ANTI - VIRAL More difficult to treat than bacterial infections because virus depends on

biochemical processor of the host cells for its replication

Drugs that interfere with virus may also damage cells MOA: inhibit viral replication by interfering viral nucleic acid synthesis in the cell

I. Agents for Influenza and Respiratory Viruses amantadine (Symmetrel) - PO oseltamivir (Tamiflu) - PO ribavirin (Virazole) aerosol inhalation rimantidine (Flumadine) - PO zanamivir (Relenza) inhaler CI: allergy, pregnancy & lactation,renal & liver disease AE: lightheadedness, dizziness, insomia, nausea, orthostatic hypotension, & urinary retention DI: with anti cholinergic drugs = increase atropine like effect Nursing Considerations: Start regimen as soon after the exposure to the virus as possible (achieve best effectiveness and decrease the risk of complications) Administer the full course of drug Provide safety measures ( protect patient from injury) II. Agents for Herpes Herpesviruses Herpes simplex virus type 1 HSV2 HSV3: Varicella- zoster (chickenpox or shingles) HSV 4: Epstein Barr virus CMV: cytomegalovirus

acyclovir (Zovirax) , famciclovir (Famvir), valacyclovir (Valtrex)- = herpes; PO cidofovir (Vistide) - IV= CMV in AIDS foscarnet (Foscavir) = both; IV ganciclovir (Cytovene) = long term treatment & prevention of CMV; IV

CI: CNS disorders, allergy, pregnancy & lactation, renal disease SE: N/V, HA, depression, rash, hair loss, inflammation & burning sensation at the site of injection and topical AE: renal dysfunction DI: + other nephrotoxic meds= inc toxicity + zidovudine= inc drowsiness TOPICAL ANTIVIRALS (HSV)

idoxuridine Penciclovir Trifluridine

Nursing Considerations: Extreme caution to children ( carcinogenic); foscarnet ( affect bone growth & development) Good hydration ( decrease toxic effects o the kidney) Administer as soon as possible, compliance

 Wear protective gloves when applying the dug topically ( decrease risk of exposure to the drug and inadvertent absorption) Safety precautions = CNS effects( orientation, siderails, lighting, assistance) Warn that GI upset, N/V can occur (prevent undue anxiety, increase awareness of the importance of nutrition) Monitor renal function Avoid sexual intercourse if with genital herpes Avoid driving and hazardous tasks if with dizziness & drowsiness

Agents for HIV & AIDS Enzymes needed by viruses: Reverse transcriptase helps uncoat the virus; single stranded viral RNA is converted into DNA Integrase- helps viral DNA migrates into the nucleus of the cell, where I is spliced into the host DNA (provirus) => duplicated together with the cell genes every time the cell divides Protease- assists in the assemble of newly formed viral particles

ANTIRETROVIRAL THERAPY
A. Reverse Transcriptase Inhibitors Nucleoside Analogues (NRTI) Nonnucleoside Analogues (NNRTI) B. Protease Inhibitors C. Entry Inhibitors A. Nucleoside/ Nucleotide Reverse Transcriptase Inhibitors (NRTIs) MOA: blocks the reverse transcriptase enzyme needed for viral replicaation zidovudine (Retrovir) didanosine (Videx) stavudine (Zerit) lamivudine (Epivir) abacavir (Ziagen) tenofovir (Viread) emtricitabine (Emtrive) Fixed dose: lamivudine/zidovudine (Combivir)

abacavir/ lamivudine/ zidovudine (Trizivir) abacavir/ lamivudine (Epzicom) efavirenz/ emtricitabine/ tenofovir (Atripla) emtricitabine/ tenofovir (Truvasa)

SE (less tenofovir renal toxicity) GI: nausea, diarrhea, abdominal pain (transient 2 weeks) Mitochondrial toxicity: lactic acidosis, peripheral neuropathy, myopathy, pacreatitis, lipoatrophy (wasting of fats in face, buttocks and extemities)

