Clinical Fun Facts Flashcards
Drugs that INCREASE calcium
Thiazides, Ca, Vit D
Drugs that DECREASE calcium
heparin, bisphosphonate, loop diuretics
Drugs that DECREASE Mg
PPIs, loop diuretics
Drugs that INCREASE potassium
AE/ARB, K-sparing diuretics, aliskiren
Canagliflozin
Cyclosporine/tacrolimus
Enzalutamide
Drugs that DECREASE sodium
SSRIs, loops, carbamazepine, oxcarbazepine
Drugs that DECREASE bicarbonate
topiramate
Drugs that INCREASE bicarbonate
loops
The major CYP3A4 Inducers
St John's wort Phenytoin Oxcarbazepine Rifampin Carbamazepine Smoking Phenobarbital
The major CYP3A4 inhibitor
Protease inhibitors Azoles Cimetidine, cyclosporine, clarithromycin Macrolides (not azithro) Amiodarone Non-DHP CCBs Grapefruit
Agranulocytosis means???
Decrease in multiple cell lines
Gaussian distribution
NORMAL distribution
__ % of data within 1 SD
68%
Type I error is false negative or false positive?
False positive (a)
Type II error is false negative or false positive?
False negative (B)
Relative risk v relative risk reduction
RR = rate in treatment v rate in control RRR = 1 - RR (% less likely in treatment group)
Odds ratio
Odds of outcome WITH prior exposure v WITHOUT prior exposure
Expected/unexpected (so exposure+ x no exposure neg/exposure- x no exposure+)
Sensitivity
# true positive/#w/condition Good sensitivity = no false negatives
Specificity
# true negative/# without condition Good specifity = no falsae positives
Case control study??
Patients with a disease compared to those without the disease (retrospective)
Cohort study??
Patients with exposure compared to those without exposure (prospective!)
Which is better - cohort study or case control?
Cohort b/c it is prospective
Cost minimization?
Equal outcomes so which one is cheapest
Cost-benefit analysis?
Benefits - costs –> but the benefits have to be measured in dollars
Cost-effectiveness analysis?
Which gets the best outcome per dollar - but both have to have the same outcome measurement
Cost-utility analysis?
Assesses outcomes including quality of life/morbidity assessment
Which pharmacoeconomic analysis is most commonly used?
Cost-effectiveness analysis
Antipsychotics do better at treating positive or negative symptoms??
Positive symptoms
Some drugs that cause psychosis?
Anticholinergics Cannabis Dextromethorphan Dopamine agonists (Sinemet, Requip, Mirapex) Interferons Stimulants Steroids
Invega Sustenna (drug and timeframe)
Paliperidone - q4weeks
Abilify Maintenna (drug and timeframe)
Aripiprazole - q4weeks
Risperdal Consta (drug and timeframe)
Risperidone - q2weeks
Haldol Decanoate (drug and timeframe)
Haloperidol - q4weeks
Invega Trinza (drug and timeframe)
Paliperidone - q12weeks
Only after 4 months on Sustenna
Black-box warnings for all of the antipsychotics?
Worsening symptoms in patients with dementia
Stroke
Chlorpromazine - what potency?
Low potency
Thioridazine - what potency?
Low potency
Side effect of thioridazine
QTc prolongation
Side effect of loxapine
bronchospasm
Loxapine potency?
Moderate potency
What is the difference between ADEs for high and low potency antipsychotics?
High potency - moderate sedation and EPS
Low potency - more CNS effects and anticholinergic effects
Haloperidol - what potency?
High potency
Fluphenazine - what potency?
High
Thiothixene - what potency?
High
Trifluoperazine - what potency?
High
Perphenazine - what potency?
Moderate
Which of the T-drug antipsychotics causes QT prolongation?
Thioridazine
What are the EPS effects?
Dystonia Akathisia Parkinsonism Tardive Dyskinesia Dyskinesia
Which of the EPS are irreversible?
tardive dyskinesia (lip smacking)
What population is most likely to experience dystonias?
Young males
How to treat Dystonia?
Diphenhydramine and benztropine
How to treat Parkinsonism?
Anticholinergics or propranolol (for tremors)
How to treat TD?
Stop drug and switch to low risk
How to treat akathisia?
Anticholinergics, propranolol, benzos (b/c akathisia has anxiety)
Non-EPS side effects of antipsychotics?
Leukopenia, neutropenia, agranulocytosis Seizures CV - increased HR, orthostatic hypotension Sexual dysfunction bronchospasms (Loxapine)
Which of the antipsychotics has the most cardiovascular effects?
IV haloperidol
What 2nd gen APs cause the most metabolic effects?
Clozapine, olonzapine, quetiapine
Which 2nd gen antipsychotic has lowest EPS?
Quetiapine
Which 2n gen antipsych causes QT prolongation?
Ziprasidone
Which 2nd gen antipsych increase procalcitonin?
Risperidone and paliperidone
What are the requirements to use clozapine?
Two treatment failures, at least 1 a 2nd generation
How long is an adequate trial of antipsychotics?
