NR 508 Final Exam study guide completed for Acing.
Final study guide
Cardiovascular management:
1. Know Inital treatment choices for HTN
AceI-
... [Show More] sartans
Arbs- ipine, verapamil & diltazem
Thiazide- iaside, chlorthalidone, imdapamide, metolazone
calcium channel blocker
2. Know frst line treatment optons for HTN for African Americans without renal impairment.
Calcium channel blockers
Thiazide
3. First line opton for HTN for anyone with chronic kidney disease
Ace inhibitors
ARB’s
Diuretcs:
4. Types, Uses, Side effects
Thiazides (HCTZ)
Uses- HTN, CHF, edema, useful in decreases calcium stone formaton
Off label HCTZ- osteoporosis and diabetes
AE- hypokalemia, hyperglycemia, arrhythmias, metabolic alkalosis, fatgue, postural Hypotension
Loop diuretcs (furosemide, torsemide, ethacrynic acid) *preferred diuretcs for renal
Impairment
Uses- CFH, HTN, nephrotc syndrome, cirrhosis, pulmonary edema
AE-hypocalcemia, hyponatremia, hypokalemia, ototoxicity
Carbonic anhydrase inhibitors (acetazolamide) *weak diuretc
Uses- edema, epilepsy, glaucoma, mountain sickeness
AE- toxic epidermal necrolysis, agranulocytosis, aplastc anemia, thrombocytopenia, metabolic acidosis
Potassium-sparing (spironolactone, eplerenone)
Uses- CHF (in combo with thiazides or ACE and loop), HTN
AE-gynomasta, n/v, erectle dysfucton, electrolyte imbalance, metabolic acidosis
**postdiuretc sodium retenton- It is important for pts to adhere to a low sodium diet. As drug
concentratons fall, there is a period of positve sodium balance
** If a pt has a sulfa allergy= take ethacrynic acid
5. Preferred diuretc with renal impairment-
Loop diuretcs because they retain efcacy even with moderate renal insufciency: such as furosemide,
buetanide, torsemide, ethacrynic acid.
Uses: Edematous states (HF, cirrhosis, pulmonary edema, nephrotc syndrome), hypercalcemia
6. Side effect of post diuretc sodium retenton pg 374
As drug concentratons decrease, period of + Na balance, this is the post diuretc sodium retenton
If there is a high Na intake then Na lost with diuresis is offset.. diuretc resistance
7. Recogniton that some diuretcs are sulfa derivatves (carbonic anhydrase inhibitors, loop diuretcs,
thiazides, but NOT ethacrynic acid)
Loops- Examples: furosemide, bumetanide, torsemide, ethacrynic acid
"The Loop FURiously BUMmed my TORSo like ACID"
Common side effects: orthostatc hypotension, excessive diuresis, tnnitus, vertgo, hyperuricemia note all
these are precursors to toxicity
Thiazides Hydrochlorothiazide, Chlorothoazide, , Chlorthalidone, Indapamide, Metolazone
1st line for HTN, Chronic Calcium Kidney Stones, HF, Idiopathic hypercalciuria, Nephrogenic diabetes
insipidus, Osteoporosis. Other common side effects: orthostatc hypotension, dizzy, drowsy, syncope,
weakness, nausea, GI irritaton, elevated BUN, depressed respiratons lethargy
1 Carbonic anhydrase inhibitors- Acetazolamide N/V/D, Drowsy, Parathesis, confusion, tnnitus, myopia,
anorexia, change in taste; polyuria, mild electrolyte changes
Uses: Edematous states ( HF, cirrhosis, pulmonary edema, nephrotc syndrome), hypercalcemia
Ethacrynic Acid
Note it's the only diuretc with "acid" in its name
8. Management of edema
Loops for volume excess
9. CHF drugs including diuretc choices
1- Loops -fluid
2- ACEIs or ARBs
3-BB - Diastolic afer stable (B-Day)
4- Digoxin - Systolic , AFib, (Dig A Syst)
5- Spironolactone - if above not effectve
6- Nitrates & Hydralazine *AA only* Think Michael Jordan goes Hy in his NIkes
CCBs ( Amlodipine/Felodipine) only for angina or HTN if EF is preserved
2- Clinical pearls for CHF- Improve SX: ACEIs, ARBs, BBs (metoprolol, Bisoprolol, Carvedilol) , Dig ( only afer
diuretcs & ACEIs)
Prolong survival: ACEIs, ARBS, BB, Hydralazine/Nitrates(AA only) Aldosterone Antagonists
BB NEVER IN ACTIVE FAILURE
Dig does not improve mortality but improves SX decreases Hospitalizaton..
CAUTION:: Loops without Spironolactone **with hyperkalemia DIG CAN BECOME TOXIC"
Neuro/Psych:
10. Know migraine management and prophylactcs (see migraine lecture)
dark, quiet room
*NSAIDS or APAP
*Triptans (sumatriptan/imitrex, zolmatriptan/zomig, rizatriptan/maxalt)
-nasal, oral, subq
-use no more than 2d/wk
-CI-recent use of MAOIs, ergots, or SSRIs, CVD, CAD, TIA, HTN, pregnancy
*Ergots (ergotamine tartrate/cafergot) not used ofen, expensive
-nasal, oral, rectal, IM, IV, siblingual
-CI-recent use of triptans, CVD, CAD, TIA, HTN, pregnancy
*Caffeine (Excedrin)
*antemetcs
Migraine preventon
*beta blockers (metoprolol, propranolol, tmolol)
-takes 2-3 months for full beneft- can decrease frequency and severity by 50%
-AE- drowsiness, exercise intolerance, depression
-CI-CHF, asthma
*antconvulsants (valproate, topiramate) effectve but both have major AE
-valproate AE- dizziness, platelet dysfuncton, hair loss, hepatotoxic, teratogenic
-topiramate AE- cognitve dysfuncton, weight loss, renal stones
*buterbur- PA free only, otherwise can cause liver damage and severe illness
11. Herbal migraine management
Buter bur root. It should be PA free or could result in liver damage.
