Clinical Overview Flashcards
Outpatient CAP: not as severe/ no risk for MRSA/ PA- regimens
Look at comorbidity: chronic heart/ lungs, liver, kidney disease?, DM, Cancer?
NO Comorbidity:
Amoxicillin 1g TID for min 5 days
**Doxycycline 100mg BID for min 5 days **
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Comorbidity:
Augmentin 500 mg TID + Azithromycin 500mg QD for 5 days (OR Doxycycline 100mg BID)
Levo 750mg or moxi 400mg QD for min 5 days
Cefpodoxime 200mg BID for min 5 days + Doxycycline 100mg BID
FIRST questions to ask
- DDI
- Comorbidities
- Alleriges
- any kidney dysfuction
- Were they recently hospitalized and given IV abx in the past 90 days? was patient from a SNF?
- Any prior isolation of MRSA and/ or Pseudomonas aeruginosa from the resp tract within 1 years?
- Assess severity based on PSI (pneumonia severity index)
Inpatient Non Severe CAP: No prior MRSA/PA insolation or hospitalization OR hospitalization+IV ABX are the only risk factor
Option 1: General Beta Lactam (Unasyn 3g Q6 or Ceftriaxone 1-2g QD) + Macrolide (Azithro 500mg QD or Clarithro 500mg BID)
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Option 2: MONO therapy - Resp FQ: Moxi 400mg QD or Levo 750mg QD
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HOWEVER…if severe CAP but no hopsital/ IV ABX OR MRSA/PA…do dual TX so option 1! or tion 2 + beta lactam
SEVERE CAP with recent hospitalization + IV antibiotic exposure
Vanco or linazolid + ANTIpseudo (Zosyn 4.5g Q6hr. Meropenem 1g Q8hr, Cefepime 2 g q8hrs) + Macrolide (Azithro 500mg QD) OR Resp FQ (levo 750mg, moxi 400mg)
SEVERE CAP or Non Severe CAP with MRSA isolation
Option 1: General Beta Lactam (Unasyn 3g Q6 or Ceftriaxone 1-2g QD) + Macrolide (Azithro 500mg QD or Clarithro 500mg BID) + VANCO/ or LINAZOLID 600mg Q12
SEVERE CAP or Non Severe CAP with PA isolation
Swap out general Beta Lactam for antipesudo Beta Lactam!!! + use dual therapy! NO MONO
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Option 1: Antipseudo Beta Lactam (Zosyn 4.5g @6hr, Ceftaroline 600mg Q12, Meropenem 1g Q8hr) + Macrolide OR Resp FQ
Duration : Rule of Thumb
For stable patient/ Outpatient: 5 days
For MRSA/PA: at least 7 days
SE to note…
Macrolide and Flouroquinolones can increase QTc prolongation!
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Alot of the other ABX also needs renal adjustments! and alot of them will haev CDiff as side effects
Guideline for ID?
IDSA
UTI - What should you ask first?
Complicated VS Noncomplicated? - Complicated: Men, Preggo, any other comorbidities like MS MG, Spinal cord injury. UNcomplication: Women with no comorbidities.
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S/Sx? to differentiate between Upper UTI (pyelonephritis): flank pain, n/v, fever. OR Lower UTI ( Cystitis): increase urination freq, pain when urinating, hematuria
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How long has it been going on? is the woman preg?
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DDI
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Allergies
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Kidney functions? CrCL
TX: Uncomplicated UTI (Lower)
- Macrobid 100mg BID 5 days (or 7 for male??) with food (CrCl needs to be < 30)
- Bactrim DS (800/160) (DO NOT USE IF SULFA ALLERGY): 1 Tab DS BID 3 days - reduce dose by 50% if CrCl <30
TX: Complicated UTI/ Pylonephritis (Mod ill - outpatient)
- Cipro 500mg BID 7 days
- Levo 750mg QD 5 days
- Bactrim DS 1 double-strength tablet twice daily for 14 days
- Augmentin Immediate release: 875 mg twice daily for 10 to 14 days
TX: Complicated UTI/ Pylonephritis (Very ill - inpatient)
- Ceftriaxone 1g QD 5-7 days (no allergies)
- Cipro IV (inpatient): 400 mg every 12 hours 5-7 days. (beta lac allergy
- If will leave outpt soon? do Ceftriaxone 1g iv once then Cipro Oral: Immediate release: 500 mg every 12 hours for 5 to 7 days.
- Reserve for critically ill patients or for patients with risk factor(s) for MDR pathogens, including ESBL-producing organisms and P. aeruginosa: MEROPENEM 1g Q8 (duration ranges from 5-14 days)
.
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step down to oral once you find bug
UTI case example
syptomatic, afrebrile, +LE, nitrites, no urine susceptibilities back, female, not pregnant, amoxil and sulfa allergy, –> diagnosed with uncomplicated cystitis… CrCL 120ml/min - how would you say it
I would recommend macrobid 100 bid x5 days, no cross-reactivity in allergies present, no DDI, no evidence pyelo or other complications. I would also refer to ISDA guideline or AUA guideline for more information if needed.
Afib - What questions to ask?
