Pharm Week 1 Study Guide: Advanced Pharmacology (Chamberlain University)

Week 1 Outline:

Chapter 1: The Role of the Advanced Practice Nurse as Prescriber

Roles and Responsibilities of APRN Prescribers

Advanced Practice Registered Nurses (APRNs) encompass Certified Nurse-Midwives (CNMs), Certified Registered Nurse Anesthetists (CRNAs), Nurse Practitioners (NPs), and Clinical Nurse Specialists (CNS). The degree of autonomy and the breadth of drugs that APRNs can prescribe vary from state to state based on the Nurse Practice Act of the state. Legislative updates are provided annually in the January issue of the Nurse Practitioner Journal and the American Journal for Nurse Practitioners, summarizing each state’s practice as it relates to titling, roles, and prescriptive authority.

Regulation of NP Practice and Prescribing Authority:

All states have title protection for NPs.
Only Oregon mandates third-party reimbursement parity for NP services.
In all but five states, the control of practice and licensure is within the sole authority of the state’s board of nursing. The other five states have joint control with the board of medicine.
Scope of practice is determined by the individual NP’s license under the Nurse Practice Act of the licensing jurisdiction.
In 17 states and the District of Columbia, NPs have independent SOP and prescriptive authority without a requirement for physician collaboration, consultation, delegation, or supervision.
Six states have full autonomous practice and prescriptive authority following a period of post-licensure/post-certification supervision and collaboration.
The Institute of Medicine (IOM) called for removing scope of practice barriers and allowing NPs to practice to the full extent of their education and training.

Clinical Judgment in Prescribing

Prescribing a drug results from clinical judgment based on a thorough assessment of the patient and their environment, the determination of medical and nursing diagnoses, a review of potential alternative therapies, and specific knowledge about the chosen drug and the disease process it is designed to treat.

Best Therapy Considerations:

The least expensive, least invasive, and least likely to cause adverse reactions.
Combining lifestyle, non-pharmacological, and pharmacological therapies.

Questions to Consider Before Drug Therapy:

Is there a clear indication for drug therapy?
- Indications and necessity should be carefully considered.
- Example: Antibiotic guidelines for Otitis Media have evolved due to the high percentage of infections resolving without intervention. Over-treatment with antibiotics can lead to resistance.
What drugs are effective in treating this disorder?
- Best and most effective drug class.
- Refer to guidelines from AHCQ, NIH, and specialty organizations.
What is the goal of therapy with this drug?
- Short-term therapy goals versus long-term chronic condition management.
Under what conditions should a different therapy or drug be tried?
- Clear understanding of expected outcomes and monitoring effectiveness.
Are there unnecessary duplications with other drugs the patient is taking?
- Regular review of patient medication history.
Would an OTC drug be as effective as a prescription drug?
- Consideration of cost and patient perception of OTC drugs.
What about the cost?
- Affordability and impact on adherence.
- Consideration of generic options and insurance coverage.

Sources of Reliable Drug Information:

Professional literature, specialty and professional organizations, and drug databases like Lexicomp and Epocrates.

Collaboration with Other Providers

Collaboration Involves:

Physicians: Expertise in biochemistry and pathophysiology.
Pharmacists: Knowledge about drug management, potential adverse reactions, and interactions.
Other APRNs: Sharing knowledge and improving patient care.
Physician Assistants (PAs): Similar practice to physicians, beneficial interaction.
Non-advanced practice nurses: Carrying out APRN orders, importance of knowing the Nurse Practice Act.

Autonomy and Prescriptive Authority

State Legislation and Trends:

Most states are expanding the legal reimbursement and prescriptive authority for APRNs.
26 states allow independent practice for NPs, and 21 states allow full independent prescribing as of January 2015.
Ongoing “turf battles” between APRNs and physicians regarding supervision and co-signature requirements.

Chapter 2: Review of Basic Principles of Pharmacology

How Drugs are Developed

Drugs are developed by pharmaceutical companies to help patients and make money. The preclinical stage involves identifying a drug target and performing studies on cells, tissues, organs, and laboratory animals. The FDA requires drugs to be both safe and effective, undergoing Phase I, II, and III clinical trials before approval.

Drug Responses

Homeostasis is the tendency of a cell, tissue, or the body not to respond to drugs but instead to maintain the internal environment by adjusting physiological processes. Before a medication can produce a response, it often must overcome homeostatic mechanisms. Drug effects depend on the amount of drug that is administered.

Types of Drug Responses:

Quantal Responses: May or may not occur, such as convulsions, pregnancy, rash, sleep, and death.
Graded Responses: Can be measured continually up to the maximum responding capacity, such as changes in BP, HR, diuresis, bronchodilation, FEV1, pain, and coma scale.

Chapter 3: Rational Drug Selection

Process of Rational Drug Prescribing:

The World Health Organization (WHO) proposes a six-step process for rational drug prescribing, emphasizing patient education and monitoring effectiveness.

Patient Education and Monitoring Effectiveness

Patient Education:

Critical to improving medication adherence.
Tailored to the patient’s understanding level and involving family/caregivers.

Monitoring Effectiveness:

Passive Monitoring: Patient is educated on expected outcomes and instructed to contact the provider if the treatment is ineffective or adverse effects occur.
Active Monitoring: Provider schedules follow-up examinations, evaluates therapeutic blood levels, and makes necessary dosage adjustments.