Nursing Considerations: Should be taken with food except didanosine (60 min AC or 2 hours PC) Requires dosage adjustment except abacavir (creatinine clearance < 50mL/min) Fixed dose avoided if with renal insufficiency A. Non- nucleoside Reverse Transcriptase Inhibitors (NNRTIs) MOA: prevent viral replication by competing with binding of the revere transcriptase enzyme at the active site Used to reserve protease inhibitors (resistance) efavirenz (Sustiva) First-choice drug PC: D CNS toxicities: dizziness, sedation, nightmares, euphoria, loss of concentration Administered as a component of Atripla OD @ HS Empty stomach / low fat meal (prevent excessive drug absorption)

nevirapine ( Viramune) alternative: Pregnancy (1st tri) Planning to conceive Not using effective/ consistent contraception < risk: rash hepatotoxicity delavirdine (Rescriptor) Least potent antiviral activity Not recommended as part of regimen

B. Protease Inhibitors MOA: act at the end of the HIV cycle to inhibit the production of infectious HIV virus lopinavir/ ritonavir (first line) atazanivir fosamprenavir (second either boosted with retonavir or not) amprenavir tipranavir darunavir saquinavir indinavir ritonavir nelfinavir NOTE:

Ritonavir boosting mainstay of PI therapy (potent inhibitory effect) Take with food + didanosine = one hr before or two hours after ritonavir

C. Entry Inhibitors

MOA: prevents HIV cell entry (fusion of HIV and CD4) enfuvirtide the only agent approved Indicated in combination with 3-5 other anti- retroviral agents (for clients with limited tx option) Expensive. 90 mg Sub-Q. BID Injection site reaction: Suncutaneous nodules, redness Others: rash. Diarrhea, serous allergic reaction (anaphylaxis)

ANTIHELMINTICS

Helminthes are large organisms (parasitic worms) that feed through the host tissue Intestine, lymphatic system, blood vessel and liver MOA: act on metabolic pathways that are present in the invading worm but absent or significantly different from human host 4 groups: Cestodes ( tapeworms) Trematodes (flukes) Intestinal nematodes ( roundworm) tissue invading nematodes

pyrantel pamoate (Combatrin) Paralysis the intestinal tract of the worm Indication: giant roundworm, hookworm, pinworm mebendzole ( Antiox) Inhibits glucose and other nutrients of helminthes Indication: roundworm, pinworm, hookworm, whipworm thiabendazole (Mintozol) Interfere in parasitic metabolism Indication: roundworm, pinworm praziquantel (Biltrizide) Paralyzes the worm tapeworm SE: HA, dizziness, fever, chills and malaise, rash, pruritus, loss of hair NURSING CONSIDERATIONS: Take drug with food, small frequent feeding Avoid driving, change position slowly Take drug as prescribed Inform health care provider about OTC meds taking For intestinal infection, some measures that help prevent worm reinfection or help prevent spread to other family members: Vigorous use of soap and water after use of toilet Showering in the morning to wash away any ova deposited in the anal area during the night Changing and laundering undergarments, bed linens and pajama daily Disinfecting toilet & toilet seats, bathroom and bedroom floors periodically Proper handling of food and food preparation Control flies Avoid sexual intercourse or use condom in with vaginal infection

ANTI- FUNGALS ( anti- mycotics)

An infection caused by fungus mycosis

Fungi differ from bacteria in that the fungus has a rigid cell wall that is made up of chitin and various polysaccharides and a membrane that contains ergosterol ( makes them resistant to antibiotics) Treatment for systemic (candidiasis, histoplasmosis) and superficial (tinea pedis/ athletes foot

I. Polyenes A. amphotericin B (Fungizone) MOA: binding to the fungal cell membrane; forming open channels >> increase cell permeability and leakage of intracellular components. Very potent but with many unpleasant side effects (renal failure) DOC: severe systemic infection; IV SE/ AD: fever, N/V, dec BP, paresthesia, thrombophlebitis, nephrotoxicity, hypersensitivit, electrolyte imbalance (hypokalemia & hypomagnesemia)

B. nystatin ( Mycostatin) MOA: increases permeability of fungal cell membrane Oral preparation- intestinal candidiasis, poorly absorb in GIT Suspension mouth or throat fungal infection Oitment, suppository, cream- vaginal SE: fever, N/V, rash, diarrhea (large dose) ***** swish>> gargle>>swallow

