CHAPTER 2
Medications
PTCE Knowledge Domain: Medications
40% of Exam
Knowledge Areas:
▪ Generic names, brand names, and classifications of medications
▪ Therapeutic equivalence
▪ Common and life-threatening drug interactions and contraindications (e.g., drug–disease, drug–drug, drug–dietary supplement, drug–laboratory, drug–nutrient)
▪ Strengths/dose, dosage forms, routes of administration, special handling and administration instructions, and duration of drug therapy
▪ Common and severe medication side effects, adverse effects, and allergies
▪ Indications of medications and dietary supplements
▪ Drug stability (e.g., oral suspensions, insulin, reconstitutables, injectables, vaccinations)
▪ Narrow therapeutic index (NTI) medications
▪ Physical and chemical incompatibilities related to nonsterile compounding and reconstitution
▪ Proper storage of medications (e.g., temperature ranges, light sensitivity, restricted access)
After reading Chapter 2 you will be able to:
▪ Recognize pharmacology principles, including absorption, distribution, metabolism, and elimination
▪ Identify the brand and generic names and drug class for the top 200 drugs
▪ Understand drug interactions and the impact on patient safety
▪ Describe dosage forms and routes of administration, and drug stability
▪ Recognize medication that have a narrow therapeutic index (NTI)
▪ Understand the proper storage of medications, including temperature ranges, light-sensitivity requirements, and restricted access
In this chapter, we review the brand and generic names and drug classifications of the top 200 prescribed medications. We also review side effects and indications of these drugs. This chapter also reviews drug interactions and stability as well as dosage forms and routes of administration. It is important to start with some basic pharmacology principles. This will help you understand drug interactions, side effects, and stability of medications later on in the chapter.
Pharmacology is the study of the effect of and mechanism of action of drugs. There are two divisions of pharmacology, known as pharmacokinetics and pharmacodynamics. Pharmacokinetics is the study of movement of drugs, or specifically, the absorption, distribution, metabolism, and elimination or excretion processes. Absorption, distribution, metabolism, and elimination/excretion are collectively known as ADME. Pharmacodynamics is study of the effect a drug has on the body.
Let’s review the ADME processes more in depth:
Absorption and distribution are the ways into the body, whereas metabolism and elimination are the ways out. Recognizing the ADME properties will help you understand drug action, such as why a medication administered intravenously works more quickly than a drug taken by mouth—the faster the drug can enter the bloodstream (absorption) and be distributed, the quicker the onset of action. It will also help you understand drug interactions and how impacting metabolism can lead to adverse effects and toxicity.
Generic Names, Brand Names, and Classifications of Medications
After a drug is approved by the FDA, it possesses three naming conventions: chemical, generic, and brand names.
The chemical name is determined while the drug is being designed and investigated. The drug is then assigned a generic name by USAN by following a naming convention that identifies the active ingredient in the drug. This naming convention specifies the drug class. A drug class is a group of drugs that are similar in action or treat the same disease. For example, ACE inhibitors used to treat blood pressure all end in -pril (lisinopril, quinapril, enalapril).
The following are a few examples of drug classes identified through the drug stem named by USAN. As we review the top 200 drugs, these are identified with each class.
After the generic name is selected, the drug company can give the drug a brand or trade name. The brand name does not need to follow a naming convention and is often designed to be appealing to patients or help them remember what the drug is treating. For example, the brand name Lipitor is used to treat high cholesterol or “lipids” in the body. This can help both prescribers and patients remember names.
Once a brand name is developed, it is protected by a patent for a specific period of time. The purpose in a drug patent is to allow the drug company to sell the drug without a generic competitor. This helps the drug company recover some of the costs of drug development. After a patent has expired, other manufacturers are permitted to develop a generic version of the brand name drug. The FDA must also approve generic drugs, but it is through an accelerated process and takes less time and resources to complete, which allows generic drugs to be sold at a cheaper price. Generic drugs must have the same active ingredient and meet the same standards for quality and safety as the brand name drug. Generic drugs are permitted to have different inactive ingredients, and for patients who are sensitive to dyes and fillers, this may result in different side effects of generic medications versus the brand name.
Top 200 Drug Generic and Brand Names and Drug Class
Learning the top 200 most frequently prescribed drugs is an important component of the PTCE and also for becoming a successful pharmacy technician. You’ll find the following table to be helpful for learning and remembering generic and brand names, as well as the drug class for each of the most commonly prescribed drugs. Remember that the top 200 drugs is subject to change each year with the changes in prescribing and new drug development, but this will make you knowledgeable about the 200 most frequently prescribed drugs.
Dosage Forms and Routes of Administration
Dosage forms are broken down into solid, liquid, and semisolid forms. Solid dosage forms include tablets and capsules. Both are convenient methods of administration and storage for patients. However, the onset of action can be delayed when taking oral tablets due to the first pass through the stomach. When medications are taken orally, absorption does not occur until the small intestine. To help speed up the absorption time, tablets have been modified into different forms, listed as follows.
Capsules are also frequently used for oral administration. They are made of a gelatin shell that makes it easier to swallow. Inside of the shell is the drug or active ingredient. You can open the capsule, and some can be sprinkled onto food or dissolved in a liquid.
