Updated: 11/6/2017

Drug Reactions and Side Effects

Topic
Review Topic
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Questions
9
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Evidence
8
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Overview
  • Drug reactions organized by system
    • cardiovascular
    • GI
    • hematologic 
    • musculoskeletal
    • neurologic
    • renal
    • reproductive/endocrine
    • respiratory
    • multiorgan
Medication Reactions
 
Reaction
Causal Agent
Cardiovascular
Atropine-like side effects
  • TCAs
Coronary vasospasm
  • Cocaine
  • Sumatriptan
Cutaneous flushing
  • Vancomycin
  • Adenosine
  • Niacin (reduced by co-administration of aspirin)
  • Calcium channel blockers
Dilated cardiomyopathy
  • Doxorubicin (Adriamycin) 
  • Daunorubicin
  • Cocaine
Torsades de pointes
  • Class IA antiarrhythmic (disopyramide, quinidine, procainamide)
  • Class III  antiarrhythmics (amiodarone, sotalol)
  • Lithium
  • Chloroquine
  • Erythromycin, clarithromycin
  • Haloperidol, thioridazine, ziprasidone
GI
Acute cholestatic hepatitis
  • Macrolides
  • Troglitazone
Focal to massive hepatic necrosis
  • Halothane
  • Valproic acid
  • Acetaminophen
  • Amanita phalloides
  • Carbon tetrachloride
Hepatitis
  • INH
  • Phenytoin
  • Methyldopa
Pseudomembranous colitis
  • Clindamycin
  • Ampicillin
  Hematologic
 Agranulocytosis  
  • Clozapine
  • Carbamazepine
  • Colchicine
  • Propylthiouracil
  • Methimazole
  • Dapsone
  • Cephalosporins
Aplastic anemia
  • Chloramphenicol
  • Benzene
  • NSAIDs
  • Propylthiouracil
  • Methimazole
  • Carbamazepine
  • Phenytoin
Direct Coombs-positive hemolytic anemia
  • Methyldopa
  • Penicillin
Gray baby syndrome
  • Chloramphenicol
Hemolysis in G6PD-deficient patients
  • Isoniazid (INH)
  • Dapsone
  • Sulfonamides
  • Primaquine
  • Chloroquine
  • Aspirin
  • Ibuprofen
  • Nitrofurantoin
  • Methylene blue
Megaloblastic anemia
  • Phenytoin
  • Methotrexate
  • Sulfonamides
  • 6-mercaptopurine
  • Cytosine arabinoside
Thrombotic complications
  • Contraceptives
Musculoskeletal
Gingival hyperplasia
  • Phenytoin
  • Cyclosporin
  • Nifedipine
Gout
  • Furosemide
  • Thiazides
  • Cyclosporin
  • Levodopa
  • Niacin
Osteoporosis
  • Corticosteroids
  • Heparin
  • Proton pump inhibitors
  • Lithium
Photosensitivity
  • Sulfonamides
  • Amiodarone
  • Tetracycline
  • Fluoroquinolones
Rash (Stevens-Johnson syndrome)
  • Ethosuximide
  • Lamotrigine
  • Carbamazepine
  • Phenobarbital
  • Phenytoin
  • Sulfonamides
  • Fluorquinolones
  • Furosemide
  • Penicillin
  • Allopurinol
Rhabdomyolysis
  • Statins
SLE-like syndrome
  • Hydralazine
  • INH
  • Procainamide
  • Phenytoin
  • Carbamazepine
Tendonitis, tendon rupture, and cartilage damage in children
  • Fluoroquinolones 
Neurologic
Cinchonism 
  • Quinidine
  • Quinine
Diabetes insipidus
  • Lithium
  • Demeclocycline
Parkinson-like syndrome
  • Haloperidol
  • Chlorpromazine
  • Reserpine
  • Metoclopramide
  • MPTP (causes permanent Parkinson's)
  • Clozapine
  • Prochlorperazine
  • Cinnarizine
Seizures
  • Bupropion
  • Venlafazine
  • Tramadol
  • Diphenhydramine
  • Imipenem/cilastatin
  • Isoniazid
Tardive dyskinesia
  • Antipsychotics (chlorpromazine)
Renal/GU
Fanconi's syndrome
  • Expired tetracycline
  • Tenofovir
Interstitial nephritis
  • Methicillin
  • NSAIDs
  • Acetominophen
  • Furosemide
  • Allopurinol
Hemorrhagic cystitis
  • Cyclophosphamide
  • Ifosfamide (prevented by mesna administration)
Reproductive/Endocrine
Adrenocortical insufficiency
  • Withdrawal of glucocorticoid therapy
Gynecomastia
  • Spironolactone
  • Digitalis
  • Cimetidine
  • Clomiphene
  • Busulfan, nitrourea, vincristine (direct testicular injury)
  • Chronic alcohol use
  • Estrogens
  • Ketoconazole
  • Finasteride
Hot Flashes
  • Tamoxifen
  • Clomiphene
Hypothyroidism
  • Lithium
  • Amiodarone
  • Neck radiation therapy
Respiratory
Cough
  • ACE inhibitors
Pulmonary fibrosis
  • Bleomycin
  • Amiodarone
  • Busulfan
  • Methotrexate
  • Cyclophosphamide
  • Hydralazine
  • Tocainide
  Multiorgan
Disulfiram-like reaction
  • Sulfonylurea
  • Metronidazole
Nephrotoxicity/neurotoxicity
  • Polymyxins
Nephrotoxicity/ototoxicity
  • Aminoglycosides (neomycin)
  • Vancomycin
  • Loop diuretics (ethacrynate, furosemide, bumetanide)
  • Cisplatin
  • Mercuric chloride