-Any other comorbidity?,
-is this a valve issue? did patietn have mechanical/ biopros valve replacement?
-nonvalvular afib? can use DOAC
We will need to calculate HAS BLED and CHADS VAS score
HAS BLED (Bleeding risk for pt on AC for stroke prevention): Factors: HTN, adbnormal kidne or liver?, hx stroke, bleeding tendencies, labile inr, old +65, drug (NSAID, ASA)/alcohol?
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CHADS VASC Stroke risk assessment
C- CHF - 1
H- HTN - 1
A -Age (+75) - 2
D - DM -1
S- Prior Stroke - 2
V - vascular disease (MI, plaque. PAD) - 1
A -Age (65-75) - 1
S - Sex female - 1
TX/ stroke PPX for AFIB - Apixaban
Apixaban 5mg po BID
Unless they fit 2/3 criterias: +80 y/o, Scr >1.5mg/dl, or Weight is less than 60kg - then do dose reduction 2.5mg bid
TX/ stroke PPX for AFIB - rivaroxaban
DEPENDS ON CRCL
- CrCl > 50: 20mg QD w food
- CrCl 15-50: 15mg QD w food
- CrcL 15? avoid
Guideline for Afib -
CHEST, AHA
AFIb - Warfarin… ugh
For pt with valve replacement
typical starting dose is 5mg Q night unless they have high riskl of bleed then 2.5mg po… will need to monitor once a day oir every other day for 2 weeks until stable!
Counsel on bleed risk and vitamin k, avoid alcohol
tell your docs youre on this med! many DDI! avoid NSAID/ st john
Guidelines for VTE
CHEST, AHA, ASH
Questions to ask before DOAC
- allergy, DDI
- preg? (x warfarin/ DOAC - only enox)
- Liver dysfunction? (x riva in CP-c)
- ## Barriers?: can you afford it?/ warfarin cheapest
DVT TX
- Apixaban 10mg PO BID x 7 days then 5mg PO BID thereafter
- Rivaroxaban 15mg BID x 21days then 20mg po QD with food
- Endoxaban 60mg qd but after 5-10 days of parenteral AC…if CrcL 30-50 do 30 mg QD (cannot use if CrCL > 95)
- Enoxaparin 1 mg/kg every 12 hours
- Heparin 80 units/kg bolus (maximum dose: 10,000 units)c, then 18 units/kg/hour
HAP: What is it? - onset, common bugs, treatment duration
Onset: >48 hrs after hospital admission (VAP is after 48 hrs after starting vent)
Common bug: Staph, P. Aerugnosa, Ecoli
Tx Duration: 7 days (depending on response)
HAP: Treatment regimens general
- All patients need abx for pseudomonas and MSSA
- Add vanco or linezolidif at risk for MRSA
- Use 2 abx for pseudomonas if at isk for MDR gram (-) pathogens
—- ABX for pseudomonas (DO NOT USE 2 Beta LACTAMS TOGETHER)
HAP: What increases the risk for MRSA infection??
Hospitalization + IV ABX in past 90 days, from SNF, prior MRSA nasal/ respiratory swas/ isolation in past year
HAP: ABX for pseudo coverage/ options
B Lactam (only one of this): Zosyn, cefepine, ceftazidime, meropenem
Other agents to be added for dual tx: levofloxacin, ciprofloxacin, aztreonam
HAP Treatment regimen:
HAP with no high risk for mortality, or exposure exposure to hospitalization/ IV ABX in past 90 days….what to do if at risk for MRSA infection?
Use single agent: Zosyn (4.5 g every 6 hours) or Cefepime (2 g every 8 hours) or meropenem (1 g every 8 hours) …..these beta lactam…if allergic? use single fq like levofloxacin (750mg QD) or ciproflox (500 QD)
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If at risk for MRSA just add vancomycin 15 to 20 mg/kg/dose (rounded to the nearest 250 mg) every 8 to 12 hours initially or linezolid 600 mg every 12 hours
HAP Treatment regimen:
HAP WITH high risk for mortality OR was hospitalized with IV ABX in past 90 days….what to do if patient was also at risk for MRSA infection?
Use dual anti pseudomonas coverage with two abx from 2 different drug classes - pick and choose below!
- Beta Lactam: Zosyn, meropenem, cefepime, ceftazidime
- Flouroquinolone: Levo, cipro
if at risk for MRSA? Just add vanco or linazolid
CDiff infections: what is it, symp
Our stomach has many organism that make up the GI flora. ABX can elminate this and cause overgrowth of c diff (gram positive anaerobic organism). It releases toxin a + b that attacks the stomach linng causing inflammation (colitis). Symp: diarrhea/ watery stool, fever, cramps
Questions to ask/reccomendations
- allergies
- comorbidity? (really just assessing for HF)
- hx of cdiff infection (within the past 6 months?)
Reccomendations: D/C any abx (if they can) and any PPI (omeprazole), If patietn does not have HF…we may consider bezlotuxumab in conj with abx regimen/ ONLY USE BEZLO if patient is at higher risk: >65 y/o, severe presentation/ symp, or expereincing 2nd ep of cdiff with in 6 mts.