There are also dosage forms that are not designed to release the drug immediately. These dosage forms can sometimes decrease the amount of doses needed in one day. You will often see these abbreviated after the medication name. For example, Ambien CR has a different release mechanism than Ambien, which is designed to both help initiate sleep and sustain sleep.
Lozenges or troches are another type of solid dosage form that are sweetened or flavored to help medication slowly dissolve locally to the throat or mouth. Additional solid dosage forms include powders, such as those ground for topical treatment or aerosol. Patches are also considered a solid dosage form and are applied transdermally to the skin, which allows the medication to absorb directly into the bloodstream.
Liquid dosage forms can be administered orally but can also be used topically for cleansing or irrigation.
Semisolid dosage forms are those that are not fully solid or liquid. These are mostly administered topically.
Routes of Administration
Most medications are given via one of three routes of administration: oral, parenteral, or topical.
Oral Routes
Oral routes of administration include any dose given by mouth (PO). This is the most commonly prescribed route for prescriptions, as it is most convenient for patients. If a more rapid route is needed, medications can be given via the buccal route (dissolved in the cheek) or sublingual route (dissolved under the tongue).
Parenteral Routes
Any route that is parenteral bypasses the intestines and goes directly into the bloodstream. Though the onset of action is quicker with parenteral routes, injections are more painful and can be a source of infection.
Medications given IV can be administered in different ways depending on the drug, infusion time, and volume to be infused.
Topical Routes
A medication administered topically is applied to a mucous membrane, such as the eye or ear, or to the skin. Topical routes also include into the nose, rectally, or vaginally.
The strength of a medication is the amount of active ingredient within the drug and dosage form. This is typically expressed in terms of mcg, mg, or g for solids, and mg/mL for liquids. Many drugs are available in more than one strength and dosage form. For example, acetaminophen is available as 325mg and 500mg tablets, 1,000mg/100mL IV solution, and 160mg/5mL oral suspension.
The duration of drug therapy is the amount of time a patient needs to take the drug for the entire treatment. Chronic conditions are those in which an illness persists for a long time, such as months, years, or even the rest of your life, such as diabetes or hypertension. Acute conditions are those with a rapid onset and resolves quickly, such as a cold or viral infection. Compliance can also be a factor in the duration of drug therapy. If a patient does not follow their course of treatment, the disease may persist longer than expected.
The indication of a drug is the use of a drug in treating a disease. For example, the indication for paroxetine (Paxil) is depression. Use of a medication for diseases or treatment outside of their FDA-approved indication is considered “off-label” use. The next section gives a brief review of the body system for each drug system. It also highlights indications for the top 200 medications and special dosing and administration considerations, side effects, dosages, contraindications, and interactions.
Cardiovascular System and Drugs
The cardiovascular system includes the heart and blood vessels networked through the body. The heart pumps nutrient-rich, oxygenated blood through the arteries and the veins carry deoxygenated blood back to the heart. Capillaries are the small vessels where the exchange of gases (oxygen and carbon dioxide) occurs between arteries and veins.
The heart has two chambers on the top (atria) and two chambers on the bottom (ventricles). These chambers are separated by valves, which open and close to allow blood to flow in the right direction. The left ventricle is the largest chamber and pumps blood through the aorta to the rest of the body. The right ventricle pumps blood through the right atrium to the lungs to become oxygenated. This blood then returns back through the left atrium and into the left ventricle to continue the circulation. This beating of the heart is controlled through an electrical conduction system. Heartbeats are recorded through EKG or ECG (electrocardiogram) and can identify abnormal rhythms.
When the heart is pumping, there is pressure created by the force of the blood pushing against the blood vessels. There are two values to this pressure: systolic pressure, which is the pressure when the heart is pumping, and diastolic pressure, or the pressure when the heart is relaxed. A normal blood pressure is 120/80 mm Hg, with the systolic reading being the top value and the diastolic the lower value.
There are many disorders of the heart that can be treated with medication. It is helpful to have an understanding of cardiovascular diseases when studying medications for treatment. A description of cardiac-related disorders follows.
The following are the drug classes that are reviewed individually for treatment of cardiovascular diseases. Many of these classes are affiliated with a USAN drug stem that is helpful when remembering what class each drug belongs to.
These drug classes to treat disorders of the cardiovascular system are reviewed to include the following:
▪ Mechanism of action
▪ Side effects
▪ Special handling and administration instructions
▪ Drug interactions
▪ Indications
▪ Dosage form
▪ Dosage and duration of therapy
The following are medications that are a combination of two different drugs used for the treatment of hypertension. Most include a diuretic to help with fluid retention or contain two different drug classes to reduce blood pressure through different mechanisms.
Gastrointestinal System and Drugs
The gastrointestinal (GI) system begins with the mouth and continues down the esophagus into the stomach. Food that travels to the stomach is broken down by acid. From the stomach, food enters the small intestine. This is where absorption occurs. After the nutrients have been absorbed, the food then passes to the large intestine, also known as the colon, where water is reabsorbed back into the body. This prepares the food for excretion through the rectum and out the anus. Additional organs to aid in digestion include the gallbladder, which stores bile for fat digestion, and the liver, which produces and secretes bile. The pancreas also has important functions in protein, fat, and starch digestion, and also releases insulin into the blood.