II. Azole Group MOA: interfere with the formation of ergosterol (major sterol in fungal cell membrane) ketoconazole (Nizoral) First effective antifungal orally absorbed Used to treat same mycoses with amphotericin B (give with food; no antacid) Shampoo= dandruff SE: diziness, blurred vision AE: hepatomegaly ; photosensitivity itraconazole (Sporanox) Systemic fungal infection; also PO miconazole (Monistar) Oitment vaginitis; IV- fungal bladder infection fluconazole (Diflucan) Oropharyngeal and systemic; hepatotoxic; also PO Voriconazole Posaconazole *****NOTE: vaginal tablet, cream, ointment and solution (topical preparation to treat candidiasis and tinea infections)

III. Antimetabolite MOA: disrupts fungal DNA and RNA synthesis flucytosine (Ancoban)- combination therapy NURSING CONSIDERATIONS ( anti fungal): GS/CS, compliance, monitor IV sites, liver & renal function tests For topical: wash hands before & after application For athletes foot: wear cotton socks, change 2-3 times daily Jock itch worm: wear well fitting, non constrictive, ventilated clothing Intravaginal Read instructions carefully Insert high into the vagina Continue use through menstruation Wear a minipad to avoid staining clothing, do not use tampon Wash applicator with mild soap and rinse thoroughly after each use Avoid sexual intercourse while using the drug

ANTIMALARIAL Malaria- cause by protozoan parasites (plasmodium falciparum, malariae, vivax,

ovale)

Causes RBC deformity and increase fragility and decrease oxygen transport

Mx: fever, chills, sweating, anemia, spleenomegaly, hepatomegaly, malaise chloroquine HCL (Aralen) The mainstay of anti malarial therapy MOA: enters human RBC and changes the metabolic pathways necessary for the reproduction of plasmodium SE: GI upset, fatigue AE: blurring of vision, blindness, ototoxicity Other drugs: Quinine sulfate chloroquine resistant malaria Primaquine, mefloquine

ANTIPARASITC (DERMA) Eg; Pediculosis lice infection (head, body, pubic) Scabies caused by sarcopte scabie, characterized by: eruptive lesion from
burrowing of the female parasite, transmitted through direct contact with skin, clothing and bedding lindane ( Kwell) MOA: unknown, thought to stimulate the parasites CNS leading to seizure and death SE: local skin irritation AE: hypersensitivity NURSING CONSIDERATIONS: Administer twice ( 1st immediately after dx; 2nd one week after the initial) Administer to all household members Wear gloves to remove nits by using fine- tooth comd with vinegar Apply to all body area except face

ANTIPROTOZOAL Use to treat:

amebiasis (E. histolytica) N/V, diarrhea, abdominal cramping and weakness trichomoniasis (T. vaginalis)- reddened inflamed vaginal mucosa, burning itching and yellowish- green discharge

metronidazole (Flagyl) MOA: inhibits DNA synthesis, bactericidal USES: DOC for intestinal and systemic amebiasis; prophylaxis fro abdominal and colorectal surgery, H. pylori and trichomoniasis SE: N/V, diarrhea, unpleasant taste AE: HA, dizziness, ataxia, superinfection NURSING CONSIDERATIONS: Avoid alcohol (disulfiram like reaction = nausea, flushing, tachycardia, increase vomiting Protected sex, proper hygeine, proper foOD preparation

ANTITUBERCULOSIS

A. Isoniazid (INH) MOA: affects the mycolic acid coating the bacterium Hepatic enzyme elevation, peripheral neuropathy (as it competes with absorption of Vitamin B6 or pyridoxine) Take AC 10-50mg pyridoxine as prophylaxis, 50-100mg as treatment B. Rifampicin MOA: alters DNA and RNA activity in the bacterium Orange discoloration of secretion and urine Best taken empty stomach but causes gastric irritation hence should be taken with food (also at bedtime) Protect drug from light C. Pyrazinamide (PZA) Both bactericidal & bacteriostatic Hepatotoxic, ototoxic, nephrotoxic, GI upset May lead to hyperuricemia, arthralgia Protect drug from light D. Ethambutol (Myobutol) MOA: inhibits cellular metabolism Lead to optic neuritis (affect the red green discrimination), skin rash Not given to children 6 years or younger because cannot reliably monitor vision Nursing Considerations Refer the following: Jaundice (ALL) Visual impairment (ethambutol) Tinnitus & hearing impairment (streptomycin) Oliguria & albuminuria (streptomycin & rifampicin) Psychosis & convulsion (INH) Thrombocytopenia & anemia (rifampicin) DRUGS FOR URINARY TRACT DISEASE Urinary Tract Antiseptics / anti infectives Urinary analgesics Urinary stimulants Urinary antispasmodics

