What are the 3 types of estrogen used in COC? Which one is MC? - CORRECT ANSWER-MC = Ethinyl estradiol (EE) ; Mestranol ; Estradiol valerate
What are
... [Show More] the types of progestin used in COC? Which one is MC? - CORRECT ANSWER-MC = Norethindrone ; Norethindrone acetate; ethynodiol diacetate; levonorgestrel; norgestrel; desogestrel; norgestimate; Drospirenone; Norethynodrel; Etonogestrol (nuvaring)
How does estrogen affect bone mineral density? - CORRECT ANSWER-Improves bone mineral density (estrogen helps inhibits osteoclasts)
In what pt population would you want to avoid COCs in? - CORRECT ANSWER-Pts over 35 + Smokers
If you missed 1 active (hormonal) pill or if you started a pack 1 day late, what do you do - CORRECT ANSWER-Take active (hormonal) pill as soon as possible and then continue taking pills daily. No additional contraceptive protection (such as condoms) is needed
If you missed 2 or more active (hormonal) pills or if you started a pack 2 or more days late - CORRECT ANSWER-Take 2 active (hormonal) pills as soon as possible and then continue taking pills daily. You should take 2 pills on the same day. Also, use condoms or abstain from sex until you have taken active (hormonal) pills for 7 days in a row.
If you missed the pills during the first week and had unprotected sex you should use - CORRECT ANSWER-emergency contraception for maximum protection, in addition to taking today's active birth control pill.
What are the 3 main drugs that cause drug interactions with OCPs? - CORRECT ANSWER-Antiepileptic + Abx + Rifampin
What are ADE from estrogen deficiency? (aka what happens in menopause from lack of estrogen) - CORRECT ANSWER-Vasomotor symptoms (hot flashes, redness)early/mid- cycle breakthrough bleeding
Which pts are better candidates for Progestin only "minipills" - CORRECT ANSWER-Patients with SLE (systemic lupus erythematosus)Patients experiencing intolerable side effects to estrogenPatients who are breastfeeding. [estrogens suppress milk production].Patients with a history of thromboembolic disease
What are the main S/E from combination oral contraceptives? - CORRECT ANSWER-Hypertension COC's can increase BP Drospirenone/EE may decrease BP Depo-Provera and IUD do not change BP ; bleeding irregularities, breast tenderness, mood swings, nausea, and headache
Which oral contraceptive is generally less effective than COCs? - CORRECT ANSWER-Progestin only "minipills"
What are the 3 types of extended use OCP? - CORRECT ANSWER-Seasonale, Jolessa, Quasense
What is the dosing for extended use OCPs? - CORRECT ANSWER-patient receives "active pills" (containing the hormones) every day for 84-days (twelve weeks) followed by a week of "inactive pills" (placebo).
What type of hormones are in the transdermal extended Orthovera patch? - CORRECT ANSWER-EE +Norelgestromin
Which hormones are in the Nexplanon? - CORRECT ANSWER-Profestin only
Which hormones are in the Nuvaring? - CORRECT ANSWER-Etonogestrel
Which hormones are inthe Annovera (contraceptive ring) - CORRECT ANSWER-Segesterone acetate + EE
What are the 3 nervous pathways involved in the pontine micturition center? - CORRECT ANSWER-Pelvic nerve (Parasympathetic)
Hypogastric nerve (sympathetic)
Pudendal nerve (somatic nerve)
What are the 2 most commonly prescribed anti-musarinic medications? - CORRECT ANSWER-Tolterodine + Oxybutynin
What is the tx for Urge (detrustor overactivity) - CORRECT ANSWER-Anticholinergics : DOC = Oxybutynin, Tolterodine
What is the tx for Stress incontinence (outlet incompetence) - CORRECT ANSWER-Topical estrogen; Alpha-agonists; Non-drug methods
What is the tx for Mixed incontinence - CORRECT ANSWER-Focus treatment on predominant symptoms
What is the tx for atonic bladder - CORRECT ANSWER-Catheterization
What is the tx for functional incontinence? - CORRECT ANSWER-Therapy choice to eliminate cause