Many disorders that affect the GI system are caused by lifestyle factors, such as poor diet or obesity. The following are disorders can impact the GI system.
The following drug classes are reviewed individually for treatment of GI disorders.
These drug classes to treat disorders of the GI system are reviewed to include the following:
▪ Mechanism of action
▪ Side effects
▪ Special handling and administration instructions
▪ Drug interactions
▪ Indications
▪ Dosage form
▪ Dosage and duration of therapy
Respiratory System and Drugs
The respiratory system is comprised of the organs that allow us to breathe in oxygen and exhale carbon dioxide. This process starts when oxygen enters our nose or mouth and travels through our sinuses. Sinuses are hollow cavities in the skull that create a mucous layer that protects our nose from dirt and infectious agents traveling in the air. Because of this first-line protection, sinuses often become infected, which can lead to drainage, blockage, and an increase in pressure in the head.
Airflows from the sinuses to the windpipe or trachea, which branches into bronchi. Bronchi extend into the lungs and branch further into bronchioles. The end of each bronchiole is covered with air sacs, known as alveoli. This is where gas exchange occurs, when blood is pumped to the lungs from the heart. In the alveoli, the carbon dioxide is removed from the blood and exhaled, while the oxygen from the air we breathe is exchanged into the blood.
The following are respiratory disorders, which are typically caused by either an infection or a chronic disease.
The following are the drug classes that are reviewed individually for treatment of respiratory disorders.
These drug classes to treat disorders of the respiratory system are reviewed to include the following:
▪ Mechanism of action
▪ Side effects
▪ Special handling and administration instructions
▪ Drug interactions
▪ Indications
▪ Dosage form
▪ Dosage and duration of therapy
Endocrine System and Drugs
The endocrine system is comprised of glands and organs that produce and secrete hormones, which helps keep the body in balance. There are 10 glands or organs in the endocrine system:
▪ Pituitary gland
▪ Thyroid gland
▪ Hypothalamus
▪ Pineal gland
▪ Parathyroid gland
▪ Adrenal gland
▪ Thymus gland
▪ Ovaries
▪ Tests
▪ Pancreas
The following lists each gland and the hormone secreted or produced. Each hormone has a site of action and function in the body that is important for physiological equilibrium.
The following are disorders that affect the pancreas.
The following are drug classes for diabetes treatment.
The following are disorders impacting the reproductive glands.
The following are drug classes for hormonal therapy.
The following are disorders of the thyroid, adrenal, and parathyroid glands.
The following drug classes are used to treat disorders of the parathyroid, thyroid, and adrenal glands.
The Nervous System and Drugs
The nervous system is composed of the brain and spinal cord (central nervous system) and the network of nerves that run through our body (peripheral nervous system). The brain releases chemicals known as neurotransmitters. Neurotransmitters act on different receptors in the brain, which coordinate responses and reactions.
The following are the neurotransmitters of the brain that can be modified by drug therapy for treatment.
When the amount of neurotransmitter is too low or too high, a chemical imbalance occurs. Many disorders of the nervous system are a result of neurotransmitter imbalance. The following are disorders of the nervous system.
The following are the drug classes that are reviewed individually for treatment of nervous system disorders.
These drug classes to treat disorders of the nervous system are reviewed to include the following:
▪ Mechanism of action
▪ Side effects
▪ Special handling and administration instructions
▪ Drug interactions
▪ Indications
▪ Dosage form
▪ Dosage and duration of therapy
The Urinary System and Drugs
The urinary (renal) system is responsible for eliminating waste, regulating blood pressure, and controlling the level of electrolytes in the blood. Blood is transported to the kidneys via the renal arteries. The kidneys contain a million small units called nephrons, and each nephron completes the processes of filtration, reabsorption, and secretion. It is through this process that the kidneys help regulate blood pressure through filtration (in the glomerulus), removal of waste through secretion, and blood volume through reabsorption.
Each nephron also contains a renal tubule, which contains the proximal convoluted tubule, loop of Henle, distal convoluted tubule, and connecting tubule. Each segment of tubule completes excretion of substances or secretion back into the bloodstream. Diuretics act on specific portions of the tubule, which impacts reabsorption and can help reduce blood pressure.
Following this filtration, reabsorption, and secretion, the urine exits each kidney through the ureters. These tubes connect the kidneys to the bladder. Urine is stored in the bladder until the body is ready for excretion. The urethra connects the bladder to external body for excretion. This tube is much longer in men than women. This often leads to more frequent urinary tract infections in women, due to the short proximity of the urethra to the bladder. The following are disorders of the urinary system.
The following drug classes are reviewed individually for treatment of nervous system disorders.