Feverfew (Tanacetum parthenium) - Acton: Antinflammatory effects Uses: migraine preventon
Interactons: Antcoagulants, antplatelet drugs, aspirin (Pg. 99)
12. What drugs can cause serotonin syndrome?
SSRIs and TRIPTANS
13. What migraine prophylactc medicaton class to avoid in patents with asthma.
2Beta Blockers such as Propranolol
cyproheptadine (Periactn) - The drug may produce an atropine-like acton, so it must be used with cauton
in patents treated for bronchial asthma (pg. 487)
14. Know the common side effects of methylphenidate Ritalin
Most common: Nervousness & Insomnia
Other common side effects:
Decreased appette
Abdominal pain
HA
Depression
Irritability
Weight loss
Rebound effect
Side effects like if I don't have my stmulant COFFEE!! Page 453
Also: Temporary slowing of growth rate/Height and weight should be monitored with long term use
ADHD management –
15. At what age can ADHD dx be made?
DX typically before age 7
16. Stmulants including: Side effects -eg HA, tcs, appette suppression, elevated BP
Stmulants: work by increasing “background” dopamine levels in the synapses. However, diagnostc trials
of stmulant medicatons have failed to distnguish between children with and those without AD/HD.
Amphetamine Like Drugs (Methylphenidate, ritalin, metadate, concerta) 1st LINE OF TREATMENT
MOA: mild cortcal stmulant with CNS actons similar to amphetamines. Inhibits reuptake of
norepinephrine & dopamine
Side effects: (may subside afer a few weeks) common –These are drugs including methylphenidate and
dexmethylphenidate
Side effects
Increased BP
Exacerbaton of behavior
Agitaton and aggression
Watch for abuse
Mania psychotc symptoms
Blurred vision
Temp stuntng of growth
Decreased appette
HA
Depression
Rebound SX
NERVOUSNESS & INSOMNIA MOST COMMON
monitor height weight and BP *
Amphetamines - (Adderall,
Vyvanse)
MOA: Norepinephrine released from central noradrenergic neurons.
Side effects: These drugs include dextroamphetamine
Side effects
Effects more severe inital days of TX
Anorexia
Weight loss
Nausea
Abdominal pain
Diarrhea Xerostomia
3Constpaton
** tcs motor or phonetc May be unmasked*
* Black Box warning sudden death with structural cardiac abnormalites***
Others- armodafnil (Nuvigil), modafnil (Provigil), Guanfacine (Intuniv), Clonidine (Kapvay)
17. At what age can medicatons for ADHD be prescribed?
6 YEARS AND UP Meds 6 and up RX of younger than 6 is off label
18. Which is the longest actng stmulant?
Long Actng: methylphenidate (AMPHETAMINE LIKE DRUG) SR
Concerta ( 12 HOURS), Metadate CD, Ritalin LA, Methylin, Daytrana Transdermal System,
amphetamine/dextroamphetamine
Adderall XR, clonidine
Kapvay
Atomoxetne is metabolized by the 2D6 enzyme system. Its half-life is 4 hours in most patents, although
this may be prolonged to 30 to 40 hours in poor metabolizers (7% of populaton).
Nonstmulant alternatves:
19. Stratera/ atomoxetne
Norepinephrine reuptake inhibitor used to treat ADHD
As effectve as stmulants
Low abuse potental
Black box increased risk of suicide
Preg C
Causes more vomitng and insomnia
Norepinephrine reuptake inhibitors (Stratera- atomoxetne) not a controlled substance and it is not a
stmulant
MOA: reuptake of presynaptc norepinephrine. It does not bind to monoamine receptors in the brain,
thereby decreasing the risk of adverse reactons compared with older norepinephrine reuptake inhibitors.
Side effects: “black box” warning increased suicide risk, vomitng, insomnia, headache, rhinits, upper
abdominal pain, decreased appette, constpaton, increased cough, flu syndrome
Half-life - Atomoxetne is metabolized by the 2D6 enzyme system. Its half-life is 4 hours in most patents,
although this may be prolonged to 30 to 40 hours in poor metabolizers (7% of populaton).
