Which SGA is the first drug simultaneously approved for both acute schizophrenia and manic or mixed bipolar disorder in adults? What dosage form does it come in?
Asenapine - only comes in SL tablets
What receptors does aripiprazole work on?
D2 partial agonist
5-HT1A partial agonist
5-HT2A partial antagonist
(acts like antagonist in mesolimbic and agonist in mesocortical)
Which SGA may decrease prolactin concentrations?
which SGA is less sedating than other SGAs
Which SGA is approved for adolescents with schizophrenia?
aripiprazole (and risperidone too)
which SGA is approved as adjunctive treatment of treatment-resistant depression?
What effects are of greatest concern with clozapine?
What effects are of greatest concern with risperidone?
What effects are of greatest concern with olanzapine?
What effects are of greatest concern with quetiapine?
lack of effect on negative symptoms of schizophrenia
What effects are of greatest concern with ziprasidone?
lack of effect on negative symptoms of schiz
(note: little weight gain)
What effects are of greatest concern with aripiprazole?
Name some Anticholinergic SEs
exacerbation of angle closure glaucoma
CIs for clozapine
agranulocytosis or granulocytopenia (or hx of it)
severe renal disease
CIs for ziprasidone
Hx of arrhythmias
drugs that can prolong QT interval
all SGAs need to be titrated up to effective dose except which one?
Which SGA is the best to use in a pt with diabetes?
What dextrose content and osmolarity is allowed when giving through a peripheral line?
dextrose content NMT 10%
osmolarity must be less than 900 mOsm/L
Equation for TPN osmolarity
[grams of dextrose/L x 5] + [grams of amino acid/L x 10] + [mEq cations/L]
What must sodium in a TPN be limited to?
What 2 electrolytes should be avoided together in TPNs? Why?
Calcium and Phosphorus - can form precipitates
Which calcium salt is preferred in TPN?
Most drugs are incompatible with TPN. Which are commonly added (are compatible)?
insulin and H2 blockers (ex. ranitidine)
How long is a TPN good for? How often do the tubes need to be changed?
good for 24 hours
change tubes q24h if fluids have lipids; q72h if only a dextrose and AA sol'n
What rate must dextrose infusion be limited to?
How should we correct the TPN in hypercapnia?
reduce calories and dextrose in TPN
What effect does propofol use have on TPN?
It is a lipid based emulsion that provides 1.1 kcal/ml of the infusion. Need to reduce lipid in the TPN.
What adjustments should be made to TPN if the BUN is > 50 mg/dL? Which patients would this be a concern in?
Reduce the amino acid goal
Concern in renal patients
If a TPN patient is acidotic what adjustments should be made? In an alkalotic patient?
If acidotic: reduce chloride and increase acetate
If alkalotic: reduce acetate and increase chloride
When should a patient receive glutamine and arginine supplementation in TPN?
In patients with chronic renal insufficiency receiving chronic TPN what vitamin should be reduced?
What is refeeding syndrome?
characterized by simultaneous hypophosphatemia, hypokalemia, hypomagnesemia and sometimes deficiency in thiamine and sodium
Occurs from fat metabolism becoming the main source of energy in starvation, then feeding being begun again and a shift to carbohydrate metabolism occurs. Pt needs ATP and there is a sudden cellular uptake of phosphate leading to severe hypophosphatemia which can lead to neurologic, cardiac, respiratory, and hematologic abnormalities, even death.
If a TPN patient's prealbumin is low, what do we do?
This means the protein synthesis is low and we must increase carbs and AAs
Where is albumin made, what is its half-life? What are the levels for depletion being considered mild, moderate, severe?
It is made in the liver
Half life of 20 days
Mild depletion = 2.8 - 3.5 g/dl
Moderate depl = 2.1-2.7 g/dl
Severe depl = < 2.1 g/dl
What is transferrin?
A blood plasma protein for iron delivery
What are the K+ and Na+ goals for TPN?
K+ is 40-100
Na+ is 80-150
How do you figure out the calorie goal when formulating TPN?
BEE x Stress Factor
How do you figure out the fluid goal when formulating TPN?
1500 ml for the first 20 kg of weight and 20 ml/kg for each add'l kg
How do you figure out the protein goal when formulating TPN?
Ranges from 0.6-2.0g/kg/d
Common is 1.2-2
Renal failure is 0.6-0.8
How do you figure out the lipid goal when formulating TPN?
it is approx 1/3 of the non-protein calorie goal
usually around 0.7 - 1.1 g/kg
How do you figure out the dextrose goal when formulating TPN?
it's the difference betw the calorie goal and the AA + lipids (or about 2/3 of the non-protein calorie goal)
What type of formula should trauma, burn, head/neck CA, and critically ill/mechanical ventilation patients have for EN?
