fish, such as
mackarel, and liver. Excessive vitamin A could result in brittle
bones. This can be caused by low levels of vitamin D. Older
adults and pregnant women should avoid vitamin A supple-
mentation if theyre getting enough vitamin A in their foods.
Vitamin D. Vitamin D is actually composed of three types of
vitamins: (1) vitamin D
3
, (2) vitamin D
2
, and (3) a D vitamin
called dihydroxycholecalciferol. The first type, vitamin D
3
, is
considered the natural form of vitamin D. Its formed in the
skin from dietary or endogenous (original) cholesterol in the
body. Its also formed from exposure to sunlight. Vitamin D
compounds are needed in the body to stimulate calcium
absorption from the small intestine and to mobilize bone
calcium. Milk and milk products are the major source of the
vitamin D
2
, the second type of vitamin D. Vitamin D
2
is also
known as ergocalciferol. The third type of vitamin D, known
as dihydroxycholecalciferol, is synthesized in the kidneys. It
increases intestinal calcium absorption, assists in bone
resorption, and prevents rickets. Osteomalacia is an adult
form of rickets that most often affects the wrist and pelvis.
Additional food sources of vitamin D include oily fish, eggs,
and fortified cereals. Too much vitamin D can weaken bones.
FIGURE 48Antioxidants
have become a lucrative
market for pharmaceutical
companies as people fight
the damage caused by
free radicals.
130
Vitamin E. Vitamin E refers to a series of eight complex
organic chemicals. The compound known as alpha-tocopherol
is the most active of the eight. Plant oils contain significant
amounts of vitamin E compounds. Vitamin E serves as an
antioxidant (delays oxidation in the body) in association with
the trace element selenium. Together, these compounds pro-
tect cell components from the destructive effects of peroxides.
It may also have a specific coenzyme role in collagen forma-
tion and steroid metabolism. Its antioxidant effects might
protect against the common cold and certain forms of cancer.
Vitamin E is used to fight Parkinsons disease, Alzheimers,
and prevent restless-leg syndrome. Its claimed to be useful
in angina pectoris and other coronary diseases, in circulatory
conditions, and in leg cramps. Vitamin E can be obtained
through the diet in leafy, green vegetables, vegetable oils,
eggs, meat, and milk. Vitamin E is often taken as a supple-
ment. Excess vitamin E can produce symptoms of tiredness,
headaches, nausea, blurred vision, and gastrointestinal
cramping and gas.
Vitamin K. Vitamin K is a necessary component of the
blood-clotting pathway, helping wounds heal properly.
Internal bleeding will occur with inadequate body levels
of vitamin K. Its also needed to help build strong bones.
A major source of the vitamin is green, leafy vegetables.
Vitamin K can be found in small amounts in vegetable oil,
and cauliflower, as well as some fruits and grains. A major
source of vitamin K occurs from the synthesis of bacteria
in the intestinal tract. Internal hemorrhage is the most
common symptom of vitamin K deficiency. The blood-
thinner class of drugs prevents blood coagulation by blocking
the effects of vitamin K in the blood coagulation pathways.
On the other hand, large amounts of vitamin K can interfere
with the action of warfarin and other anticoagulants.
Water-Soluble Vitamins
Water-soluble vitamins arent fat soluble or absorbed from
fatty diets. Most of these vitamins are found in citrus fruits
and green, leafy vegetables. Water-soluble vitamins travel
directly into the blood stream. They arent stored in the body,
so excess amounts are excreted through the urine.
131
Vitamin B
1
. Vitamin B
1
, chemically known as thiamin or
thiamine, works with other B-group vitamins to help break
down and release energy from carbohydrates. Its also neces-
sary for healthy central nervous system function and healthy
muscle, including the heart. Alcoholism and inadequate diet
can lead to vitamin B
1
deficiency, as well as a diet high in
raw fish and shellfish, which are high in an enzyme that
destroys this vitamin. Though rare in developed countries,
beriberi is a condition caused by an inadequate amount of
vitamin B
1
, which is found in the hull of rice grains, pork,
beef, fresh greens, peas, beans, milk, cheese, fresh and dried
fruit, eggs, whole-grain breads, and some fortified cereals.
Vitamin B
2
. Vitamin B
2
is chemically known as riboflavin.
