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Methamphetamine Epidemic Act
- Restricts sales of cough and cold products that contain methamphetamine precursor chemical (ephedrine, pseudoephedrine, or pehylpropranoamine)
- Daily & Monthly limit on retail/internet purchases
- Retailers must ask for ID and keep a log
What are the laws regarding OTC
- Safe (benefits outweigh risks)
- Low potential for abuse/misuse
- Can be labeled
- patient must be able to self diagnose their condition
- must be for a condition the patient can manage without supervision
COX1 and COX 2 inhibitors (& inhibits PGE synthesis)
analgesic, antipyretic, antiplatelet, and anti-inflammatory
NSAID Drug Interactions
- Decreased effectiveness of anti-HTN (including Betablockers)
- Anticoagulants: inc. risk of bleeding
- Lithium: increased lithium level
- Hydantoins: increased phenytoin level
- Loop diuretics: decreased effectivenesss of diuretic
- Probenecid: increased conc. (toxicity risk of NSAID)
- Salicylates: decreased conc. of NSAIDs
NSAID Side Effects
- GI Irritation
- DO NOT USE IF RENAL IMPAIRMENT
- DO NOT USE IF CHRONIC/ACTIVE ULCER in GI tract
- CAUTION w/Hepatic impairment
NSAID while pregnant...
- 1st and 2nd trimester = C
- 3rd = D
(Use Tylenol instead)
Tylenol MOA and use
- Central inhibition of Prostaglandin synthesis:
- NOT ANTI-INFLAMMATORY
- Antipyretic & Analgesic
Max dose of Tylenol
Tylenol Drug Interactions
= BAD FOR LIVER
- Loop Diuretics don't work as well w/Tylenol
- Zidovudine = less effect because Tylenol increases clearance of it
- Oral Contraceptives: decreases 1/2 life of Tylenol (NSAID better for prolonged use)
- Beta adrenergic blockers = increased effect of tylenol (blocking enzyme to break it down) so don't use propanolol w/tylenol
- Probenecid: increased effectiveness of Tylenol
= delayed absorption
Tylenol while pregnant...
B (Better than NSAIDs!)
Tylenol and liver disease (aka acute hepatic necrosis)....
DON'T DO IT!!!!
Diphenhdyramine (aka Benadryl) Uses
- First generation ant-histamine...
- Sleep aid
....lets just say Benadryl fixes all of life's problems...but it makes you sleepy
Can Benadryl reverse extra pyramidal symptoms?
YES! reverses EPS r/t phenothiazines (which I believe is another type of anti-emetic) so no EPS and the patient won't be nauseous :)
When should you NEVER use Diphenhydramine?
- CONTRAINDICATED in:
- Narrow angle glaucoma
- Lower Respiratory Tract Infections (thickens secretions and impairs expectoration)
- Stenosing peptic ulcer
- Symptomatic prostate hypertrophy
- MAOI (can prolong/intensify effect of anti-histamine)
USE CAUTION when prescribing Diphenhydramine to someone with....
- urinary retention
- history of bronchial asthma (is there another type?)
- Increased intraocular pressure
- CV disease
TRUE or FALSE. Kids can get really hyper w/Benadryl (aka diphenhydramine)
TRUE! Paradoxical stimulation can occur in young children = the EXACT opposite of what you want!
What two guides should the APN refer to about herbals?
Natural Standard and Rakel's Evidence vs Harm Scale
Licorice use and drug interactions
Interacts w/anti-HTN, diuretics, digoxin, spironlactone, and quinidine
Ginko use and drug interactions
Improves thinking ability, concentration, and memory
Interacts w/anti-coagulants and anti-platelets =bleediing
St. John's Wort Use and drug interactions
Interactions: TCAs, MAOIs, sympathomimetics, OTC cold/flu medications, Narcotics, SSRI = serotonin syndrome!!!
Ginseng Use and Drug Interactions
Confusion & Memory loss
Interactions: insulin, hypoglycemics, MAOIs
Phenytoin is used for....
1st line tx for tonic clonic and partial complex seizures
Levels of phenytoin will increase with...
- ACUTE ALCOHOL INTAKE
- valproic acid
Levels of phenytoin decrease with....
Barbiturates, antacids, calcium, and chronic alcohol use
Hypersensitivity reaction to phenytoin
- Phenytoin-induced hepatits
TRUE or FALSE. if hypersensitivity to phenytoin occurs, lower the dose
FALSE! Hydantoins are contraindicated w/hypersensitivity
Phenytoin drug level check in...
Phenytoin + valproate means what?
need to do free phenytoin drug level (this is also true w/low albumin level)
What meds can decrease the effect of phenytoin?
- CARDIAC GLYCOSIDES
Lichuan has seizures and wants to be on phenytoin. Can you prescribe it to her?
