Key Takeaways
- Penicillin allergies affect about 10% of patients; cross-reactivity with cephalosporins is approximately 1-2%.
- Fluoroquinolones have a black box warning for tendon rupture and should be avoided in children when possible.
- Opioid analgesics are Schedule II controlled substances requiring special handling and DEA compliance.
- NSAIDs can cause GI bleeding, kidney damage, and cardiovascular events; avoid in patients with kidney disease.
- Acetaminophen maximum daily dose is 3-4 grams; hepatotoxicity risk increases with alcohol use.
Anti-Infective and Analgesic Medications
Anti-infective and analgesic medications are among the most commonly dispensed drugs. Pharmacy technicians must understand their classifications, uses, and safety considerations.
Antibiotic Classifications
Penicillins (-cillin)
| Generic Name | Brand Name | Spectrum | Key Points |
|---|---|---|---|
| amoxicillin | Amoxil | Broad | Most prescribed antibiotic |
| amoxicillin/clavulanate | Augmentin | Broad + beta-lactamase | Clavulanate extends coverage |
| ampicillin | Principen | Broad | Available IV |
| penicillin V | Pen-Vee K | Narrow | Strep throat first-line |
Storage: Amoxicillin suspension - refrigerate after reconstitution; discard after 14 days
Allergy Alert: ~10% of patients report penicillin allergy; true IgE-mediated allergy is less common
Cephalosporins
| Generation | Examples | Generic | Brand | Coverage |
|---|---|---|---|---|
| 1st | cephalexin | cephalexin | Keflex | Gram-positive, some gram-negative |
| 2nd | cefuroxime | cefuroxime | Ceftin | Expanded gram-negative |
| 3rd | ceftriaxone | ceftriaxone | Rocephin | Broad, CNS penetration |
| 3rd | cefdinir | cefdinir | Omnicef | Oral, good coverage |
Cross-Reactivity: ~1-2% cross-reactivity with penicillin allergy (lower than previously thought)
Fluoroquinolones (-floxacin)
| Generic Name | Brand Name | Key Indications |
|---|---|---|
| ciprofloxacin | Cipro | UTI, respiratory, anthrax |
| levofloxacin | Levaquin | Respiratory, UTI |
| moxifloxacin | Avelox | Respiratory (no UTI coverage) |
Black Box Warnings:
- Tendon rupture (especially Achilles)
- Peripheral neuropathy
- CNS effects
- Avoid in children unless no alternative
Drug Interactions: Chelates with divalent cations (Ca, Mg, Fe, Al) - separate from antacids by 2-4 hours
Macrolides (-mycin/-thromycin)
| Generic Name | Brand Name | Key Points |
|---|---|---|
| azithromycin | Zithromax, Z-Pak | QT prolongation risk |
| clarithromycin | Biaxin | CYP3A4 inhibitor |
| erythromycin | E-Mycin, Ery-Tab | GI side effects common |
Common Use: Azithromycin 250 mg - "Z-Pak" is 6 tablets: 2 on day 1, then 1 daily for 4 days
Tetracyclines (-cycline)
| Generic Name | Brand Name | Key Points |
|---|---|---|
| doxycycline | Vibramycin, Doryx | Photosensitivity, take with food |
| minocycline | Minocin | Vertigo, discoloration |
| tetracycline | Sumycin | Take on empty stomach |
Warnings:
- Contraindicated in pregnancy (category D)
- Avoid in children under 8 (tooth discoloration)
- Photosensitivity - avoid sun exposure
- Take with full glass of water; remain upright 30 minutes
Antiviral Medications
| Generic Name | Brand Name | Indication | Key Points |
|---|---|---|---|
| acyclovir | Zovirax | Herpes, shingles | Dose adjust for renal function |
| valacyclovir | Valtrex | Herpes, shingles | Prodrug of acyclovir, better absorption |
| oseltamivir | Tamiflu | Influenza | Start within 48 hours of symptoms |
| tenofovir/emtricitabine | Truvada, Descovy | HIV prevention (PrEP) | Once daily |
Antifungal Medications
| Generic Name | Brand Name | Type | Key Points |
|---|---|---|---|
| fluconazole | Diflucan | Azole | First-line for Candida; CYP inhibitor |
| itraconazole | Sporanox | Azole | Take with food; drug interactions |
| terbinafine | Lamisil | Allylamine | Onychomycosis; hepatotoxicity risk |
| nystatin | Mycostatin | Polyene | Topical/oral only; not absorbed |
| clotrimazole | Lotrimin | Azole | OTC topical antifungal |
Analgesic Medications
Non-Opioid Analgesics
Acetaminophen (Tylenol)
| Parameter | Details |
|---|---|
| Maximum Daily Dose | 3-4 grams/day (lower in liver disease, elderly, or with alcohol use) |
| Mechanism | COX inhibition in CNS; no peripheral anti-inflammatory effect |
| Hepatotoxicity | Leading cause of acute liver failure; risk increases with alcohol |
| Antidote | N-acetylcysteine (NAC) |
Counseling: Check all medications for acetaminophen content (combination products like Vicodin, Percocet, NyQuil)
NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
| Generic Name | Brand Name | Key Points |
|---|---|---|
| ibuprofen | Motrin, Advil | Most common OTC NSAID |
| naproxen | Aleve, Naprosyn | Longer duration (BID dosing) |
| meloxicam | Mobic | Once daily, COX-2 preferential |
| diclofenac | Voltaren | Available topical |
| celecoxib | Celebrex | COX-2 selective, less GI risk |
Black Box Warning: Increased risk of cardiovascular events (MI, stroke) and GI bleeding
Contraindications:
- Active GI bleeding or ulcer history
- Severe renal impairment
- Third trimester of pregnancy
- Post-CABG surgery
Opioid Analgesics (Schedule II Controlled Substances)
| Generic Name | Brand Name | Relative Potency | Key Points |
|---|---|---|---|
| hydrocodone/APAP | Vicodin, Norco | Moderate | Schedule II; max APAP dose |
| oxycodone | OxyContin, Roxicodone | High | Immediate and extended release |
| oxycodone/APAP | Percocet | High | Watch total APAP dose |
| morphine | MS Contin, Kadian | Reference standard | Gold standard for severe pain |
| hydromorphone | Dilaudid | Very high | 4-7x more potent than morphine |
| fentanyl | Duragesic patch | Highest | 100x more potent than morphine |
| codeine | Tylenol #3 | Low | Schedule III with acetaminophen |
| tramadol | Ultram | Low | Schedule IV; serotonin syndrome risk |
Opioid Side Effects:
- Constipation (tolerance does NOT develop)
- Respiratory depression
- Sedation
- Nausea/vomiting
- Pruritus (itching)
Naloxone (Narcan): Opioid antagonist for overdose reversal; available OTC in many states
Controlled Substance Schedules Review
| Schedule | Characteristics | Examples |
|---|---|---|
| C-II | High abuse potential, accepted medical use | Oxycodone, morphine, fentanyl, amphetamines |
| C-III | Moderate abuse potential | Codeine combinations, testosterone |
| C-IV | Low abuse potential | Benzodiazepines, tramadol, zolpidem |
| C-V | Lowest abuse potential | Pregabalin, some cough syrups |
C-II Requirements: No refills allowed; prescriptions expire (varies by state, typically 90 days)
A patient presents a prescription for ciprofloxacin and asks about taking it with their calcium supplement. What should they be advised?
What is the maximum recommended daily dose of acetaminophen for a healthy adult?
Which of the following statements about opioid medications is TRUE?