January 14, 2011

Pharmacology 2:
CLINICAL MANAGEMENT TARGETS

Note:

-Penicillin Binding Proteins (PBP’s) is the binding site of most B- Lactam Antibiotics.
-PBPs are responsible for the synthesis of the cell wall or peptidoglycan formation.
Antiviral Agents:
Anti-fungal Agents:
Malaria

Salient Feature Drug of Choice or Medical Management

Fever Paracetamol
- Immuno-stimulation and release of - Inhibits PGE1
TNF alpha Hydration  IV Infusion & Resuscitation
- TNF alpha  PGE1 TSB  Ineffective
Pain

PGE1 Features:
Pain
Vasodilation & Edema

Hyperthermia r/t inflammatory process

of rbc destruction by malarial parasite.

Acute pain r/t inflammatory process of

malarial infection
Etiology: Parasite 1st Line Agents
P. Ovale Primaquine
P. Malaria DOC: Chloroquine (250mg)
P. Falciparum Sulfadoxine-Pyrimethamine (500mg/25mg)
P. Vivax 2nd Line Agents
Artemeter 20mg, Lumefantrine 120mg
3rd Line Agents
Quinine
Tetracycline or Doxycycline

Heme  prevented from forming

Hemozoin (Hz)
- This now generates O2  Free
Radicals  Destroy Malarial
 Parasite

Anopheles Mosquito sp. Over KILL (Fumigation, Control the

breeding grounds  Water)
Prophylaxis  Potential Visitors in the Chloroquine 250mg 2tabs once/week
endemic areas prior or before 2 weeks of exposure.
Complications:

Anemia (Hemolytic)  BILIVERDIN rises Blood Transfusion Replacement

Jaundice Hemodialysis
Risk for kernicterus Hydration  prevent Hemoconcentration
Risk for Hypoxia  Loss of RBC no Intubation
binding site O2 in the Fe+

Ineffective tissue perfusion r/t continual

damage of rbc by the malarial parasite.

Seizure Diazepam
Delirium Strict Bed Rest
Restraint Policy
Risk for injury (Falls) r/t uncontrolled
patient response secondary to the
brains inflammatory process.
Secondary bacterial infections Antibiotics according to the Culture &
-Nosocomial Sensitivity Test
- Immunosuppression effects and
cortisol release due to stress.

Leptospirosis:

Salient Feature Drug of Choice or Medical Management

Headache & Fever (PGE1) Paracetamol
Joint Pains (PGE1)
Etiology: Bacteria
Leptospira spirochete Penicillin G 1.5 mil units qid for 1
family: (Syphilis sp) week or
- Animals (Dogs/Cats/Rats)  Doxycycline 100mg PO BID for 1 week
exposed to rat urine

Jaundice & Liver Failure

Dehydration Fluid & Electrolyte Replacement
Renal Failure Dialysis
Dopamine Drip
Tetanus

Salient Feature Drug of Choice or Medical Management

Wound Infection (site of injury)
- Dead debris or cells (no oxygen) 
lactic acid & CO2  breeding
grounds for C. tetani.
Risk infection r/t continual growth of
microorganisms on the devitalized and
hypoxic tissue.
Muscular Rigidity
- Inhibition of GABA release
- Tetanospasmin/Tetanolysin 
Inhibits inhibitory neurotransmitter
release (GABA)
- AcH surge  M3  Muscular
Contraction  Rigidity
Skin Debridement/ Removal of the dead
cells (damaged/devitalized tissues)
Hydrogen Peroxide (Malunod ka sa
oxygen) & Betadine
Sterile
Diazepam (Benzodiazepine)
- GABAmimetic agent (Presynaptic
Cleft).
- Releases GABA  Inhibition to the
M3 activation (AcH)  Muscular
relaxation