Maybe, need to check patients with asian ancestry for HLA-B 1502. (could get SJS or TENs)
ADR of Phenytoin?
- GINGIVAL HYPERPLASIA
- dizziness, pruritius, parathesia, HA, somnolence, ataxia, ↓BP, ↑HR, N/V, anorexia, constipation, dry mouth, urinary retention, urine discoloration (pink/red/brown)
To prevent gingival hyperplasia on phenytoin what should you tell your patients to do?
Good oral hygiene and take folic acid supplementation (0.5mg/day)
Before starting on Phenytoin what base line labs should you get?
CBC, UA, LFTs, TSH
Who should you use caution prescribing phenytoin to?
- pt w/renal or hepatic disease (shocking I know)
- pt w/myocardial insufficiency and hypotension
When is Phenytoin CONTRAINDICATED?
- Sinus bradycardia
- Sinoatrial block
- 2nd and 3rd degree AV block
- Stokes-Adams syndrome
Carbazepine (which is an Iminostilbene) is used for what type of seizures?
- Tonic clonic seizures
- Partial seizure
What is the BLACK BOX warning for carbamazipine?
It can cause blood dyscrasias. and serious serous dermatologic reactions (SJS oor TEN)
What is so special about the pharmacokinetics of carbazepine?
It induces its own metabolism (and that of many CYP 450 substrates)
Single dose 1/2 life is longer than 1/2 life w/long term use
What type of long term monitoring do you need to do with carbamazipine?
- Check levels at 3,6,9 weeks. (Goal 4-12mcg/ml)
- Check every 2 M thereafter
- Check CBC every 3-4M (remember it can cause blood dyscrasias)
According to our book, what baseline labs would you want to get before starting carbamazipine?
Baseline CBC, chemistry, LFTs, & TSH
Common SE of carbamazipine
N/V, diarrhea, hyponatremia, rash, pruritis, fluid retention
Can Jackie Chan be on carbamaipine to control his tonic clonic seizure?
Maybe. Should check a HLA-B1502 allele prior to starting carbamazepine d/t high risk of SJS or TEN
Carbamazipine levels can INCREASE with???
Carbamazipine levels can DECREASE with?
- Beta blockers
- Oral Contraceptives
What patient should you use CAUTION with when prescribing Carbamazipine?
pt w/increased intraocular pressure (it has mild anticholinergic effect)
Who should you NEVER prescribe Carbamazipine to?
- Those w/hypersensitivity to carbamazipine or TCAs
- history of bone marrow suppression (blood dyscraisa risk!)
- Concurrent MAOIs
- (and Asians)
Your patient on carbamazipine for partial seizures comes in for 3M follow up with a fever, sore throat, & weakness. Are you concerned?
YES! It cn cause bone marrow depression! (onset within 1st 3M of tx)
TRUE or FALSE. Carbamazipine can cause liver damage or impair thyroid function
Side effects of carbamazpine
- Drowsiness, dizziness, blurred vision, N/V, dry mouth, diplopia, HA
- (hint: give dose at bedtime)
Ethosuximide (Zarontin) is a succinidmide used to treat what type of seizure?
ABSENCE seizure in kids/adults
When should you check drug level of Ethosuximide (Zarontin)?
Check levels 1-3weeks after iniation of treatment. (want 40-100mcg/ml)
Michelle Duggar has absence seizures and has started on ethosuximide (Zarontin), what should she be aware of?
- 18 is enough kids!!!
- Use a back up of birth control because Ethosuximide can decrease the effectiveness of birth control.
What is a serious problem with taking Ethosuximide for absence seizures?
Agranulocytosis, aplastic anemia, & granulocytopenia. Blood dyscrasias uncommon but can be fatal.
(Absense seizure & Agranulocytosis/aplastic anemia for Ethosuximide!)
Beside checking for a therapeutic level after 1-3weeks of treatment, what other baseline and intermitent lab should you get for Ethosuximide?
CBC (can cause blood dyscrasias). Look for sore throat, fever, pallor, weakness, infection, easy bruising, etc.
What is the MOST common ADR of Ethosuximide?
GI symptoms & Somnolence
Topiramte is used as ADJUNCTIVE therapy for what two types of seizures?
partial and primary generalized tonic clonic seizures
(Not sure if this helps but To(o) = adjunct)
What are some ADRs of Toprimate?
- Weight loss (stabilizes 2-3yr)
- Impaired cognition (dose related, reversible)
- Depression & mood problems
- Decreased sweating (heat intolerance & hyperthermia in kids)
What are serious ADRs of Toprimate?
- Metabolic acidosis (measure bicarb at baseline and 2-4M)
- Myopia and secondary angle glaucoma
Your patient is taking Topriamte as an adjunct for partial seizures. He exhibits a change in level of consciousness unexplained lethargy, and is vomiting. What should you do?
Besides the ABCs....check a serum ammonia level!
