Care essentials by kaiser permanente hawthorne portland or 97214

FOURTH EDITION

PHARMACOTHERAPEUTICS FOR ADVANCED PRACTICE

NURSE PRESCRIBERS

3827_FM_i-xviii 03/07/15 10:25 AM Page i

3827_FM_i-xviii 03/07/15 10:25 AM Page ii

PHARMACOTHERAPEUTICS FOR ADVANCE PRACTICE

NURSE PRESCRIBERS

Teri Moser Woo, RN, PhD, CPNP-PC, FAANP

Associate Professor of Nursing Associate Dean for Graduate Nursing Programs Pacific Lutheran University School of Nursing Tacoma, WA and Pediatric Nurse Practitioner Kaiser Permanente Northwest Region

Marylou V. Robinson, PhD, FNP-C

Associate Professor University of Colorado Anschutz Medical Campus College of Nursing Aurora, CO

FOURTH EDITION

3827_FM_i-xviii 03/07/15 10:26 AM Page iii

F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com

Copyright © 2016 by F. A. Davis Company

Copyright © 2016 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwis e, without written permission from the publisher.

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Senior Acquisitions Editor: Susan R. Rhyner Developmental Editor: Jennifer Schmidt Director of Content Development: Darlene D. Pedersen, MSN, FNP, BC Content Project Manager: Echo K. Gerhart Design & Illustration Manager: Carolyn O’Brien

As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and n ew information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs.

Library of Congress Cataloging-in-Publication Data

Woo, Teri Moser, 1962- , author. [Pharmacotherapeutics for nurse practitioner prescribers] Pharmacotherapeutics for advance practice nurse prescribers / Teri Moser Woo, Marylou V. Robinson. — Fourth edition.

p. ; cm. Preceded by Pharmacotherapeutics for nurse practitioner prescribers / Teri Moser Woo, Anita Lee Wynne. 3rd ed. c2011. Includes bibliographical references and index. ISBN 978-0-8036-3827-3 (alk. paper) — ISBN 0-8036-3827-2 (alk. paper) I. Robinson, Marylou V., author. II. Title. [DNLM: 1. Pharmacological Phenomena—Nurses’ Instruction. 2. Drug Prescriptions—Nurses’ Instruction. 3. Drug Therapy—nursing.

4. Nurse Practitioners. QV 4]

RM300 615'.1–dc23

2015020959

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee o f $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1169-2/04 0 + $.25.

3827_FM_i-xviii 03/07/15 10:26 AM Page iv

I would like to dedicate this book to my family. My husband, John, and my three sons, Michael,

Patrick, and Nicholas, have been wonderfully supportive as I have completed this project.

TMW

To my students who continually impress me with their idealism and inspire me to always strive for excellence.

MVR

3827_FM_i-xviii 03/07/15 10:26 AM Page v

3827_FM_i-xviii 03/07/15 10:26 AM Page vi

vii

discussion of volume of distribution and therapeutic drug monitoring. Volume of distribution is important in prescrib- ing drugs with very large or very small volumes of distribution and for selecting drugs for patients with cardiac or renal fail- ure, during pregnancy, or when a patient is underweight or obese. Knowing what tests to order and when to order them to assess plasma drug levels by bioassay and to monitor for adverse drug reactions are necessary in making choices about when or if dosage alterations are required or drugs need to be stopped. These topics are also covered in Unit I.

Legal and professional aspects of the prescriber role are presented in Chapter 4. Issues surrounding the legal author- ity of the APRN to prescribe a drug, the conditions under which the prescription may be written, and how to write the prescription are presented. Risk management issues are also discussed, including informed consent, dealing with multiple providers, and substance abuse and drug-seeking behaviors.

Nurse practitioners have a history of high levels of patient satisfaction with the care provided. This is related, in part, to their holistic approach to each patient. Several chapters are de- voted to information that reflects this approach. Cost, knowl- edge deficits, dealing with complex treatment regimens, and negotiating a shared responsibility for drug management are discussed in Chapter 6. Many patients choose to use comple- mentary therapies such as herbal remedies. Chapter 10 dis- cusses herbal therapy and other complementary therapies.

A relatively new area in pharmacotherapeutics is ethnophar- macology. As more research is done in this area, treatment guidelines are beginning to include which drugs are best for dif- ferent racial groups. Cultural and ethnic considerations in pre- scribing drugs are the subject of Chapter 7. Pharmacogenomics involves the influence of both race/ethnicity and individual genetic make-up on drug metabolism. Chapter 8 provides a discussion of the role of pharmacogenomics in prescribing.

Consideration of drug and food interactions has long been a part of nursing knowledge, but the interrelationship be- tween nutrition and drug therapy beyond these interactions has been largely overlooked. Chapter 9 provides a discussion of this interrelationship, including nutritional supplementa- tion and nutrition as therapy.

In an age of integrated use of technology, the APRN must be able to acquire information about drugs and to deliver care to patients using technology. The use of electronic health records (EHR) to aid in prescribing decision making is found in Chapter 11.

Cost issues cannot be ignored when making prescribing decisions. Chapter 12 provides a discussion of pharma- coeconomics.

Over-the-counter drugs may be prescribed by the APRN or chosen by patients on their own. These drugs are often er- roneously perceived to be less powerful and have fewer ad- verse reactions than prescription drugs. Understanding their role in pharmacotherapeutics is the focus of Chapter 13.

T he increasing volume of pharmacology-related informa-tion presents a challenge to acquire and maintain current knowledge in the area of pharmacotherapeutics. The number of new drugs coming on the market each year, the changes in “the best” drugs to use for any given disease state based on the latest research, the influence on patient and practitioner alike of advertising and promotion, and restricted formular - ies create competing pressures on the prescriber. This book is designed to provide nurse practitioner students and the nurse practitioner in the primary care setting with a thor- ough, current, and usable pharmacology text and reference to address these challenges.

The design of this book assumes knowledge of basic phar- macology from one’s undergraduate education in nursing. Although a brief review of basic pharmacology is presented in Chapter 2, the focus of the book is on advanced pharma- cology and the role of the advanced practice nurse in phar- macotherapeutics. The authors of the text are practicing nurse practitioners, pharmacists, or selected specialists in a field. The book is by advanced practice registered nurses, for advanced practice registered nurses.