Treatment: 1st episode of CDiff
- Fidaxomicin (Dificid): 200mg BID x 10 days
or - Vanco (standard regimen) 125mg PO QID X 10 days
or - IF NOT SEVERE: Metronidazole 500mg PO TID x 10 days
Treatment: 2nd Episode of CDiff
Fidaxomicin regimen OR Vanco (standard regimen followed by prolong tapered course)…may consider bezlo now
Treatment: 3rd episode/ subsequent episodes of Cdiff
Fidaxomicin or vanco taper regimen or fecal transplant…
Meningitis: what is it, symp, dx, common bug
Inflammation of the meninges (membrane) that covers spinal cord/ brain. Symp: HA, fever, neck stiffness, and mental alteration. DX: Lumbar puncture/ sample of CSF. Common bugs: N. Meningitidis, S. Pneumo, H. Influenzae
Meningitis TX duration is dependent on the bug!
- N. Meningitidis and H. Influenzae: 7 days
- S. Pneumoniae: 10-14 days
- Listeria (more common in neonates/ older adults): at least 21 days
Empiric TX for Meningitis: Age 1-50
Ceftriaxone (2 g every 12 hours) + vancomycin (15-20mg/kg @ 8-12hrs)
Empiric TX for meningitis: Age +50
Ceftriaxone + vanco PLUS AMPICILLIN (for listeria coverage) 2 g every 4 hours
Sepsis: Patho, common bugs
The body’s response to infection becomes dysregulated leading to a systemic inflammatory responses. this can progess to septic shock where it leads to a decrease in BP + mutiple organ dysfunction. Common bugs: S. Aureus, Strep pyrogene, EColi, Pseudomonas Aergunosis.
SEPSIS: Guidelines
Society of Crit Care/ Surviving Sepsis/ Maybe IDSA
Sepsis 1 hr bundle care
- Measure lactate levels ( muscle excertion! Thsi is due to hypotension/ hypoprofusion! Decreased O2 = increase anaerobic metabolism = lactate as byproduct
- Obtian blood culture/ admin broad spectrum ABX
- Admin 30ml/kg crystalloid fluid (NS or LR) for hypotension or lactate > 4!
- Add vasopressors if hypotensive during or after fluid to maintain MAP > 65mmhg (2*DBP + SBP/ 3)
Sepsis: Vasopressor options for sepsis
- Norepi 0.05-0.15 OR 1mcg/kg/min(1st line) or epi 0.01 to 0.5 or 0.1 mcg/kg/minute, titrate to meet goal MAP > 65
- Vasopressin 0.03 units/minute
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For Norepi and Epi just do 1mcg/kg/min to make life easier
Sepsis Screening Tool: SIRs Criteria (must meet 2 of the following to be sepsis)
- Temp >38.3c or under 36c
- HR > 90 BMP
- RR > 20 or mech vent
- WBC >12,000 or <4000
TX for the different causes of SEPSIS: Pneumonia
Ceftriaxone 2g Q24hr + Azithromycin 500mg Q24hr
OR
Lexofloxacin 750mg Q24hrs
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Plus vanco if mrsa!
TX for the different causes of SEPSIS: UTI
Aztreonam 2g q8hrs OR Ertapenem 1g q24hrs
TX for the different causes of SEPSIS: Skin Structure Infection (eg. Diabetes foot infection/ osetomylitis)
- Zosyn 4.5g Q8hrs OR Meropenem 1g Q8hrs
- PLUS VANCOMYCIN 15-20mg/kg
TX for the different causes of SEPSIS: Osteomylitis
Vancomycin plus a third- (ceftriaxone) or fourth-generation cephalosporin (cefepime).
TX for the different causes of SEPSIS: Cellulitis (SSSI)
Cefazolin 2g Q8hrs + Vanco
Why crystolloids > Collids ? for fulid resec?
Colloids
Potential longer intravascular retention time vs. crystalloids
No evidence of reduced mortality compared with crystalloids;
benefits may exist with certain subsets of patients
Hydroxyethyl starch: FDA warning for increased mortality, severe
renal injury and risk of bleeding – do not use in critically ill patients
Dextrans: increased risk of anaphylaxis, may aggravate bleeding,
and cause renal dysfunction
Other stuff to consider if patient has Sepsis
1. GLUCOSE CONTROL .. Hyperglycemia, hypoglycemia and glycemic variability are associated with increased mortality
We RECOMMEND initiating insulin therapy at a glucose level of ≥ 180 mg/dL (Typical target blood glucose range is 140-180 mg/dL for ICU/ med unit inpatient! )…from NICE-SUGAR Study
2. VTE PROPHYLAXIS
We RECOMMEND low molecular weight heparin (LMWH) over unfractionated heparin (UFH) for VTE prophylaxis
What is ACS/ ASCVD?
ACS refers to a group of conditions that results from decrease blood flow to the heart due to blockage of the coronary artery (due to build up of fatty deposits/ plaque). ASCVD includes STEMI vs. NSTEMI (heart attacks)
STEMI vs NSTEMI
STEMI: Complete blockage! More extensive damage. On EKG - ST is elevated
NSTEMI: Partal blockage, less damage, no ST elevation but can show ST depression or T wave inversion
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Both will show an elevated level of troponin! this is a marker of cardiac injury
General treatment guide for STEMI VS NSTEMI
STEMI: MONA-GAP-BA + PCI (optimal time is 90mins from door to balloon or 120mins from first medical contact - ambulance) or fibrinolytics (if PCI is not possible.. 30 mins of door to needle time!)