These drug classes to treat disorders of the urinary system are reviewed to include the following:
▪ Mechanism of action
▪ Side effects
▪ Special handling and administration instructions
▪ Drug interactions
▪ Indications
▪ Dosage form
▪ Dosage and duration of therapy
The Immune System and Drugs
The immune system consists of many structures that help protect the body from pathogens (bacteria, virus, or other organism) and aid in immunity. As mentioned earlier, the thymus gland produces T-cells, which play an essential role in the immune response. T-cells are a type of lymphocyte, or white blood cell, and help kill foreign cells or regulate the immune response. The lymph system also plays a role in immunity by circulating lymph (clear fluid made of white blood cells) through the body to lymph nodes and other organs that help fight infection. If a pathogen is recognized in the lymph fluid, the nodes produce more white blood cells causing them to swell. Lymph nodes are located in clusters throughout the body, including the neck, armpit, and groin. The spleen also aids in immunity by filtering old red blood cells and storing platelets and white blood cells. Disorders of the immune system are typically a result of an infection, allergic reaction, or autoimmune reaction.
The following are the drug classes are reviewed individually for treatment of immune system disorders.
These drug classes to treat disorders of the special senses are reviewed to include the following:
▪ Mechanism of action
▪ Side effects
▪ Special handling and administration instructions
▪ Drug interactions
▪ Indications
▪ Dosage form
▪ Dosage and duration of therapy
The Musculoskeletal System and Drugs
The musculoskeletal system consists of muscles, bones, joints and other supportive structures to provide stability and movement for the body. The following are the main structures of the system and potential disorders.
The following are the disorders of the musculoskeletal system.
The following are the drug classes are reviewed individually for treatment of musculoskeletal system disorders.
These drug classes to treat disorders of the special senses are reviewed to include the following:
▪ Mechanism of action
▪ Side effects
▪ Special handling and administration instructions
▪ Drug interactions
▪ Indications
▪ Dosage form
▪ Dosage and duration of therapy
Special Senses and Drugs
The special senses system includes the organs devoted to our senses of vision, hearing, balance, taste, and smell. These organs include the eyes, ears, nose, and throat. Medications used in the ear and eye can be solutions, suspensions, or ointments. Ophthalmic medications are able to be administered into the ear, but otic medications must never be used in the eye, due to the pH of otic solutions burning if administered in the eye. Medications given through the intranasal route are administered through a nasal spray, which is a solution that forms a mist when sprayed into the nose. Medications for the throat are typically lozenges or sprays that act as a numbing agent to treat pain, such as benzocaine.
You can review some common senses disorders that follow.
The following drug classes are reviewed individually for treatment of special sense disorders.
These drug classes to treat disorders of the special senses are reviewed to include the following:
▪ Mechanism of action
▪ Side effects
▪ Special handling and administration instructions
▪ Drug interactions
▪ Indications
▪ Dosage form
▪ Dosage and duration of therapy
Dietary Supplements
Vitamins are essential substances that the body does not produce and we must instead get from our diet. Most vitamins are available as a supplement OTC, but some are prescribed for deficiencies.
The following are the most common vitamins with their drug name, function, and what food source contains a higher concentration.
Some vitamins are prescribed frequently and indicated for treatment of disease. The following are the most commonly prescribed vitamins and the indication for each.
Minerals are also needed in the body in small amounts for proper functioning. They can be taken as an OTC supplement or prescribed as well. Each mineral has a specific function in the body.
The following are the most common minerals in our body and the source of food in which they’re found.
Some minerals are prescribed and indicated for treatment of disease. The following are the most commonly prescribed minerals and the indication of each.
Herbal supplements are nutrients extracted from a plant or natural source for a therapeutic benefit. Although the FDA does require testing for safety, these products are not required to prove effectiveness. Herbal supplements may also interact with prescription medications, and a lack of research prevents data on all potential interactions.
The following are common herbal supplements and the proposed use of each. Keep in mind, each labeled bottle of supplement will state that “these statements have not been evaluated by the Food and Drug Administration.” This means the FDA does not stand by the health claims of the manufacturer.
Drug Interactions
Drug interactions occur when one drug or substance alters the action of another drug. This can produce unexpected side effects, toxic concentrations, or lack of effectiveness of a drug. Drug interactions can be harmful and include interactions with both OTC and supplements.
There are several different types of drug interactions that can occur. The following is a list of the different interactions and examples of each type.
Therapeutic Equivalence
Therapeutic equivalence is defined by the FDA as drug products that can be substituted and produce the same clinical effect and have the same safety profile. Certain requirements must be met before a drug can be considered therapeutically equivalent, including:
▪ Must contain the same active ingredient
▪ Must be the same dosage form, route of administration, and strength
▪ Clinical effect and safety profile are the same when administered to patients under same conditions as specified in labeling
▪ Bioequivalence is demonstrated
If all the listed criteria are met, the FDA will assign an A-rated therapeutic equivalence (TE) code. These TE codes are published in the FDA Orange Book. The Orange Book consists of all drugs that are approved as therapeutically equivalent and given an A-code. A drug product the FDA does not deem to be therapeutically equivalent is given a B-code.
While there are many different TE codes based on the dosage form, the following are some examples of A- and B-rated TE codes that are listed in the FDA Orange Book.