4-6 weeks
Tell me about asenapine
Sublingual 2nd gen antipsychotic
Metallic aftertaste
Tell me about aripiprazole
AKA Abilify
Comes in IM long-acting Maintenna
Causes INSOMNIA, anxiety, akathisia
(Only one that’s insomnia)
Tell me about lurasidone
2nd Gen antipsychtoic
Latuda
Neutral metabolic effects
W/food
Tell me about olanzapine
Metabolic effects
CYP3A4 - smoking decreases conc
Sedation
Relprevv q2-4week injection, ODT
What’s special about Relprevv
Olanzapine IM injection - requires monitoring for 3 hours after injection
Tell me about Paliperidone
Invega
Ghost tablets in stools
Increases procalcitonin, EPS
Tell me about quetiapine
Seroquel
Lowest EPS
Metabolic effects, somnolence
Without food or <=300kcal for XR
Tell me about risperidone
Risperdal
EPS, increased procalcitonin levels
Tell me about ziprasidone
Geodon
Increased QTc
Take WITH food
What drug is used for psychosis with PD?
Pimavanserin
What drugs are used for TD?
Valbenazine (VMAT inhibitor)
Deutrabenazine
What are symptoms of neuroleptic malignant syndrome?
Hypertension, muscle rigidity, increase HR/BP/RR
Treatment of neuroleptic malignant syndrome?
Stop drug
Cool off with ice
Dantrolene/benzos for muscle relaxation
Progestin-only pills have what administration requirements?
Within 3 hours of the same time - or else need 48 hours of alternative contraception
What populations are good for POPs?
After childbirth - can be used with breastfeeding
Patients with migraine w/aura (estrogen contraindicated due to stroke risk)
What is the active ingredient in Depo-Provera
Medroxyprogesterone
what is unique about Xulane?
Has higher AUC –> increased thrombotic risk
Contraindications of estrogen?
h/o DVT/stroke, migraine w/aura, breast/ovary/liver cancer
uncontrolled htn
What’s special about drospirenone?
Progestin component - with highest VTE risk, lowest water retention/bloating, increases K+
ADE of medroxyprogesterone
Decreased BMD (supplement with Ca/Vit D)
How long medroxyprogesterone be used?
3 years
How long should back-up contraception be used after starting COC?
7 days
or 0 days if started w/in5 days of menses
What is the weight limit for the patch?
198 pounds
Which contraceptive needs back up x 1 week unless started on day 1 of menses?
Nuvaring
Water or oil-based lubricants?
water
What are 3 emergency contraceptives?
Paragard (within 5 days)
Plan B (levonogestrel x1 or x2 within 3 days or 5 off-label)
Ella (Ulipristal acetate within 5 days)
ADEs of Plan B
NAUSEA
ADEs of Ella
HA, nausea, abdominal pain
Delays ovulation - so period can be weird
1st-line treatment for female infertility
Clomiphene - SERM
2nd-line treatment for female infertifility
Gonadotropins (ie FSH/LH)
What people need a reduction in PDE-5 starting dose?
> 65 years old
Taking CYP3A4 inhibitor
Have renal/liver dysfunction
—50% reduction
Time before sex of the PDE-5 inhibitors?
Sildenafil: 60 minutes
Tadalafil: 30 minutes
Aranafil: 15-30 minutes
Vardenafil: 60 minutes
Starting doses of PDE-5 inhibitors
Aranafil: 50-100 mg
Tadalafil: 10mg
Sildenafil: 50mg
Vardenafil: 10mg
What are the ADEs of PDE-5 inhibitors?
Headache, flushing, dizziness Priapism Hearing loss Vision loss Hypotension Impaired color discrimination Back pain
What class is aloprostadil?
PGE1
Storage requirement for aloprostadil?
Fridge
Treatment of hypoactive sexual desire disorder?
Flibanserin (Addyi)
Contraindication to Flibanserin
Alcohol
Cyp3a4 inhibitors
hepatic impairment
ADEs of filbanserin
Hypotension, fainting
What BUN:SCr ratio is dehydration
> 20:1
Which diuretic class increases calcium?
Thiazides
What drugs cause kidney disease?
Polymyxin Loop diuretics Vancomycin Aminoglycosides NSAIDs Amphotericin Radiographic dye Tacrolimus/cyclosporine Cisplatin
Who gets ACE-i’s and ARBs?
DM + Proteinuria (albuminuria >30)
HTN + Proteinuria
CKD
What %SCr increase after starting ACE/ARB needs to stop the drug?
30% increase
Which drugs needed renal adjustments?
Beta-lactams Fluconazole FQ Xarelto H2RAs metoclopramide Bisphosphonates
When is nitrofurantoin contraindicated?
CrCl <60mL/min
What drugs are contraindicated at CrCl <50mL/min?
IV voriconazole
TNF-DF
What drugs are contraindicated at CrCl <30mL/min
TNF-A
Rivaroxaban, dabigatran
NSAIDs
What drugs are contraindicated at eGFR <30?
Metformin
SGLT2-i’s
Which of the phosphate binders isn’t systemically absorbed?
Sevelamer (Renvela)
ADEs of calcium-based phosphate binders?
Increased calcium
ADEs of aluminum-based phosphate binders?
Al accumulation; dialysis dementia
ADEs of aluminum/ca free phosphate binders?
Contain iron - Ferric citrate and lanthanaum carbonate
Ferric citrate has iron absorption
N/V/D, constipation
Which Vitamin D is made in skin?
Cholecalciferol (D3)
Which vitamin D is made in plants?
Ergocalciferol (D2)
What is calcitriol?
Vitamin D3
What is cinacalcet?
calcimimetic that decreases PTH
Does cinacalcet increase/decrease Ca?
Decrease
Do Vit D analogs increase/decrease Ca?