20. Clonidine derivatves eg guanfacine (intuniv)- these tend to be most effectve in younger boys with
hyperactvity symptoms and can be helpful with insomnia
armodafnil (Nuvigil), modafnil (Provigil), Guanfacine (Intuniv), Clonidine (Kapvay)
Use in children younger than 6 years of age is off-label. Most effectve in younger boys
Hyperactve SX and insomnia
Stmulate alpha 2 adrenoreceptors, reduce sympathetc outlow
21. Buproprion (wellbutrin) (it is an off-label use) – consider in adolescent who also has depressive symptoms
Off label for ADHD CONSIDER IN ADOLESCENT WHO HAD DEPRESSION SX NOTE WITH ANY ALPHA
AGONISTS OR ANTIDEPRESSANTS RISK FOR ADVERSE CARDIAC EVENTS
22. Know the treatment of Alzheimer’s and the educaton behind the medicaton management of the disease.
(When are each of them indicated? What is their beneft?)
cholinesterase inhibitors. Cholinesterase inhibitors (ChE inhibitors (this abbreviaton may be seen on the
exam) eg donepezil: Can be used at any stage; Helps with functoning
Donepezil SEVERE
Rivastgmine MILD TO MOD
Galantamine MILD TO MOD THIS CLASS IS CONSIDERED 1ST LINE SPECIFICALLY DONEPEZIL, GALANTAMINE
ER , and RIVASTIGMINE DUE TO THEIR ONCE A DAY DOSING
THESE DRUGS ARE SHOWN TO DELAY PROGRESSION OF DEMENTIA SX THUS IMPROVING FUNCTION
DOES NOT HALTER DISEASE OR CURE
4 NMDA Receptor Antagonists - Memantne for moderate to late stages; can be added to ChE inhibitors
Memantne PREVENT COGNITIVE DAMAGE WIRH VASCULAR DEMENTIA
MANAGEMENT MOD TO SEVERE DEMENTIA
STAGES 5-7 Global Deterioraton Scale = START MEMANTINE WITH DONEPEZIL
Do not change doses
Inital and long term term side effects GI SX common , sleep disturbances
Explain purpose expectatons tme frame versus no cure
Behavioral and environmental management
Long term care
May need to take Donepezil during day of sleep effected take fll or empty stomach
Do not switch meds untl afer 6 months
Only change meds if lack efcacy, inital response then fail, safety issues
* increase or decrease dose before changing meds**
Parkinson Disease: Drugs including
23. Levodopa/carbidopa – monotherapy or adjunctve; most effectve therapy for slowness, stffness, tremor;
can cause dyskinesias (abnormal movements)
Dopamine Precursors
Carbidopa
Carbidopa / Levodopa * 1st Line MOST EFFECTIVE* Effect of protein on absorpton of levodopa-They
compete for absorpton. From what I can fnd on the internet eat carbs in the day (levodopa in the
morning) and proteins at night
DOPA all drugs have DOPA sufx- ** can cause dyskinesias (abnormal movements)
monoamine oxidase B (MAO-B) inhibitors
Selegiline - MAOI (eg selegiline) – monotherapy for slowness, stffness therapy; adjunctve as well for
motor fluctuatons – wearing off phenomena
Rasagiline *1st Line drug*
Mono therapy for slowness stffness
Adjunct for motor fluctuatons
** WEARING OFF PHENOMENA
3 glutamate Antagonists modulators
Amantadine Amantadine – not the most effectve but can be tried as adjunctve therapy for classic PD sx
of slowness, stffness and tremor
Dopamine Agonists
Apomorphine - . Apomorphine – ANTIVIRAL DOPAMINE AGONIST used for late stage PD as an
adjunctve therapy for wearing off symptoms
Pramipexole- Pramipexole – this is a dopamine agonist and can be used as mono or adjunctve therapy
for classic PD sx
Ropinirole
Bromocriptne
Canergoline
5- antcholinergic agents
Benztropine- Benztropine – this is an antcholinergic that can be used to treat tremor in younger
patents with PD; it can also be used to treat excessive drooling; antcholinergics can cause confusion,
hallucinatons, dry mouth, blurred vision and urinary retenton (antcholinergic adverse effects more
commonly a problem for older patents)
Trinexphenidyl
Diphenhydramine
6- catechol-O- methyl transferase COMT inhibitors
Tolcapone
Entacapone
Depression medicatons including
524. SSRIs
**1ST LINE DRUGS**
Abrupt SSRI discontnuing = withdraw, flu like, rebound depression
Except FLUOXETINE doesn't require taper
Avoid SSRIs with linezolid, MAOIs, Lithium
All have risk of SI untl age 24
⬆ risk of SIADH, hyponatremia – WITH OLDER ADULTS
Typically RX for elderly - Effectve less toxic FLUOXETINE FOR ELDERLY
*** SAFE IN OVERDOSE *
Drugs:
Fluoxetne ALOT of drug interactons
Fluvoxamine
Vilazodone
Citalopram- avoid in renal, QT prolonged
Escitalopram - avoid in Renal
Sertraline
Paroxetne - **weight gain, sexual dysfuncton sedaton, AVOID IN OLDER ADULTS DUE TO INCREASED RISK
OF SEDATION AND DRUG INTERACTIONS
25. SNRIs
Drugs
Venlafaxine **1st Line increases BP
2nd lines
Duloxetne
Milnacipran
Desvenlafaxine
The DMD fghts with the V for frst place
26. Recogniton that the SNRI duloxetne can be used for pain management as well It has ofcial approval for
both OA and fbromyalgia and neuropathic pain.