Why would an injectable hormone like Depoprovera be preferred? - CORRECT ANSWER-If pts family thinks the pt would not be compliant in taking a medication
How do muscarinic antagonists work for overactive bladder? Why would the s/e be those related to sympathetic activity? - CORRECT ANSWER-antagonizing post-junctional excitatory muscarinic receptors (M2/M3) in the detrusor muscle
Inhibits parasympathetic system = increases sympathetic = dry everything
What are the top s/e associated with anticholinergics (muscarinic antagonists) - CORRECT ANSWER-urinary/GI obstruction, Alzheimer dementia (especially with those that penetrate CNS), closed-angle glaucoma
Why does Trospium, Darifenacin, and Fesoterodine not cross the BBB? - CORRECT ANSWER-Due to them containing a p-glycoprotein substrate and their lipophilic
When would botox be recommended for pts? - CORRECT ANSWER-If they were unresponsive with anticholinergics
What is the MOA for BOTOX? - CORRECT ANSWER-Cleaves the SNARE protein which prevents the cell from releasing acetyl-co-a which causes muscles to relax (lasts 6 months)
Sympathomimetics are indicated for urinary incontinence + urgency + increased urinary frequency, what drugs are included in this class? - CORRECT ANSWER-Mirabegron
Vibegron
Phenylephrine
(Off label = Psuedoephedrine and ephedra + Ma Huang)
What is the MOA for the sympathomimetic Mirabegron? - CORRECT ANSWER-Beta 3 selective agonist ; Increases bladder capacity by relaxing detrusor smooth muscle during storage phase of urinary bladder/fill cycle
What are the s/e associated with both Mirabegron and Vibegron? - CORRECT ANSWER-Produce or worsen HTN
*Monitor BP changes overtime
What is the MOA for Vibegron? - CORRECT ANSWER-Beta - 3 adrenergic antagonist
Phenylephrine is a sympathomimetic, what is the MOA? - CORRECT ANSWER-Alpha agonist = constriction of urethral smooth muscle
What is the indication for Phenylephrine? - CORRECT ANSWER-Stress incontinence
What are the 2 drugs used for management of urinary retention? - CORRECT ANSWER-Bethanechol and Neostigmine
What is the MOA for Bethanchol? - CORRECT ANSWER-Peripheral cholinesterase resistant muscarinic agonist
What are the s/e associated with Bethanechol? - CORRECT ANSWER-Cholinergic effects at "off target" sites:Lightheadedness, syncopeDiarrhea, stomach crampsExcessive tear production, miosis
What is the MOA for Neostigmine (used to tx urinary retention) - CORRECT ANSWER-acetylcholinesterase inhibitor at both muscarinic & nicotinic receptors =
Stops breakdown of acetyl choline to increase cholinergic tone - result occurs everywhere including cardiovascular system
What are the s/e of neostigmine? - CORRECT ANSWER-Cholinergic effects at "off target" sites:AV block, brady-arrhythmia, dysrhythmia, cardiac arrestHypotension, syncope
What are the 2 drugs indicated for opiate -induced urinary retention? - CORRECT ANSWER-Methylnaltrexone and Naloxone
What are the main s/e associated with Methylnaltrexone and Naloxone - CORRECT ANSWER-Detrusor relaxation readily reversed with opiate antagonists; Runs the risk of reducing the analgesic effect of drugs
What are the short acting selective a-1 blockers used to treat BPH? - CORRECT ANSWER-Alfuzosin
selectively binds to and inhibits alpha(1)-adrenergic receptors in the lower urinary tract. This leads to the relaxation of smooth muscle in both the prostate and bladder neck, resulting in the improvement in urine flow and a reduction of urinary symptoms.
Which drug is uro-selective to tx BPH but is not formally recognized as selective a-1 antagonis? - CORRECT ANSWER-Alfuzosin
Which drugs are used for BPH that are long acting selective a-1 blockers? - CORRECT ANSWER-Terazoisin + Doxazosin
What are the S/E of Terazosin and Doxazosin? - CORRECT ANSWER-Retrograde ejaculation (ejaculate goes into bladder)Decreased ejaculation; highest risk of itra-operative floppy iris syndrome ; uroselective in its clinical effects, do not produce a significant hypotensive effect.