Increase
What are requirements for using ESAs?
HgB <10 and must stop before >11 b/c of increased VTE risk
Drugs that increase K+
Drospirenone ACEs/ARBs/aliskiren Aldosterone antagonists Transplant drugs Bactrim Canagliflozin
Treatment for hyperkalemia
- Calcium gluconate (stabilize mycoardium)
- Push K intracellular
Insulin + Dextrose
Nebulized albuterol
Bicarbonate - Remove K+
Loops
Dialysis
Keyexalate/Na polystyrene sulfonate
(separate these from other drugs)
What bicarb level is metabolic acidosis
<22mEq/L
How to treat metabolic acidosis
Sodium bicarbonate
Sodium citrate
(Monitor Na)
What BMI indicates that a patient can use weight-loss therapy?
BMI >30
BMI >27 w/weight-related comorbidity
Tell me about Qsymia
Phentermine/Topiramate
Increase HR, hyperthyroidism, glaucoma
Taper due to seizure risk
Tell me about Contrave
Naltrexone/bupropion
BBW: Suicidal thinking in adolescents
CI: Opioid use, uncontrolled HTN, seizure disorder, anorexia, pregnancy
Caution w/psych disorders
Tell me about Belviq
Lorcaserin
Serotonin agonist
Warning for NMS, serotonin syndrome, hypoglycemia
Tell me about Saxenda
Liraglutide
Pancreatitis and medullary thyroid cancer and hypoglycemia and nausea
Tell me about Orlistat
Alli/Xenical
Alli available OTC
Requires 30% fat reduction from regular diet
ADEs: GI (flatus and fatty stools)
Requires ADEK supplement (but separate by 4 hours)
Tell me aout other sympathomimetics for weight loss
CI with CV disease, hyperthyroidism, glaucoma, pregnancy, drug abose
ADEs: HR/BP, agitation
How long can stimulant weight loss drugs be used?
12 weeks maximum
What sreening tool is used for Alzheimer’s and what score indicates cognitive impairment?
MMSE
Score <24
What natural products are used in alzheimer’s?
Ginkgo
Vitamin E
Vitamin D
ACHe Inhibitors ADEs
Decreased HR
Nausea (take in evening or use rivastigmine patch/ODT donepezil)
Insomnia (take in morning)
T/F: Memantine capsules can be sprinkled on food
TRUE – even though XR
What is the treatment order for Alzheimer’s?
- ACHe Inhibitors (ie donepezil)
2. Can add memantadine for mod-severe alzheimer’s OR can use memantadine as monotherapy
What are the acetylcholine esterase inhibitors?
Rivastigmine (Donepezil)
Donepezil (Aricept)
Galntamine (razadyne)
Name of donepezil + memantadine?
Namzaric
Which systemic steroid is used to treat Addison’s Disease?
Fludrocortisone
What are symptoms of Cushing’s syndrome? (the ones you don’t normally remember)
Glaucoma Acne Cataracts Hypothyroidism Stretch marks Poor bone health Hirsuitism Irregular periods
Equivalency of Steroids
Cortisone: 25 (short-acting) Hydrocortisone: 20 Prednisone: 5 (Intermediate-acting) Prednisolone: 5 Triamcinolone: 4 Methylprednisolone: 4 Dexamethasone: 0.75 (long-acting) Betamethasone: 0.6
What dose of systemic steroid causes immunosuppression?
20mg prednisone/day for 2 weeks
or >2mg/kg/day for 2 weeks
First-line treatment for RA
Methotrexate
ADEs/warnings of methotrexate
Trexall
Hepatotoxicity, teratogenic, mucositis/stomatitis, immunosuppression
N/V/D, alopecia, arthralgia/myalgia
Avoid alcohol
What does folate do with MTX?
Reduces hematologic toxicities
How is MTX dosed for RA?
weekly!
Hydroxychloroquine ADEs/BBW?
Irreversible retinopathy
Sulfasalazine ADEs?
Yellow/orange discoloration of skin/urine
SULFA allergy
Leflunomide ADEs?
Teratogenic - requires REMS and 2 birth controls
Hepatotoxicity
How long do you have to wait before conceiving after on leflunomide?
2 years - unless you use cholestyramine/activated charcoal to increase clearance
What are the anti-TNF DMARDs?
Etanercept (Enbrel) Certolizumab Pegol (Cimzia) Adalimumab (Humira) Infliximab (Remicade) Golimumab (Symponi)
Which anti-TNFs are IV?
Golimumab and Remicade
Both require filter
Remicade requires NS
Which anti-TNFs can only be given with MTX?
Remicade and Symponi
Which Anti-TNF SC is given weekly?
Enbrel
Which Anti-TNF SC is given monthly?
Golimumab
What are the warnings for all anti-TNFs?
Demyelinating disease, reactivation of Hep B, worsening HF, hepatotoxicity, DILE Latent TB infections Malignancies Serious infections Avoid live vaccines
Where can the anti-TNFs be injected?
Humira: Abdomen/thigh
Etanercept/golimumab: abdomen, thigh, upper arm
What class are tofacitinib and baricitinib?
JAK inhibitors
ADEs of infliximb?
Other Anti-TNFs + infusion reaction (premedicate with APAP, antihistamine, and steroid) and delayed HSR
Other Biologic DMARDs for RA (besides TNFs)
Rituximab (anti-CD20, use with MTX, pre-medicate) Anakinra (IL-1 antagonist) Abatacept (CD80/CD86) Tocilizumab (IL-6) Sarilumab (IL-6)
Which RA meds require screening for Hep B reactivation before use?