Your 20 year old patient is starting Topiramte as an adjunct to primary generalized tonic clonic seizures. What should you warn about?
There is a risk of suicidal behavior and ideation. Tell family and patient about potential neuropsychiatric ADR!
Gabapentin is indicated for what two types of seizures?
- Partial seizures (add on for refractory partial seizures)
- Secondary generalized seizures
What to warn pt (and family) of w/Gabapentin?
- Neuropyschiatric events of kids 3-12yr
- Increased risk of suicide
Serious reaction of Gabapentin?
Leukopenia or Thrombocytopenia
Common reactions of Gabapentin
Dizziness, somnolence, weight gain
So you're dizzy, tired, and fat..but you are seizing...awesome
What type of monitoring should you do for your patient on Gabapentin?
- CBC for leukopenia/thrombocyopenia
- NO ROUTINE MONITORING (no monitoring of drug levels)
Avoid ___ ___ for Gabapentin
abrupt withdrawl, can get withdrawal status epilepticus
Keppra (Levetiracetam) is used for what 3 types of seizures?
Adjunctive therapy for partial onset seizures & myoclonic seizures, generalized tonic clonic seizures
Keppra and KIDS ( K & K). What kinds of seizures is this used for?
- Kids 4yr and older, adjunct partial seizure
- Kids 6yr and older, primary generalized tonic clonic
How long does Keppra take to kick in?
Many patients are seizure free after starting Keppra on their 1st day!
Keppra has some side effects, what are they?
- Mood disturbances
- Paradoxical worsening of seizures
- Weight loss
- Reversible Thrombocytopenia
What drugs does Keppa interact with?
There are few drug interaction, if any
Can you stop Keppra cold turkey?
NO! can get withdrawal seizures if abruptly d/c
TRUE or FALSE. Keppra has the potential to cause suicidal thoughts/behaviors.
Lamotrigine (Lamictal) is used as an adjunct for what type of seizures?
- primary generalized tonic-clonic seizures
- partial seizures in adults/kids ≥2yr
*Concurrent use w/valproic acid & phenytoin
Lamictal levels can DECREASE with what drugs?
- ESTROGENS (↓ level 50%!)
- MEFLOQUINE (malaria drug)
- Phenytoin (which is what it is often used as an adjunct with....)
What drugs can INCREASE levels of Lamictal (Lamotrigine)?
- VALPROIC ACID: ↑ SJS risk 2 fold (which it is used as adjunct with)
- CNS depressents
What type of monitoring should you do with a patient on Lamotrigine (Lamictal)?
- CBC w/diff
- renal & hepatic function
Some not so serious ADR of Lamictal (Lamotrigine)
- Mostly GI (N/V/ constipation)
- CV: chest pain, peripheral edema
- CNS: somnolence, fatigue, dizziness, anxiety, insomnia, HA, amblyopia, nystagmus
Serious ADRs of Lamictal (Lamotrigine)
- Blood dyscrasia
- Multi Organ failure
- hepatic failure
Black Box of Lamictal (Lamotrigine)
Rashes-->SJS or TENs
Causes of drug resistance
- Recent abx use
- overuse of broad spectrum abx
- age younger than 2yr or older than 65yr
- day care center attendance
- exposure to young children
- multiple medical comorbidities
TRUE or FALSE.
Vaccination w/pneumococcal vaccine has decreased resistance
What dose a local antibiogram do?
- Determines organisms sensitivity to antibodies.
- Recommends antibacterial agents based on: anatomic site, diagnosis, & modifying circumstances
- Allergic reactions to medications in different classes.
- Ex: PCN has cross sensitivity w/cephalosporins so substitute with erythromycin or clindamycin
Cross resistance =
- bacterial resistance
- Ex: cephalosporins & PCN both have beta lactam rings so can get cross resistance
Fluroquinolones has a black box warning for what?
- Tendonitis/tendon rupture (elderly & young adults at higher risk)
- DO NOT prescribe to children <18yr
What are the ADRs of Fluoroquinolones
- GI: pseudomembranous colitis (also abd. pain, nausea, & altered taste)
- CNS: sleep disorders, dizziness, acidosis
- Renal/Hepatic failure
- CV: angina, atrial flutter
TRUE or FALSE. Fluoroquinolones can have hypersensitivity reaction (SJS)
What are Fluoroquinolones used for?
- Complicated UTI, pyelonephritis infections, chronic baterial prostatis
- Pneumonia/chronic bronchitis exacerbation
- PCN resistant S. pneumonia, skin infections, bone/joint infections, complicated intra-abdominal, infectious diarrhea
What should you tell your patient who is taking Fluoroquinolones?
- Take with full glass of water (not food-it will delay absorption)
- Stay hydrated to avoid crystal urea (avoid urine alkalizers, such as citrus drinks, baking soda, & antacids
- Tendon tenderness occurs STOP med & notify
TRUE or FALSE. If your patient has a reaction to a penicillin, you should try another type of penicillin.