ORGANIZATION

This book is organized around four distinct content areas: The Foundation, Pharmacotherapeutics with Single Drugs, Pharmacotherapeutics with Multiple Drugs, and Special Drug Treatment Considerations.

The Foundation The 13 chapters in Unit I provide the foundation of ad- vanced pharmacology and the link between this knowledge and professional practice. Chapter 1 discusses the role of the advanced practice registered nurse (APRN) in both the United States and Canada as prescriber and the knowledge needed to actualize this role. Current issues about the evolv- ing role and education of these providers are also presented in this edition, including discussion of the Doctorate of Nursing Practice.

Discussion of the roles of other advanced practice nurses in prescribing is included. Factors involved in clinical judg- ment related to prescribing are a central focus, and collabo- ration with other health-care providers is also presented.

The pharmacology knowledge required for rational drug selection requires more depth than that given in undergradu- ate pharmacology, where the focus is on safe administration of drugs prescribed by someone else. Advanced pharmacology information on receptor reserve and regulation, bioavailability and bioequivalence, metabolism of drugs, including a focus on the cytochrome P450 microsomal enzyme system, half-life, and steady state are provided in Chapters 2 and 8. Informa- tion central to the prescribing role includes an in-depth

PREFACE

3827_FM_i-xviii 03/07/15 10:26 AM Page vii

Pharmacotherapeutics With Single Drugs The next two units are organized around specific drugs and the diseases they are used to treat. The chapters in Unit II are organized to provide easy access to information based on spe- cific drug classes. Many practitioners have a personal formu- lary of drugs they use for disease processes that they commonly see. When presented with a patient requiring drug therapy, they know the class of drug from which they will make a rational drug choice. The information they seek is about drugs within that class that would be most appropriate for their patient.

Pharmacokinetics, pharmacodynamics, and pharma- cotherapeutics for each drug class are discussed in the chap- ters in Unit II. The chapters include tables with easy-to-access information on the pharmacokinetic properties of each drug, drug interactions, clinical use and dosing, and available dos- ing forms. A major focus is on rational drug selection and on monitoring parameters. Patient education specific to each drug class is provided—designed around administration of the drug, adverse drug reactions to monitor for and what to do if they occur, and lifestyle modifications that complement the drug therapy.

To provide the most up-to-date, accurate, and relevant in- formation possible, contributors to this unit are practicing clinicians and the newest published guidelines are consis- tently used. The “Clinical Pearls” features, drawn from the daily practice of these contributors, are incorporated throughout the text. Drugs currently in development that may influence drug choices in the near future are also included in the “On the Horizon” features.

Pharmacotherapeutics With Multiple Drugs The chapters in Unit III provide drug information from the viewpoint of the disease processes they are commonly used to treat. Patients often have complex health and illness issues and treatment needs requiring multiple drugs in different drug classes. Unit III facilitates acquisition of complex pre- scribing knowledge by providing information from a disease process format. The diseases in this unit are those commonly seen in primary care and for which multidrug therapy from more than one drug class may be recommended.

Pharmacotherapeutics is discussed in Unit III in relation to the pathophysiology of the disease and the goals of treatment. Each chapter explores how patient variables, economic consid- erations, concurrent diseases, and drug characteristics influence rational drug selection. Evaluating outcomes along with guide- lines for consultation and referral are included. Where relevant, the newest published professional guidelines are incorporated. Each patient is unique and no set of guidelines or treatment al- gorithm applies to each patient. However, these tools, drawn from the clinical knowledge and experience of experts in a given specialty, are helpful in rational drug selection, especially for the student and novice practitioner. Clinically based case studies,

provided in an online supplement to this edition, provide a framework for application of pharmacotherapeutic knowledge.

Special Drug Treatment Considerations Unit IV focuses on special populations. Age-related vari- ables are explored in Chapter 50, “Pediatric Patients,” and Chapter 51, “Geriatric Patients.” Gender variables are con- sidered in Chapter 48, “Women as Patients,” and Chapter 49, “Men as Patients.”

The final chapter in the book deals with one of the most common yet often perplexing issues with which prescribers deal: pain. Chapter 52 focuses on management of both acute and chronic pain across the age continuum. The fourth edi- tion includes the most current information on newer drugs used to treat chronic pain and new pain assessment tools for patients with dementia. The chapter includes a discussion of the legal aspects of prescribing related to drug-dependent pa- tients and includes coverage of Material Risk Assessment and Pain Management Contract documents.

FEATURES

Throughout the text, care has been taken to provide the reader with a consistent and logical presentation of material. Visual appeal is provided through the generous use of tables, illustrations, and flowcharts. Other features are unique to the specific units:

Unit I chapters In-depth pharmacology base for advanced pharmacother-

apeutics Herbal and complementary therapies Ethnopharmacology and pharmacogenomics Nutrition and nutraceuticals as therapy Pharmacoeconomics Information technology including EHR and how it is used

in a busy practice

Unit II chapters Tables for ease of access to information

Pharmacokinetics tables Drug Interactions tables Dosage Schedule tables Available Drug Dosage Forms

Rational drug selection and monitoring parameters Patient Education Clinical Pearls On the Horizon feature

Unit III chapters Integration of pathophysiology and pharmacotherapeutics Integration of professional treatment guidelines Drugs Commonly Used tables Patient Education displays

viii • Preface

3827_FM_i-xviii 03/07/15 10:26 AM Page viii

Unit IV chapters Variables related to special populations

Pediatrics Geriatrics Women Men Pain management

SUMMARY

Every effort has been made to make this text as comprehen- sive, accurate, and user-friendly as possible. The generous use of tables for ease of access to information, the focus on ra- tional drug selection, the inclusion of often hard-to-find

monitoring parameters, and the integration of patient edu- cation throughout the text are examples of this user-friendly approach. The authors hope that you will find this a valuable resource both as a student and in your practice.

TMW MVR

ACKNOWLEDGMENTS

I would like to acknowledge my mentors who have supported me throughout my nursing career. Included in this list are Dr. Sheila Kodadek, who has been my mentor and friend throughout my nursing career, and the late Dr. Terry Misener.