Riboflavin is a component of specific coenzymes vital to
oxidation-reduction reactions in cell metabolism. Its neces-
sary for growth and good health of skin, nails, hair. Vitamin
B
2
is also needed to maintain good vision. Its found in whole
grains, eggs, meat, fish, and liver. Milk is a major dietary
source of riboflavin.
Vitamin B
3
. Vitamin B
3
, known as niacin, or nicotinic acid,
is vital to keep skin, eyes, mucous membranes, and the nerv-
ous system healthy. It also helps to produce red blood cells
and steroids. Niacin might also help in iron absorption. In
high doses, vitamin B
3
will lower triglycerides and cholesterol.
Dietary sources are grains, milk, eggs, peas, and beans, rice,
lean meats, liver, poultry, fish, fortified cereals, and mush-
rooms. Vitamin B
3
can produce liver toxicity. An often noted
side effect of vitamin B
3
is burning and reddening of the skin,
especially around the face and neck. Your pharmacist might
recommend that patients take one regular-strength aspirin
one-half hour before taking vitamin B
3
to prevent this com-
mon side effect.
Vitamin B
5
. Vitamin B
5
(pantothenic acid) is needed for the
metabolism and synthesis of carbohydrates, proteins, and fats.
Its been used to treat acne and has been found to lessen
peripheral neuropathy. Pantothenic acid comes from the Greek
word pantothen meaning from everywhere and is found in
small quantities in many foods (Figure 49). Large amounts of
pantothenic acid can be found in whole-grain cereals and
brown rice, legumes, tomatoes, eggs, broccoli, and meat.
132
Vitamin B
6
. Vitamin B
6
, known as pyridoxine, is required
for protein and hemoglobin metabolism. It also plays an
important role in converting tryptophan to niacin. The nerv-
ous and immune systems also need vitamin B
6
to function
efficiently. Vitamin B
6
is needed for the synthesis of serotonin
and dopamine. These neurotransmitters are required for nor-
mal nerve cell communication. There seems to be a link
between vitamin B
6
deficiency and some neurologic condi-
tions such as seizures, chronic pain, depression, migraines,
and Parkinsons disease. Vitamin B
6
is used to treat drug-
induced or naturally occuring neuropathies. Vitamin B
6
can
be found in fortified cereals, salmon, tuna, pork, chicken,
and turkey. It can also be obtained by eating bananas, soy-
beans, eggs, peanuts, and a variety of vegetables. Excessive
amounts of vitamin B
6
can cause peripheral neuropathy.
Vitamin B
7
. Vitamin B
7
, more often referred to as biotin,
is used in the metabolism of fats and amino acids. Also
referred to as vitamin H, biotin assists in cell growth and
the production of fatty acids. In addition, biotin helps to
transfer carbon dioxide and helps maintain a steady blood
sugar level. Type 2 diabetics often have lowered biotin levels.
Some studies have shown that biotin affects the synthesis
and release of insulin and might help to improve blood sugar
control in those with diabetes, particularly type 2 diabetes.
Biotin is found in many cosmetic and health products for the
hair and skin, though theres no evidence its helpful unless
FIGURE 49Many vita-
mins and minerals can
be obtained naturally
through a balanced diet
that includes fresh fruits
and vegetables.
133
used when theres a deficiency, which is rare. Biotin is found in
some meats, eggs, and some fruits and vegetables, including
dried mixed fruit.
Vitamin B
9
. Folic acid, which is vitamin B
9
, is involved in
the synthesis of key intermediates in amino acid metabolism.
Its necessary for the production of healthy red and white
blood cells and is used to treat anemia. Healthy levels of folic
acid are vital for the prevention of certain birth defects such
as spina bifida. Folic acid is also recommended to increase
the likelihood of carrying a baby to full term. Low levels of
folic acid can be the result of alcoholism, malabsorption,
dieting, and liver disease. Folic acid can be found in fortified
cereals, leafy vegetables, broccoli, Brussels sprouts, aspara-
gus, peas, and chickpeas, fruits, yeast, liver, brown rice, and
orange juice. Folic acid is contraindicated when patients are
undergoing certain chemotherapies since it interferes with
the actions of these drugs.