FALSE! Any patient allergic to penicillin will be allergic to all other penicillins risk for cross allergy to related drugs (cephalosporins & betalactamase inhibitors)
What are PCNs used for?
- Commonly prescribed for infections seen in PCP office
- Acute Otitis media & sinusitus (amoxicillin)
- Steptococcal pharyngitis
- Infection following bites (Augmentin)
- Upper Resp Infections
Erythromycin is used for what 5 things?
- Community acquired pneumonia
- H. Pylori
- Chronic Bronchitis
If your patient is allergic to PCN, what type of med may you use?
erythromycin is an common alternative
What are some ADRs of erythromycin?
- GI: N/V, abd. pain, cramping, & diarrhea (risk for pseudomembranous colitis)
- Skin: urticaria, bullous eruptions, eczema, & SJS
What patient population should you caution when prescribing erythromycin?
Those w/liver impariment
What monitoring do you need to do w/a patient on erythromycin?
- Always do a druge/drug interaction check
- Hepatic/renal impairment
- Hearing loss
- QT prolongation-syncope
- (also monitor plt count)
April 2013, there was a warning about Erythromycins causing what?
Potentially fatal arrhythmias (QT prolongation)
Sulfonamides are indicated for what?
- UTI (most common)
- MRSA (susceptible in some areas)
(also otitis media & some STDs)
GI: anorexia, N/V, diarrhea, stomatitis, rashes, increased hypersensivity reactions (SJS), photosensitivity, CNS, HA, dizziness, peripheral neuropathy
Sulfonamides cross hypersensitivity can occur with which meds?
Sulfonylureas, thiazides, loop diuretics, and sunscreens w/PABA
Avoid sulfonamides in _____ deficiency
G6PD deficiency. Inherited disorder results in body lacking enzyme that normally protects RBC from toxic chemicals.Certain drugs can cause RBC breakdown and anemia.
Sulfanomides are structurally similar to ______ and act as a competitive inhibitor
TRUE or FALSE. Sulfanomides are no longer the 1st choice in infectious disease but they are used as low cost alternative for pregnancy, kids, and those w/PCN allergy.
TRUE or FALSE. Resistance is not a problem with Sulfonamides
FALSE! Resistance is an issue.
Long term use of Sulfonamides, you need to check ____
Tetracylcines are used for
- Genitourinary infection
- P. Acnes
- H. Pylori
- Lyme Disease
- Disease rarely seen in US (like Malaria)
Tetracycline common ADRs
- STAINED TEETH (no pregnant women or kids <8yr)
- GI: N/V/D, anorexia, esophageal ulcers
- CNS: light headedness, dizziness, vertigo, pseudotremor cerebri (benign intracranial HTN)
- Dermatologic: photosensitivity
Joey thinks he has Lyme Disease and wants to take an old dose of some leftover Tetracycline he has, should he?
NO, do not take outdated product. Degradation products of these drugs are highly nephrotoxic & reversible nephrotoxicity has been reported.
Administer tetracyclines ___ before or ___ after meals and give ___ before antacids
1hr before and 2 hours after meals and give 2 hrs before antacids
What are the s/s of a superinfection? (Tetracycline)
pruritus, hoarseness, glottitis, dysphagia, vaginal itching or discharge. If patient had hepatotoxicity, upper abdominal pain, N/V, dark urine, clay colored stools, & jaundice.
Diarrhea (6+ stools) or blood in stool could indicate
Clindamycin is used for?
- 1st line therapy for MRSA in some areas
- Infections where pt has allergy to PCN
- Dental infections
- 2nd or 3rd line therapy for upper/lower resp infections
- GI: N/V, bitter metallic taste
- Derm: rash, burning, itchingg, erythema
- CNS: dizziness, vertigo, HA
- CV: ↓ BP, rare arrhythmias
- Transient eosinophila, neutropenia, thrombocytopenia
BLACK BOX WARNING for Clindamycin
SEVERE COLITIS (during or 2M following tx)
As a CRNA, you are concerned your patient has been on clindamycin, why?
surgery/general anesthesia during or a day after therapy, can intensify the neuromuscular junction
If your patient gets MILD diarrhea while on clindamycin, what do you tell your patient to do?
Kaopectate for 2 hrs before or 3 hrs after taking the medication.
BUT if 6 stools or bloody diarrhea, need to call you
Oseltamivir is used for
Influenza A & B
Oseltamivir is reserved for?
pt of high risk complication from infections when vaccination is contraindicated or to protect pt until active immunity can develop after vaccination.
TRUE or FALSE. Sensitivity can vary year to year to Oseltamivir
ADR to Oseltamivir
- GI: N/V, constipation
- CNS: depression, dizziness, insomnia
Use caution for Oseltamivir in patients with
seizure disorders or psychosis
What should you monitor for the patient on Oseltamivir?