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NSTEMI: MONA-GAP-BA +/- PCI
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MONA: ASAP
GAP: Inpatient
BA: in 24hrs or discharge
STEMI/NSTEMI: MONA Drugs
M: Morphine (pain and anxiety): 2-5mg IV Q10-30mins PRN
O: Oxygen! only if less than 90%
N: Nitrate (decrease chest pain/ preload): subling 0.4mg Q5mins PRN
A: ASA 162-325mg then 81mg lifelong
STEMI/NSTEMI: GAP Drugs
G: GP2B/3A Antagonist: Abciximab, tirofiban…before PCI (w or w/o stent)
A: Anticoag: if they are undergoing PCI: Heparin (bolus with 60u/kg then 12u/kg/hr infusion) and bivalirudin (also for HIT!) and LMWH
P: P2Y12 Inhibitor: Clopidogrel 300-600mg LD then 75mg QD with ASA for 6-12mts
STEMI/NSTEMI: BA drugs
B: Beta Blocker: decrease BP, HR and prevent remodeling! Metoprolol tart 5-15mg IV then 25-50mg BID oral OR Carvadlol 6.25 BID then titrate 25mg BID
A: ACEi decrease pre/afterload. Lisinopril 5-10mg mg QD
More details/ cavets on P2Y12 Inhibitors
- LD for Clopidogrel is 300-600mg but if undergoing PCI? then 600mg!
- AVOID Parsugrel or Ticagrelor if CABG is likely
- Prasugrel is for ACS with PCI; LD 60md and maintain with 10mg w/ASA…once PCI is planned give dose no later than 1 hr after PCI!
STEMI/ NSTEMI: GP2B/3A Antagonist
They are option for medical management of ACS or patietn recieving a PCI (w or w/o stent). Abciximab is ONLY indicated for PCI! if used in PCI? it has to be given with heparin!
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Typically these meds are not used for patients with NSTEMI…but can be if NSTEMI is unresponsive to conventional medical therapy, when PCI planned within 24 hrs… NOT RECCOMENDED FOR NSTEMI WITHOUT PCI!!!! …regarding abciximab…
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However, Tirofiban and eptifibatide can still be used in NSTEMI without PCI ….
BUT a good rule of thumb : Glycoprotein IIb/IIIa inhibitors like are not routinely used in NSTEMI without PCI
STEMI: Fibrinolytics
These medications break down clot! USED ONLY FOR STEMI. PCI is pref. but in situation where PCI is not avalible or there is a delay in getting pt to a cath lab, or there is a C/I to PCI (eg. cannot take dual antiplatlet, mutilple PCI restenosis/ bloackage even after multiple PCI, increased risk)..fibrinolytics are used!
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C/I to fibrinolytics: active internal bleeding/ hx of recent stroke/ any prior ICH
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1. Altaplase 100mg IV over 5 mins, 50mg over 30 mins, then 35mg over 1 hr (for those with 65kg and over!/ doing is different for kg less tahn 65!)\
2. Tenecteplase; many dosing but ranges from 30-50mg based on weight!
Secondary prevention after ACS/MI
- ASA 81 mg forever
- P2Y12 Inhibitor: NonPCI: Clopidogrel or Ticagrelor + ASA for at least 12mts; PCI treated use tica, clopid, or prasugrel + ASA for at least 12 mts
- Nitroglycerin forever PRN
- BBlocker
- ACEI
- STATIN: High Intensity Ie. Atorvastatin 40-80mg qd or Rosu 20-40mg
- Lifestyle: smoking cessation, managing HTN/DM, avoid excessive alcohol, encourage physical activites and healthy diet
What are the 3 types of strokes?
- TIA: Short term blockage of semi occlusived vessel, symp resolve on it’s own with in 24hrs but pt needs meds/ take action to prevent another stroke
- Ischemic stroke: 85% of all stroke, result from occlusion with in cerebral artery or emboli from other places! most common cause being afib! clot from in heart/ travel from heart.
- Hemorrhagic stroke - bleeding in brain due to ruptured blood vessel
S/S of Stroke
B: Balance, loss of balance
E: Eyes, blurred vision
F: face drooping
A: Arm/leg weakness/ tingling
S: Speech slurred
T: Time to call ambulance
Ischemic Stroke Treatment/ Management
CAn use either mechanical removal of clot (stent) or IV fibrinolytic (only if patient does not have brain bleed)
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TX: Altaplase - can be administerw/in 3 hrs of symptom onset or within 60mins of hospital arival. BP should be <185/110 prior to starting altaplase! if not you control that first! (IV labetalol or nicardipide)
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ASA given 24-48/ hrs post stroke (wait 24hr after TPa!); DVT ppx with IPC device! Do not start subq AC until after 24 hrs after TPa!