TMW

Preface • ix

3827_FM_i-xviii 03/07/15 10:26 AM Page ix

3827_FM_i-xviii 03/07/15 10:26 AM Page x

xi

MARYLOU V. ROBINSON, PHD, FNP-C Marylou V. Robinson received her BSN from the Walter Reed Army Institute of Nursing, University of Maryland; her Master’s as a CNS from The Catholic University of America, her post-Master’s as an FNP from Pacific Lutheran University, and her PhD from Oregon Health & Science University. After a 22-year U.S. Army career spanning from Vietnam to Desert Storm, she joined academia. Currently, she is an Associate Professor at the University of Colorado College of Nursing at the Anschutz Medical Campus. She has been a National Ski Patroller for over 26 years.

TERI MOSER WOO, RN, PHD, CPNP-PC, FAANP Teri has been a pediatric health-care provider for 30 years. She received her BSN from Oregon Health Sciences University (OHSU) in 1984. Teri earned an MSN in Childrearing Family Nursing in 1989 and a post-Masters Pediatric Nurse Practitioner Certificate in 1993 from OHSU. In 2008, she earned a PhD in Nursing from the University of Colorado College of Nursing, Denver. Teri was president of the Oregon Pediatric Nurse Practitioner Association from 1998 to 2000 and from 2011 to 2013 and is a Fellow in the American Academy of Nurse Practitioners. She is an Associate Professor and Associate Dean for Graduate Nursing Programs at Pacific Lutheran University School of Nursing in Tacoma, Washington. Teri continues to practice as a Pediatric Nurse Practitioner for Kaiser Permanente in pediatric ambulatory care.

ABOUT THE AUTHORS

3827_FM_i-xviii 03/07/15 10:26 AM Page xi

3827_FM_i-xviii 03/07/15 10:26 AM Page xii

xiii

Lorena C. Guerrero, PhD, MN, ARNP, FNP-BC Assistant Professor School of Nursing Pacific Lutheran University Tacoma, WA

Anne Hedger, DNP, ACNP-CS, ANP-CS, CPNP-AC, ENP-BC, CCRN Associate Clinical Professor Acute Care Curriculum Coordinator/AGACNP Program School of Nursing Boise State University Boise, ID

Leila N. Jones, MSN, BA, RN Madison House—Genesis Healthcare Madison, CT

Jennifer Jordan, RPh, PharmD, BCPS Associate Professor School of Pharmacy Pacific University Hillsboro, OR

Tracy Klein, PhD, FNP, ARNP, FAANP, FRE, FAAN Assistant Professor, College of Nursing Washington State University, Vancouver Vancouver, WA

Ashim Malhotra, BPharm, PhD Assistant Professor School of Pharmacy Pacific University Hillsboro, OR

Theresa Mallick-Searle, MS, RN-BC, ANP-BC Division of Pain Medicine Stanford Health Care Redwood City, CA

Erin Anderson, MSN, CPNP Pediatric Urology Oregon Health & Science University Portland, OR

Cally Bartley, MSN, FNP-C Instructor School of Medicine, Department of Dermatology University of Colorado Anschutz Medical Campus Aurora, CO

Jane M. Carrington, PhD, RN Assistant Professor College of Nursing University of Arizona Tucson, AZ

Diana L. Dewell, ARNP, ANP Family Medicine Clinic Madigan Healthcare System Fort Lewis, WA

Gina Dobbs, MSN, CRNP Nurse Practitioner and Sub-Investigator 1917 HIV/AIDS Outpatient/Research Clinic University of Alabama at Birmingham Birmingham, AL

Krista Estes, DNP, FNP-C Assistant Professor College of Nursing University of Colorado Anschutz Medical Campus Aurora, CO

Teral Gerlt, MS, RN, WHCNP-E Instructor School of Nursing Oregon Health & Science University Portland, OR

Theresa Granger, PhD, ARNP, FNP Visiting Professor Chamberlain College of Nursing Downers Grove, IL

CONTRIBUTORS

3827_FM_i-xviii 03/07/15 10:26 AM Page xiii

Fujio McPherson, RN, DAOM, MSN, FNP, LAC Internal Medicine Clinic Madigan Army Medical Center Fort Lewis, WA

Benjamin J. Miller, PhD, MN, ARNP, FNP, ACNP Assistant Professor College of Nursing Seattle University Seattle, WA

Anne E. Morgan, PharmD Clinical Pharmacy Specialist, Department of Neurology University of Colorado Hospital Aurora, CO

Joan Nelson, DNP, RN Associate Professor College of Nursing University of Colorado Anschutz Medical Campus Aurora, CO

Patricia Nodine PhD, CNM Assistant Professor College of Nursing University of Colorado Anschutz Medical Campus Aurora, CO

Kristen Lambert Osborn, MSN, CPNP–AC/PC Pediatric Nurse Practitioner UAB Division of Pediatric Hematology and Oncology Children’s of Alabama Birmingham, AL

James L. Raper, DSN, CRNP, JD, FAANP, FAAN HIV/AIDS Outpatient, Research and Dental Clinic Associate Professor of Medicine & Nursing University of Alabama at Birmingham Birmingham, AL

Peter J. Rice, PharmD, PhD, BCPS Professor Skaggs School of Pharmacy and Pharmaceutical Sciences University of Colorado Anschutz Medical Campus Aurora, CO

Laura Rosenthal, DNP, ACNP Assistant Professor College of Nursing University of Colorado Anschutz Medical Campus Aurora, CO

Ruth Schaffler, PhD, FNP Emeriti Associate Professor School of Nursing Pacific Lutheran University Tacoma, WA

Tracy Scott, DNP, FNP Assistant Professor Department of Family Medicine School of Medicine University of Colorado Anschutz Medical Campus Aurora, CO

Kathy Shaw, DNP, RN, CDE Assistant Professor College of Nursing University of Colorado Anschutz Medical Campus Aurora, CO

R. Brigg Turner, PharmD, BCPS Assistant Professor School of Pharmacy Pacific University Hillsboro, OR

Connie Valdez, PharmD, MSEd, BCPS Associate Professor, Department of Clinical Pharmacy Skaggs School of Pharmacy and Pharmaceutical Sciences University of Colorado Anschutz Medical Campus Aurora, CO