Can be used for pain management
Ofcial use for
OA
Fibromyalgia
Neuropathic Pain
27. Which SSRI is approved for use in children/teen?
Fluoxetne 8 and up
Others only 18 and up
28. Monitoring of depression.
Monitor depression - labs etc
All antdepressants- weight
TCAs - ECG, CBC, LFTs, Glucose
SSRIs - CBC, Electrolytes
SNRIs - BP , Electrolytes
Depression monitoring
Most drugs are preg C or even D
**Reserve for severe depression in pregnancy typically either fluoxetne or sertraline
Acute TX phase- DX to 6/8 weeks
Low dose and ttrate up.. effects not seen untl few weeks
No response in 8-12 weeks slow ttrate down and change drug
Contnuaton phase - 16-20 weeks
Preserve remission
6Maintenance phase - 4-9 months dose reducton not recommended
Discuss plan to contnue vs tapering off
Depression monitoring
Cauton with MANY DRUG COMBINATIONS THAT ARE NOT COMPATIBLE
ALSO ALL ANTIDEPRESSANTS MONITOR RISK OF SI
ESP WITH TCAS PT MAY PLAN TO OD
29. Side effects of antpsychotcs
Extrapyramidal sx : acute / tardive SX ( dystonia, akathisia, tremor)
More common in high potency drugs
Monitor and assess at each encounter using the
Use of the Abnormal Involuntary Movement Scale
TD May be irreversible
Clozapine has low rate of EPS and TD
Acute phase of TX
Begin antpsychotcs dose low and ttrate slow
Several weeks
Do not exceed dose that causes EPS
Provide adjunct TX : BB, benzo, antdepressants, mood stabilizers
Stable phase of TX
Do not decrease dose to limit EPS it may also cause relapse of SX
Once therapeutc effect is met, then atempt to decrease dose for long term maintenance
Men younger than 40 and women at greater risk
Remember TD is abnormal involuntary movements
Progressive or irreversible
Rhythmic movements of tongue, face, mouth
Major limitaton of 1st gen antpsychotcs
2nd gen antpsychotcs are used to decrease the risk of EPS : Dibenzepines, Benzisoxazoles, Quinolinones
30. What is the side effect of antpsychotcs that can lead to abnormal rhythmic movements? How should this be
managed?
Acute phase of TX
Begin antpsychotcs dose low and ttrate slow
Several weeks
Do not exceed dose that causes EPS
Provide adjunct TX : BB, benzo, antdepressants, mood stabilizers
Stable phase of TX
Do not decrease dose to limit EPS it may also cause relapse of SX
Once therapeutc effect is met, then atempt to decrease dose for long term maintenance
31. Serentl- Mesoridazine
Phenothiazines- piperidines 1st generaton antpsychotc
Really not other info in book except dose.. Medscape doesn't even list it.. maybe off market?
On lesson week 4 it's listed as a low potency 1st gen with high incidence of sedaton, antcholinergic effects ,,
32. Lab monitoring required with Clozaril
Clozapine: Monitor weekly CBC with differental, in keeping with the manufacturer's protocol. The
manufacturer maintains a confdental register (800-448-5938); patents must be enrolled and have a
baseline white blood cell (WBC) count and absolute neutrophil (ANC) count before initaton of therapy.
Treatment should not be initated if the baseline WBC is <3500/mm3 or ANC is <2000/mm3. Issue of
weekly supplies of the drug is dependent on the results of the weekly white blood cell count; the results
are sent to the natonal registry via forms supplied by the manufacturer. If afer 6 months of weekly
monitoring, the WBC has contnuously remained ≥3500/mm3 and the ANC has remained ≥2000/mm3, the
monitoring of blood counts through the registry may be reduced to every 2 weeks for 6 months.
7If acceptable WBC and ANC counts (WBC ≥3500/mm3 and ANC ≥2000/mm3) have been maintained during the
second 6 months of contnuous therapy, WBC and ANC may then be monitored every 4 weeks startng at the
end of the 12 months and thereafer. page 557, Edmunds, M. W., & Mayhew, M. S. (2014). Pharmacology for
the Primary Care Provider. Saint Louis: Elsevier Health Sciences.
33. Side effects of carbamazepine and lab monitoring
2nd gen antpsychotcs
*signifcant risk of agranulocytosis *
Monitor leukocyte count (WBC) CBC with diff before, every week, and weekly 4 weeks afer DC
Aplastc anemia and agranulocytosis, although rare, have been reported in associaton with carbamazepine
therapy. (Edmunds 500)
Side effects:
Rare but serious
Aplastc anemia & agranulocytosis
Benign leukopenia
Mild antcholinergic— use cauton with increased intraocular pressure, confusion/agitaton elderly
Exacerbated SZ in mixed SZ DO
Ok for kids under 6
Preg D
Monitor
CBC before TX
Repeat CBC q 3 months for frst year
Baseline and periodic liver functon
Baseline and periodic urinalysis- SIADH
baseline and periodic eye exams
34. Know frst line treatment for generalized seizure management (eg Dilantn) not adjunct therapies
Generalized tonic clonic SZ
Phenytoin - hydantoins
Carbamazepine - misc drug
Phenobarbital - barbiturates
Valproic Acid - GABA analogs
Topiramate - GABA analogs
Generalized epilepsy :
Benefcial
Carbamazepine - misc
Phenobarbital - barbiturates
Phenytoin - hydantoins
Valproate GABA analogs
Note GABA drugs are newer drugs
GU:
35. Be familiar with Beer’s Criteria
Explicit not evidence based guidelines techniques for assessing appropriateness of drugs RX to elderly
Many drugs that are high risk for ADRs and likely to produce ADRs are identfed
Topics include
Decreased Renal clearance
Decreased hepatc clearance
Meds to avoid over 65 yrs the beers short list:
sedatng anthistamines, sedatve hypnotcs, sedatng antdepressants, antspasmodic,
Meds to avoid over 65 long list
Antcholinergic
Sedatng anthistamines
8Ticlopidine
Methyldopa
Resperine
Disopyramide
Meperidine
Propoxyphene
Barbiturates
Benzos
Increased risk for physical performance decline
Drugs on concern
Analgesics
Antbiotcs
Antcholinergics
Anthistamines
Antparkinsons
Benzos
Barbituates
Cardiovascular
Muscle relaxants
Proton pump inhibitors
Psychotropics
Remember drugs with strong antcholinergic propertes
Anthistamines
Antdepressants *TCAs
Antmuscarinics
Antpsychotcs
Antspasmodics
Skeletal muscle relaxers
36. Evaluaton of incontnence – inital steps
Inital steps
Focused assessment
Voiding diary
UA / PVR
TX based on type of incontnence
Stress incontnence
SNRIs, estrogen cream, ring, imipramine, pseudoephedrine
Urge incontnence
1st line
Oxybutynin, darifenacin, solifenacin, tolterodine, trospium
37. Meds for erectle dysfuncton know which have a quick onset of acton. – which has quickest onset: tadalafl
(Cialis), sildenafl (Viagra), avanafl (Stendra) or vardenafl (Levitra)?