Rituximab
Anti-TNF
Malar butterfly rash is a sign of what?
Systemic lupus erythematous (SLE)
Drugs that induce lupuse
Methimazole Methyldopa Minocycline Isoniazid TNF inhibitors Terbinafine Hydralazine Procainamide Propylthiouracil Quinidines
Belimimumab is used for???
Lupus
What vaccines in asthmatic kiddos?
Flu and Pneumovax-23
Prevnar-13 only if on high-dose steroids
Using albuterol more than _____ means step up in therapy needed
2 times/week
How many inhalations per albuterol inhaler?
200
except Ventolin can have 60
What is Xopenox?
Levalbuterol (r-isomer of albuterol)
ADEs of ICS?
Dysphonia, thrush
Which ICS can be nebulized?
Pulmicort (budesonide)
Serevent?
Salmterol
Spiriva?
Tiotropium
Symbicort?
Budesonide/formoterol
Advair?
Fluticasone/salmeterol
Dulera?
Mometasone/formoterol
Breo?
Fluticasone/vilanterol
Which MDIs should NOT be shook?
QVAR, Respimat
Dose of montelukast (by age)
Adult: 10mg
Child 1-4: 4mg
Child 5-14: 5mg
ADE of LTRAs?
neuropsychiatric events
How can montelukast granules be given?
- straight into the mouth
- into 5mL of breast milk/formula
- Into spoonful of carrots, rice, apple sauce, or ice cream
what are the LTRAs(drugs)?
montelukast
zafirlukast
zileuton
Theophylline MOA?
Blocks phosphodiesterase to increase cAMP
Thophylline TDM?
Peak of 5-15mcg/mL
Thophylline toxicity
Arrhythmias, vomiting, seizures
What drugs can increase theophylline?
Cipro
Zafirlukast
Zileuton
What drugs can decrease theophylline?
CYP3A4 inducers, ritonavir, high-protein diet and charbroiled meat
Omalizumab MOA? and place in therapy?
IgE binding inhibition - allergic asthma
What is omalizumab counseling note??
Has to be given in HEALTH CARE SETTING every single time
What are IL5 antagonists for?
Eosinophilic asthma
T/F: LABAs can be used for exercise-induced asthma
True - use salmeterol 30 minutes before exercise
T/F: Spacers help prevent thrush
True
PFM directions for use (when to use)
In the morning BEFORE taking medications
How to use PEFR?
Compare personal best to daily - need treatment if less than 80% of PB
How long can an open package of Pulmicort Respules last?
2 weeks
Washing MDIs?
Warm water - but NO water for symbicort/dulera
Washing DPIs?
No water!
When should you refer kiddos to urgent care (what temperature)?
<3 months: 100.4
3-6 months: 101
>6 months: 103
What is a healthy APGAR store and when is it measured?
1 minutes and 5 minutes after birth
Healthy: 7-10
What medication is given at birth to prevent bleeding?
IM Vitamin K
What can help PDA close?
NSAIDs given within 14 days of birth
Respiratory distress syndrome is caused by deficiency of _____ which should be replaced in most babies born
Surfactant
<35weeks
What is nuchal rigidity?
Inability to bend the neck
How can you diagnose meningitis n young children?
Don’t have typical symptoms
Require lumbar puncture
Empiric meningitis treatment in neonates?
Ampicillin + cefotaxime or gentamicin
Which medication is not use in neonates due to bilirubin-induced brain damage?
Ceftriaxone
Ceftriaxone use is contraindicated with concurrent use of what med?? Why?
IV calcium - precipiates and causes embolisms
How to treat RSV?
Usually supportive care
Severe w/underlying condition = inhaled ribavirin (Viraozole)
what medication is for prevention of RSV disease?
Palivizumab (Synagis
Who gets RSV prophylaxis?
Premature infants (<29 weeks or <32 weeks with chronic lung disease), children with select medical conditions (heart conditions) during RSV season (same as flu)
Palivizumab administration?
IM (into thigh) monthly
Max # of RSV doses?
5
What is croup?
Viral infection that causes stridor, cough, hoarseness
How is croup treated?
Systemic steroids
Nebulized racemic epinephrine if needed
What medication is used for nocturnal enuresis?
Desmopressin
What med for intestinal gas in infants?
Simethicone drops
OTC cough and cold meds should not be used in children
2 years old
What age can APAP be used?
0+
What age can NSAIDs be used?
<6 months
First-line constipation in kids?
PEG for intermittent constipation
Glycerin suppositories for babies
Pediatric dose of APAP?
10-15mg/kg/dose every 4-6 h
Pediatric dose of ibuprofen?
5-10mg/kg/dose every 6-8h
What is first-line treatment for tick-borne Rickettsial disease?
Doxycycline (even in kids)
Topical teething agents with ___ are not recommended in <2 year old
Benzocaine
Measles symptoms
Koplik spots in mouth; maculopapular rash
How is measles spread?
airborne
Difference by Type A and Type B interactions?
Type A: Predictable and dose-dependent
Type B: Unpredictable and not dose-dependent
4 types of drug allergies
Type I: Immediate, IgE-mediated (hives, anaphylaxis, angioedema)
Type II: minutes-hours after exposure
Type III: Immune-complex reactions (hours to weeks)
Type IV: Delayed hypersensitiity reactions (48h-weeks)
What type of drug allergy is PPD?