Drug, Patient, and Provider Factors Influencing Drug Selection

Drug Factors:

Pharmacodynamic and Pharmacokinetic Factors: Specificity, selectivity, bioavailability, metabolism, dosing schedule.
Therapeutic Factors: Clinical evidence, guidelines, cost considerations.
Safety and Cost: Varies with the population and impacts adherence.

Patient Factors:

Previous adverse drug reactions, health beliefs, current therapy, age, pregnancy status.

Provider Factors:

Ease of prescribing, monitoring, and familiarity with the drug.
Formularies influencing drug choices.

Influences on Rational Prescribing

Pharmaceutical Promotion:

Funded research, free samples, and incentives influencing prescribing practices.

Antibiotic Resistance:

Need for re-education on appropriate prescribing to combat resistance.

Chapter 4: Legal and Professional Issues in Prescribing

New Drug Approval Process:

Preclinical research, clinical phases (I, II, III), and FDA approval.

Off-label Use:

Prescribing an FDA-approved drug for an unapproved indication based on scientific evidence.

Controlled Substance Laws:

Prescriber education, recognizing behavioral red flags, dealing with prescription scams, and implementing systemic solutions.

Chapter 5: Adverse Drug Reactions

Classification of ADRs:

Mechanistic (Pharmacological vs. Idiosyncratic), Immune-mediated (Types I-IV), Time-related, Dose-related, and Severity.
Common causes, including drug classes with high incidences of ADRs and risk factors.

Chapter 6: Factors that Foster Positive Outcomes

Nonadherence:

Addressing high-risk groups and communication barriers.
Simplifying drug regimens, scheduling follow-ups, and using reminders.
Overcoming sensory and mobility challenges.

Chapter 7: Cultural and Ethnic Influences in Pharmacotherapeutics

Cultural Influences on Care:

Understanding health disparities and the role of cultural heritage.

Ethnopharmacology:

Study of racial differences in drug metabolism and response.
Research on genetic markers and enzyme systems influencing drug response.

Chapter 9: Nutrition and Nutraceuticals

Nutrient–Drug Interactions:

Foods affecting drug absorption, metabolism, and excretion.
Education on diet impacts and specific nutrient-drug interactions.

Chapter 12: Pharmacoeconomics

Impact of Generic Drugs:

Reducing costs without compromising care.
Generic substitution practices and Medicare Part D coverage.

Chapter 13: Over-the-Counter Medications

Regulation and Safety:

Requirements for OTC medications, sales data, misuse hazards, interactions, and patient education.

Chapter 24: Drugs Used in Treating Infectious Diseases

Antimicrobial Resistance:

Factors contributing to resistance and guidelines for antibiotic use.

Overview of Specific Drug Classes:

Beta-Lactams: Penicillins and Cephalosporins
- Uses, mechanisms of action, mechanisms of resistance, pregnancy category, ADRs, drug interactions, and cross-reactivity.

Penicillins:

Effective for bacterial upper respiratory infections, pneumonia, STIs, UTIs, and wound infections.
Mechanism: Inhibiting bacterial cell wall mucopeptide synthesis.
Resistance: Inactivation by beta-lactamases or alteration in target PBPs.
Pregnancy Category B: Limited evidence in women, use when clearly indicated.

Cephalosporins:

Used for respiratory tract infections, skin infections, and UTIs.
Mechanism: Disrupt synthesis of the peptidoglycan layer of bacterial cell walls.
ADRs: Diarrhea, headache, sore mouth or tongue, vaginal itching, and discharge.

Antibiotic Use Guidelines:

Sinusitis: Treat only if symptoms persist or are severe.
Pharyngitis: Treat Group A beta-hemolytic strep with penicillin or alternatives.
UTIs: Treat with trimethoprim/sulfamethoxazole or nitrofurantoin; alternatives include amoxicillin/clavulanate.
Skin and tissue infections: Treat post-animal bites with amoxicillin/clavulanate.

Age, Pregnancy, and Genetic Factors:

Avoid certain drugs in neonates and pregnant women due to toxicity risks.
Genetic factors influencing drug metabolism and adverse effects.

Fluoroquinolones:

Risks of tendon rupture and CNS effects, not recommended for children, pregnant/lactating women, and certain conditions.

Macrolides:

Used for upper respiratory and gram-positive bacterial infections, precautions, contraindications, and adverse drug reactions.

Systemic Azoles and Antifungals:

Precautions, contraindications, and monitoring.

Sulfonamides, Trimethoprim, Nitrofurantoin, and Fosfomycin:

Spectrum of activity, resistance, precautions, contraindications, and adverse drug reactions.

Tetracyclines:

Precautions, contraindications, adverse drug reactions, and use in adolescents.

Antimycobacterials:

Isoniazid: Precautions, contraindications, adverse drug reactions, and interactions.

Nucleoside Analogues:

Drugs in this class, spectrum of activity, adverse drug reactions, clinical use and dosing, rational drug selection, and patient education.

Antivirals for Influenza:

Clinical use and dosing of drugs like oseltamivir and zanamivir, and CDC guidelines for prophylaxis and treatment.

This guide provides an overview of the key topics for the first week of advanced pharmacology, emphasizing the role of the APRN as a prescriber, clinical judgment in prescribing, collaboration with other healthcare providers, and foundational pharmacological principles.