Altered breathing pattern  Hypoxia High Fowlers

Risk Aspiration Side lying
Acute Pain NPO
Risk for Injury NGT
Impaired physical mobility
Airway & Respiratory Compromise Intubation
(Muscular Rigidity & Spasm of the Diazepam
pharyngeal passageways  Upper
respiratory tract obstruction. (STRIDOR)
Sedation Purposes Diazepam
Tetanolysin Human Tetanus Immunoglobulin
- Neutralize toxin
Etiology: Bacteria Penicillin G 4Mil Units QID/IV
Clostridium tetani sp. (SOIL) Metronidazole 500mg
Supportive:
GI Bleeding & stress ulcers  CORTISOL NGT & Sucralfate or Antacids
RELEASE (Loss of PGE1 OF GMB)
Pain Paracetamol or
Fever Ibuprofen

Syphilis

Salient Feature Drug of Choice or Medical Management

Etiology: Bacteria Benzathine Pen G 2.4 mil IM
Treponema palladium sp. Doxycycline PO or Tetracycline or
Erythromycin

Gonorrhea

Salient Feature Drug of Choice or Medical Management

Credes Prophylaxis (*at birth only) Silver Nitrate
Erythromycin Eye Ointment
Etiology: Bacteria /STD Azithromycin
Ofloxacin
Neisseria gonorrhea sp.(Gonococcus) Metronidazole
Cerebral Neisseria Meningitides Pen G
(Meningococcus) Vancomycin

Vaginal Candidiasis

Salient Feature Drug of Choice or Medical Management

Etiology: Fungus Hygiene
Candida sp. Fluconazole
Itchiness
Creamy vaginal secretions

Chicken Pox

Salient Feature Drug of Choice or Medical Management

Etiologic: Virus Acyclovir (Zovirax)
Varicella zoster sp.
Herpes zoster sp. Valaciclovir (Valtrex)
Pain NSAIDS
Neurobion (Vitamin B Complex)
Itchiness Calamine lotion
Canadryl (Benadryl lotion)
Hygiene
Fever Paracetamol
Avoid Aspirin (Reyes Syndrome in
children)

H1N1

Salient Feature Drug of Choice or Medical Management

Etiologic: Virus Oseltamivir: Neuramidase Inhibitor 
H1N1 Prevents Attachment.
Immunomodulation Effects
- Histamine release
- Direct damage in lining of the
bronchous
- Goblet cell hypersecretion
Bronchoconstriction  AIRWAY
OBSTRUCTION
Secondary Infections
a. Nosocomial Infection
- Pseudomonas
- Stap.
Bronchodilators:
Salbutamol  Beta agonist (B2)
Ipratropium Hbr  Muscarinic receptor
blocker (blocks the vagal receptors)
1. Bronchodilate
2. Inhibit hepersecretion
Aminophylline  Beta Agonist
Phospholiapse A2 inhibitor
Hydrocortisone
1. Lipooxygenase inhibition  reduce
Histamine production
Intubation
Pulmonary Toilet  Suctioning
Antibiotics based on Culture and Sensitivity
Test
Empiric Therapy:
3rd Cephalosporin, Vancomycin

Rabies

Salient Feature Drug of Choice or Medical Management

Prophylaxis Rabies Vaccine
a. Animal Vaccination Equine Rabies Immune globulin (Favirab)
b. Persons who handles
- Pet shop/owner
- Veterinarian
- Nurses/MD under infectious cases
Post-Exposure Animal Bite
Wound Site Wash running water (soap)
- Open soil exposure from animal bite Skin Debridement
(C. tetani) Tetanus Post exposure (Human Tetanus
 - Other bacterial infections Immunoglobulin)
Cloxacillin
RIG (Rabies Immune Globulin)
Rabid Human
Confusion Isolate
Delirium Restrict Bed rest
Less stimulation (sounds/Temp/light/air)
Laryngospasm  Upper airway NPO
obstruction and pain IV INFUSION
Hydrophobia NGT
Phagophobia Goal: Let the patient die with dignity and
Odynophagia (Painful swallowing) avoid CONTAMINATION
Survival in rabies is RARE