Mary Weber, PhD, PMHNP-BC, FAANP Associate Professor College of Nursing University of Colorado Anschutz Medical Campus Aurora, CO

xiv • Contributors

3827_FM_i-xviii 03/07/15 10:26 AM Page xiv

xv

Joan Parker Frizzell, PhD, CRNP, ANP-BC Associate Professor School of Nursing & Health Sciences La Salle University Philadelphia, PA

Tammy Gilliam, DNP, APRN-BC, FNP Assistant Professor of Nursing/Adjunct Faculty University of South Carolina/USC Upstate Spartanburg, SC

Cathy R. Kessenich, DSN, ARNP, FAANP Professor of Nursing, MSN Program Director University of Tampa Tampa, FL

Pamela King, PhD, APRN, FNP, PNP MSN Program Director Spalding University Louisville, KY

Angela I. Kulesza, DNP, NP-C Assistant Professor School of Nursing, Science and Health

Professions Regis College Weston, MA

Christine Nelson-Tuttle, DNS, RN, PNP-BC Associate Professor, Undergraduate Chair St. John Fisher College Rochester, NY

David G. O’Dell, DNP, ARPN, FNP-BC Graduate Nursing Program Director South University Royal Palm Beach, FL

JoAnne Pearce, MS, PhDc, RN, APRN Director of Nursing Programs Idaho State University, College of Technology Pocatello, ID

Marianne Adam, PhD, RN, CRNP Assistant Professor Moravian College Bethlehem, PA

Nancy Beckham, PhD, FNP-C Associate Professor Gonzaga University Spokane, WA

Christopher W. Blackwell, PhD, ARNP, ANP-BC, AGACNP-BC, CNE Associate Professor College of Nursing University of Central Florida Orlando, FL

Sharon Chalmers, PhD, CNE, APRN-BC Associate Professor University of North Georgia Dahlonega, GA

Patsy E. Crihfield, DNP, APRN, FNP-BC, PMHNP-BC, PMHS Chair of Nurse Practitioner Tracks, Graduate Program Union University Germantown, TN

Linda Dayer-Berenson, PhD, MSN, CRNP, CNE, FAANP Associate Clinical Professor Drexel University–CNHP Philadelphia, PA

Carolynn A. DeSandre, PhD, CNM, FNP-BC Assistant Professor University of North Georgia Dahlonega, GA

Abimbola Farinde, PharmD, MS Clinical Pharmacist Specialist Webster, TX

REVIEWERS

3827_FM_i-xviii 03/07/15 10:26 AM Page xv

Julie Ponto, PhD, RN, ACNS-BC, AOCNS Professor Winona State University–Rochester Rochester, MN

Susan Quisenberry, DNP, APRN, CNP, FNP-C Assistant Professor University of Oklahoma College of Nursing Oklahoma City, OK

Sandra Restaino, DNP, NP-C, FAANP, CSC Nurse Practitioner and Assistant Professor Eastern Michigan University Ypsilanti, MI

Maria Rosen, PhD, RN, PNP-BC Interim Director of Graduate Nursing Programs Massachusetts College of Pharmacy and Health Sciences Worcester, MA

Kathleen R. Sheikh, MSN, FNP-BC Assistant Professor Misericordia University Dallas, PA

Jennifer Sipe, RN, MSN, APRN-BC Assistant Professor La Salle University Philadelphia, PA

Angela Thompson, PhD, PharmD Nursing Instructor University of North Dakota Valley City, ND

Diane Yorke, MSN, MBA, PhD, RN, CPNP Clinical Assistant Professor (Adjunct) University of North Carolina Chapel Hill School of Nursing Chapel Hill, NC

xvi • Reviewers

3827_FM_i-xviii 03/07/15 10:26 AM Page xvi

xvii

Chapter 16 Drugs Affecting the Cardiovascular and Renal Systems 295 Marylou V. Robinson, PhD, FNP-C

Chapter 17 Drugs Affecting the Respiratory System 361 Teri Moser Woo, PhD, CPNP

Chapter 18 Drugs Affecting the Hematopoietic System 415 Teri Moser Woo, PhD, CPNP and Kristen Lambert Osborne MSN, CPNP AC/PC

Chapter 19 Drugs Affecting the Immune System 447 Teri Moser Woo, PhD, CPNP

Chapter 20 Drugs Affecting the Gastrointestinal System 497 Teri Moser Woo, PhD, CPNP

Chapter 21 Drugs Affecting the Endocrine System 541 Marylou Robinson, PhD, FNP and Kathy Shaw, DNP, RN, CDE

Chapter 22 Drugs Affecting the Reproductive System 615 Diana L. Dewel, ARNP, ANP

Chapter 23 Drugs Affecting the Integumentary System 647 Cally Bartley, MSN, FNP-C

Chapter 24 Drugs Used in Treating Infectious Diseases 691 Jennifer Jordan, RPh, PharmD, BCPS; R. Brigg Turner, PharmD, BCPS; and Teri Moser Woo, PhD, CPNP

Chapter 25 Drugs Used in Treating Inflammatory Processes 801 Teri Moser Woo, PhD, CPNP

Chapter 26 Drugs Used in Treating Eye and Ear Disorders 837 Teri Moser Woo, PhD, CPNP

UNIT III. PHARMACOTHERAPEUTICS WITH MULTIPLE DRUGS 863

Chapter 27 Anemia 865 Teri Moser Woo, PhD, CPNP and Kristen Osborn MSN, CPNP AC/PC

Chapter 28 Chronic Stable Angina and Low-Risk Unstable Angina 881 Laura D. Rosenthal, DNP, ACNP

Chapter 29 Anxiety and Depression 897 Mary Weber, PhD, PMHNP-BC, FAANP and Krista Estes, DNP, FNP-C

UNIT I. THE FOUNDATION 1

Chapter 1 The Role of the Nurse Practitioner as Prescriber 3 Teri Moser Woo, PhD, CPNP and Marylou V. Robinson, PhD, FNP-C

Chapter 2 Review of Basic Principles of Pharmacology 11 Peter J. Rice, PharmD, PhD, BCPS

Chapter 3 Rational Drug Selection 29 Teri Moser Woo, PhD, CPNP

Chapter 4 Legal and Professional Issues in Prescribing 37 Tracy Klein, PhD, FNP

Chapter 5 Adverse Drug Reactions 51 Connie A. Valdez, PharmD, MSEd, BCPS; Anne E. Morgan, PharmD; and Peter J. Rice, PharmD, PhD, BCPS