Narrow Therapeutic Index (NTI)
If a drug has a narrow therapeutic index (NTI), a small difference in dosing could lead to a major therapeutic failure or adverse reaction that could be life-threatening. NTI drugs often have requirements for generic substitution, because if there are any even minor differences in bioequivalence, it could result in toxic effects or a lack of effectiveness, leading to treatment failure. Treatment failure itself can be life-threatening, as many of these medications are anticonvulsants, and if dosing is not precise, seizures may not be controlled. If a prescriber is going to modify a treatment regimen, it will often be in very small incremental dosages to avoid potential adverse effects.
The following are frequently prescribed drugs with an NTI:
Drug Stability
Drug stability refers to the capacity of a product to retain its established strength, quality, and purity. This includes chemical, physical, and therapeutic properties. The following factors can affect drug stability:
▪ Temperature—high temperature can accelerate drug breakdown
▪ pH—too alkaline (basic) or acidic can influence how quickly a drug degrades
▪ Light—can cause reactions that break down drug; some drugs are photosensitive and must be protected from light (packaged in amber vial)
▪ Moisture—water can induce reactions, which can degrade a drug
A drug shelf life or expiration date is determined by the manufacturer of the medication and indicates the time a drug will be stable if it is stored under appropriate conditions. This is different from a beyond-use-date (BUD), which is determined by the pharmacy compounding the medication and is based on sterility and stability information from pharmacy standards. A BUD is the date or time a compounded product is no longer stable or sterile and may not be dispensed to a patient.
Reconstituted Medications
The stability of a drug can also depend on the dosage form. Solid dosage forms are more stable than liquid dosage forms, and this is demonstrated in reconstitutables such as oral suspensions or reconstituted injections. These medications are in a powder form that then becomes liquid after adding a diluent. Reconstitution occurs when a diluent, or liquid used to dilute or reconstitute, is added to a powder, forming a liquid.
Oral suspensions have an expiration date from the manufacturer on the bottle, and once the diluent is added, the BUD is significantly shorter. The BUD is the amount of time the suspension will be stable, assuming that the medication was stored properly. To maximize shelf life, oral suspensions and reconstituted injections are not reconstituted until needed for patient treatment. This helps keep good-dated inventory available for use.
Oral suspensions can often be stored at room temperature, though some require refrigeration. The following are frequently prescribed oral suspensions and storage and stability for each.
Whether reconstituting an oral suspension or injection, the required volume of diluent is indicated on the label. It is very important the diluent chosen and volume used for reconstitution are the same as what is indicated on the label or in the product package insert. Oral suspensions are typically reconstituted with distilled water, while injections may use sterile water or sodium chloride as a diluent.
Not all injectable drugs require reconstitution. Liquid injectable drugs are available as solutions or suspensions and as single-dose vials (SDV) or multiple-dose vials (MDV). SDVs do not contain a preservative and are therefore used for one patient or treatment. Once an SDV is opened, it must be used within 6 hours (if opened in an ISO class 5 hood). If an SDV is opened outside of a hood, it must be used within 1 hour.
Ampules are also single use and do not contain a preservative. They are a glass container that is designed to be broken at the neck. The medication inside is removed using a filter needle, to protect against any residual glass that may have fallen in the contents. As soon as the ampule is open, it is exposed to air, and the stability is limited.
MDVs do contain a preservative, and this prevents the growth of microbials. MDVs, once opened, typically have a BUD of 28 days, though this may depend on the drug. Pharmacy technicians are often responsible for reviewing MDVs on nursing units to ensure the BUD has been properly dated on each vial after opening. As long as the patient dose from an MDV is not drawn up in the patient’s room, the remaining contents of the vial may be used on another patient. If the MDV is opened or a dose drawn in the patient treatment area, the vial could become contaminated when the needle is inserted. This could potentially spread infection to others receiving the drug.
Insulin
Insulin vials are similar to MDVs in that they are stable until the expiration date on the vial before opening. After opening, most are good for 28 days, though there are some insulin types that have a longer BUD. The stability of insulin is dependent upon the storage conditions and the time since opening.
The following are top prescribed insulins and stability dating for each.
Vaccinations
Vaccine stability depends on the dosage form and storage conditions. Vaccines are available in SDVs, MDVs, syringes, and reconstitutable vials, and storing each properly is an important part in vaccine protection for patients. The package insert of vaccines will define the BUD after opening. SDVs and syringes expire based on the expiration date assigned by the manufacturer. Vaccines that are MDV are typically still good until the expiration date of the manufacturer after opening. It’s always important to check the vaccine package insert to determine the BUD. Vaccines that are reconstituted should be prepared immediately prior to administration to avoid limitations in BUD.
The following are a few commonly administered vaccines and BUDs (assuming appropriate storage conditions).
Storage of Medications
An important component to maintaining drug stability is ensuring medications are stored properly. This includes storing in the appropriate temperature range, light and moisture precautions, and whether the drug should have restricted access.