PDE5 inhibitors sildenafl (Viagra), tadalfl (Cialis), vardenafl (Levitra), avanafl (Stendra) are the 1st line
unless contraindicated.
Vardenafl ( levitra) 60 mins prior
Sildenafl (viagra) 30 mins to 4 hours prior
Tadalafl (Cialis) 30-45 mins prior
** avanafl ( Stendra) newest drug shortest 1/2 life, 30 mins prior some have effect in 15 mins***
Lower dose of sildenafl with ritonavir, ketconaxole, itraconazole, erythromycin. Vardenafl may prolong QT.
Other treatments- Hormone replacement therapy in cases of documented androgen defciencies without
contraindicatons.
9Alprostadil (MUSE)-intrathecal placement of pellet in urethra, inital dose must be done under healthcare
supervision due to risk of syncome. Yohimbe (herbal) pg 389-391
38. Why should we avoid use of chronic nitrofurantoin in older adults? (See Geriatric lecture)
Peripheral neuropathy, pulmonary & hepatc toxicity possible, avoid if CrCl less than 60 & neurotoxicity
Endocrine:
39. Know the treatment and labs for Hyperthyroid and Hypothyroid (know normal TSH and T4 labs as well as
patern seen with hypo vs hyperthyroidism)
Normal TSH. 0.3-5.5 Hyper TSH ⬇ Hypo TSH ⬆
Normal T4 5-12. Hyper T4 ⬆. Hypo T4 ⬇
Free T4 0.9-1.7. Hyper FreeT4 ⬆. Hypo free T4 ⬇
TX Hyperthyroidism Graves Disease
1st line Radioactve iodine - pretx in cardiovascular /elderly with ant-thyroid
2nd line surgery
3rd line ant thyroid meds: Methimazole perverted ***except 1st trimester than do propylthiouracil PTU
tx hypothyroidism
1st line levothyroxine pure T4 safe in pregnancy
L-thyronine pure T3 rarely used
40. What dose of levothyroxine should be started in a patent who has coronary artery disease?
Start with 25mcg daily
***Note usual maintenance dose is 75-150 mcg daily
41. How ofen should one obtain a TSH when initally treatng hypothyroidism?
Monitor monthly untl stable
42. Know what labs indicate Hypothyroid and which indicate Hyperthyroid
Labs indicatng hypothyroidism: Elevated ⬆ TSH with low circulatng levels of free (unbound) T3 & T4
Labs indicatng hyperthyroidism: Low ⬇ or undetectable TSH with high circulatng levels of T3&T4
42. Know side effects of hyperthyroid medicatons
For both PTU now with black box for liver damage & Methimazole ( preferred over PTU)
potental agranulocytosis, thrombocytopenia, aplastc anemia ***monitor CBC
Hepatotoxic *** AST, ALT, LDH, bilirubin, PT, alkaline phosphate
GI irritaton
43. How to monitor methimazole therapy- pg 587
Monitor every 3-6 weeks. Monitor for signs of infecton and decreased pluse, BP, weight, eliminaton of
nervousness and tremor. Potental for hepatoxicicity, AST, ALT, alkaline phosphatase, LDH, bilirubin, & PT.
44 . What is the typical course of congenital hypothyroidism – will the child always need thyroid replacement?