Renal function (esp in elderly and debilitated pt)
Metronidazole is used for
- Anaerobic bacterial infections
- Bacterial vaginosis
- H. Pylori
(recommended for C. Diff overgrowth)
Mitronidazole less serious ADR
Anorexia, nausea, abd pain, dizziness, HA, metallic taste, dry mouth, diarrhea, rash, peripheral neuropathy
Metronidazole rare but serious ADR
Seizure or leukopenia
DO NOT USE metronidazole for patients with a history of ____. Use cautiously for pt with history of ____ ____.
- CONTRAINDICATED: seizure hx
- CAUTION: blood dyscrasias
Your patient is on metronidazole, they should avoid _______ due to disulfiram-like reaction.
Disulfram reaction: N/V, flushing of the skin, tachycardia, & SOB
What are some CNS symptoms of metronidazole?
Ataxia, mood changes, clumsiness, seizures, peripheral neuropathy
How does Progestin prevent pregnancy?
- Suppresses LH surge needed for ovulation.
- Thickens cervical mucus
- Atrophy of endometrium
How does Estrogen help prevent pregnancy?
Suppresses FSH so don't develop dominant follicle. also helps with cycle control (decreases break through bleeding)
When prescribing birth control, what should you take into consideration?
- Pt knowledge & commitment
- medical hx
- current medications
- prior experience w/methods
- SE (migraines, dysmenorrhea, n/v)
- pt weight
- progestin sensitivyt, weight gain, fatigue, varicose veins
Benefits of OCs
- reduces benign breast disease
- reduces endometrial cancer
- reduces ovarian cancer
- reduces PID
- reduces menstrual issues (anemia, dysmenorrhea)
Risks (of combined OCs)
- Benign liver tumors
- retinal & mesentaric artery thrombosis
- gall bladder disease
- Increased cholesterol
- Raises BP
Increased risk of VTE is most common risk of combined OCs, what part of the OC is it related to?
- Estrogen. Increases blood viscosity, increases adhesiveness of plts, increases level of clotting factors, decreases AT3 activity.
- So D/C 4 wk prior to surgery/immbolity
Use CAUTION when prescribing OCs to
- Breastfeeding 6wk-6mo
- undx vag/uterine bleeding
- past hx of breast ca w/no evidence in <5yr
- meds that affect LFTs
- gall bladder & sickle cell disease
- DM w/out vascular dz in women <35yr
OC is ABSOLUTELY CONTRAINDICATED in
- DVT/PE or hx of one
- CVA, CAD, (or hx)
- Structual cardiac dz
- subacute bacterial endocardiits
- breast ca
- DM w/vascular dz or ≥20yr hx of
- Breastfeeding ≤6wk
- Liver dz or abnl LFTs
- HA w/neuro sx
- HTN w/vascular dz (or BP ≥1601/100)
- Major surgery w/immbolity
- ≥35yr old smoker
Common OC SE
- BTB (spotting)
- N/V, breast tenderness
- Mood swings (happens more w/progestin only)
What are the OC "ACHES"
- Abodminal pain (abd artery throbmosis, GB, liver)
- Chest pain & SOB ( MI)
- HA (CVA, HTN, migraines)
- Eyes (visual changes, retinal artery thrombosis)
- Severe leg pain (VTE)
Check every visit and document!
How do progestin only pills prevent pregnancy?
- Thickens cervial mucus (primary effect)
- Endometrial changes
- Ovulation inhibition (less predictable than combined OCs)
Progestin only is good for what patient population?
Those who have contraindication to estrogen. good for smokers. Thrombosis is less of an issue. BP changes are usually not a problem.
Why do you need to have GREAT compliance on progestin only birth control?
Its a low hormone level. Effect is strongest @ 2-4hrs then decreases at 22hr. If taken late, use a back up for 48hrs.
What patient education do you need to do w/progestin only pill?
- Need good compliance!
- No placebo pill, active only!
- Ease of use
- Limited remembering
- Better cycle control, less BTB than OCs by releasing steady hormones
Who is Nuvaring contraindicated in?
Those w/ cystocele, rectocele or uterine prolapse
What are the SE of Nuvaring?
- Same as oral combined OCs
- Also: vaginitis, leukorrhea, "feeling it", or expulsion
How long can the Nuvaring be out before a back up method of birth control is needed?
TRUE or FALSE. The Nuvaring works immediately, no back up method needed while starting on it.
FALSE, need back up for 1 week
TRUE or FALSE. Plan B is an abortifacient
FALSE. It is used to prevent ovulation or implantation.
Plan B is _______ only.
How do you instruct the patient to take Plan B?
2 tables, PO Q12hr x1
Plan B can be taken up to ______ hrs post sexual intercourse
What are the SE of Plan B?