Vitamin B
12
. Vitamin B
12
, or cyanocobalamin, is useful in
specific cells reactions involving cell division. Its also neces-
sary for the synthesis of chemicals in the myelin sheath of
nerve cells. Vitamin B
12
is important for healthy red blood
cells. Though stored in the body and rarely deficient, low levels
of vitamin B
12
result in pernicious anemia, which causes
fatigue, problems with memory, gastrointestinal problems,
and irritability. Vitamin B
12
is necessary for the metabolism
of folic acid. A folic acid deficiency can occur because of
vitamin B
12
deficiency. Vitamin B
12
can be found in nearly all
meat products, salmon, cod, milk, cheese, eggs, seaweed, and
some fortified cereals. Theres no scientific evidence of the
effects of high levels of vitamin B
12
.
Vitamin C. Vitamin C is chemically known as ascorbic acid.
Most animals make vitamin C in their bodies. Only humans
and a few other species must consume the vitamin because
they lack the enzymes to make it. Vitamin C is necessary for
the biosynthesis of compounds to make collagen, a substance
necessary to the formation of scar tissue and wound healing,
and dentine, which is a component of teeth. It also aids in
the absorption of iron. Vitamin C is necessary to prevent
scurvy (a deficiency disease). A deficiency of vitamin C will
cause impairment of wound healing and the reopening of old
134
wounds. Vitamin C is the most vulnerable vitamin to the
effects of heat, oxygen, and alkalinity. This vitamin is found
mainly in peppers, oranges and other citrus fruits, kiwi fruit,
broccoli, Brussels sprouts, and sweet potatoes. Vitamin C has
been promoted as a preventive agent for the common cold,
though these claims are based mainly on anecdotal (scien-
tifically unverified) personal experience.
Choline. Finally, the water-soluble micronutrient choline is
required for the biosynthesis of acetylcholine and is a compo-
nent of a chemical called phosphatidyl choline, or lecithin.
Lecithin is a phospholipid (a source of fuel for the body con-
taining phosphates) used in cell membrane structure and cell
metabolism. Choline can be obtained in the diet by eating egg
yolks, soy, and cooked beef and chicken livers. Choline is
most readily available via lecithin, which is derived from soy
or egg yolks and often used as a food additive. Supplements
of lecithin/choline have reduced homocysteine levels in the
blood and are therefore thought to reduce heart disease. This
reduction, however, might be related more to the cholesterol-
carrying capacity of lecithin than to the role of choline.
Minerals
Minerals are important components of metabolic reactions,
and most enzymatic systems wouldnt function without vari-
ous amounts of minerals. Minerals such as calcium are also
important components of bone structure and cell structure.
Minerals are often divided into major and microminerals (often
called trace elements). Larger amounts of major minerals are
needed in the body to maintain health. Microminerals, or
trace elements, appear in smaller quantities.
Calcium. Calcium is the major structural component of bones
and teeth and is the most abundant mineral in the human
body. Its also necessary for blood clotting and for muscle,
heart, and nerve cell function. Calcium is recommended to
treat osteoporosis, osteomalacia, and muscle spasms. A suf-
ficient quantity of calcium also prevents a disease known as
rickets. Calcium loss can be a result of the bodys inability to
properly absorb calcium from foods and supplements. It can
also be caused by a deficiency in vitamin D and poor kidney
function. Calcium can be obtained from food sources such as
135
dairy products, dark green leafy vegetables, eggs, and fish.
Excessive calcium will be eliminated in the urine, so the
pharmacist will recommend that patients take no more than
500 mg in each dose.
Chloride. Chloride, along with sodium, maintains osmotic
pressure in the bodys cells. It acts as an electrolyte, aiding
absorption of nutrients in the body. In developed countries, a
large amount of dietary chloride comes from table salt. Chloride
is also found in fruits and vegetables. If youve ever noticed
that perspiration is salty, its because chloride is absorbed in
the intestines and removed from the body in sweat.
Magnesium. Magnesium is required for bone structure and
is essential for the functioning of important enzyme systems
in carbohydrate and protein metabolism. Magnesium is also
responsible for proper muscle relaxation and nerve impulse
transmission. Lack of healthy levels of magnesium results in
loss of appetite, fatigue, nausea, numbness and tingling,
muscle contractions and cramps, and irritability. Dietary
magnesium can be found in green leafy vegetables, some
legumes, nuts, seafood, whole grains, and cocoa. Excessive
magnesium can cause muscle weakness and tiredness.