Tadalafil is a PDE-5 inhibitor, what is the MOA? - CORRECT ANSWER-By blocking cGMP breakdown --> PDE-5 inhibitors = smooth muscle relaxing effects; My notes = PDE- inactivates cGMP - stops calcium entry into sm muscle = need calcium for contraction = loss of intracellular K+ that will hyperpolarizes= reduction in intracellular calcium = Cell not contracting = SMOOTH MUSCLE RELAXATION
What are the MC s/e associated with Tadalafil? - CORRECT ANSWER-Commonly used to treat EDRelaxation of s.m. in corpus carvernosum ; Only PDE-5 inhibitor approved for BPH due to length of action (PO QD)
What are the 5-alpha reductase inhibitors used to tx BPH? - CORRECT ANSWER-Finasteride + Dutasteride
What is the MOA for Finasteride + Dutasteride? - CORRECT ANSWER-5-alpha-reductase catalyzes the conversion of testosterone to dihydrotestosterone (more potent androgen); Remove androgen or reduce potency --> 5a inhibitor = decreased rate of growth of tissue ** Acts on Androgen receptor
What are the s/e associated with 5-alpha inhibitors? - CORRECT ANSWER-5-alpha-reductase inhibitors reduce the dihydrotestosterone-driven proliferation of the prostate, and in doing so, provide relief for urinary evacuation by reducing the prostate from pressing on and constricting urine flow along the urethra. ***Can Take 3-6 months to decrease prostate size + serum PSA level**
Which class of BPH medications are category X? - CORRECT ANSWER-Category X (not carried in semen)
What are the 2 alternative medicine products used to tx BPH? - CORRECT ANSWER-Beta-sitosterols + saw palmetto
Why do women need hormone replacement - CORRECT ANSWER-HRT indications
Menopausal symptoms
Osteoporosis prevention
Women with a uterus = estrogen + progesterone
Women without a uterus = estrogen only
What are the main benefits of hormone therapy? - CORRECT ANSWER-Vasomotor symptoms (hot flashes) + vaginal atrophy (dryness, dyspareunia, UTIs) + Osteoporosis prevention, colon cancer risk reduction
What are the main risks associated with hormone therapy? - CORRECT ANSWER-CVD, Breast cancer, stroke + VTE
What are the ABSOLUTE contraindications for HRT? - CORRECT ANSWER-Endometrial cancer
Breast cancer
Undiagnosed vaginal bleeding Thromboembolism
Active liver disease
What are the RELATIVE contraindications for HRT? - CORRECT ANSWER-Relative contraindications :
Uterine leiomyoma
Migraine headaches
Seizure disorder
No oral estrogen for women with:
Hypertriglyceridemia
Liver disease
Gallbladder disease
What are the effects of Progestins? - CORRECT ANSWER-Thickening of the endometrium in preparation for pregnancy
Production of a sticky mucus to plug the cervical os
Thinning of the vaginal mucosa
Relaxation of the smooth muscle along the fallopian tubes and uterus
What effects does Progetins cause outside of the Reproductive system? - CORRECT ANSWER-Stimulates lipoprotein activity
Increases basal insulin levels and responses to glucose
Promotes glycogen storage in the liver
Increases body temperature
What are medical problems associated with osteoporosis? - CORRECT ANSWER-- Rheumatoid arthritis-
-Hyperthyroidism
- Hyperparathyroidism
- Cushing's syndrome
- Diabetes
What medications increase liklihood of osteoporosis? - CORRECT ANSWER-- Glucocorticoids
- Phenytoin
- Phenobarbital
- Heparin
- Lithium
What are the 2 scores associated with a DXA scan to determine severity of osteoporosis? - CORRECT ANSWER-Z score- compares patient's BMD to a group matched to the patient's age, sex, weight, and race
T score- the number of standard deviations of a patient's BMD is away from the mean BMD of a normative reference group made up of young women or men
What are the non pharmacological recommendations for osteoporosis prevention? - CORRECT ANSWER-- Diet
- Social Habits(Minimize alcohol
Smoking cessation)
- Exercise(Aerobics, weight bearing, and resistance exercises promote the preservation of BMD)
- Fall Prevention(Environmental hazards, ambulation-assist devices, review meds)
What happens if you take a Bisphosphonate with food or beverage? - CORRECT ANSWER-Absorption reduced to almost zero when taken with food or beverage
What is the t1/2 of Bisphosphonates? - CORRECT ANSWER-2-10 years
What pt education should be provided w/ Bisphosphonates? - CORRECT ANSWER-Administration:
- Take tablet with 6 to 8 ounces of plain tap water first thing in the morning before eating or drinking
- Don't lie down, eat, drink, or take other medications or at least 30 minutes following dose
- Eat breakfast before lying down
- Do not double doses if miss a dose
Exceptions: Ibandronate (Boniva) administer one hour prior to morning meal and Atelvia can be taken after breakfast
Why would oral estrogen be used for tx of HRT of osteoporosis? - CORRECT ANSWER-Indicated for relief of moderate to severe hot flashes; to treat moderate to severe dryness, itching, and burning in and around the vagina; and to help prevent and treat osteoporosis
What are absolute contraindications for oral estrogen? - CORRECT ANSWER-Absolute contraindications
Endometrial cancer
Breast cancer
Undiagnosed vaginal bleeding Thromboembolism
Active liver disease
Estrogen to treat HRT and osteoporosis comes in which 3 forms? - CORRECT ANSWER-Oral estrogen
Transdermal patches
Vaginal cream
Vaginal gels and emulsions
What is the indication for vaginal gels/emulsions? - CORRECT ANSWER-Used for vasomotor symptoms
What is the MOA for selective estrogen receptor modulators (SERMs) ? - CORRECT ANSWER-bind to estrogen receptors and function as tissue-specific estrogen antagonists or agonists.
What drugs are included in the SERM class to tx HRT & osteoporosis? - CORRECT ANSWER-Raloxifene
What are the contraindications for raloxifene (SERM)? - CORRECT ANSWER-Increases risk for VTE
Contraindications: history of thrombosis
What are other therapies used to tx hot flashes - CORRECT ANSWER-SSRI - 1st line - Paroxetine or fluoxetine
Velafaxine - SNRI
Megestrol Acetate
Clonidine
Gapapentin
Which tx for hot flashes has an increased risk for breast cancer - CORRECT ANSWER-Megestrol acetate
Osteoporosis tx can be divided into 2 categories: - CORRECT ANSWER-Anti-resorptive and bone formation
anti-resorptive agents - CORRECT ANSWER-medication used to decrease the removal of calcium from bones as a treatment for osteoporosis
Which calcium anti-resorptive tx is the DOC? - CORRECT ANSWER-Calcium carbonate (TUMS, OsCal, Mylanta,Caltrate)
What are the main s/e associated with calcium meds? - CORRECT ANSWER-- Constipation
- Gas (calcium carbonate)
- Stomach upset
What should always be taken with Calcium? - CORRECT ANSWER-Vitamin D increases calcium absorption
Which calcium medication requires an acidic environment? - CORRECT ANSWER-Calcium carbonate requires acidic environment for absorption
— calcium citrate does not
What pt education should be provided to pts when taking a calcium supplement? - CORRECT ANSWER-Can decrease the absorption of the following:
Cipro
Phenytoin
Levothyroxine
Tetracycline
Generally recommended to space these drugs at least 2 hours before or after calcium dosingE
Excess vitamin D (In excess of 5000 IU per day) can cause: - CORRECT ANSWER-- Hypercalcemia
- Hypercalciuria
Which drug interactions need to be considered when taking Vitamin D - CORRECT ANSWER-Decrease vitamin D absorption: Cholestyramine and colestipol should separate by at least 2 hours
Increase vitamin D metabolism: Phenytoin and barbiturates
SERMs (selective estrogen receptor modulators) are used for HRT, but can also be used to prevent osteoporosis and are a great alternative for pts that cant tolerate: - CORRECT ANSWER-Biphosphonates OR women with increased risk of breast cancer
What is the monoclonal antibody used in anti-resorptive tx for osteoporosis? - CORRECT ANSWER-Denosumab (Prolia)
What is the MOA of Denosumab (Prolia)? - CORRECT ANSWER-It targets RANKL, a protein that acts as the primary signal to promote bone removal
leads to inhibition of osteoclast formation, function, and survival
What are serious s/e associated with Denosumab? - CORRECT ANSWER-Common—back pain, arthralgias, fatigue, headache, dermatologic reactions, diarrhea, and nausea
Serious--Hypocalcemia, hypophosphatemia, dyspnea, and skin infections
A part of Risk Evaluation and Mitigation Strategy (REMS) program
Calcitonin is released from thyroid when serum calcium levels are low, so this is used as a replacement tx for osteoporosis. It is a 2nd line tx because - CORRECT ANSWER-It is less effective then bisphosphonates
Bisphosphonates MOA - CORRECT ANSWER-Pyrophosphate analogs; bind hydroxyapatite in bone, inhibiting osteoclast activity.