HIV

Salient Feature Drug of Choice or Medical Management

Prophylaxis
Anti-retroviral Agent for 1 month
Diagnostic work ups to 6 months
Test for Susceptible Host Based on
History
Goal: Reduce the growth of the virus (chance
that infectious process wins)
Needle prick accidents to a suspected HIV
patients (Nurses/MD)
GOAL: To confirm HIV infection

Diagnostic Test:

Elisa Test
Western Blot (Confirmatory)

Post Exposure (HIV +) GOAL:

Reduce the Viral Load and increase CD4
Target: CD4 T Lymphocyte Lymphocytes:
a. Preventing Opportunistic Infections
Diagnostics: b. Preventing HIV heterogenicity
(mutation) RESISTANCE
c. Preventing oncogenesis (Cancer)
CD4 Count: (n) >1,500 d. Reduce transmission and infecting
(AIDS) <350 other susceptible.
Viral Load: (n) 0.00
(High) 150,000 OTHERS: MONEY & Support
Suspected Culture for opportunistic
Infections 1 capsule  380 pesos x 2 a day

Biopsy for suspected Tumors NB: Walang pera walang gamut

Philippines: DOH & PGH offers free (Combivir) if
the CD4 count falls below 300.

Anti-Retroviral Agents:
- Avoid Mutation of HIV
- Reduce Growth of HIV

Reverse Transcriptase  RNA becomes the

DNA’s template  Different Amino Acids 
Mutation/DNA Damage  Apoptosis

I. Protease Inhibitors
– Ritonavir (Norvir)
– Saquinavir (Fortavase; Invirase)
– Nelfinavir (Viracept)
– Indinavir (Crixivan)
– Amprenavir (Agenerase)
- Lopinavir

II. Nucleoside Reverse Transcriptase Inhibitor

– AZT (zidovudine; Retrovir)
– 3TC (lamivudine; Epivir)
– d4T (stavudine; Zerit)
– ddI (didanosine; Videx)
– Abacavir (Ziagen)
– ddC (zalcitabine; Hivid)

III. Non-Nucleoside Reverse Transcriptase

Inhibitors
– Efavirenz (Sustiva)
– Nevirapine (Viramune)
– Delavirdine (Rescriptor)

IV. Fusion Inhibitors

- Fuzeon
V. Vaccine
- Clinical Trials

Naïve Patients: (HIV + patients who are not yet

receiving Anti-retrovirals)

Nursing Responsibility:
1. Monitor the Baseline:
 a. Confirm that the patient HIV +
b. Secure CD4 count & Viral Load
Count
c. Liver Enzymes (AST/ALT)
d. Pancreas (Serum Amylase)
e. Renal Function (BUN/Creatinine)
f. WBC/RBC
2. Compliance Medication:
- Cocktail of drugs (more than 2 agents)
- medication tray/cabinet (Time frame)
- Diary of Symptoms
3. Health Teachings
- avoid drinking Alcohol  Toxicity
- avoid drinking GrapeJuice and other herbal
drinks these interact with HIV agents.
- Promotion of peer groups/anonymous
- Promotion of Health and SEXUAL
EDUCATION.

PTB

Salient Feature Drug of Choice or Medical Management

Pre-Exposure:

Mantoux Test  Immunologic reaction is Vaccination: BCG (LIVE)

tested that the patient is exposed with the - Immunostimulant
M. tuberculosis. - Contraindicated immunosuppressed &
a. Exposed before but you are not carrying pregnant
the agent/ you are not infected. - Can result PTB osteomyelitis
b. Infected ka
Isolation
Sputum AFB  GOLD STANDARD Hand washing
carrier and infectious Waste Disposal  Sputum
Mask

PTB AGENTS: 6 Months Duration

Part 1: Initial Phase ( 2 months)
Part 2: Continuous Phase (4 Months)
Gastric Analysis  NGT Lavage and
Gavage  Children who fails to follow
instructions of spitting.