Phosphorus. Phosphorus is essential for most metabolic
reactions. Its a structural component of bone in association
with calcium, such as calcium phosphate salt. Phosphorus is
necessary for healthy bones, teeth, and cells. Most foods con-
tain phosphorus, especially meat, poultry, fish, and eggs.
Patients who have high levels of phosphorus will often have
low levels of calcium and vice versa.
Potassium. Potassium is partly responsible for maintaining
fluid and electrolyte balance in the body. Its also important
in brain and nerve function. Potassium plays a major role in
osmotic balance between cells and cellular fluid balance.
Potassium deficiency can cause muscle cramps, weakness,
irregular heartbeats, and mental confusion. Potassium
deficiency can be triggered by diuretics prescribed for high
blood pressure, so potassium supplementation is often rec-
ommended for hypertensive patients on diuretics. Foods rich
in potassium include avocados, potatoes, bananas, broccoli,
orange juice, soybeans, and apricots.
136
Sodium. Sodium works with potassium and chloride to keep
a healthy balance of fluid in the bodys cells. Muscles need
sodium to function properly. Sodium also works to maintain
the volume of plasma. Theres little chance of an average
American having a sodium deficiency. Table salt is the major
source of sodium in the diet, but processed foods, such as
canned soups, are high in sodium, as are many cheeses and
other processed foods. Too much sodium can cause hyper-
tension and water retention.
Sulfur. Sulfur is the third most abundant mineral in the
human body, and it accounts for one percent of your body
weight. Sulfur is necessary for cartilage formation and to
maintain skin, hair, and nails. Sulfur is also a component of
other important body chemicals, including insulin and
heparin. Finally, sulfur is important in cell respiration.
Sulfur is found in meats, poultry, fish, egg yolks, broccoli,
cauliflower, leafy green vegetables, legumes, Brussels
sprouts, leeks, onions, and garlic. Sulfur is also found in
supplements, including alphalipoic acid, chondroitin and glu-
cosamine, garlic, and glutathione. Studies have shown that
sulfur as contained in methylsulfonylmethane (MSM) lessens
nerve pain, inflammation, and muscle spasms.
Trace Elements
Trace elements, or microminerals, are present in extremely
small quantities in human tissues and are essential for
healthy cell function. The trace elements include copper,
manganese, chromium, selenium, molybdenum, silicon, tin,
nickel, vanadium, iron, zinc, fluoride, iodine, and cobolt.
Chromium. Chromium is a component of the glucose
tolerance factor, and influences how insulin behaves in the
body. Chromium deficiency can result in glucose intolerance.
It also plays a role in carbohydrate, fat, and protein metabo-
lism. Chromium can be found in oysters, liver, potatoes, and
brewers yeast, as well as certain seafoods, whole grains,
lentils, spices, and cheeses. Preliminary findings indicate that
chromium may also improve endurance and strength taken
at high doses.
137
Cobalt. Cobalt aids the healthy function of cells and the
development of red blood cells in its role in the formation of
vitamin B
12
. Without sufficient vitamin B
12
, the body can
become anemic. Meat is a good source of cobalt, as are eggs
and milk. If patients are vegetarians, pharmacists should
suggest a supplement of vitamin B
12
to maintain sufficient
levels of both vitamin B
12
and cobalt. Excessive cobalt might
affect the heart and decrease male fertility.
Copper. Copper is a component of many enzymes that are
necessary for life and is found in all human tissues and blood.
Copper is necessary for healthy bones, hair, skin, nervous
system, and immune system. It also plays a role in the
metabolism of iron and triggers the release of iron to form
hemoglobin. Copper is also thought to be important for infant
growth and brain development. A person who develops a cop-
per deficiency will be anemic, with decreased white counts
and bone abnormalities. Copper can be obtained from food
sources, including meat, shellfish, legumes, nuts, grains, and
dried fruits. Supplementation of high amounts of copper can
cause vomiting and diarrhea.
Fluoride. A diet deficient in fluoride can result in dental
caries. Fluoride is naturally occuring in water, seafood, and
tea. Fluoride supplementation can prevent cavities and aid in
strong, healthy teeth. Too much fluoride, however, can cause
discoloration and pitting of the surface of teeth. Excessive
fluoride in older adults can cause bone brittleness.