Management of Hemorrhagic Stroke/ ICH
Need to lower ICP via elevating head and using mannitol or hyertonic solution
Heart Failure/Stroke Guideline
AHA/ACC
Heart Failure: What is it/ what are the symptoms/ what are the 4 different stages
HF occurs when the heart is not able to supply O2 rich blood due to impaired ability of ventricle to either fill or eject blood. Most HF cases is due to damage for MI or long standing HTN. Symp: fluid overload and HIGH BNP (over 100 - streching of heart). HFrEF : less than 40% for LVEF
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Stage A: no s/s of HF, no abnormal markers
Stage B: Pre HF. no sign/symp but has one of the following: stuctural issue, increase filling pressure, or abnormal markers
Stage C: Symptomatic HF
Stage D: Advance HF - interference with daily/ normal activity
HF Stage 3 (HFrEF): medication for all patient
- ARNi > ACEi> ARB: note - there is a 36 hr washout period required when trasitioning form ACEi to ARNi
- Beta Blocker (evidence based): Metoprolol Succ, Bisoprolol, and Carvedilol
- MRA: sprinolactone 12.5-25mg or eplerenone (Serum k must be UNDER 5)
- SGLT2i: with or without DM ( empag or dapag 10mg QD)
- Diuretics (loop is preferred): furosimide, bumetadine, torsemide
HF Stage 3 (HFrEF): medication for specific patient group
- Hydralazine + isosorbide Dinitrate: for african american with class NYHA 3-4
- Ivabradine: MYHA class 3-4 with LVEF less than 35, on max tolerated B blocker and resting HR > 70
- Omega 3: NYHA class 2-4
- Digoxin: if symptomatic dispite all medication
HF: ARNi: info
- Start low dose: 24/26mg BID and titrate as tolerated q 2wks for target dose of 97/103 mg BID … remember the wash out period (36 hrs) with ACEi! due to increased risk of angioedema!
- Like ARBs and ACEi: monitor: Scr, BUN, electrolytes particularly K+ (hyperk!)
Dosing for HF medication: B Blocker
- ONLY 3 that are reccomended via guidelines for HF: Metoprolol Succ, Bisoprolol, Carvedilol
- Metoprolol Succ - 12.5-25mg the titrate Q2wks to reach 200mg QD… DO NOT D/C suddenly! Need to taper off to avoid tachy, decrease dose if HR is less than 60
- Carvedilol - 3.125mg BID titrate to 25-50mg BID TAKE WITH FOOD
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Hold titration if HR <50bpm…consider dose decrease
Dosing for HF medication: Loop Diuretics
Blocks Na/Cl reabsorption… Increase excretion of Na, Cl, K, Ca, and H2O! Decreases fluid volume/ congestion symptoms
- Furosemide 20-40mg QD
- Bumetanide 0.5-1mg QD
- Torsemide 10-20mg QD
Monitor electrolytes and stuff
DOSES QD OR BID DEPENDING
HF: MRA (mineralcorticoid receptor antagonist) Info
- Use only if eGFR/ CrCl is over 30, and K+ is under 5
- Monitor K+ (it can go up!), BUN/Scr
- Sprinolactone 12.5-25mg QD or Eplerenone 25mg QD
HF: diuretic monitoring/ cavets
Make sure K+ is between 4-5 meq/l (supplement with potassium and Mg2 if low).
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Diuretics are class 1 reccomendation for pt woth HFrEF Class C!!
HF: SGLT2 inhibitor: information
- Inhibits the SGLT2 recpetor in prox tubules to increase excretion of glucose and Na+, also decreases volume! :)
- Monitor: CRCl/ eGFR, BUN/Scr, volume stats, electrolytes, BP, UTI!!! if DM patient…watch out to not cause hypoglycemia/ may need to decrease other antiDM agents.
- Empagliglozin (jardiance) 10mg QD
- Dapagliflozin 10mg QD
Dosing for HF medication: ACEi and ARBs
ACEi - blocks conversion of Angio 1 to Angio 2 resulting in decreases vasoconstriction + aldosterone secretion = vasodilation; DO NOT USE if has hx of angioedema (dont even use ARBs!); SE: cough, increased K+ and Scr
- Lisinopril 5mg -> 20-40mg
- Enalapril 5mg-> 10-20mg
- Ramipril 10mg
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ARBs - block Angio 2 from binding to the receptor; similar SE but less cough and angioedema
- losartan 25 - 50mg QD
- Valsartan 40mg BID
HF: Ivabradine: information
- Specific group of ppl only…: For Class 2-3 stable chronic HFrEF < 35% who are on GDMT including beta blocker at MAX dose and who are in sinus rhythm with resting HR > 70 BPM
- Initiate 2.5-5mg BID
- $$$
- DO NOT USE IF PREG, Take with food, can causes AFib
What about Statin, AC, and omega 3 for HF?
No solid evidence….AC only if HF + Afib, and Statin if have dyslipidemia. not benefical when rx for only HF. Omega 3 may be helpful…wouldnt hurt to try it.