Chapter 6 Factors That Foster Positive Outcomes 61 Marylou V. Robinson, PhD, FNP-C and Teri Moser Woo, PhD, CPNP

Chapter 7 Cultural and Ethnic Influences in Pharmacotherapeutics 75 Lorena C. Guerrero, PhD, MS, ARNP, FNP-BC and Leila M. Jones, RN, MSN

Chapter 8 An Introduction to Pharmacogenomics 103 Ashim Malhotra, BPharm, PhD

Chapter 9 Nutrition and Neutraceuticals 115 Teri Moser Woo, PhD, CPNP

Chapter 10 Herbal Therapy and Nutritional Supplements 129 Fujio McPherson, RN, DAOM, MSN, FNP, LAC

Chapter 11 Information Technology and Pharmacotherapeutics 151 Jane M. Carrington, PhD, RN

Chapter 12 Pharmacoeconomics 159 Teri Moser Woo, PhD, CPNP

Chapter 13 Over-the-Counter Medications 165 Teri Moser Woo, PhD, CPNP

UNIT II. PHARMACOTHERAPEUTICS WITH SINGLE DRUGS 171

Chapter 14 Drugs Affecting the Autonomic Nervous System 173 Tracy Scott, DNP, FNP

Chapter 15 Drugs Affecting the Central Nervous System 225 Teri Moser Woo, PhD, CPNP

CONTENTS

3827_FM_i-xviii 03/07/15 10:26 AM Page xvii

Chapter 30 Asthma and Chronic Obstructive Pulmonary Disease 913 Benjamin J. Miller, PhD, MN, ARNP, FNP, ACNP

Chapter 31 Contraception 943 Teri Gerlt, MS, RN, WCHNP

Chapter 32 Dermatological Conditions 957 Teri Moser Woo, PhD, CPNP

Chapter 33 Diabetes Mellitus 991 Kathy Shaw, DNP, RN, CDE and Marylou Robinson, PhD, FNP-C

Chapter 34 Gastroesophageal Reflux and Peptic Ulcer Disease 1021 Teri Moser Woo, PhD, CPNP

Chapter 35 Headaches 1035 Theresa Mallick-Searle, MS, RN-BC, ANP-BC

Chapter 36 Heart Failure 1063 Laura Rosenthal, DNP, ACNP

Chapter 37 Human Immunodeficiency Virus Disease and Acquired Immunodeficiency Syndrome 1081 James Raper, DSN, CRNP, JD, FAANP, FAAN and Gina Dobbs, MS, CRNP

Chapter 38 Hormone Replacement Therapy and Osteoporosis 1103 Marylou V. Robinson, PhD, FNP-C

Chapter 39 Hyperlipidemia 1129 Marylou V. Robinson, PhD, FNP-C

Chapter 40 Hypertension 1155 Marylou V. Robinson, PhD, FNP-C

Chapter 41 Hyperthyroidism and Hypothyroidism 1179 Marylou V. Robinson, PhD, FNP

Chapter 42 Pneumonia 1195 Anne Hedger, DNP, ACNP-CS, ANP-CS, CPNP-AC, ENP-BC, CCRN

Chapter 43 Smoking Cessation 1205 Benjamin J. Miller, PhD, MN, ARNP, FNP, ACNP

Chapter 44 Sexually Transmitted Diseases and Vaginitis 1217 Theresa Granger, PhD, ARNP, FNP

Chapter 45 Tuberculosis 1237 Teri Moser Woo, PhD, CPNP

Chapter 46 Upper Respiratory Infections, Otitis Media, and Otitis Externa 1253 Teri Moser Woo, PhD, CPNP

Chapter 47 Urinary Tract Infections 1267 Erin Anderson, MSN, CPNP

UNIT IV. SPECIAL DRUG TREATMENT CONSIDERATIONS 1281

Chapter 48 Women as Patients 1283 Priscilla M. Nodine, PhD, CNM

Chapter 49 Men as Patients 1303 James Raper, DNS, CRNP, JD, FAANP, FAAN

Chapter 50 Pediatric Patients 1321 Teri Moser Woo, PhD, CPNP

Chapter 51 Geriatric Patients 1337 Joan M. Nelson, DNP, RN

Chapter 52 Pain Management: Acute and Chronic Pain 1351 Ruth L. Schaffler, PhD, FNP

INDEX 1373

xviii • Contents

3827_FM_i-xviii 03/07/15 10:26 AM Page xviii

THE FOUNDATION

UNIT I

3827_Ch01_001-010 01/07/15 12:33 PM Page 1

3827_Ch01_001-010 01/07/15 12:33 PM Page 2

3

CHAPTER 1

THE ROLE OF THE ADVANCED PRACTICE NURSE AS PRESCRIBER

Teri Moser Woo • Marylou Robinson

Other APRNs

Physician Assistants

Nurses Not in Advanced Practice Roles

CANADIAN NURSE PRACTITIONER PRACTICE, 8

CURRENT ISSUES AND TRENDS IN HEALTH CARE AND THEIR EFFECT ON PRESCRIPTIVE AUTHORITY, 8

Autonomy and Prescriptive Authority

Interdisciplinary Teams

Level of Education of Team Members

Reimbursement

N urses have been administering medications prescribedby another provider for many years. The knowledge base to safely perform this activity has been an integral part of basic nursing education. With the advent of the ad- vanced practice nurse, the role of the nurse in relation to medications has evolved to include prescribing the med- ications as well as administering them. The prescriber role requires additional knowledge beyond that taught in un- dergraduate nursing programs. More than that, it requires the willingness and ability to assume a different level of re- sponsibility for this activity. Advanced practice nurses other than nurse practitioners (NPs) may gain prescriptive authority or prescribe under protocol; therefore, the term advanced practice registered nurse (APRN) will be used in this chapter to include NPs, certified nurse midwives (CNMs), certified registered nurse anesthetists (CRNAs), and clinical nurse specialists (CNSs) with prescribing au- thority, as determined by the individual state nurse practice

act. The focus of the discussion will remain primary care prescribing.