Type IV
What type of drug allergy is anaphylaxis?
Type I
What type of allergy is hemolytic anemia?
Type II
Who develops REMS?
Manufacturer (approved by FDA)
What are MedGuides and when should they be dispensed?
Patient-friendly handouts
At each fill - original and refill
Not required inpatient
What scale is used to determine the likelihood an event was caused by a drug?
Naranjo Scale
What is TTP?
Blood clots forming throughout body – causes bleeding/purpura on the skin
What drugs cause TTP?
Clopidogel and Ticlopidine
What drugs to avoid with peanut and soy allergies?(3)
Propofol
Clevidipine
Progesterone
What drugs/vaccines to avoid with egg allergy (4)
Propofol
Clevidipene
Yellow fever vaccine
Flu vaccines (FluBlok has no egg, others can still be used)
What drugs contain sulfa (that I didn’t already know) - 3?
Acetazolamide
Zonisamide
Darunavir
(NOT sulfate)
Does desenstivation cure an allergy?
Nah
What is the name of the EpiPen with voice instructions?
Auvi-Q
BBW of rituximab?
Infusion reactions
Main treatment for MS?
Glatiramer acetate (Capoxone) INterferon Beta products
Which MS treatment for pregnancy?
Glatiramer acetate
ADEs of glatiramer acetate?
Injection site reactions, dyspnea, diaphoresis
ADEs of interferon beta products?
psychiatric disorders, injection site necrosis, increased LFTs, thyroid dsyfunction, flu-like symptoms (pre-medication)
Which interferon can be injected q2weeks?
Peginterferon B-1A (Plegridy)
ADEs of flingolomid (Gilenya)
Decreased HR
Macular edema, hepatotoxicity, myelosuppression
How often are TNF inhibitors administered?
Either weekly (etanercept) or every other week (adalimumab and certolizumab)
First-line treatment for Raynaud’s?
CCBs (nifedipine)
Sjogren’s syndrome treatment - dry eyes?
Artificial tears, Restasis, Lifitegrast
Sjogren’s syndrome treatment - dry mouth?
Xylitol gum, lozenges, antimicrobial mouthwash, oral muscarinics (pilocarpine)
Treatment for psoriasis
- Phototherapy
- Topical: steroids, tazarotene (Retinoid), coal tar, calcipotriene (Vit D analog), anthralin, topical calcineurin inhibitors
- Systemic: Retinoid, PDE4 inhibitors, IL antagonists, MTX, hydroxyurea
Which topical psoriasis options to go on face?
Steroids and calcineurin inhibitors
Natural products used in anxiety (4)
Kava
St John’s Wort
Valerian
Passion flower
1st line treatment for anxiety?
SSRIs/SNRIs (takes 4 weeks)
2nd line treatment for anxiety? (3)
Buspirone (takes 2-4 weeks)
TCAs
Hydroxyzine
Can buspirone be used with MAO inhibitors?
Nah
Which benzodiazepines are preferred in elderly patients? Why?
Lorazepam
Omazepam(?)
Temazepam
(LOT)
Inactive metabolites
Which benzos preferred for anxiety?
Clonazepam Lorazepam Alprazolam Diazepam (CLAD)
Antidote for benzos?
Flumazenil
Toxicity of benzos?
Ataxia
Which benzo comes IM?
Midazolam
What drugs decrease seizure threshold?
Abx: PCNs, FQs, carbapenems
Pain: Meperidine, tramadol
Psych: Buspirone, clozapine, lithium
Misc: chantix, theophylline
What are ADEs of all antiepileptic drugs?
BBW for suicidal thoughts
Osteoporosis/decreased BMD (take Ca/VitD)
Teratogenicity (take folate)
CNS depression
Equation for phenytoin corrected?
Phenytoin = phenytoin/(0.2*alb+0.1)
Which AEDs have worst side effects in kids?
Lamotrigine
Topiramate/zonisamide
Which drugs increase GABA?
benzos, valproic acid
Which drugs block Na channels?
carbamazepine, phenytoin, lamotrigine, topiramate
Which drugs block Ca channels?
Keppra, gabapentin, ethosuximide
What are the broad spectrum AEDs?
Lamotrigine
Valproate
Keppra
Topiramate
Lamotrigine ADE
SJS (titrate dose)
Levetiracetam ADEs
psychiatric events, somnolence, fatigue
Topiramate ADEs
Hyperammonemia Oligohydrosis Metabolic acidosis Weight loss/anorexia Fetal toxicity nephrolithiasis Closed-angle glaucoma
Volpric acid ADEs
Fetal harm (decreased IQ) Hyperammonemia Weight gain Thrombocytopenia Alopecia Hepatotoxicity
TDM for valproic acid
50-100
TDM for carbamazepine
4-12
TDM for phenobarbital
20-40
TDM for phenytoin
10-20
Carbamazepine ADEs
skin reactions, aplastic anemia, agranulocytosis, SIADH, fetal harm
What HLA test for carbamazepine/oxcarbazepine?