Medications to Avoid in HF
CCBs, antiarrhyt drug (amio), TCA, Pioglitazone, NSAID, pregabalin
Counseling Points for Patient with HF
- Optimize/ control other comorbidities: DM/ Obesity
- Smoking cessation
- Chekc your weight daily! call provider if gaining 2lbs/day or 5 per week
- Sodium restriction! 1.5-2g/day
- Avoid alcohol
- Exercise regularly
HIT - what is it?/ Guideline?
A rare but serious side effect to heparin. This occurs when heparin binds to a protein in the plt called PF4. This hen forms a complex whihc triggers your immune system to make antibody against it. The antibodies bind to the heparin-PF4 complex and leads to plt destruction = thrombocytopenia (<150K).
ASH guidelines
Criteria for HIT (4 T’s)
- Thrombocytopenia (plt fall >50% -2 pts, fell 30-50% -1 pt)
- Time of plt fall (5-10 days - 2 pts, unclear 1 pt)
- Thrombosis (new thrombosis/ necrosis -2pts, unclear 1pt)
- Other possible causes of thrombocytopenia? (none - 2pts, possible 1pt)
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4T scores should be confirmed by ELISA and Serotonin Release Assay
Treatment and management of HIT
- D/C All heparin product including LMWH
- Select one of the following instead: Argatroban, bivalirudin, fondaparinux
1. Argatroban (injectation direct thrombin inhibitor) - 2 mcg/kg
2. Bivalirudin (inj direct thrombin inhibitor), typically reserved for PCI
3. Fondaparinux (inj indirect factor Xa inhibitor)
DKA - what is it?, Lab findings
Hyperglycemia crisis; insulin insufficency leads to dehydration + acidosis. W/o insulin, cells cannot take up / use glucose, thus the body shifts to alternative energy source. The body starts to break down fat thus ketone is release. Ketones are acidic! this this decreases the body’s pH.
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Lab findings:
Blood glucose: over 250
pH: less than 7.3
Bicarb: < 18 (bicarb is basic so it is low in this case)
Anion Gap: >10 (normal is 7-9) (Na-Cl-HCO3 = anion gap)
Ketones: Positive
Treatment/ Mangement of DKA
- Fluids: NS first hr, then NS or .45% NaCl until normalized, then after DKA resolve switch to dextrose
- K+ replacement: when acidosis restores, K+ will shift into cell leading to lower K+! the goal is 4-5meq/l…replace when K is < 5.2meg. Use 20-30 meq (IV or PO) K+ to replace. If K+ is < 3.3 DO NOT USE INSULIN!!!
- Sodium Bicarb (maybe - this is controversial)…if pH is very low.. <6.9. can use bicarb..if not we wil not use
- INSULIN with regular insulin. do 0.1 u/k bolus then 0.1 u/kg/hr continuous IV OR 0.14 u/kg/hr continnuous IV —- get glucose to less than 200 —– then we can decrease insulin to 0.05u/kg/hr. GOAL is to get blood glucoe 150-200, pH >7.3, Bcarb >18, and close anion gap <12.
Infective Endocarditis: What is it? / who’s most at risk?/ Bugs?/ empiric regimen?
Infection of the inner tissue of the heart, typically in the heart valves. Pt’s with prosthetic heart valves, chronic IV drug users - are those most at risk. The 3 most common bugs: staphylococci, streptococci, and enterococci…IE is fatal if left untreated!!! Empiric tx usually involves vanco and ceftriaxone. Gentamicin is added to the regimen for synergy when the infection is more difficult to eradicate (ie such as prosthetic valve infections or when treating a more resistance organisms.
Infective Endocarditis (IE): tx duration
4-6 weeks of IV abx. However if gentamicin is used, he duration of gebntamicin varies from 2-6 weeks
If gentamicin is used for IE, what is the goal?
target peak: 3-4 mcg/ml and trough levels is < 1 mcg/ml
When is rifampin used in IE/ what is it’s role?
Some bacteria form a biofilm, esp on prosthetic valves…thsi is hard for some abx to penetrate. Rifampin may be used in these cases of staphpylococcal prosthetic valve endocaditis due to its ability to treat organisms in a biofilm
Infective Endocarditis Treatment: Viridan group streptococci
- Penicillin G 3 g q6hrs OR
- Ceftriaxone 2g QD
WITH or WITHOUT Gentamicin 1 mg/kg every 8 hours
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If the patient is allergic to beta lactam? just use monotherapy VANCOMYCIN
Infective Endocarditis Treatment: Staphylcocci (MSSA)
- Nafcillin 12 g/day in 4-6 divided doses OR
- Cefazolin 2 g every 8 hours
WITH OR WITHOUT Gentamicin and rifampin 900 mg/day if prosthetic valve involvement
.
If beta lactam allergy? Use mono Vanvomycin with or without gentamicin and rifampin
Infective Endocarditis Treatment: Staphylcocci (MRSA)
Vanvomycin with or without gentamicin and rifampin
Infective Endocarditis Treatment: Enterococci
Penicillin G + ampicillin + ceftriaxone
.
Allergy to beta lactam? Vancomycin + gentamicin
.