Each drug has a specified temperature range indicated on the packaging to avoid loss of stability. For example, a drug that is intended to be stored at room temperature will have a labeling that states:
Store at Controlled Room Temperature
20°C to 25°C (68°F–77°F) (See USP)
The USP standards for temperature ranges are defined as follows:
In addition to temperature ranges, light and moisture sensitivity are important to consider when storing medications. Some medications require dispensing in the original manufacturer’s packaging to protect from light sensitivity. Amber bottles, such as those generally used in a retail pharmacy, help minimize exposure to light and can protect against light degradation. Nitroglycerin is a medication that must be dispensed in original packaging. If a medication is light sensitive, it will be indicated on the labeling such as:
Warning: Keep these tablets in original container.
Close tightly immediately after use to prevent loss of potency.
Similar to light sensitivity, if a medication is moisture sensitive, it will degrade in the presence of liquid. For these medications, a desiccant is used as a drying agent. This absorbs any moisture that could potentially degrade the medication. When a desiccant is packaged with a medication, the original packaging should be dispensed. If a medication is moisture sensitive, it will be indicated on the labeling such as:
Warning: Moisture sensitive tablets—do not remove from container until immediately prior to administration.
or
Store at Controlled Room Temperature
20°C–25°C (68°F–77°F) and protect from moisture
Another aspect of drug storage is restricting access to medications that are not in their final dosage form and require compounding before administering to a patient. One example of this is concentrated electrolytes in a hospital. If these medications were stocked in a nursing unit outside of the pharmacy, the consequence of a medication error could be deadly. These include:
▪ Hypertonic sodium chloride 3%
▪ Potassium chloride 2mEq/mL
▪ Magnesium sulfate 50%
▪ Sodium bicarbonate 8.4%
▪ Sodium chloride 23.4% solution
Other restricted access would include controlled substances, which will be discussed more in Chapter 3, and hazardous drugs, which will be discussed more in Chapter 4.
Incompatibility
Drug stability can also be impacted by compatibility of drugs and the containers in which they are compounded. Incompatibility occurs when a drug reacts with a solution or diluent, the container it’s compounded in, or with another drug. There are two types of incompatibility: physical and chemical.
A physical incompatibility is the interaction of two or more substances that results in a change in color, odor, taste, viscosity, or physical structure. An example of this would be a precipitate forming when two substances are mixed that are incompatible. Physical incompatibility can also include the insolubility or immiscibility of two substances. For example, when compounding creams, lotions, or ointments, if the active ingredient is not soluble, it would result in a physical incompatibility and the active ingredient would not be distributed evenly throughout the compound.
A chemical incompatibility is a reaction between two or more substances that causes a change in the chemical properties of a drug. Chemical incompatibilities are often unseen but can be observed through a temperature or color change due to oxidation. Change in pH or release of gas (effervescence) can also occur. Chemical incompatibilities can be dangerous to patients due to potential toxicity of the compounded medication. It can also cause treatment failure through ineffectiveness if the chemical reaction renders the drug inactive. A chemical incompatibility could occur in a compound with a light-sensitive ingredient not stored in a light-resistant container. The light could cause a breakdown in the medication, causing a lack of effectiveness.
When compounding medications, part of the master formula record is to monitor for signs of incompatibility. Ensuring the proper diluent is selected for compounding can help prevent incompatibility. Also, some medications are sensitive to polyvinyl chloride (PVC), which is the main component of IV bags. PVC-free IV bags are available for medications that may adhere to the PVC and not disperse within the fluid. Nitroglycerin is an example of this and must be dispensed in a glass container.
Review Questions
The following questions help you review the chapter. Test your knowledge by working through the next 50 questions to test yourself and identify any areas you may need to review.
1. The generic name for Hytrin is
A. budesonide
B. mupirocin
C. labetalol
D. terazosin
2. The drug class of meclizine is
A. ACE inhibitor
B. antiemetic
C. antiviral
D. Alzheimer’s disease agent
3. Which of the following is the name brand of aripiprazole?
A. Lotensin
B. Bactroban
C. Abilify
D. Seroquel
4. A smaller volume of fluid administered IV, typically less than 250mL, is known as
A. IV piggyback
B. IV push
C. large volume parenteral
D. IM injection
5. Which route of administration involves the use of a machine to create a mist for medication inhalation into the lungs?
A. nebulized
B. otic
C. nasal
D. ophthalmic
6. Which of the following drugs is available as a sublingual tablet?
A. hydralazine
B. nitroglycerin
C. metoprolol
D. lisinopril
7. Which of the following is indicated to treat vertigo?
A. polyethylene glycol 3350
B. dicylomine
C. pantoprazole
D. meclizine
8. Which of the following is used for allergic and inflammatory disease and is dispensed in a Dosepak with a 21-day treatment?