HLA-B*1502
Lacosamide ADE
QT prolongation
Oxcarbazepine ADEs
hyponatremia, SJS?TEN
Phenobarbital ADE
Tolerance, dependence, hangover effect, resp depression
Prodrug of phenobarbital
Primidone
Max Phenytoin/Fosphenytooin infusion rate
50mg/min and 150PE/min
ADEs of phenytoin
SJS, fetal harm, extravasation(Purple Glove)
Phenytoin toxicity
Nystagmus, diplopia, ataxia
Chronic phenytoin ADEs
hepatotoxicity, gingival hyperplasia, hair growth
what med used for absence seizures?
ethosuximide (Zarontin)
ADEs of felbamate?
Hepatic failure, anemia
ADEs of zonisamide
sweating, weight loss, nephrolithiasis
ADEs of vigabatrin (sabril)
Vision loss
Natural products for hypertension
Fish oil, coenzyme Q10, L-arginine, garlic
What BP cut-off for treatment in pregnancy?
160/105
Drugs to use in HTN in pregnancy
Labetalol
Nifedipine XR
Methyldopa
CrCl needed for thiazide
> 30mL/min
ADEs of thiazides
increased LDL/TG/BG
which antihypertensives decrease lithium clearance?
Thiazides
ACEs/ARBs
ADEs of DHPs
gingival hyperplasia
When should nifedipine IR be used?
NOT after heart attack
Really only in pregnancy
What’s up with clevidipine?
DHP CCB
Has soybean/eggs
Lipid emulsion
12h BUD
What is the caloric content of clevidipine?
2kcal/ml
Contraindication to ACEs?
Bilateral renal artery stenosis
How long washout for ACEs/ARBs and neprilysn?
ACEs: 36 hours
ARBs: none
Which beta-blockers need to be with food?
Carvedilol
Metoprolol tartrate
what is the conversion of metoprolol tartrate PO to IV?
1:2.5
What is the conversion of carvedilol to carvedilol xr?
3.25:10
MOA of nebivolol?
B1 and NO
Which Beta blockers are intrinsic sympathomimetic activity?
Acebutalol, pindolol, peributolol (do not use post-MI)
ADEs of alpha-2 agonists?
Rebound HTN, dry mouth, dizziness, constipation, bradycardia, hypotension
Methyldopa contraindicated with what med?
MAO inhibitors
Methyldopa ADEs
Hemolytic anemia, DILE
How often is clonidine applied?
weekly
What are the vasodilators?
Hydralazine and minoxidil
minoxidil ades
fluid retention, increased HR, hair growth
What is aliskirenin
Direct reinin inhibitor (like ACEs/ARBs)
How much to decrease BP in first in hour in hypertensive emergency?
25%
Age of RFs for ACS?
M>45 F>55 FH: M<55 F<65
When should cardiac enzymes be checked?
Onset and 6 hours later
PCI should be performed within __ hours
2hours
What meds are used post-MI?
MONA
GAP
(GLP antagonists, P2Y12 inhibitors, anticoagulants)
What are the glycoprotein IIb/IIIa antagonists?
Abciximab
Eptifibatide
Tirofiban
What meds to avoid after ACS?
NSAIDs and IR nifedipine
Which P2Y12 causes dyspnea?
Ticagrelor
Which P2y12 needs to stay in original container?
Prasugrel
Which P2y12 is contraindicated in stroke?
prasugrel
How to transition from cangrelor to oral P2y12?
Give loading dose of oral after discontinuing
Dose of alteplase in ACS?
100mg
Drug interaction with clopidogrel?
CYP2C9 inhibitors - omeprazole and esomeprazole
How long to continue beta-blocker after ACS?
3 years
What is simple compounding?
adding ingredient per manufacturer (reconstituting)
What is the sensitivity requirement for torsion balance?
within 5mg;
Min Wt Quan = SR/acceptable error rate
When do use each type of mortar/pestle?
Glass: liquids
Porcelain: Blending powders
Wedgewood: Crushing dry crystals
What 2 types of documentation for nonsterile compounding?
Master formulation record (recipe) Compounding record (products including lot #'s, Rx#, etc)
What to do if no expiration date?
pharmacist assigns one within the next 3 years
Comminution
Decreasing particle size by grinding/crushing/vibrating
Trituration
Mix thoroughly (grinding or shaking liquid)
Levigation
Grinding by adding small amount of liquid
Pulveration by intervention
Dissolving crystal in water
Solute v suspension v emulsion
Solute: dissolved in solvent for homogenous mixture
Suspension: Solid dispersed in liquid
Emulsion: liquid dispersed in liquid
BUD of non-sterile compounding
Oral liquid: 14 days
Topical liquid: 30 days
Nonaqueous: 6 months
What causes migiraine?
Vasodilation
What medication is contraindicated in patient with aura?
Estrogens (increased stroke risk)
Natural products used for migraine - 7
Caffeine Magnesium Butterbur Coenzyme Q10 Feverfew peppermint Riboflavin
Drug classes used for migraines
APAP, NSAIDs, caffeine
Triptans
Ergotamines
Opioids/butalbitol/tramadol
Triptan mechanism
5HT-1 agonist (vasoconstriction)
Contraindications to triptans
Cerebrovascular disease, uncontrolled HTN, ISHD, PVD
How many doses of triptans allowed?
2, then must wait 24 hours
Triptan with long half-life?
Frovatriptan (Frova) and naratriptan (Amerge)
Which triptans can be used in kids
Almotriptan, zolmitriptan, treximet, rizatriptan
Which triptans are CI with MAOIs?