Can possibly stop therapy at 3 years of age. Then recheck thyroid to see if it is stll needed
Child typically needs higher dose of meds untl age 3 to meet metabolic demands
TX may be stopped 2-8 weeks afer child turns 3
If TSH levels remain normal the TX is DC permanently
45. Know how to prescribe oral diabetc medicatons and what labs to monitor.
Mono therapy HbA1C < 7.5
Multple agents A1C> 7.5
In order of recommendatons
Biguanides : Metormin MONITOR RENAL OBTAIN eGFR
GLP-1 Receptor Agonists : Exenatde Liraglutde
SGLT2 Inhibitors: canaglifozin empaglifozin
DPP-4 inhibitors : Sitagliptn, saxagliptn, linagliptn
TZDs: glitazone, ploglitazone, rosiglitazone
Alpha glucosidase inhibitors : acarbose, miglitol MONITOR LFT Q 3 MONTH
10 Amylin mimetc: pramlintde
Amylin is a hormone
Meglitnides : glinides,
Sulfonylureas : Glipizide, Glyburide, Glimepiride MONITOR CBC, RENAL
All start with G end in IDE
REMEMBER DIET & EXERCISE ALWAYS FIRST
46. Know frst line medicaton management in Type II Diabetes.
1. frst line: Metormin
If liver disease consider Sulfonylureas
Per the textbook
2nd line agents include
Sulfonylureas
DPP-4
Meglintnides
Alpha glucosidase inhibitors
Pregnant use typically recommend changing to insulin
Metormin, glyburide , glipizide used
Metormin cat B
Glyburide for gestatonal DM
Type 2 DM with renal disease
Non obese
2nd gen Sulfonylureas
Obese
Alpha glucosidase inhibitors
Other choice for both: thiazolidinedione’s
47. Know frst line oral diabetes management in a patent with and without renal disease.
NORMAL RENAL FUNCTION
NON-OBESE
metormin
Thiazolidinedione’s TZD
2nd gen Sulfonylureas
Non-Sulfonylureas secretagogues (erratc meals)
OBESE
ELEVATED FASTING BLOOD SUGAR
metormin
TZD
2ng gen Sulfonylureas
Incretns
ELEVATED POSTPRANDIAL BLOOD SUGAR
nonSulfonylureas secretagogues if erratc meals
Alpha glucosidase inhibitors
2nd gen Sulfonylureas
IMPAIRED RENAL FUNCTION
NON-OBESE
2nd gen Sulfonylureas
nonSulfonylureas secretagogues if erratc meals
TZD
OBESE
Alpha glucosidase inhibitors
TZD
11Sulfonylureas
Incretns
DM:
48. Preferred frst line oral agent- Metormin
1st line- metormin, biguinide
moa-decreases hepatc glucose producton, ASSESS RENAL FUNCTION RISK FOR LACTIC ACIDOSIS
49. Vitamin defciency associated with this drug (Metormin)
B12
50. Side effects of this drug (Metormin)
side effects- b12 defciency, n/v/d, chills, rash, no wt. gain, dyspnea, lactc acidosis, hypoglycemia, metallic
taste
contraindicated- renal dysfuncton, metabolic acidosis, dka, hold for iodine contrast imaging
Vit B12 defciency = Anemia & neuropathy
LACTIC ACIDOSIS
GI SX
51. MOA and side effects of acarbose pg 493
acarbose (precose)- alpha-glucosidace inhibitor (** hypoglycemia occurs less with this vs other drugs**)
contraindicated- dka, cirrhosis, IBS, intestnal obstructons
warning-carcinogenic x renal tumors
MOA: it's an alpha glucosidase inhibitors, slows intestnal carb digeston and absorpton
Side effects : GI - flatulence diarrhea
Elevate LFTs
52. MOA and side effects of canaglifozin
canaglifozin SGLT-2 inhibitor
MOA: inhibits SGLT2 in proximal nephron which blocks glucose reabsorpton by kidney increasing
glucosuria
Side effects
Yeast infecton
Polyuria
Volume depleton
Hypotension
Dizzy
Falls/FX
Increased amputatons
Increased LDL
Increase Cr
DKA
UTI
Hyperkalemia
reduced bone density
From our discussion board gluscouria = Canaglifozin is working
ENT:
53. Know the treatment for Otts Media and Otts Externa
TX for Otts Media
Amoxicillin 80-90 mg/kg/day divide bid x 5-10 days
Alternatve
Amoxicillin / Clavulanate (recent amox use ), cefuroxime, cefdinir, cefpodoxime, cefriaxone IM
Alternatve
TMP/SMX -s. Pneumoniae resistant to bactrim
12Azithromycin
Clindamycin
Tx failure
Amox/clav
Cetrixone IM x3 days
Clindamycin
Referal
Hold antbiotcs over 2, not severely ill, follow up ensured , tx can start if SX persists..
60% will resolve without meds
Otts media with effusion
Without evidence of infecton
Watch non high risk
Persists 3 months hearing testng
TX Otts Externa
Acetc acid, boric acid, benzalkonium chloride, aluminum acetate (burow's soluton) antbacterial and
antfungal propertes
Cipro otc soluton
Possibly add steroids: cortsporin otc soluton
54. Preferred medicaton for impetgo (honey crusted skin lesions)? What are the recommended therapies if the
impetgo is in a limited area vs more extensive?
Oral dicloxacillin is the frst choice. Bactroban may also be applied topically for mild lesions.
First choice oral dicloxacillin
Mupirocin- bactroban topical also effectve cheaper
Other alternatves
Azithromycin
Clarithromycin
Erythromycin
Cephalexin
55. Preferred frst line antbiotc for acute OM including dose and management of otorrhea in a patent who has
tympanostomy tubes
per lecture slide: 1st line treatment-Amoxicillin 80-90mg/kg/day divided BID for 5-10 days.
Alternatve-Augmentn, cefuroxime, cefdinir, cefpodoximine, cefriaxone IM.
*if recent amoxicillin use, Augmentn is 1st line.
If PCN allergy-TMP/SMX, axithromycin, clindamycin. If no improvement in 2-3 days, change to
Amox/Clav, Cefriaxone IM x 3 days, clindamycin and consider referral to specialist.