- Same as oral OCs
- Generally N/V, BTB/spotting
What patient education is needed w/plan B?
- Risk/Benefits, SE/use
- Menses within 4-6weeks
- UHCG if no menses
- Can take up to 4x/yr but need to talk about changing method, STDs/HIV
What is the only contraindication to Plan B
Pregnancy. Need to test before prescribing.
What is the goal of HRT?
- Tx of mod-severe vasomotor symptoms
- Tx of mod-severe vulvar/vaginal atrophy
- Prevention of postmenopausal osteoporosis
HRT: without a uterus get what type?
Estrogen only. Progestin is used to balance estrogen hyperstimulation of endometrium (and increased endometrial ca risk). No uterus = no need for progestin!
HRT is to use ______ _____ of hormone for the _______ duration possible.
lowest dose for shortest duration. (2yrs in lecture, book says 5, waiting from Nancy to find out which to know)
Your patient on HRT complains it is not working at 4 weeks, should you increase the dose?
No, it takes 6-8weeks to reach a max effect. No dose increases until then.
How often should you review risks/benefits with your patient on HRT?
Every year. Explain non-pharmacological things too, like weight loss, smoking cessation, reduced alcohol intake, regular exercise, and healthy diet.
ERT and HRT is contraindicated in those with ....
history of breast ca (& those w/1st degree relative w/breast ca) or those w/gynecologic ca.
(HRT/ERT does decrease risk of colon ca though!)
Risks of HRT
- Breast Ca
- Gall bladder dz
- urinary incontinence
Risks of ERT
- Ovarian/Uterine Ca
- Gall bladder dz
- urinary incontinence
- ?Breast ca & dementia
Benefits of HRT/ERT
- vasomotor symptom suppression (no hot flashes)
- preserves urogenital tract
- preserves bone mineral density & osteoporotic fx
- decreases risk of colorectal ca (not estrogen alone)
- Womens Health Initiative (WHI)
- Heart & Estrogen/progestin Replacement Study (HERS)
What should you monitor for your patient on HRT/ERT?
- annual exam & complete hx
- LFTs & lipids @ baseline & annually if abnormal
- women 45yr+ for adult onset DM
When starting HRT, when should you follow up
Follow up at 3M, 6M then follow closely. Get the patient through the hump of menopause then taper off (again 2-5years is max, waiting on final answer...)
Vaginal estrogen is used for?
Symptom management. Vaginal application of estrogen thickens and revascularizes the vaginal epithelium increasing the number of superficial cells and reverses vaginal atrophy (improvement seen in 2 weeks)
FDA recommends vaginal estrogen (topical preparations) for ______ _____.
Risk factors for osteoporosis
- Family hx
- Age 62yr in women or 70yr in men
- Estrogen deficiency <45yr
- slight build
- fair complexion
- low calcium &/or vitamin D diet
- minimal sun exposure
- weight <70kg
- sedentary lifestyle
- smoking & alcohol use
Diseases and drugs that increase risk of osteoporosis
- glucocorticoid use (>5mg/day >3M)
- long-term PPI
- Heavy tobacco or alcohol use
AA women have a higher bone density, how are they at risk for osteoporosis
- AA women tend to have lower Ca intake (and more likely to be lactose intolerant per the book).
- Risk increases with age
Asians are high risk for osteoporosis, why?
They consume inadequate calcium (and per book are more likely to be lactose intolerant)
Hispanic women have same risk as white women for osteoporosis. True or False?
________ prevents bone resorption action of PTH
Estrogen (Why hormone replacement therapy can be good for osteoporosis)
Name a SERM used for osteoporosis
Raloxifene (Evista) has estrogen EFFECTS on bone. It is 2nd line therpa, decreases risk of vertebral fx. Can get hot flashes (main cause to d/c)
Also protective against Breast Ca
__________ reduce bone resorption by inhbiting osteocast activity
Bisphosphonates are used in what patient populations.
- primary prevention in women >70yrs w/risk factors or >65yr with vertebral fx
- 1st line therapy for post menopausal women w/osteoporosis
- 1st line therapy for men older than age 70yr w/osteoporosis
_______balances PTH by increasing osteoblastic activity. (also has analgesic effect on bone pain)
What patient population is calcitonin good for?
- Women >65yr w/hx of vertebral fx
- NOT for prevention of bone loss
- (Intranasal administration)
Before starting tx for osteoporosis, what should you rule out?
- Other disorders that may cause low BMD
- Vit. D deficiency
- Renal disease
What lab work should you get for a osteoporosis work up?
- serum Ca+ & albumin
- 25 Hydroxy Vit. D
- Serum creatinine level
(to r/o other disorders)
DEXA measure BMD. ____% loss = double fx risk
10% loss equals double the fracture risk
Buspirone (Buspar) is used for what disorders?