ROLES OF REGISTERED NURSES IN MEDICATION MANAGEMENT

Registered Nurses Experienced registered nurses (RNs) often find themselves in the position of discussing what might be the “best” drug a patient should receive with a physician or other prescribing provider. The RN is an advocate for the patient and his or her input should be sought and highly valued in the prescribing process. Collaboration between the nurse and prescriber improves patient safety and the quality of care the patient receives; however, the responsibility for the final decision regarding which medication to prescribe remains with the prescriber.

ROLES OF REGISTERED NURSES IN MEDICATION MANAGEMENT, 3

Registered Nurses

Advanced Practice Registered Nurses

ROLES AND RESPONSIBILITIES OF APRN PRESCRIBERS, 4

ADVANCED KNOWLEDGE, 4

BENEFITS OF AN APRN AS PRESCRIBER, 5

CLINICAL JUDGMENT IN PRESCRIBING, 5

COLLABORATION WITH OTHER PROVIDERS, 7

Physicians

Pharmacists

3827_Ch01_001-010 01/07/15 12:33 PM Page 3

Advanced Practice Registered Nurses APRNs have a higher level of responsibility related to phar- macotherapeutics than RNs. The nature of this responsibility depends on whether the APRN can prescribe medications. States vary in their laws related to prescriptive authority for APRNs. Twenty-one states have fully independent prescribing by nurse practitioners (AANP, 2013b; National Council of State Boards of Nursing, 2015). Some states have full or limited prescribing allowed by CNSs, including Alaska, Colorado, Connecticut, Hawaii, Iowa, Idaho, Minnesota, Montana, Nevada, New Mexico, North Dakota, Oregon, Utah, Vermont, Washington, DC, and Wyoming (National Council of State Boards of Nursing, 2015).

Because nonprescribing APRNs have in-depth knowledge of the drugs used in their specialty areas, their collaboration with the health-care providers who are prescribing is valu- able. They may assist in determining the pharmacotherapeu- tic protocols for their patients and may be credentialed by their organization to select drugs within those protocols to be administered to their patients. These roles related to pharmacotherapeutics represent an intermediate level of responsibility between the staff RN, who administers drugs chosen by another provider, and the NP, who prescribes a drug without the need for a protocol. APRNs also collaborate with other providers in designing and implementing research protocols to test the efficacy of a new drug. They also have a central role in educating nurses and other providers in the appropriate use of these new drugs.

ROLES AND RESPONSIBILITIES OF APRN PRESCRIBERS

APRNs exist in a range of practices and include certified RN anesthetists, certified nurse midwives, and others whose title includes the words nurse practitioner or advanced practice registered nurse. The responsibility for the final decision on which drug to use and how to use it is in the hands of the APRN prescriber. The degree of autonomy in this role and the breadth of drugs that can be prescribed vary from state to state based on the nurse practice act of that state. Every year, the January issue of the Nurse Practitioner journal and an issue of the American Journal for Nurse Practitioners present a legislative update providing a summary of each state’s practice acts as they relate to titling, roles, and pre- scriptive authority. As of January 2015 (Philips, 2015), the following were true of NP regulation of practice and prescrib- ing authority:

• All states have title protection for NPs. • Only Oregon has mandated 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 nurs- ing. These five states have joint control in the board of nursing and the board of medicine.

• Scope of practice is determined by the individual NP’s license under the nurse practice act of the licensing

jurisdiction. Some have a graduated scope based on experience level. New prescribers need to understand that their employment sites may restrict this legal scope of practice but cannot extend it.

• In 17 states and the District of Columbia, NPs have in- dependent scope of practice and prescriptive authority without a requirement or attestation for physician col- laboration, consultation, delegation, or supervision.

• Six states have full autonomous practice and prescrip- tive authority following a period of postlicensure/ postcertification supervision or collaboration.

The 2010 Institute of Medicine’s (IOM) publication Future of Nursing: Leading Change, Advancing Health called for removing scope of practice barriers and allowing NPs to practice to the full extent of their education and training (IOM, 2010). Many states are responding to this call, with the expectation that the above list will be significantly modified in years to come.

ADVANCED KNOWLEDGE

General knowledge about the pharmacokinetics and phar- macodynamics of drugs, how to administer them safely, and what to teach the patient is learned in undergraduate nursing courses and subsequently refined in practice. Additional knowledge, critical thinking, and assumption of a higher level of legal responsibility are required to assume the prescriber role. Knowledge of medicine, pharmacology, and nursing in- tertwine in the NP role. As a prescriber, it becomes the role and responsibility of the NP to determine the diagnosis for which the drug will be ordered, prescribe the appropriate drug, monitor the expected outcome of the drug, and incor- porate a holistic assessment of the impact of disease and ther- apy on patient lives.

The APRN role requires advanced knowledge about pathophysiology, medical diagnoses, and pharmacology to choose an appropriate drug. Determining the medical diag- nosis is not within the scope of this book, but rational drug selection requires knowledge of the disease processes (med- ical diagnoses) for which a drug may be prescribed and the mechanism of action of a specific drug and how it affects this disease process. Rational drug selection is discussed through- out the book.

The prescriber role requires advanced pharmacology knowledge beyond that taught in basic nursing education. Knowledge required for rational drug selection includes, for example, bioequivalence and cost when deciding whether to use a generic form of a given drug; the enzyme systems used to metabolize a drug for deciding about potential drug inter- actions; and the pharmacokinetics of a drug for determining the loading, maintenance, and tapering doses. The terms may sound familiar, but the underlying depth of information and the role of this information in determining the best drug to prescribe are beyond basic nursing pharmacology knowledge. Volume of distribution, for example, receives little discussion in undergraduate nursing pharmacology texts, but it is often critical in determining dosage for drugs with very large or

4 • The Foundation

3827_Ch01_001-010 01/07/15 12:33 PM Page 4

small volumes of distribution and in selecting drugs for patients with cardiac or renal failure, pregnant patients, or patients who are underweight or obese. Assessment of plasma drug levels by bioassay may be a familiar concept, but the use of this knowledge to determine whether a drug should be pre- scribed or the prescription altered will be new. The RN may know a given drug’s effect on renal functioning, but the pre- scribing APRN needs to know what tests to order and when to order them to appropriately monitor that functioning, as well as when or if to alter the dosage or stop the drug. Diag- nostic tests and their role in drug monitoring may be briefly covered in a basic nursing pharmacology course, but appro- priate modification of drug therapy based on results is added knowledge that an APRN needs to be a safe prescriber.