Otorrhea with tympanostomy tubes-quinolone otc drops.
check hearing if effusion persists for 3 months or longer or at any tme if signifcant
hearing/language problem.
56. How should you manage OME? When should you check hearing in a patent who has OME?
Hydrocortsone, neomycin sulfate, polymyxin-cortsporin otc
Cipro and hydrocortsone suspension Cipro HC otc
Hearing test afer 3 months if effusion persists or at any tme if signifcant hearing/language problem
57. How should you treat resistant AOM?
No SX improvement 2-3 days suggests bacterial resistance
Afer changing meds also consider tympanocentesis with the referral
(See lecture slides under Course Resources)
58. Tx of otts externa
floroquinolones (pg. 692)
patho book says commonly caused by pseudomonas, staph, and ecoli. pg. 516
GI/nutriton:
1359. Know evaluaton and treatment of IBS including specifc medicatons and their side effects, assessment of
abdominal pain, evaluaton and tx of IBS
Alternatng constpaton/diarrhea:
• Increased dietary fber (25 g/day)
Pain
• Antspasmodic (antcholinergic) medicaton—short term
• TCAs—long term
DIarrhea
• Loperamide—short term; ofen used for breakthrough diarrhea
• Antdepressants (TCAs)—long term
• Alosetron (ordered by GI specialists) if resistant to all other interventons
Constpaton
• Fiber, Laxitves
CRAMPING ABDOMINAL PAIN
Antspasmodic (antcholinergic) PRN if SX present shortly afer meal
ABDOMINAL PAIN FREQUENT OR SEVERE
TCAs
PAIN SX WITH DIARRHEA
TCAs
PAIN SX WITH CONSTIPATION
SSRIs conflictng efcacy
SIMETHICONE
Use for problems with gas, explosive BM, belching, flatus
LUBIPROSTONE AND POLYETHYLENE GLYCOL
also RX for IBS
60. Tx of infant with oral candidiasis/thrush
1st line treatment: fluconazole 6 mg/kg x1 then 3-12 mg/kg x 2 week minimum (pg. 723)
61. Vitamin defciency questons (eg what the symptoms of various vitamin defciencies are?)
Vitamin A- Fat soluble (Retnol, beta carotenes, carotenoids)
Blindness
Vitamin D (Vitamin D2, Ergocalciferol, d3, Cholecalciferol)
Rickets, bowlegged, contracted pelvis, skull malformaton, dental erupton delay
Vitamin E (Alpha-tocopherol)
BILIARY OBSTRUCTION OR PANCREATICE INFUFFCIENCY
Vitamin K- for those who take Coumadin be careful it’s a clotng factor. It interferes with metabolism and
absorpton
Vitamin B12 – disrupton in GI in habits absorpton, peripheral nervous system changes, central nervous system
changes
Folic acid- fetal neural tube defects, spinal bifda, anencephaly
Vitamin C- scurvy , lack of repair of collagenous tssue causing muscle weakness
62. What vitamin defciency is common with chronic alcohol abuse?
Vitamin B1 Thiamine
63. What iron defciency is associated with overconsumpton of milk in toddlers? What is the screening test that
should be ordered?
Iron Defciency Anemia
Check CBC to confrm
64. What side effect can occur with salt substtutes?
Hyperkalemia
Potassium toxicity
14 Confusion, fatgue, intestnal tract changes, irregular rapid HR, dropping BP, paralysis arms legs,
convulsions, coma, cardiac arrest
66. Vitamins a vegetarian may require
Vitamin B12 pg 796, Cobalt, zinc
67. How to prevent osteoporosis
Sufcient intake of calcium
Ability to absorb calcium - fat intake vs fber fat may increase absorpton
Vit D for calcium utlizaton
Risks
Inadequate calcium
Vit D defciency
High phosphorus intake soda processed meats eggs peanut
Excessive calcium use - multple pregnancies
Steroids during bone building years
Smoking cessaton:
68. How to taper nicotne nasal spray pg 786
useful for patents with severe cravings and wants immediate relief.
Fastest nicotne delivery, most closely resembles nicotne effects of smoking.
Each spray delivers 0.5 mg of nicotne
Normal dose 1-2 sprays per waking hour for 3-6 months
Taper period half number of doses used each week
Also 1-2 0.5 mg sprays each nostril/hour. Do not exceed 5 sprays/ hour or 40/sprays day. gradually reduce
rate over 6-8 weeks pg 785
ID:
69. Tx of Rocky Mountain Spoted Fever? What to do if patent fails oral therapy? Pg 660
Doxycycline 100mg po bid x 7 days
Fail oral TX
Chloramphenicol 50mg/kg/day IV q 6 hrs x7 days
70. Know the indicatons for the use of Vancomycin pg 668
Vancomycin IV is used most ofen in
serious or life-threatening staphylococcal or streptococcal infectons.
Pseudomembranous colits caused by C-Diff oral form when flagyl not effectve
The primary care use of vancomycin is for pseudomembranous colits caused by C. difcile. It is
given in oral form when treatment with metronidazole is contraindicated or ineffectve
Prevents synthesis of the bacterial cell wall by blocking peptdoglycan strand formaton.
71. Know Vancomycin mechanism of acton pg 668
preventng synthesis of the bacterial cell wall by blocking peptdoglycan strand formaton. pg668
Prevents synthesis of the bacterial cell wall by blocking peptdoglycan strand formaton.