Sumatriptan, rizatriptan, zolmitriptan
ADEs of triptans
high BP, parasthesia, triptan sensations (heaviness in chest)
Rizatriptan DF
Tablet and ODT
Sumatriptan DF
SC, nasal spray, nasal powder
Zolmitriptan
ODT, nasal spray
Treximet
Sumatriptan + naproxen (dispense in original container)
Ergotamine mechanism
Non-selective serotonin agonists
Ergotamine contraindications
CYP3A4 inhibitors, ISHD, uncontrolled HTN, pregnancy
Ergotamine ADEs
Peripheral ischemia, cardiovascular effects
DF of dihydroergotamine
injection and nasal spray
Schedule of butalbitol products
III (abuse/dependence)
Which of the nasal sprays do NOT need primed?
Triptans
Who gets migraine ppx?
just has to decrease QoL
What meds are used for migraine PPX
Beta-blockers Topiramate Valproate TCAs (amitriptyline) Venlafaxine Erenumab (aimovig) Botox (>15 migraine days/month)
Erenumb mechanism
Calcitonin gene-related peptide antagonist
Aimovig
Erenumab
How many types per week can acute drugs be used?
2-3 weeks
Natural product for acne
Tree oil
Natural product for cold sore
Lysine
OTC acne treatment
Benzoyl peroxide (the best)
Salicylic acid
Azelaic acid
Adapalene
Differin
Adapalene
How long do retinoids take to work?
4-12 weeks
ADEs of retinoids
teratogenic and photosensitivity
How to apply retinoids
Pea size all over face for ~20 minutes
Topical antibiotics used for acne
Erythromycin, clindamycin, dapsone gel
Isotretinoin ADEs
Teratogen (requires 2 forms of BC for 1 month)
Dryness
What oral antibiotics for acne?
Minocyclin (Solodyn)
Doxycycline
Alopecia treatment
Finasteride (takes 3 months to work)
Minoxidil
Propecia
Finasteride
Rogane
Minoxidil
Treatment for thinning eyelashes
Bimatoprost (Latisse)
Topical cold sore treatment
Docasanol (Abreva) - OTC
Acyclovir (Zovirax) - Rx
Danduff treatment
SElenium sulfide, pyrithione zind, coal tar
2nd line: Ketoconazole shampoo
Nizoral
Ketoconazole shampoo (A-D is OTC)
Diapar rash treatment
topical azoles, hydrocortisone
Eczema treatment
- moisture
- topical steroids/antihistamines
- topical calcineurin inhibitors or topical PDE-4
- IL-4 (Dupilumab)/oral immunosuppressants
Protopic
Topical tacrolimus
Elidel
Pimecrolimus (topical CNI)
ADEs of topical CNI
Photosensitivity, lymphoma, skin cancer
Fungal skin infection tx
Terbinafine, clotrimazole, ketoconazole
Lamisal AT
terbinafine
Extina
Ketoconazole
Lotrisone
Betamethasone/clotrimazole
Fungal nail infection tx
Terbinafine or itraconazole for a year
How to diagnose fungal nail infection
KOH
Terbinafine ADE
hepatotoxocity
Itraconazole CI
HF
Fungal vaginal infection treatment
Monistat (miconazole) Teraconazole Clotrimazole Butaconazole 1, 3, or 7 days Fluconazole - 1 day
OTC test for vaginal fungal infection
Vagisil Screening Kit
Genital warts tx
Imoquimod
Hemorrhoid treatment
Fiber
Phenylephrine
Hydrocortisone
Witch hazel (for itching)
Preparation H
Phenylephrine
First-line Lice treatment
Pyrethrin (Rid)
Permethrin (Nix)
Lindane ADE
Neurotoxicity (only for refractory lice)
Scabies treatment
Premethrin
Ivermectin
What’s in triple antibiotic ointment
Polymyxin, bacitracin, neomycin
MRSA topical treatment
Mupirocin
Cortisporin
Bacitracin, neomycin, polymyxin B, hydrocortisone
Pinworms tx
Pyrantel pamoate (reese's) - 3 tx over 3 weeks Mebendazole, albendazole
What steroids available OTC?
Hydrocortisone 0.5% and 1%
ADEs of topical steroids
Telangectasia
Rosacea
Skin thinning
Pigment changes
Sunburn SPF requirement
15-30 q2h, reapply after swimming
Topical steroid potency
Clobetasone Betamethasone Mometasone ointment Fluocinonide ointment Fluocinonide cream Mometasone cream Triamcinolone cream hydrocortisone
Clobex
Clobetasone
Diprolene
Betamethasone
Elocon
Mometasone
Lidex
Fluocinonide
Kenalog
Triamcinolone
Cortaid
Hydrocortisone
Concerning weight change for CHF
2-4lbs/day or 3-5lb/week
When to fluid restrict
<1.5L in Stage D
OTC for CHF
Hawthorn
CoQ10
Fish oil
Drugs that worsen HF
IFNs
Class I antiarrhythmics
Itraconazole
TNF inhibitors
Who gets BiDil
AAs or people who can’t use ACE/ARB
When to use ivabradine
HR >70bpm
Which loop has highest ototoxicity?