IF VRE use daptomycin ot linezolid
Skin and Soft Tissue Infection (SSTIs)
Very broad. Can be divided into superficial, nonpururlent (subq tissue/ cellulitis), and purulent (contains pus) infection like abscesses. These can further be classified as mild, mod, severe
SSTIs
Nonpurulent (ex. Cellulitis, Necrotizing infection) - general rule of thumb, these are strep bacteria.
TREATMENT for Mild case
Mild: cases of typical cellulitis without any wetness or pus.
.
TX: Oral:
- Penicillin VK 500 mg BID OR
- Cephalexin 500 mg QID OR
- Clindamycin 300 mg QID (if beta lactam allergy)
.
Duration: 5-7 days for mild-moderate case
SSTIs
Nonpurulent (ex. Cellulitis, Necrotizing infection): Treatment for Moderate Case
Moderate: Case of typical cellulitis and erysipeias ith systemic signs of infection (ie. Temp >100.4F or 38C, HR >90, WBC >120000 or <4000)
.
TX: IV
- Ceftriaxone 2 g QD OR
- Cefazolin 2 g Q8hrs OR
- Clindamycin IV 600 to 900 mg every 8 hours (if beta lactam allergy)
.
Duration 5-7 days
SSTIs
Nonpurulent (ex. Cellulitis, Necrotizing infection): Treatment for Severe Cases.. like nec fas (S. pyrogenes)
Severe: patient who did not response to oral abx, those with weak immune systems, those meeting SIRS crietria, or showing signs of deeper infection
.
EMPIRIC RX: Vancomycin (or linezolid) + Zosyn or meropenem, then get culture and susceptibility… following the results, the abx therapy should be adjusted.
SSTIs
Purulent (Ex. Abscess, furuncel, carbuncle): Treatment for Mild cases
Mild: single abscess with no systemic signs: incision/ drainage Plus culture and susceptibility..and thats it
SSTIs
Purulent (Ex. Abscess, furuncel, carbuncle): Treatment for Moderate case
Moderate: systemic signs or mul;tiple sites of infection: Perform I & D, culture the fliud and use oral abx that also covers MRSA:
- Bactrim DS 1-2 tabs PO BID OR
- Doxycycline 100md BID
.
If culutr shows MSSA then switch to Cephalexin
SSTIs
Purulent (Ex. Abscess, furuncel, carbuncle): Treatment for severe case
Severe: patient who did not response to oral abx, those with weak immune systems, those meeting SIRS crietria, or showing signs of deeper infection.
.
I & D and C & S
.
Use one of these to empiric coverage!
- Vancomycin 15-20mg/kg q 8-12hrs
- Daptomycin 4 to 6 mg/kg QD
- Linezolid 600 mg BID
.
Duration 7-14 days… once stable switch to oral abx
Diabetes foot infection: what is it?, common bugs
Due to neuropathic damage of diabetes… common cause of amputation! The most common bugs: staphlcoccus and strepococcus. But infection can be polymicrobial so empiric is needed and culture needed to narrow down therapy.. if deeper infection is present -> OSTEOMYLITIS lnger course of iv abx is needed
Diabetes Foot Infection: TX Regimens
Monotherapy: When MRSA Coverage is NOT needed - Unsyn, Zosyn, meropenem, mocifloxacin
.
Combination tx WHEN MRSA COVERAGE IS NEEDED
Vancomycin plue one of the following
- Zosyn, Cefepime, Meropenem, aztreonam (these has pseudomonas coverage! yay!)
Diabetes foot infection: Duration of treatment
mild: 7-14 days
More severe deeper tissue: 2-4 weeks
Severe/ limb threathening/ joint or bone infection/ ostemylitis: 4-6 weeks… some osteomylitis cases may be more than 6 weeks!
Inpatient Glucose Control
Inpatient glucose control: if oral intake is adquate VS. Poor intake?
If oral intake is adequate, a regimen with basal, bolus (prandial), and correction doses (usually added to the mealtime bolus dose) is perferred.
.
Poor intake: a basal and correction dose strategy is reccomended
Inpatient glucose control: What is correction dose ?
Correction dose insulin is given when BG is already high. Like sliding scale insulin, the insulin dose given will crrelate with the BG, on a scale . The difference is that the correction dose is designed for a specific patient - it’s based on the patient’s insulin sensitivity - which indicated how much the BG will drop with each unit of insulin
Inpatient Glucose Control: Sliding Scale
- <60mg/dL = HOLD INSULIN
- 150-200 = 2 units
- 200-250 = 4 units
- 250-300 = 6 units
- 300-350 = 8 units
- 350-400 = 10 units
- +400 = call MD
.
Rapid acting is is prefered (insulin lipro = humalog, insulin aspart = novolog
Inpatient Glucose Control : starting a basal bolus regimen (outpt and inpt) rule of thumb for DM2 patient!!!