What type of EN formulation is best for ARDS and severe respiratory failure patients?
one that has anti-inflammatory lipids and antioxidants
"pulmonary" formulas not recommended
When should a pt with severe acute pancreatitis receive EN?
What EN formula should pts with severe liver disease receive?
standard polymeric formulations
What product added to EN gives 3 g/L of protein?
What supplement can be added to EN to give 6 g/L of carbohydrate?
What product can be added to EN to give 10 g/L of fat?
What do fructooligosaccharides or FOS do?
they help stimulate growth of beneficial GI bacteria
Which 2 alpha-agonists are used clinically? When are they typically used?
Clonidine- drug addiction
Which other HTN med may be used in pregnancy (besides methyldopa)?
labetalol - it has the most data in pregnancy
Best HTN meds to use in Diabetes are
ACEIs and ARBs
Recommended HTN treatment in migraine
Beta blockers (especially non-selective such as verapamil)
Which HTN meds should be avoided in asthma/COPD?
Recommended HTN treatment in tachycardia/Afib
beta-blockers and non-DHP CCBs
HTN meds to avoid in depression
HTN meds to avoid in bradycardia/AV block
HTN meds to avoid in pregnancy
ACEs and ARBs
Best HTN med to use in osteoporosis
Which HTN meds should be used in renal insufficiency patients? Which should be avoided?
use: ACEs, ARBs, loops
avoid: K+ sparing, thiazides
Stages of HTN
stage 1 HTN 140-159/90-99
stage 2 HTN >160/>100
Order of potency of statins
Which hyperlipidemia med is the DOC for high LDL?
Which hyperlipidemia med is the DOC for high LDL and high TG?
Which hyperlipidemia med is the DOC for high LDL, high TG, and low HDL?
Which is the DOC for treating high TG, low HDL, or both?
What is the DOC for treatment and prevention of DVT and PE in pregnancy?
When is APTT measured?
When a pt is on treatment doses of unfractionated heparin
What is the dose of UH for prevention?
5000 units SQ q8-12h
What is the treatment dose for UH?
loading dose is 80 units/kg IV
maintenance is 18 units/kg IV
What is the length of treatment with UH?
d/c when INR has been therapeutic for 24 hours for a minimum of 5 days
What is the prophylactic dose of enoxaparin?
30 mg SQ bid (or 40 mg SQ qd)
What is the treatment dose of enoxaparin?
1 mg/kg SQ bid
What is the antidote for bleeding caused by heparin?
What drugs can be used to treat clots in a pt with HIT, Heparin-induced thrombocytopenia?
Direct thrombin inhibitors (lepirudin, argatroban)
MOA of warfarin
inhibits vitamin K-epoxide reductase which decreases levels of vitamin K in the body
What is the duration of therapy with warfarin in a pt who is being treated for their first VTE?
What is the goal INR for most patients?
How long is warfarin treatment in a patient with recurrent DVT/PE?
For a pt with thrombosis who has had a mechanical valve replacement what is the duration of warfarin therapy and what is the goal INR?
When is warfarin therapy started in a DVT/PE patient?
as soon as APTT is therapeutic from heparin
How long should heparin and warfarin therapy be overlapped?
at least 5 days
What is the starting dose of warfarin in treatment of DVT/PE? In prophylaxis?
5-10 mg PO QD for treatment
2.5 - 5 mg PO QD for prophylaxis
For reversal of bleeding and/or high INR what actions do we take and at what INR levels?
INR of 3-5 and pt not bleeding, hold 1-2 doses and resume tx at lower dose
INR of 6-9 and pt not bleeding, stop therapy, give 2.5 mg PO Vitamin K, recheck in 24 h
INR of 10-20 and pt not bleeding, stop therapy, give Vitamin K 5 mg PO, recheck INR in 24 h
INR >20 or seriously bleeding, stop therapy, give Vitamin K 10 mg IV infusion, recheck INR q 6-12 h, may repeat Vitamin K IV q 12 h, may supplement with fresh frozen plasma or prothrombin complex concentrates, resume heparin therapy until patient responsive to warfarin
Are warfarin and heparin compatible with pregnancy and breastfeeding?
Warfarin not with pregnancy - Category X - ok to use heparin
Warfarin ok in breastfeeding - heparin no
The 10A drugs that interfere with warfarin
Why do we tell patients on coumadin to take their medication in the evening?
Because if they come into the clinic and their INR is high, we can still adjust that day's dose
Which class of antihypertensives should be avoided in patients with severe PAD?
Which receptor on the platelet adheres to the subendothelium?
What factors/parts of the coagulation cascade does Thrombin (Factor IIa) activate?
At what point in the coagulation cascade do both pathways merge into one?
At factor X
What receptor on the platelet allows platelets to adhere to each other?