Decreases bone reabsorption
What are other indications for Bisphosphonates - CORRECT ANSWER-Other indications: Paget disease of bone
Hypercalcemia Osteolytic bone lesions of metastatic cancer
What drugs are under the Bisphosphonates class? - CORRECT ANSWER-Riserdronate
Ibandronate
Zolendronic acid (relcast, IV only)
What are main s/e of Bisphosphonates? - CORRECT ANSWER-S/E for ALL:
-Nausea
- Abdominal pain
- Dyspepsia
GI irritation:
Perforation
Ulceration
Bleeding
- Flu-like symptoms, fever, pain in muscles or joints, and headache (IV only)
- Fractures- Osteonecrosis of the jaw
-Few reports with IV bisphosphonates
What are the preventive indications and tx indications for Bisphosphonates? - CORRECT ANSWER-Prevention:
- Postmenopausal osteoporosis- Glucocorticoid-induced osteoporosis
Treatment:
- Postmenopausal osteoporosis
- Glucocorticoid-induced osteoporosis
- Osteoporosis in men
What is contraindicated in bisphosphonates? - CORRECT ANSWER-Drug Interactions:
Calcium supplements and antacids decrease the absorption of bisphosphonates and should not be taken at least 2 hours or before
Contraindications
CrCl < 35 ml/min for alendronate
CrCl <30 ml/min for risedronate
What are the 2 bone formation medications? - CORRECT ANSWER-Teriparatide and Fluoride
What is the MOA for bone formation therapies - CORRECT ANSWER-Hyperparathyroidism leads to osteoporosis, BUT therapeutic doses given for a shorter period of time stimulates bone formation
Ostosarcoma is a BBW for which drug? - CORRECT ANSWER-Bone formation therapies (Teriparatide + fluoride)
Bone formative therapy may have a rapid loss following cessation, what should be prescribed post therapy? - CORRECT ANSWER-May have a rapid loss of bone following cessation of therapy—should be followed by a bisphosphonate or other antiresorptive agent
What is the main factor affecting uptake of inhaled anesthetics? - CORRECT ANSWER-Concentration of inspired gas
How is dose or potency defined for a gas? - CORRECT ANSWER-Minimum Alveolar Concentration: essentially an ED50 - vol %1.2 % (isoflurane) - 6.0% (desflurane) - 105% (N2O)
A higher MAC = a lower potency drug
Each inhaled agent has a different blood-lipid solubility, defined as blood:gas partition coefficient (ratio), so a smaller ratio means what? - CORRECT ANSWER-Smaller ratio = more rapid onset + recovery ;
MAC = 2.0 = Very Potent;
Want a low blood solubility so it can rapidly absorb into the brain
Why is N2O often mixed? - CORRECT ANSWER-Speeds onset of volatile by "second-gas" and "concentration" effects ; Spares cost and adverse effects of volatile
Smoothens course of anesthesia, maintains protective reflexes (since N2O doesn't act on GABA + analgesia properties)
What is the "second gas effect" - CORRECT ANSWER-High volume of N2O transfers rapidly across alveolus, leading to a concentration of remaining alveolar gases (volatile agent, N/O2), ↑ driving pressure of volatile agent into the blood ;
Volatile agent is carried in with high movement of high concentration of No2
What is the "concentration effect"? - CORRECT ANSWER-Loss of volume leads to an augmentation of ventilation; providing a higher concentration of N2O or volatile agent further increases effect (concentration effect) ;
Increase in relative percentage in the alveolar sacs to help carry volatile agent across
So what happens when the anesthetist stops administering the anesthetic gas or vapor? - CORRECT ANSWER-the concentration gradient is reversed and the drug moves down the concentration gradient to be eliminated almost exclusively by exhalation ;
Put mask on 100% oxygen to prevent diffusional hypoxia
The least soluble/ high volume agents are eliminated - CORRECT ANSWER-Most Rapidly!