- Generalized anxiety disorder
- Social phobia
Augments SSRIs or SNRIs for agitated or anxious depression
______ is good because it does not have a tolerance or dependency. No CNS depression or sedation either!
How long before Buspar takes effect?
Takes 2 weeks to reach therapeutic effect (up to 6wks for max effect)
How often is Buspar dosed?
Multiple daily dosing
BUSPAR is contraindicated in _______ & __________.
panic attacks and severe hepatic/renal disease
Adverse Drug Effect of Buspar
Few ADR and they resolve with continued use. Light headedness, HA, insomnia, nausea, nervousness, & dry mouth. Akathesia & involuntary movements (rare)
*No congnitive impairment of BZDs*
What kind of drug interactions can happen with Buspirone (Buspar)?
- Serotonergic drugs (MAOIs & SSRIs) can cause serotonin syndrome
- Antipyschotic drugs (Haldol) increased Haldol levels d/t competitive metabolism
- Trazadone (increased ALT)
Excitalopram is a cleaned up version of Citalopram (Celexa). what does this mean?
No sedation properties like Celexa
What would you use Fluoxetine (Prozac) for?
- Panic disorder
- Bulimia nervosa
- (lastly for depression)
What would you use Escitalopram (Lexapro) for?
SSRI like Escitalopram or Fluoxetine are contraindicated iwth concurrent use of ______
MAOIs (or within 14 days of MAOIs)
When should you use caution with SSRIs like Fluoxetine or Escitalopram?
Severe hepatic or renal impairment & should be avoided in the 1st and 3rd trimester of pregnancy
ADRs with SSRIs (like Fluoxetine or Escitalopram)
N/V, HA, light headedness, dizziness, dry mouth, increased sweating, weight gain/loss, exacerbation of anxiety & agitation
What is a MAJOR side effect of SSRI
Sexual dysfunction (change to different SSRI or decrease the dose)
_________ can cause insomnia so you should give it in the morning.
_____ are common w/Prozac
Do NOT prescribe more than _____ weeks of an SSRI.
Four weeks max, want to see patient at 4weeks and if you give 3M supply, that may not happen
What is a serious ADR of SSRI
serotonin syndrome. Rapid onset (2-72hrs after start of tx), can be fatal, N/D, chills, sweating, hyperthermia, HTN, myoclonic jerking, tremor, agitation, ataxia, disorientation, hyperreflexia, fever, confusion, & delerium
To prevent serotonin syndrome, you should avoid __________.
adjunctive combination of serotonergic agents
How much time should you wait when changing from one serotonergic agent to another?
- 2 weeks should elapse after d/c MAOI before starting SSRI
- 5-6 weeks should elapse between d/c SSRI before starting MAOI
How do you taper SSRI off?
allow 5 1/2 lives per dose decrease
Medications associated with serotonin syndrome
- drugs of abuse (LSD, MDMA)
- Herbal drugs & supplements
What is the ONLY SSRI you do not need to taper?
Fluoxetine, it has active metabolites.
There is a risk of _____ with SSRIs. This risk is increased with the concommitant use of ASA or NSAIDs.
Risk of bleeding.
Elderly on SSRI: watch for _____
How long does it take before you see therapeutic effects of SSRIs
Pharmacokinetics of Fluoxetine (Prozac)
- peak 6-8hr
- 1/2 life ~16hr
- significant 1st pass in liver & is metabolized by CYP450. Parent drug has 1/2 life of 1-3 days but its 1st metabolite has additional 1/2 life of 4-16days so overall 1/2 life is 4-26hrs)
Single dose of _______ can be helpful in last step of tapering off SSRI and avoiding withdrawal.
How would you d/c Escitalopram (Lexapro)
1/2 life is 27-32hr. Allow FIVE 1/2 lives per dose decrease (so 5.5-6.5 days), decrease by 50% each time but may need to go slower. Can show withdrawal symptoms after 1 missed dose
Escitalopram (Lexapro) acts only on _________
What are the general steps for diagnosing depression?
- Step 1: rule out medical disorders (CBC, Chem 10, LFTs, Lipids, UA, TSH, lead toxicity)
- Step 2: screen for substance abuse
- Step 3: Prenancy test
- *Need to assess suicidal risk*
What is the tx algorithm for SSRI therapy
- week 1-3 Monotherapy
- week 4-6 increase dose (or switch if SE)
- week 6-8 (if not enough increase dose, or if at max then titrate back down and make switch)
- week 8-10 (increase dose if needed)
- continuation period
- 12-18M later, taper off (unless hx of 3 episodes then continue)
TRUE or FALSE.
SSRI tx: monotherapy at lowest dose, adequate 8 week trial (@ max dose), if not effect, taper and switch to another SSRI, if not effect then try SNRI, if no effect REFER!
When prescribing an SSRI, when should you follow up?