Chest PA  APICAL hyperaireation

Fever (afternoon/night) Paracetamol

Weight Loss  Its not nutritional cause Increase Diet
TNF alpha (Chronic Inflammation) Drink Anti-PTB Drugs
2 week of cough Increase Oral Fluid Intake
Oral care

UNIT X. Drugs for Communicable Diseases

Pulmonary Tuberculosis
Primary Drugs
Streptomycin
Isoniazid (INH)
Rifampicin
Pyrazinamide (PZA)
Ethambutol
Secondary Drugs
Capreomycin
Ethionamide
Para-aminosalicylate sodium
Cycloserine
1.4 Phases of Treatment
1.4.1 Initial Phase
1.4.2 Continuation phase
2. Pneumonia
2.1 Streptococcal pneumonia
a. Penicillin G
b. Cefotaxime
c. Fluoroquinolone
2.2 Haemophilus pneumonia
a. Amoxicillin-Clavulanate
b. Non-beta-lactamase- Amoxicillin
2.3 Mycoplsma pneumonia
a. Macrolide
b. Tetracycline
2.4 Viral Pneumonia
a. Oseltamivir
b. Zanamivir
2.5 Chlamydia pneumonia
a. Fluoroquinolone
2.6 Hospital-acquired
Pneumonia/Pseudomonas Pneumonia
a. Penicillin + Ciprofloxacin
b. Levofloxacin
c. Aminoglycoside
2.7 Klebsiella pneumonia
a. Aminogygosides
b. Cepahlosporins
c. Meropenem
d. Levofloxacin
e Piperacillin/Tazobactam + Amikacin
3. Malaria
3.1 Chloroquine
3.2 Primaquine
3.3 Quinine
3.4 Sulfadoxine
4. Leptospirosis
4.1 Mild Leptospirosis
a. Doxycycline
b. Amoxicillin
4.2 Moderate to Severe Leptospirosis
a. Penicillin G
b. Ampicillin
5. Filariasis
5.1 Diethylcarbamazine (DEL)
5.2 Albendazole
5.3 Doxycycline
5.4 Ivermectin
6. Chicken Pox (Varicella)
6.1 Acyclovir
7. Typhoid fever
7.1 Ciprofloxacin
7.2 Cloramphenicol
7.3 Azithromycin
7.4 Ampicillin
7.5 Cotrimoxazole
8. Viral Hepatitis
 8.1 Lamivudine
8.2 Interferon
8.3 Isoprinosine
9. Rabies
9.1 Rabies Immunoglobulin (RIG)- post-exposure prophylaxis
( tetanus antiserum/anti-rabies vaccine)
10. Tetanus
10.1 Penicillin G Na
10.2 ATS, TAT or TIG
11. Scabies
11.1 Permethrin cream
11.2 Lindane lotion
12. Carbuncle
12.1 Penicillin G
12.2 Vancomycin
13. Gonorrhea
13.1 First Line
a. Ceftriaxone
b. Doxycycline
13.2 Alternative
a. Ceftizoxime
b. Cefotetan + Probenecid
14. Chlamydia
14.1 Doxycycline
14.2 Tetracycline
14.3 Azithromycin (Pregnant)
15. HIV/AIDS
15.1 Reverse-Transcriptase inhibitors
a. Zidovudine (ZDV)
b. Didanosine
c. Zalcitabine
d. Stavudine
e. Lamivudine
f. Nevirapine
15.2 Protease inhibitors
a. Saquinavir
b. Ritonavir
c. Indinavir
15.3 Integrase Inhibitor
a. Raltegravir
16. Schistosomiasis
16.1 Praziquantel
17. Ascariasis
17.1 Albendazole
17.2 Ivermectin
17.3 Piperazine Citrate
 17.4 Pyrantel Pamoate
18. Enterobiasis
18.1 Mebendazole
18.2 Pyrantel pamoate