Rapid elimination of high volume of N2O leads to - CORRECT ANSWER-diffusional hypoxia
APPLY O2 by mask during initial re-equilibration period
What is so great about the new inhaled anesthetics? - CORRECT ANSWER-Regarding metabolism, this is limited with the newer agents, consequently they are not associated with some of the hepatotoxic effects seen with earlier agents like halothane; Newer drugs don't have any issues with metabolism
IV Anesthetics undergo what type of metabolism? - CORRECT ANSWER-Ultimately, drugs undergo hepatic metabolism via CYP/UGT or ester hydrolysis to inactive products which are eliminated in the urine
What is a life-threatening adverse drug reaction seen with anesthesia? - CORRECT ANSWER-Malignant Hyperthermia = autosomal dominant disorder of skeletal muscle
How do anesthetics trigger malignant hyperthermia? - CORRECT ANSWER-uncontrolled calcium release from the sarcoplasmic reticulum (SR) through the ryanodine receptor (RYR1), causing a rapid and sustained rise in myoplasmic calcium. The high intracellular calcium activates calcium pumps at the SR and the sarcolemma to reuptake calcium into SR or to transport it into the extracellular space respectively. The energetic cost to regain cellular calcium control causes a need for ATP, which in turn produces heat. Muscle membrane integrity is compromised leading to hyperkalemia and rhabdomyolysis
What was determined to be the main culprit of malignant hyperthermia? - CORRECT ANSWER-Succinylcholine & ALL VOLATILE ANESTHETIC AGENTS
now labeled NOT for routine use in children
What is the tx for malignant hyperthermia? - CORRECT ANSWER-antrolene [Dantrium] + AVOID Ca2+ channel blockers!
stop giving trigger agent, hyperventilate with O2
correct hyperkalemia and acidosis, cool core temperature
In ~25% of cases, the condition may re-emerge within 36 hr
Monitor in ICU; continue dantrolene for 24 hr
What is the order of loss in regards to local anesthetics? - CORRECT ANSWER-ORDER OF LOSS: PAIN - TEMPERATURE - TOUCH - PRESSURE
What happens when the drug wears off, what is the order? - CORRECT ANSWER-When the drug effects wear off, functionality reappears in the reverse order; Pressure --> Touch --> Temp --> Pain
In order to block a myleniated nerve what needs to occur? - CORRECT ANSWER-Must block 3 successive nodes of Ranvier to produce block in a myelinated nerve
How can bulky local anesthetic physically reach the sodium channel binding site? - CORRECT ANSWER-the sodium channel binding site when the channel is either in the activated or in the inactivated state.
Given that the activated state is so transient, the majority of drug binding takes place with open inactivated sodium channels.
Why is tissue pH important? - CORRECT ANSWER-An acidic environment (pH < pKa) means most drug is ionized and unable to access the nerve membrane to reach active site inside Na+ channel
If the extraneural pH declines, as it would in areas of tissue inflammation,how would this impact absorption? - CORRECT ANSWER-How much of a drug application is capable of passing rapidly across the nerve to provide clinical effect
What happens if there is a inherited BCHE gene mutation (autosomal recessive) or acquired BCHE mutation? - CORRECT ANSWER-DEFICIENCY impacts succinylcholine - short-acting NM blockerPseudocholinesterase deficiency often is first suspected after an episode of prolonged respiratory paralysis following general anesthesia
How would you test for BCHE gene mutation? - CORRECT ANSWER-Enzyme testing uses butyrylthiocholine as a substrate and dibucaine as a wild-type enzyme inhibitor to yield a "dibucaine number," a measure of enzyme capacitySubstrate-impregnated test paper
In the event of significant systemic toxicity occurring with local anesthetic exposure, what is the tx? - CORRECT ANSWER-Administration of lipid emulsion shown to "rescue" patients from bupivacaine toxicity
What 2 considerations should be discussed with pts regarding anesthetics? - CORRECT ANSWER-Potential sedation - warn about driving
Acute angle closure glaucoma [Show Less]