72. Know the mechanism of acton of Cephalosporinspg 678
Cephalosporins interferes with bacteria cell wall (Bacteriocidal)
Beta lactame - antbodies interfere with cell wall synthesis through inhibiton of synthesis of bacterial
peptdoglycan in cell wall
73. What class is erythromycin?
Macrolides
Analgesia:
74. Know the side effects of Acetaminophen
When acetaminophen is used as directed, adverse effects are rare. Skin eruptons, urtcaria, erythematous
skin reactons and fever, increases asthma in kids,
15 Extremely rare hematologic reactons include hemolytc anemia, leukopenia, neutropenia, and
pancytopenia. Other reactons are hypoglycemia and jaundice.
Adverse effects are usually dose dependent. Hepatc toxicity may occur following intake of >7.5 g within 8
hours.
Alcoholics and patents on hepatc metabolizing medicatons are more susceptble to hepatc toxicity. This
is very important because hepatc toxicity can be caused by binge drinking.
75. Know the signs of Acetaminophen toxicity
Symptoms that appear in the frst 24 hours are
o nausea,
o vomitng
o drowsiness
o lethargy
o malaise
o confusion.
76. NSAID side effects; use of topical NSAIDs
GI upset, dizziness, headaches, bleeding, fluid retenton
HA, increased sweatng, photosensitve, rash, pruritus, urtcaria, Steven Johnson's syndrome,
toxic epidermal necrolysis, anaphylaxis pulmonary infltrate, asthma, tachycardia, palpitaton,
HTN, MI, HF, arrhythmia, PE AFib, GI bleeding, N/V, constpaton, dyspepsia. Flatulence, CVA,
confusion, sedaton, blurred vision, tnnitus, hearing loss, vertgo, increased LFTs low Cr
hyperkalemia, renal,
Use of topical NSAIDs
o Capsaicin for OA
77. Know the difference between nonselectve vs selectve NSAIDs pg 407
Nonselectve more GI issues COX1&COX2 COX 1 responsible for GI
Selectve are COX2 not as much GI issues
78. Know the Management of Osteoarthrits
APAP 1st line long term - be effectve in treatng the pain of OA because many patents have minimal
inflammaton. If not effectve then
NSAIDS for flares
o Intraartcular injecton of steroids for knee hip mod to severe pain- NSAIDs can be used. NSAIDs
are more effectve than acetaminophen for OA of the knee or hip. They are also more effectve in
moderate to severe disease. Some patents’ conditons can be managed via long-term
acetaminophen therapy with short-term use of NSAIDs for flare-ups. Because of the decreased
risk of GI toxicity,
Non pharm exercise with rest weight loss
o A supervised walking program can improve functonal status. Recommend weight loss to
overweight patents to reduce strain on joints. The patent must be realistc about the limitatons
of medicatons and about his own prognosis. (Edmunds 409)
COX-2 inhibitors are useful for long-term management of OA in elderly patents.
Intraartcular injecton of steroids can be provided on a limited basis.
o Topical creams such as capsaicin can also help with the pain. Surgical measures such as
hip or knee replacement may be necessary in joints that are seriously affected.
(Edmunds 409)
PPT= Aspirin and Celecoxib (cox-2)
79. Know acetaminophen toxicity, and indicatons in children
Acetaminophen is used commonly for pain and fever in children and generally is well tolerated.
Use cauton to avoid over dosage.
16 Acute over dosage of acetaminophen can result in hepatotoxicity and is life threatening. Toxicity
is likely to occur if a patent takes more than 250 mg/kg in a single dose or greater than 12 g
within a 24-hour period.
Afer 24 hours up untl 72 hours, symptoms abate and liver toxicity (AST/ALT elevaton) normally
occurs. An increase in liver enzymes within 24 hours is a sign of permanent injury.
Liver enzyme elevaton usually peaks at between 72 and 96 hours afer ingeston, along with
other markers of liver functon such as the INR and a total bilirubin concentraton above 4.
The last stage, which consists of recovery, lasts anywhere from 4 days to 2 weeks; recovery is
complete in many cases.
The patent should immediately receive actvated charcoal. Further treatment should take place
in a hospital setng with the patent receiving N-acetylcysteine (NAC), the specifc antdote for
acetaminophen poisoning
. Acetaminophen is metabolized in the liver.
Toxic metabolite is detoxifed with hepatc glutathione.
Hepatc necrosis can occur if glutathione stores have been depleted by long-term or toxic doses
of acetaminophen.
Children at increased risk for acetaminophen toxicity include those with diabetes, concomitant
viral infectons, a family history of hepatotoxic reactons, obese children, and chronically
malnourished children.
More than 250 mg/kg in a single dose or
More than 12 G in 24 hours
350mg/kg severe hepatotoxicity life threatening
o
N/V drowsy lethargy, malaise, confusion
Elevated AST, ALT
Tx actvated charcoal and n-acetylcysteine IV
o Children:
High risk for APAP toxicity
Failure to give correct dose, dose may be confusing
Children with DM, viral infectons, family history of hepatotoxic reactons, obese,
chronically malnourished at greater risk for toxicity
10-15 mg/kg oral
10-2 mg/kg rectal
o Do not exceed 2.6 grams day
Give every 4-6 hours
17 [Show Less]