A. alendronate
B. prednisone
C. methylprednisolone
D. estradiol
9. Which of the following is indicated for treatment of narcolepsy and ADHD?
A. sumatriptan
B. dextroamphetamine and amphetamine
C. lorazepam
D. esomeprazole
10. Which of the following is indicated for overactive bladder?
A. hydrochlorothiazide
B. spironolactone
C. oxybutynin
D. finasteride
11. Which of the following is indicated to treat UTI, otitis media, and traveler’s diarrhea?
A. mupirocin
B. sulfamethoxazole and trimethoprim
C. doxycycline
D. clindamycin
12. Which of the following inhibits COX-2?
A. celecoxib
B. methotrexate
C. allopurinol
D. cyclobenzaprine
13. A coated tablet designed to bypass the stomach and dissolve in the small intestine is
A. chewable
B. buccal
C. enteric coated
D. sublingual
14. Which type of dosage form is a thick liquid sweetened with sugar?
A. irrigation
B. suspension
C. syrup
D. enema
15. Which dosage form is solid at room temperature and melts at body temperature?
A. suppository
B. ointment
C. gel
D. cream
16. If a medication should be stored refrigerated, what temperature range would this be?
A. −13°F to 14°F
B. 36°F to 46°F
C. 68°F to 77°F
D. 86°F to 104°F
17. A technician compounding a cream notices the active ingredient powder is not dispersed throughout and is not dissolving into the base. What type of incompatibility might this be?
A. physical
B. chemical
C. therapeutic
D. desiccant
18. A drug packaged with a desiccant should be protected from
A. light
B. moisture
C. sodium chloride
D. amber bottle
19. TDAP contains which of the following vaccines?
A. tetanus, diphtheria, and pneumococcal
B. measles, mumps, and rubella
C. varicella, diphtheria, and pertussis
D. tetanus, diphtheria, and pertussis
20. Within how many days must most multi-dose vials be used after opening?
A. 7
B. 14
C. 28
D. 30
21. Which of the following would require a diluent to become a liquid?
A. suspension
B. syrup
C. elixir
D. ODT
22. An A-rated code in the FDA Orange Book means the drug is
A. an injectable
B. therapeutically equivalent
C. a topical product
D. not therapeutically equivalent
23. When one drug reduces the effect or inhibits another drug, this is a(n)
A. additive drug–drug interaction
B. antagonistic drug–drug interaction
C. potentiated drug–drug interaction
D. synergistic drug–drug interaction
24. Which of the following supplements can help prevent UTIs?
A. flaxseed
B. saw palmetto
C. melatonin
D. cranberry
25. A medication used to treat glaucoma would
A. reduce secretion from the eye
B. reduce stinging in the eye
C. reduce pressure within the eye
D. increase blood pressure
26. A generic medication that ends in -olol is which type of medication?
A. benzodiazepine
B. cephalosporin
C. ACE inhibitor
D. beta blocker
27. Amlodipine is used to treat
A. high cholesterol
B. high blood pressure
C. diabetes
D. thyroid disorder
28. The generic for Zoloft is
A. albuterol
B. omeprazole
C. sertraline
D. pantoprazole
29. Rosuvastatin is which type of drug?
A. antihypertensive—beta blocker
B. antihyperlipidemic—HMG-CoA reductase inhibitor
C. antiplatelet
D. antihypertensive—calcium channel blocker
30. A buccal tablet is administered between the
A. gum and cheek
B. tongue and throat
C. skin and muscle
D. tongue and roof of mouth
31. A solution used to wash wounds or bladders is a(n)
A. enema
B. suspension
C. irrigation
D. elixir
32. A medication administered IM is injected into the
A. skin
B. muscle
C. vein
D. artery
33. Which of the following drugs must be very carefully prescribed and has an NTI?
A. lithium
B. diphenhydramine
C. lisinopril
D. spironolactone
34. Ferrous sulfate is used to treat
A. hypokalemia
B. iron deficiency anemia
C. indigestion
D. hypertension
35. Vitamin B12 is also known as
A. ergocalciferol
B. folic acid
C. phytonadione
D. cyanocobalamin
36. Latanoprost is indicated to treat
A. bacterial conjunctivitis
B. elevated intraocular pressure
C. corneal ulcer
D. otitis media
37. Hydroxychloroquine can be used to treat malaria and
A. breast cancer
B. rheumatoid arthritis
C. macular degeneration
D. diabetes
38. Which of the following is given as one 150mg dose PO to treat vaginal candidiasis?
A. hydrocortisone
B. fluconazole
C. tetracycline
D. cephalexin
39. Metronidazole has a significant interaction if taken with
A. alcohol
B. water
C. milk
D. grapefruit juice
40. Photosensitivity is a side effect of which medication?
A. hydrocodone
B. sulfamethoxazole and trimethoprim
C. docusate
D. dicyclomine
41. Tamsulosin is indicated to treat
A. overactive bladder disorder
B. alopecia
C. UTI
D. BPH
42. Which medication is indicated for the treatment of migraines?
A. atomexetine
B. calcitonin
C. sumatriptan
D. levalbuterol
43. Dementia caused by Alzheimer’s disease can be treated with
A. carbidopa/levodopa
B. donepezil
C. quetiapine
D. amitriptyline
44. Divalproex is in which class of drugs?
A. antiparkinson agent
B. nitrate
C. antirheumatic agent
D. anticonvulsant
45. The generic name of Lotensin is
A. enalapril
B. benazepril
C. donepezil
D. lisinopril
46. A drug with an ending of -statin belongs to which class?
A. fibric acid derivative
B. lipid regulating agent
C. antihyperlipidemics (HMG-CoA reductase inhibitors)
D. nitrates
47. Ezetimibe is indicated for
A. edema associated with CHF
B. myalgia
C. lupus
D. adjunctive treatment for reduction of cholesterol
48. Which of the following can be used to treat nausea and vomiting associated with chemotherapy?
A. adalimumab
B. ondansetron
C. esomeprazole
D. guaifenesin
49. Which of the following is available as an MDI and nasal spray?
A. tiotropium
B. albuterol
C. fluticasone
D. triamcinolone
50. Temazepam is indicated to treat
A. depression
B. insomnia
C. ADHD
D. dementia
Answer Key
1. D
The generic name of Hytrin is terazosin.