Iodine. Iodine is required for the synthesis of thyroid hormone
in the thyroid gland. Iodine plays a part in keeping cells
healthy and regulating the bodys metabolic rate. Without
iodine, the thyroid gland enlarges, resulting in the classic
thyroid goiter. The addition of iodine to table salt has virtually
eliminated goiter in the United States. Besides table salt,
iodine can be ingested by eating saltwater fish, including
sardines, as well as clams and lobster. High iodine intake
can produce an unpleasant tase in the mouth along with
burning and soreness of the gums and throat.
Iron. Iron plays an important role in oxygen and electron
transport. Its a component of hemoglobin, the molecule that
carries oxygen inside the red blood cells. Between 60 and 70
percent of total body iron is found in red blood cells. The two
138
types of iron found in the body are functional iron and stored
iron. Functional iron is found in hemoglobin and myoglobin.
Stored iron is found in the liver, spleen, intestines, bone mar-
row, and hemoglobin. A deficiency of iron causes anemia,
resulting in fatigue, weakness, a sensitivity to cold, brittle
nails, and constipation. Anemic patients will usually appear
paler than usual. Iron can be found in liver and other organ
meats, lean meats, poultry, legumes, nuts, egg yolks, whole
grains such as brown rice, dried fruits, and enriched cereals
and breads. Most dark green leafy vegetables such as water-
cress and curly kale are high in iron. Spinach, contrary to
popular belief, actually inhibits iron absorption to a degree.
Even though iron is found in so many foods, many patients
need iron supplementation. The pharmacist will probably
advise patients that taking iron supplements will cause con-
stipation unless they change their diets or take a stool
softener. Excessive iron ingestion will cause toxicity, espe-
cially in children. Ingesting excessive iron will cause pain,
vomiting and diarrhea, and even shock.
Manganese. Manganese is required to metabolize many
foods, especially fats and carbohydrates. Manganese is involved
in the production of sex hormones, reproduction, and growth.
Manganese also aids the bodys use of vitamin E. Humans can
obtain manganese from foods such as legumes, nuts, whole
grains, fruits, and vegetables. Tea is also a good source of man-
ganese. Excessive manganese over an extended time might
cause nerve damage, fatigue, and depression.
Molybdenum. Molybdenum is present in several enzymes in
the human body that are involved in creating and repairing
genetic material. Its found in tooth enamel and can affect
protein synthesis, metabolism, and growth. Molybdenum can
be obtained by eating liver, green beans, eggs, sunflower seeds,
lentils, and grains. Foods that grow above ground, such as
peas, broccoli, spinach, and cauliflower are higher in
molybdenum than root vegetables. Molybdenum deficiency
and toxicitiy are rare. Some evidence suggests taking supple-
mental molybdenum might cause joint pain.
139
Nickel. Nickel is present in urease, an enzyme that assists
in the hydrolysis of urea in the body. Nickel is also important
in red blood cell production and plays a role in the way the
body absorbs iron. Nickel is found in lentils, oats, and nuts.
Selenium. Selenium is a trace element thats essential for
humans because it plays a role in fat metabolism and con-
tributes to a healthy immune system. In addition, selenium
is responsible, in part, for protecting cells. This antioxidant
protection might play a role in cancer prevention. Selenium
deficiency can be caused by cirrhosis of the liver. Rarely, its
caused by poor diet or impaired metabolism. Selenium is
found in meats, seafoods, grains, milk, and onions. Excessive
selenium can result in nausea, vomiting, abdominal pain,
and fatigue, as well as nerve, hair, and nail damage.
Silicon. Silicon seems to have a part in the health of connec-
tive tissue and bone. Silicon can be obtained through eating
root vegetables, oats, barley, and rice.
Tin. Tin is a trace element that can be obtained by eating
many fresh foods and foods packed in tin cans. The amount of
tin found in fresh food depends on the amount of tin present
in the soil where the food is grown. Little is known about any
effects tin might have on the human body. Very high amounts
of tin consumption would cause vomiting and diarrhea.
Vanadium. Vanadium is thought to be related to human
growth and reproduction. Its available through a wide variety
of foods including seafood, meat, mushrooms, dairy foods,
cooking oils, fresh fruit, vegetables, parsley, dill seed, and
black pepper. Supplementation isnt probably necessary,
since vanadium is found in such a wide variety of foods. Its
believed that excessive vanadium affects growth and causes
diarrhea and anorexia.