Follow up in 1 week. First 3 weeks there can be suicidal ideation so need to check in
S/S of abrupt withdrawal of SSRI
- dizziness, lethargy, diarrhea, flu-like symptoms, vertigo, tremors, tinnitus, insomnia, & vivid dreams
- anxiety, agitation, irritability, confusion, and slowed thinking
Phenelzine (Nardil) is a ______
What is a huge risk for interaction w/Phenelzine (Nardil)
Interaction w/tyramine & phenylethylamine. Can get rapid extreme HTN
Phenelzine (Nardil) with concurrent use of anticholinergic, sympathomimetics, & stimulants can cause a ____ ____.
Your patient on Phenelzine (MAOI) took an anticholinergic and now has a HA, palpiation, stiff/sore neck, chest tightness, ↑HR, sweating, & dilated pupils. What do you do?
Having a HTN crisis. Tx immediately with phentoiamine (Regitine) 5mg IV, then 0.25-0.5mg IM Q4-6hr
When would you prescribe Phenelzine (Nardil)?
To tx refractory unipolar depression. (atypical depression, mixed anxiety/depression, panic disorders, eating disorders, & depression w/borderline personality disorder)
Phenelzine (an MAOI) has a _____ 1/2 life than SSRI/SNRIs.
How quickly does Phenelzine work?
relief of depression immediately or within 14 days (Works quicker than SSRIs or SNRIs)
When is Phenelzine (Nardil) an MAOI contraindicated?
- liver/renal disease
- CHF or arteriosclerotic disease
- 60yr +
- impulsive, congnitively impaired, or can't follow diet
ADRs of Phenelzine (Nardil)
- Insomnia, anxiety, agitation d/t delayed metabolism of Dopamine
- Dry mouth, blurred vision, urinary retention, & constipation (anticholinergic)
- Common SE: dizziness, HA, insomnia, restlessness, & (orthostatic) hypotension
What types of food should Donny avoid on Pehnelzine (Nardil)?
Tyramne: cheese, yogurt,sour cream, aged meat & meat products, dried fish & herring, alcohol, fermented veggies like sauerkraut, soy sauce, miso soup, bean curd, fava beans, avacados, bananas, raisins, caffeine, chocolate, & ginseng.
What lab test should you monitor for your patient on Pehnelzine (Nardil)?
Monitor LFTs, d/c if abnormal
Why is Clonzapam preferred over Xanax or Serax?
It has longer half life and daily dosing
A benefit of Serax (oxazepam) is...
good for detox, easy on the liver
What are BZDs used for?
- Anxiolytic (anxiety & insomnia)
- Many other uses: muscle relaxant, pre-anesthesia sedation, prevention/tx of panic attacks, acute agitation, dystonia, emergent tx of seizures, restless leg syndrom, IBS, chemo induced N/V
Bad part about Alprazolam (Xanax)
More likely to cause dependence bc high potency & rapid short term action
Alprazolam (Xanax) drug interactions
Cimetidine, omeprazole, macrolide abx, disulfiram, grapefruit juice (decreases metabolism so inc. effect of xanax), & Ketoconazole (contraindicated concurrent use)
TRUE or FALSE. To wean off BZD, Clonazepam (Klonopin) is good to substitute (an equivalent dose) in place of short acting BZD then titrate down.
TRUE or FALSE. Clonazepam (Klonopin) is not good for panic disorders because it takes time to work.
FALSE. Long acting BZD are 1st choice for panic disorders because taking them prior to anticipatory event to PREVENT panic attack rather than tx as needed.
TRUE or FALSE. After 1 week of controlled symptoms on BZD, it is time to switch to SSRI. So you would increase SSRI while decreasing BZD (like Clonazepam).
TRUE. (if needed Clonazepam can be used as adjunctive tx)
What is a drug interaction with Clonazepam (Klonopin)?
Lithium (increased sexual dysfunction)
______ ______ potentiates Oxazepam (Serax)
Elderly may need ______ dose of BZD.
when are BZD contraindicated?
- Pregnancy & Lactation
- Hepatic & Renal disease
- Not for kids under 6yr
- Acute narrow angle glaucoma
What are some ADRs of BZDs
- CNS depressant (sedation)
- CV or Resp. depression
- Common SE: dizziness, confusion, blurred vision, & hypotension
- Additive effects w/other CNS depressants (Barbituates, alcohol, antihistamine, & neuroleptics)
BZD can increase levels of ____ or ____
TCAs or digitalis
BZDs metabolized by conjugation are better tolerated by patients with impaired ______ function or who are _____ or ______.
patients with impaired liver function, or elderly or smokers
BZDs metabolized by oxidation may have prolonged effect in _______
______ can also be used for Premenstrual Dysphoric Disorder
Fluoxentine (Prozac). Approved as 1st line tx for affective & occupational functioning. Not for physical symptoms. Low dose (20mg/day)