Pharmacology

A

• ACE Inhibitors and ARBs - Renal and Potassium Principles

  Check creatinine and potassium after initiation or dose changes, expect small creatinine rise, and manage hyperkalemia risk especially with CKD.
• Aminoglycoside - Extended Interval Dosing and Nomograms

  Use once daily extended interval dosing with nomograms to optimize peak to MIC and reduce toxicity; avoid in pregnancy, severe burns, or dialysis.
• Amiodarone - Toxicity Interactions and Monitoring

  Monitor thyroid, liver, and lungs; watch for ocular and skin effects; review multiple drug interactions including warfarin and digoxin.
• Antibiotic Allergy - Test Dose and Desensitization Overview

  Use graded challenge for low risk histories and formal desensitization for essential therapy with high risk allergy, following strict protocols.
• Antibiotic IV to PO - Switch Criteria and Candidates

  Identify stable patients eligible for oral step down to shorten stay, reduce line complications, and maintain efficacy with high bioavailability agents.
• Antibiotics in Obesity - Dosing Considerations

  Use actual or adjusted body weight per drug specific guidance, consider extended infusion beta lactams, and monitor exposure when feasible in severe obesity.
• Antimicrobial Deescalation - Day 3 Principles

  On day 3, review cultures, source control, and clinical response to narrow or stop antibiotics and set total duration targets.
• Antipsychotics - QTc and Metabolic Monitoring

  Monitor QTc, weight, glucose, and lipids; choose lower risk agents when possible and mitigate metabolic effects with lifestyle support.

B

• Benzodiazepine Deprescribing - Gradual Taper Protocols

  Reduce long term benzodiazepines with patient centered gradual tapers, nonpharmacologic support, and alternative agents when indicated.
• Beta Blockers - Indications Contraindications and Titration

  Use for heart failure, arrhythmias, and ischemia; titrate slowly, avoid abrupt withdrawal, and recognize contraindications such as severe asthma or bradycardia.
• Beta Lactam Allergy - Cross Reactivity and Practical Approach

  Clarify reported penicillin allergy, understand side chain cross reactivity, and consider test dose or allergy referral to expand options.

C

• Calcium Channel Blockers - Dihydropyridine vs Nondihydropyridine

  Differentiate class effects, manage edema with dihydropyridines, and avoid dangerous combinations of nondihydropyridines with beta blockers in conduction disease.
• Clostridioides Difficile - Pharmacotherapy Choices

  Choose fidaxomicin or vancomycin for initial episodes, consider bezlotoxumab for recurrence risk, and avoid unnecessary proton pump inhibitors and antibiotics.

D

• Digoxin - Therapeutic Drug Monitoring and Toxicity

  Monitor levels at steady state, recognize bradyarrhythmias and visual changes, correct electrolytes, and use digoxin immune Fab for life threatening toxicity.
• DOAC Dosing - Renal and Hepatic Considerations

  Dose direct oral anticoagulants by indication, kidney function, weight, age, and drug interactions; avoid in select hepatic impairment.

F

• Fluoroquinolone Safety - Tendinopathy Aneurysm and QTc

  Use fluoroquinolones only when benefits outweigh risks such as tendon rupture, aortic aneurysm, neuropathy, dysglycemia, and QTc prolongation.

G

• Gabapentinoids - Dosing Renal Risks and Misuse

  Adjust for renal function, monitor for sedation and misuse, and avoid hazardous combinations with opioids or sedatives.

H

• Heparin Induced Thrombocytopenia - 4T Score and Management

  Estimate pretest probability with the 4T score, stop all heparin if intermediate or high probability, and start a non heparin anticoagulant.

I

• Inhaled Corticosteroids - Steps Risks and Spacer Use

  Use stepwise dosing, teach spacer technique and mouth rinsing, and monitor for local effects and systemic exposure at higher doses.
• Insulin - Outpatient Titration Basal Bolus and Education

  Teach basal and bolus insulin titration with simple algorithms, hypoglycemia prevention, and sick day rules while coordinating with devices when used.