Ethacrynic acid
Lab changes from loops
Increased BS, TG, cholesterol, bicarbonate
Equivalency of loops
Bumetanide 1 mg
Torsemide 20mg
Furosemide 40mg PO = 20mg IV
Ethacrynic acid 50mg
ADEs of BiDIl
Syncope, tachyphylaxis (requires 10-12 hournitrate free interval)
Digoxin is a ___inotropic and __ chronotropic
Positive inotrope
Negative chronotrope
Digoxin therapeutic range for HF
0.5-0.9
Dig toxicity
N/V, loss of appetite, bradycardia
Dig electrolyte abnormalities
Decrease K, Mg, increased Ca
Corlanor
Ivabradine
Ivabradine ADEs
AF, phosphenes, QT prolongation, HTN
What potassium DF is open capsules?
Micro-K
What Potassium DF is dissolvable tablets?
Klor-Con M
what drugs can cause PAH?
SSRIs in pregnancy and cocaine
Treatment of PAH
Wwarfarin Loops Digoxin CCBs (if vasoreactive responders - NOT verapamil) Vasodilators (if non-responders)
What are the vasodilators for PAH?
Prostacyclin analogs
PDE-5 inhibitors
Endothelin Receptor Antagonists
SGC
Prostacyclin analogues ADEs
Rebound PH when d/c
Jaw pain
Infusion site reaction
What’s important about PG infusion?
Cannot have interruptions in infusion
Flolan (& administration requirements)
Epoprostenol - PG
Protect from light
Ice for stability
ERA ADEs
Embryo-fetal toxicity Hepatotoxicity Decreased HgB/Hct Fluid retention HA
ERA drugs
-sentan
Bosentan
Ambrisentan
Macitentan
Which ERA decreases OC?
Bosentan
What is sGC?
guanylate cyclase stimulator - riociguat (Adempas)
Riociguat ADEs
embryo-fetal toxicity
decreased BP, HA
Riociguat Drug interactions
NITRATES and PDE-5s
What drugs cause pulmonary fibrosis
Amiodarone Bleomycin Dronedarone MTX nitrofurantoin sulfasalazine
Harriet Lane book
Pediatric dosing
Who does NDA approval
Center for Drug Evaluation and Research
Red Book
Drug pricing
Orange book
therapeutic equivalencies
Purple book
biological products/biosimilarities
Pink book
vaccines
Yellow book
International travel
Green book
Animal products
Pink Sheet
Pharma/industry
Red book Pediatrics
Peds ID/vaccinations
Compounding resources (3)
Allen’s
Merck Index
Remington
Sanford Guide
ID
International drug info
Index Nominum
Martindale
USP Dictionary
King Guide
IV drug comptability
Goodman and Gilman’s
Pharmacology
Brigg’s
Pregnancy
Hale’s
Pregnancy
How long to take antihistamines before motion sickness?
30-60 minutes
How long to use scopolamine patch before motion sickness?
4 hours
Does Scop patch needed removed before MRI?
Yes
Scop patch ADE
Pupil dilation, anticholinergic
CI for antihistamines
Glaucoma
What are the antihistamines for motion sickness?
Cyclizine
Diphenhydramine
Dimenhydrinate
Meclizine
Dramamine
Dimenhydrinate
Meclizine
Dramaminen Less Drowsy
Ae limit for promethazine
> 2 years old (and Rx only)
Drugs contraindicated with G6PD deficiency
Chloroquine Dapsone Methylene Blu Nitrofurantoin Primarquine Probenecid Quinidine Quinine Rasburicase Sulfonamide
Drugs affected by albumin
warfarin
phenytoin
valproate
calcium
What is the insulin breakdown product used to tell T1 from T2DM?
C-peptide
Digoxin therapeutic goal for AF
0.8-2
PT is falsely increased by what drug?
Daptomycin
Folate decreased by what drugs?
Phenytoin, phenobarb, MTX, bactrim
Eosinophis indicate what infection
Parasite
What CBC indicates viral infection?
Lymphocytes
FAST means
Face
Arms
Speech
Time
Treatment for ischemic stroke
alteplase
Max dose of alteplase in stroke
90mg
Criteria for giving alteplase
Within 3 hours of symptoms, BP <185/110
Secondary prevention after stroke?
Antiplatelets - aspirin or clopidogrel o rdipyridamole/ASA
What is the most important RF for stroke?
hypertension
Yosprala
Omeprazole + ASA
Aggrenox
Dipyridamole + ASA
Dipyridamole ade
Inhibits adenosine in platelets and increases cAMP
What medication for intracerebral hemorrhage?
Mannitol (to decrease ICP)
What medication for acute subarachnoid hemorrhage?
Nimodipine - prevents ischemia
ROA for nimodipine
Oral - canNOT give IV
Can open capsules to get liquid
What are the different incontinence types?
Urge - from PD/DM/neuropathy
Stress - from laughing/physical exertion
Overflow - from BPH
or MIXED
What muscle causes the symptoms of OAB? What receptors?
Detrusor
M3 receptors
Treatment for OAB?
Kegel exercises
Anticholinergics
B3 agonists
Botox (LAST LINE)
Treatment of nocturia
Desmopressin
What anticholinergic for OAB is not selective?
Oxybutynin
oxybutynin DFs
Patch (Oxytrol), tablet (Ditropan), gel (Gelnique)
What anticholinergic for OAB is non-selective and why does this matter?
Solifenacin, tolterodine, darefnacin, fesoterodine
Fewer CNS effects
Vesicare
Solifenacin
B3 agonist MOA
relaxes detrusor muscle
B3 agonist
Mirabegron (Myrbetriq)
ADEs of Mirabegron
HTN, less dry mouth
Desmopressin CIs
Patients with risk from fluid retention - HF, uncontrolled HTN