 

 

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Questions (9)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M1.PH.17) A 75 year-old gentleman presents to the primary care physician with a 2 week history of right sided achilles tendon pain. He states that the pain has had a gradual onset and continues to worsen, now affecting the left side for the past 2 days. He denies any inciting event. Of note the patient performs self-catheterization for episodes of urinary retention and has been treated on multiple occasions for recurrent urinary tract infections. What is the most important next step in management for this patient's achilles tendon pain? Review Topic

QID: 104902
1

Refer patient to an orthopedic surgeon

3%

(6/194)

2

Switch medication and avoid exercise

68%

(131/194)

3

Place permanent urinary catheter

7%

(13/194)

4

Perform MRI

12%

(23/194)

5

Perform CT scan

9%

(17/194)

M1

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PREFERRED RESPONSE 2
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(M1.PH.54) A 55-year-old man presents to his primary care provider complaining of blood clots in his urine. On further questioning, he also reports suprapubic discomfort and a feeling of bladder fullness with difficulty voiding. The patient reports recently starting treatment for a newly diagnosed non-Hodgkin lymphoma. Vital signs are within normal limits. Physical exam reveals pain on palpation of the suprapubic region. What is the mechanism of action of the drug most likely responsible for the patient’s complaints? Review Topic

QID: 106368
1

Alkylating agent

64%

(142/223)

2

Intercalating agent

11%

(24/223)

3

Reverse transcriptase inhibitor

4%

(9/223)

4

Microtubule inhibitor

16%

(35/223)

5

Folic acid analogue

4%

(10/223)

M1

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PREFERRED RESPONSE 1

(M1.PH.4707) A 32-year-old female presents to her primary care physician with a 4 day history of vaginal odor. When prompted, she says that she has also had some discharge but does not remember details about the discharge. She last had unprotected sex with a new partner 2 weeks prior to presentation. Physical exam reveals minimal inflammation and wet mounts show the cells demonstrated in Figure A. The antibiotic most likely prescribed in this case has which of the following notable side effects? Review Topic

QID: 108437
FIGURES:
1

Alcohol intolerance

53%

(153/290)

2

Aplastic anemia

11%

(33/290)

3

Ototoxicity

21%

(60/290)

4

Red man syndrome

3%

(9/290)

5

Tendon rupture

10%

(29/290)

M1

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PREFERRED RESPONSE 1
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(M1.PH.75) A 37-year-old female with systemic lupus erythematosus is started on a new regimen of corticosteroids to better control her symptoms. The prescribing physician counsels the patients on the possible side effects including weight gain, hirsutism, and skin changes. The physician goes on to state that corticosteroids can also cause a number of changes on the patients laboratory studies. Which figure correctly identifies the cell type that would be expected to INCREASE as a result of corticosteroid use? Review Topic

QID: 106846
FIGURES:
1

Figure A

58%

(82/141)

2

Figure B

7%

(10/141)

3

Figure C

16%

(23/141)

4

Figure D

6%

(9/141)

5

Figure E

8%

(11/141)

M1

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PREFERRED RESPONSE 1

(M1.PH.21) A 42-year-old female with a history of systemic lupus erythematous (SLE) has a 3-year history of daily prednisone (20 mg) use. Due to long-term prednisone use, she is at increased risk for which of the following? Review Topic

QID: 101958
1

Hair loss

0%

(0/26)

2

Weight loss

0%

(0/26)

3

Pancreatic insufficiency

8%

(2/26)

4

Systolic hypertension

31%

(8/26)

5

Pathologic fractures

58%

(15/26)

M1

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PREFERRED RESPONSE 5
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