Zinc. Zinc is an essential metal for a number of enzymes
known as metalloenzymes. Zinc is necessary in the metabo-
lism of carbohydrates, fats, and proteins. Zinc is used to heal
wounds and burns and plays a role in reproductive organ
development and growth. In addition, zinc is necessary for
healthy function of the prostate. Zinc can be found in meat,
poultry, shellfish, whole-grain cereals, milk, cheeses, beans,
and nuts. High-fiber diets may interfere with zinc absorption.
140
Herbals
More and more Americans are turning to herbal products to
either replace or supplement traditional prescription medica-
tions. Herbs are plant or parts of plants that are used for
their therapeutic properties. Herbs, which are also referred to
as botanicals, are used for their scents and flavors as well. In
addition to over-the-counter supplements, herbal products
are being added to many common foods and drinks. Many
alternative medicine therapies are being used by patients,
though patients are sometimes reluctant or forgetful when it
comes to including these supplements in the information
they provide their treating physicians.
A pharmacy technician, if directed by the pharmacist, can
encourage patients to disclose all dietary supplements that
they may be taking. Its quite helpful to see the actual label,
since many herbal products contain several ingredients of
varying strengths. Patients dont always recall the names of
these products accurately.
As dietary supplements become increasingly popular, the
FDA requires certain information to be included on each
label. The following information is currently required on the
labels of dietary supplements:
The Latin botanical name
A boxed text listing supplement facts
An FDA disclaimer that reads, These statements have
not been evaluated by the FDA. This product is not
intended to diagnose, treat, cure, or prevent any disease.
The FDA allows manufacturers to label the products with
functional claims, but not claims as to how the product will
affect a particular disease.
In addition to FDA oversight, the National Institues of Health
(NIH) has created the Office of Dietary Supplements, which
compiles research statistics. This information provides con-
sumers and medical personnel with a much better look at how
and when dietary supplements work effectively (Figure 50).
141
As do most drugs, herbal supplements have side effects and
allergic reactions to be considered carefully. Unlike with
drugs, however, theres no comprehensive way to report and
compile this information, though the FDA is considering a new
system for handling adverse event reports.
There are computer software programs that screen for
potential drug-herbal interactions. As more and more data
becomes available, these software systems will cross-check
for many more potential interactions. However, computer
programs are only as accurate as the information entered
into the system.
FIGURE 50Many plants
and their parts have
been used as medicinals
for centuries.
142
Because many herbal products are metabolized in the liver,
toxic levels may cause liver damage. In addition, since many
drugs are also metabolized by the liver, herbals increase or
decrease the effects of prescribed drugs the patient is taking.
As with any prescribed drug or over-the-counter medication,
concerns about herbal supplements should be referred to the
pharmacist. A good pharmacy technician will be attentive to
certain situations that might present risk, including allergies;
taking, changing, or discontinuing prescription medications;
pregnancy and nursing; a history of hypertension or diabetes;
and the patients age (a young child or older adult).
NOTES
Self-Check 1
143
Self-Check 4
Questions 110: Match the drug on the left with its action on the right. Indicate your
choices in the spaces provided.
______ 1. Vitamin K
______ 2. Keratolytics
______ 3. Antineoplastic agents
______ 4. Corticosteroids
______ 5. Cardiotonics
______ 6. Anticholinergics
______ 7. Diuretics
______ 8. MAO inhibitors
______ 9. Antihistamines
______ 10. Antilipemic drugs
a. Destroy and soften the outer layer of the skin
b. Block the effects of cold and allergy symptoms
c. Restore the heartbeat to its normal force and
efficiency
d. Promote the excretion of sodium and water
from the kidneys
e. Used to treat tumors or cancer
f. Used to treat severe forms of depression
g. Lower blood cholesterol
h. Block nerves that cause excessive contractions
in an overactive bladder
i. Used to treat inflammatory diseases
j. Helps woulds heal properly by promoting blood
clotting
144
1. True
2. True
3. True
4. False
5. False
6. False
7. True
8. False
9. False
10. True
Self-Check 2
1. True
2. True
3. False
4. False
5. False
6. True
7. False
8. True
9. False
10. True
Self-Check 3
1. f
2. d
3. g
4. j
5. b
6. i
145
A
n
s
w
e
r
s
A
n
s
w
e
r
s
7. a
8. c
9. e
10. h
Self-Check 4
1. j
2. a
3. e
4. i
5. c
6. h
7. d
8. f
9. b
10. g
Self-Check Answers
146

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