I. Urinary Tract Antiseptics/ Anti-infectives

nitrofurantoin (Macrodantin) MOA: interferes with CHON metabolism, bactericidal (high doses) Spectrum: Broad esp E- coli Uses: acute & chronic UTI CI: hypersensitivity, renal dse, pregnant, lactating DI: dec absorption if with antacid SE: NAVDA Dizziness ( institute safety measures) Rust/brown urine (harmless/ inc OFI) Staining of teeth ( do not crush tablets, dilute suspension, rinse mouth) AE: peripheral neuropathy, agranulocytosis, hemolytic anemia, superinfection, hepatotoxicity

methanamine (Hiprex) MOA: in the presence of acidic urine (pH < 5.5) converted to formaldehyde = bactericidal Uses: chronic UTI DI: inc crystalluria if taken with sulfonamides Dec if taken with NaHCO3

SE: NAVDA, dizziness AE: allergic reaction to dye, Crystalluria; HA. Nervousness, confusion

Nursing Considerations: GS/CS before therapy Take with food Comply compliance Increase OFI; UO and SG. Report dec UO Acidify urine ( cranberry juice, vitamin C/ ascorbic acid) Avoid alkaline foods ( milk, vegetables, antacids, NaHCO3) Dont use clinitest for glucose testing In additon women should: Avoid bubble baths, pantiliners, scented tissue Wipe from front to back Void after coitus, void whenever with urge

II. Urinary Analgesics

phenazopyridine HCL (Pyridium) An azo dye excreted in the urine MOA: provides a topical analgesic effect to the urinary tract within 30 mins Uses: releives mx of UTI ( pain, burning sensation, frequency & urgency of urination) SE: red- orange urine (harmless); NAVDA; vertigo, rash AE: hemolytic anemia; thrombocytopenia; leukopenia; hepato/ nephrotoxicity Nursing Considerations: Check the underlying cause of pain Caution that reddish orange urine may occur, permanently stain clothing, tears will stain contact lenses Take with food / milk to decrease gastric distress Stop drug if sclera turn yellow (a sign of drug accumulation) Treatment should not exceed 2-3 days ( inc toxic effects) Can alter glucose urine test

III. Urinary Stimulants

Used when bladder function is decreased or lost as a result of: Neurogenic bladder ( dysfunction caused by lesion of nerve) Spinal cord injury Severe head injury ===== urinary retention DOC: bethanecol chloride (Urecholine) MOA: direct acting parasympathomimetic (cholinomimetic) L/T contraction of detrusor muscle and relaxation of sphincter L/T urination May stimulate gastric motility

SE: flushing of skin & headache ( vasodilation) AE: flushing, increase sweating, colicky pain, abdominal cramps, diarrhea, increase salivation, involuntary defecation, bradycardia, hypotension, cardiac arrest ANTIDOTE: atropine sulfate

Nursing Considerations: Monitor VS, ECG Administer on an empty stomach to decrease N/V, bathroom facilities stay in cool environment, use lightweight clothing (flushing & sweating)

IV. URINARY ANTISPASMODICS

AKA: antimuscarinics MOA: blocks parasympathetic activity L/T relaxing the detrusor muscle Uses: relief urinary tract spasm d/t UTI / trauma

CI: obstructive urinary tract problem, glaucoma, myasthenia gravis, acute hemorrhagic / GI obstruction SE: N/V, dry mouth, constipation, dizziness, nervousness, visual changes, Increase BP, tachycardia, increase IOP AE: urinary retention, hepato/ nephrotoxicity, photosensitivity

propantheline bromide (Pro- banthine) oxybutynin (Ditropan)- increase bladder capacity and decreases frequency of voiding in neurogenic bladder tolterodine (Detrol) inhibits bladder contraction, decreases detrusor muscle pressure, delays the urge to void flavoxate (Uripas)- counteract spasm in smooth muscle dimethylsulfoxide (DMSO)

Nursing Considerations Arrange for the treatment of the underlying cause Arrange for an opthalmological examination, institute safety measures Monitor and manage constipation, dry mouth, Assess changes in VS