L

• Linezolid - Serotonergic Drug Interactions and Precautions

  As a reversible MAO inhibitor, linezolid can precipitate serotonin toxicity with SSRIs or other serotonergic drugs; weigh risks, hold interacting drugs when feasible, and monitor.
• Lithium Therapy - Monitoring Toxicity Renal and Thyroid

  Check levels regularly, assess renal and thyroid function, counsel on hydration and drug interactions, and manage toxicity with fluids and in severe cases dialysis.
• Local Anesthetic Systemic Toxicity - Recognition and Lipid Therapy

  Recognize CNS and cardiovascular toxicity after local anesthetic exposure; stop injection, manage airway and seizures, and initiate lipid emulsion therapy.

M

• Macrolides - QTc and Drug Interaction Management

  Macrolides can prolong QTc and inhibit CYP interactions; review risk factors and choose alternatives or monitor closely.
• Methotrexate Weekly Low Dose - Safety and Folate

  Ensure once weekly dosing, supplement folate, monitor blood counts and LFTs, and counsel on teratogenicity and interactions.

N

• Neuroleptic Malignant Syndrome - Treatment Principles

  Rigidity, hyperthermia, and autonomic instability after dopamine blockade; stop triggers, give supportive care, and consider dantrolene or bromocriptine.
• Neuromuscular Blockers - Rapid Sequence and ICU Uses

  Choose agents for rapid sequence intubation and ventilator synchrony; monitor depth, avoid awareness, and manage contraindications.

O

• Opioid Analgesics - Safe Prescribing and Naloxone

  Use lowest effective dose with functional goals, check risk factors, co prescribe naloxone when appropriate, and avoid dangerous combinations.

P

• P Glycoprotein and CYP3A4 - Inhibitors and Inducers

  Recognize common inhibitors and inducers that alter drug exposure for DOACs, statins, calcineurin inhibitors, and many others; manage by avoiding or adjusting.
• Piperacillin Tazobactam - Extended Infusion Principles

  Extended infusion beta lactam dosing can improve time above MIC; implement with nursing coordination and stability guidance.
• Proton Pump Inhibitors - Deprescribing and Risks

  Reassess indications, step down dose or stop when appropriate, and counsel on rebound acid; be mindful of infection and malabsorption risks.

S

• Sedation and Analgesia in ICU - Light Sedation Bundles

  Prioritize analgesia first, target light sedation with validated scales, perform daily awakenings, and prevent delirium with nonpharmacologic bundles.
• Serotonin Syndrome - Recognition and Management

  Triad of altered mental status, autonomic instability, and neuromuscular hyperactivity after serotonergic drugs; stop agents, give benzodiazepines, and consider cyproheptadine.
• Statin Therapy - Intolerance and Drug Interactions

  Confirm true statin intolerance, use rechallenge or alternate dosing, select lower interaction agents, and manage interactions with macrolides or azoles.

T

• Thiazide Diuretics - Hyponatremia and Hypokalemia

  Recognize thiazide induced hyponatremia and hypokalemia, assess timing and risk factors, and adjust regimen or discontinue as needed.
• Trimethoprim Sulfamethoxazole - Renal Dosing and Hyperkalemia

  Adjust dose in kidney disease; monitor for hyperkalemia and creatinine rise due to trimethoprim effect, and consider interactions with ACE inhibitors or potassium sparing agents.

V

• Valproate Therapy - LFT Thrombocytopenia and Hyperammonemia

  Monitor liver function and platelets, recognize hyperammonemia even with normal LFTs, and manage with dose adjustment or L carnitine in select toxicity.
• Vancomycin - AUC Guided Dosing and Monitoring

  Prefer AUC guided vancomycin dosing over troughs to balance efficacy with nephrotoxicity risk; use Bayesian tools or paired levels when available.
• Vasopressors - Norepinephrine First Line and Choices

  Norepinephrine is first line in septic shock; tailor vasopressor and inotrope choices to hemodynamics and adverse effect profiles.

W

• Warfarin - Initiation Bridging and INR Monitoring

  Start with appropriate loading strategies, use parenteral bridging when indicated, monitor INR frequently, and adjust dose with standardized algorithms.