A nurse who is studying to be an APRN will need addi- tional knowledge about prescriptive authority. Does the chosen drug fit within the legal authority of an APRN to pre- scribe in his or her state? What are the conditions under which the prescription may be written, and how does one correctly write it? What constraints may be in place because of the patient’s health insurer or lack of health insurance?

Additionally, the APRN needs to be aware of new drugs that come on the market, medication alerts, and label changes due to postmarketing analysis. In 2014 there were a record 41 novel new drug entities approved by the U.S. Food and Drug Administration (FDA), with an average of 25 new drugs approved annually (U.S. Food and Drug Administra- tion Center for Drug Evaluation and Research, 2015). The FDA sends out alerts to health-care providers via the Med- Watch Safety Alert system as new information becomes available from post-marketing surveillance and modifies drug labels as appropriate. Ever-changing drug information requires the APRN to remain up-to-date on drug informa- tion at all times.

BENEFITS OF AN APRN AS PRESCRIBER

Although the focus of this book is on pharmacotherapeutic intervention, alternative treatment options are also part of the armamentarium that can be used to treat a given disor- der and may interact with the pharmacotherapeutic inter- vention. Discussion of common therapies that may be chosen as treatment options or that are integral to drug therapy is integrated throughout the drug-specific and disease-specific chapters.

Some therapies have traditionally been part of what all nurses teach, and they remain central to the role of the APRN, for example, lifestyle management issues for a cardiac patient, relaxation techniques for a patient experiencing stress, and appropriate exercise for a patient with low back pain or arthritis. Herbal therapies have been part of the health practices of people throughout history, but it is only recently that health-care providers have acknowledged them and con- sidered them in planning treatment. If the APRN chooses to use herbal therapy or the patient is using this therapy as sug- gested by another provider, there must be reliable resources

about the therapy and its impact on prescribing. This book includes a separate chapter on herbal therapy and the uses of complementary therapies and also integrates the use of herbal interventions throughout.

Nutrition is also a common issue in nursing, but often the nurse’s knowledge of nutrition related to pharmacology is limited to food–drug interactions or the low-sodium diet for a patient with hypertension. Knowledge regarding how foods and nutrition affect drug prescribing is integrated throughout the book; how foods are used as therapy is in- cluded in Chapter 9, “Nutraceuticals.”

Choosing among pharmacological and other treatment options also involves advanced knowledge. The right choice depends on accurate information about the patient and his or her situation and the effects of any alternative treatment options on health outcomes. Choices also depend on the patient’s culture, preferences for different health outcomes, attitudes toward taking risks, and willingness to endure often uncomfortable adverse drug effects during treatment for some possible future benefit.

Characteristic of APRNs and their practice are consider- ation of the whole patient, the joint setting of therapeutic goals with other members of the health-care team, and the inclusion of the patient in each decision about care. This holistic approach remains a central element in APRN prac- tice and is often cited by patients and other providers as a hallmark and distinguishing feature of APRN practice when compared with other primary care providers. Adherence to a drug treatment regimen has traditionally been less than optimal. Statistics cited often place patient adherence (taking the drugs as prescribed) at less than 50 percent. Research shows that adherence is better for prescriptions given by NPs than by physician assistants (Manhattan Research, 2013). The reasons for the difference include consideration of the whole patient and inclusion of the patient in decision making. Another factor in improved adherence is patient ed- ucation; APRNs spend more time than other providers in teaching their patients about the disease process and the relationship of the treatment regimen to it (Gielen, Dekker, Frecke, Mistiaen, & Krozen, 2013; Manhattan Research, 2013). Each of these important aspects of drug choice and utilization is covered in this book.

CLINICAL JUDGMENT IN PRESCRIBING

Prescribing a drug results from clinical judgment based on a thorough assessment of the patient and the patient’s envi- ronment, the determination of medical and nursing diag- noses, a review of potential alternative therapies, and specific knowledge about the drug chosen and the disease process it is designed to treat. In general, the best therapy is the least invasive, least expensive, and least likely to cause adverse reactions. Frequently, the best choice is to have lifestyle, non- pharmacological, and pharmacological therapies working together. When the choice of treatment options is a drug, several questions arise.

The Role of the Advanced Practice Nurse as Prescriber • 5

3827_Ch01_001-010 01/07/15 12:33 PM Page 5

Is There a Clear Indication for Drug Therapy? In the age of health-care reform and increased awareness of the limitations of drugs, whether a medication is the best option for treatment has become an important question. For example, in treating acute otitis media, guidelines regarding the use of antibiotics has been evolving. A high percentage of otitis media infections resolve without inter- vention, so how does one know that the antibiotic was the cause of the cure? Of concern is organisms’ resistance to antibiotics, with antibiotic overtreatment considered a contributing factor to resistance. Before drug therapy is chosen, the indication for and necessity of using a drug should be carefully considered.

What Drugs Are Effective in Treating This Disorder? Several drugs may be effective in treating a condition, so which one is best for a particular patient? Even if only the most effective class of drug is considered, few classes of drugs include only one drug. How does one determine “best”; what are the criteria? Are there nationally recognized guidelines that can be used? The Agency for Health Care Quality (AHCQ), the National Institutes of Health (NIH), and many specialty organizations publish disease-specific treatment guidelines that include both pharmacological and nonphar- macological therapies.

What Is the Goal of Therapy With This Drug? What is the best drug to achieve treatment goals? Various goals are possible in the choosing of therapy. The goal may be cure of the disease and short term in nature. If cure is the goal, troublesome adverse effects may be better tolerated and cost may be less of an issue. If the goal is long-term treatment for a chronic condition, adverse effects and costs take on a different level of importance, and how well the drug fits into the lifestyle of the patient can be a critical issue.