2. B
Meclizine is an antiemetic drug, which is used to prevent nausea and vomiting.
3. C
Abilify is the name brand of aripiprazole.
4. A
IV piggyback is a small volume of fluid, usually under 250mL, that is administered IV.
5. A
Nebulized treatments are administered through a nebulizer for inhalation.
6. B
Nitroglycerin is available as a sublingual tablet to dissolve under the tongue.
7. D
Meclizine is indicated to treat vertigo.
8. C
Methylprenisolone is indicated for the treatment of allergic and inflammatory disease, and is available as a 21-tablet tapering Dosepak.
9. B
Dextroamphetamine and amphetamine are indicated for treatment of narcolepsy and ADHD.
10. C
Oxybutynin is indicated for treatment of overactive bladder.
11. B
Sulfamethoxazole and trimethoprim is indicated to treat UTI, otitis media, and traveler’s diarrhea.
12. A
Celecoxib inhibits COX-2.
13. C
Enteric-coated tablets are designed to prevent breakdown in the stomach so they can be absorbed in the intestine and cannot be crushed or chewed.
14. C
Syrup is a thick liquid sweetened with sugar.
15. A
A suppository is solid at room temperature and designed to melt at body temperature after insertion.
16. B
Refrigerated is in the temperature range 36°F to 46°F, or 2°C to 8°C.
17. A
Physical incompatibility can occur if the active ingredient is not soluble and would not be evenly distributed throughout the compound.
18. B
If a medication is moisture sensitive, it will degrade in the presence of liquid. For these medications, a desiccant is used as a drying agent. This absorbs any moisture that could potentially degrade the medication.
19. D
Tetanus, diphtheria, and pertussis is a vaccine called TDAP.
20. C
MDVs, once opened, typically have a BUD of 28 days.
21. A
Reconstitution occurs when a diluent, or liquid used to dilute or reconstitute, is added to a powder, forming a liquid, such as when a suspension is reconstituted.
22. B
The FDA will assign an A-rated therapeutic equivalence (TE) code if a drug is therapeutically equivalent.
23. B
An antagonistic drug–drug interaction is when one drug reduces the effect of or inhibits another drug.
24. D
Cranberry can be used to treat and prevent UTIs.
25. C
A medication used to treat glaucoma reduces intraocular pressure within the eye.
26. D
A beta blocker ends in -olol such as metoprolol or propranolol.
27. B
Amlodipine is a calcium channel blocker used to treat hypertension.
28. C
The generic for Zoloft is sertraline.
29. B
Rosuvastatin is an antihyperlipidemic—HMG-CoA reductase inhibitor. These drugs all end in -statin.
30. A
A buccal tablet is administered between the gum and cheek to dissolve and absorb into blood vessels in the mouth.
31. C
An irrigation is a continuous flow of solution used to wash wounds, bladders, or eyes.
32. B
IM is intramuscular, which is injected into the muscle.
33. A
Lithium is a bipolar disorder agent that has a narrow therapeutic index (NTI).
34. B
Ferrous sulfate is used to treat iron deficiency anemia.
35. D
Vitamin B12 is also known as cyanocobalamin.
36. B
Latanoprost is indicated to treat elevated intraocular pressure, as seen in glaucoma.
37. B
Hydroxychloroquine can be used to treat malaria and rheumatoid arthritis. It can also be used to treat lupus.
38. B
Fluconazole is an antifungal medication used to treat vaginal candidiasis as a once 150mg PO dose.
39. A
Metronidazole must not be taken with alcohol.
40. B
Sulfamethoxazole and trimethoprim can cause photosensitivity.
41. D
Tamsulosin is indicated to treat BPH.
42. C
Sumatriptan is indicated for the treatment of migraines.
43. B
Donepezil can be used to treat mild, moderate, and severe dementia caused by Alzheimer’s disease
44. D
Divalproex (Depakote) is an anticonvulsant.
45. B
Benazepril is the generic of Lotensin.
46. C
Antihyperlipidemics (HMG-CoA reductase inhibitors) end in -statin.
47. D
Ezetimibe is indicated as adjunctive therapy with diet for reduction of total cholesterol.
48. B
Ondansetron is indicated for the prevention of nausea and vomiting associated with chemotherapy.
49. C
Fluticasone is available as both an MDI (Flovent) and nasal spray (Flonase).
50. B
Temazepam is indicated for the treatment of insomnia.