Under What Conditions Is It Determined That a Drug Is Not Meeting the Goal and a Different Therapy or Drug Should Be Tried? At the onset of therapy, the provider and patient should have a clear understanding of what outcome or goal is expected of the medication prescribed. Follow-up and monitoring times are established to see how well treatment with the drug is meeting the goal. Often, monitoring parameters are pub- lished for a drug but may need to be adjusted based on the age or concurrent disease processes of the patient. Part of the decision-making process may include questions about when to consult with or refer the patient to a specialist.

Are There Unnecessary Duplications With Other Drugs That the Patient Is Already Taking? The patient’s medication history should be reviewed at each encounter to detect duplications or medications that may be discontinued. Sometimes drugs from different classes are given together to achieve a desired effect, and

this is a therapeutic choice. It may also be that the provider is not aware of the overlap, especially if the patient is seeing several different providers. For example, a patient who is on a diuretic to treat hypertension may be receiving potas- sium supplementation. Another provider may decide to use an angiotensin-converting enzyme (ACE) inhibitor to treat heart failure. An ACE inhibitor can also be used to treat hypertension. Rather than a treatment regimen with three drugs, it may be possible to use a combination of an ACE inhibitor with a diuretic in one tablet, and because ACE in- hibitors cause potassium retention, no supplemental potas- sium would be needed. Use of an integrated electronic health record can assist the provider in discovering dupli- cation of therapy and collaborating with other providers to develop a simplified regimen.

Would an Over-the-Counter Drug Be Just as Useful as a Prescription Drug? Increasing numbers of drugs are being moved from pre- scription to over-the-counter (OTC) status. This may lead to a reduction in cost for the patient, or it may increase patient costs due to insurance no longer paying for the medication. Patients may not consider OTC medications as “drugs” because they are not prescribed; therefore, a careful history of all medications would specifically ask about OTC medications.

What About Cost? Who will pay for this drug? Can the patient afford it? Will the cost of the medication affect adherence to the treatment reg- imen? Cost is an issue for several reasons. Many insurance policies do not cover the cost of drugs or only provide partial coverage, so the patient must pay “out of pocket.” The newer the drug, the more likely the cost is to be high based on the drug manufacturer’s need to reclaim research and develop- ment costs while the corporation still holds the patent on that drug. Newest is not always best, and consideration of cost is a major factor in choosing between newer drugs and ones that have been around long enough to be available in generic form. Many insurance plans have larger co-pays for name-brand drugs than for generic medications. Multiple national retail pharmacies have developed $4.00 prescription formularies. Awareness of what is on the local discount formulary may save the patient hundreds of dollars in prescription costs and may increase compliance. Factors likely to lead to poor adherence include a drug that is expensive in relation to a patient’s finances, a drug that must be taken daily as part of a complex regimen, and a drug that is not covered by insurance.

Where Is the Information to Answer These Questions? Nurses evaluate sources of drug information and learn which ones to trust. For an APRN, the sources of drug information expand to include the wide array of professional literature that ranges from the well-reputed journals to literature from specialty and professional organizations, the multitude of computerized drug databases (e.g., Micromedix, Lexicomp,

6 • The Foundation

3827_Ch01_001-010 01/07/15 12:33 PM Page 6

The Role of the Advanced Practice Nurse as Prescriber • 7

Epocrates), information from the U.S. Food and Drug Administration, and formula programs that can be accessed via a handheld device or computer.

The APRN prescriber needs to evaluate how reliable the drug information is. How can reliability be determined? Is the information source written by someone who may benefit from presenting biased information? Is the information source current? Today’s “wonder drug” may be removed from the market tomorrow. Is the information relevant to the specific patient for whom the drug will be prescribed? If the information is a research report, what type of research design was used? Are there questions about the validity and reliabil- ity of the data? Are national or international guidelines used to inform prescribing or does the reference suggest prescrib- ing outside established guidelines? To prescribe drugs appro- priately, APRNs must be able to answer these questions; to answer them, they must master sources of information and use them on a regular basis.

COLLABORATION WITH OTHER PROVIDERS

No one member of the health-care team can provide high- quality care without collaborating with other team members. They most often collaborate with physicians, pharmacists, podiatrists, mental health specialists, therapists, and other providers, including APRNs who are not NPs, physician assistants (PAs), and other nurses.

Physicians Collaboration with physicians has been something of a roller- coaster ride for NPs. Early in the development of the NP role, physicians were the teachers in the NP programs and accepted NPs as physician-extenders. As the role of the NP evolved to clearly indicate that it was advanced nursing prac- tice, and as legislation made autonomy of practice possible, the relationship became more adversarial, with the American Medical Association (AMA) issuing statements regarding the NP and PA scope of practice (AMA, 2009), often for eco- nomic reasons. An AMA document, AMA Scope of Practice Series: Nurse Practitioner, stated, “It is the AMA’s intention that these Scope of Practice Data Series modules provide the background information necessary to challenge the state and national advocacy campaigns of limited licensure health care providers who seek unwarranted scope-of-practice expan- sions that may endanger the health and safety of patients” (AMA, 2009, p 4). The AMA responded to the IOM Future of Nursing report by reiterating that NPs are not qualified to provide patient care because of lack of hours in clinical education (Patchin, 2010).

Although this struggle still continues at the national level (Patchin, 2010; American Academy of Nurse Practitioners [AANP], 2013; AMA, 2013), NPs and physicians do work to- gether very effectively on an individual basis and in collegial care teams. In an era of health-care reform, our joint con- cerns about patient care decisions require us to be allies.

Physicians may offer insight or advice on pharmacological management from their experience. A physician’s expertise re- lated to pharmacology is based on understanding biochemistry and prescribing for a given pathophysiology. The emphasis is on the disease and the drug, with less emphasis on the impact on the patient. Patient education by physicians may be limited or left to a nurse or pharmacist.

APRNs traditionally approach prescribing drugs in a slightly different manner from that of physicians. As APRNs prescribe a drug for a given pathophysiology, their nursing background leads them to place equal emphasis on under- standing the impact the drug will have on the patient. Patient education is a central focus of nursing and APRN practice. Knowledge and clinical experience shared from the mingling of medical and nursing perspectives are mutually beneficial to the providers and the patient. The APRN can benefit from the in-depth knowledge about the drugs in the physician’s specialty area. The physician can benefit from APRNs’ focus on the impact of the drug on the patient and from their patient education skills. In the age of health-care reform, increasing emphasis is being placed on these latter issues.