Basal (glargine): 10 u OR 0.1-0.2 u/ kg/ day
bolus/ prandial imsulin: 4 units or 10% of basal dose once daily prior to largest meal
General inpatient glucose goal
blood glucose target of 140 to 180 mg/dL
Dislipidemia: Statins - SEs, counseling points, toxicites
SEs: Muscle pain, increased AST/ALT, GI Upset, HA
Counsleing pts: avoid grapefruit juice (CYP3A4 inhibitor) - except with rosuvastatin
Toxicity: 1.) hepatox 2.) muscle toxicity (check for CPK)= myopathy = rhabdomyolysis! break down of muscle. pain/ weakness in muscle as well as dark borwn/ red urine. Risk with cotherapy of statin + fibrates or red yeast rice
Mod intensity statin
- Atorvastatin 10-20mg
- Rosuvastatin 10mg
- Simvastatin 20-40mg
- Pravastatin 40-80mg
High Intensity Statin
- Atorvastatin 40-80 mg
- Rosuvastatin 20-40 mg
Statin Algorithm: Primary prevention… for LDL > 190, DM?, None of those two
- LDL > 190: Start high intensity statin
- DM?: Multiple ASCVD risk factors - high intensity statin; No risk factors: mod intensity statin
- NONE: Claculate ASCVD risk! <5%? lifestyle, 5-19% Mod intensity statin with LDL reduction goal of 30-49%; >20% start high intensity with reduction goal of 50%
What are the ASCVD Risk Factors?
age > 65 y/o, hx of PCI or coronary bypass, DM, CKD CrCl <60, Current smoker, Hx of CHF
Dislipidemia: Second prevention… for what? what are the events
Acute coronary syndrome, hx of MI, hx of stroke, symptomatic peripheral arterial disease or previous revascularization
Statin Algorithm Secondary Prevention
START ON HIGH INTENSITY STATIN! - if LDL > 70 on statin? …add Ezetimibe 10 mg QD… if LDL > 70 even on statin + ezetimibe? ADD P5CK9 inhibitor (for very high risk patients).
What to do if patient is experiencing side effects/ muscle pain
- Order CPK, vitamin D, and thyroid labs - all are associated with myalgia
- Make sure it’s not sure to statin: working out?
.
Mild- Moderate symp: discontinue statin, check CPK. If CPK is greater than 10? consider other therapy: Ezetimibe 10 mg Q. If under 10? wait for resolution of symp and start on lower dose of same statin.
.
Severe. D/C statin. risk vs benefit assessment.
What to consider first when evaluating patients with DM?
- annual eye and foot exam
- need to add statin: mod- high intensity depending on risk
- Assess HTN - if hyperalbuninuria * 2 time will need to be on ACEi or ARB
- make sure patient has DM testing supplies (monitor, test stripes, lancets)
DM: first line consideration?
First-line pharmacotherapy (metformin or other agents) should be selected based upon patient-specific factors (e.g., glycemic goals, cardiorenal risk, comorbidities, cost and access). Consider combination pharmacotherapy at initiation if A1C ≥1.5% above target goal
Glycemic Goals
Most patients: A1C: <7.0; Preprandial 80 - 130mg/ dL; 2 hrs after meal <180 mg/dL
DM: Step 1: Established/High-Risk of ASCVD, Heart Failure, or Chronic Kidney Disease? Recommended independent of baseline A1C, target A1C goal, or use of metformin
1.) ASCVD: GLP-1 RA or SGLT2i with proven CVD benefit… If A1C above target (wait like 3 months to assess) use both agents!
.
2.) Heart Failure: SGLT2i with HF benefit
- Avoid TZDs
- Avoid saxagliptin
.
3.) Chronic Kidney Disease (On maximally tolerated ACEi/ARB): SGLT2i with primary evidence for reducing CKD progression! … if A1C still above goal? add on GLP1 RA
DM: GLP1 RA and the benefits
FDA approved CVD AND Renal benefit:
* dulaglutide (trulicity) - 0.75 mg once weekly, then 1.5mg max
* liraglutide (victoza/ saxenda) 0.6mg once daily x1 week, then increase to 1.2 mg once daily
* semaglutide (SUBQ) -Initial: 0.25 mg once weekly for 4 weeks, then increase to 0.5 mg once weekly - Ozempic
DM: SGLT2i and the benefits
FDA approved CVD benefit:
* canagliflozin - 100-300mg QD
* empagliflozin (jardiance) - 10-25mg QD
.
FDA approved HF benefit:
* dapagliflozin (Farxiga) - 5-10mg QD
* empagliflozin
.
FDA approved renal benefit:
* dapagliflozin
* empagliflozin
.
…when in doubt just use empag (jardiance).. it does everything
If A1C is still high after SGLT2i + GLP1 RA +/- Metformin? add on these other ones based off of goal/ cost
Be familiar with these DM drug classes
HTN Algorithm initial drug therapy (aside from lifestyle interventions): Uncomplicated HTN no comorbidity Stage 1 HTN (130-139/80-89)
Black: Start 1 drug - CCB or Thiazide
NonBlack: Start 1 drug: ACEi, ARBS, CCB, or thiazide
.
Not at goal? increase dose of the current drug
.
Still not at goal? add on another agent; blacks can use ACEi/ ARBs at this point
HTN Algorithm initial drug therapy (aside from lifestyle interventions): Uncomplicated HTN no comorbidity Stage 2 HTN (>140/90)
Blacks: Start with 2 drugs: CCB + thiazide
NonBlacks: Start with 2 drugs: CCB or Thiazide + ACEi/ ARBs
.
If not at goal? Increase doses or add medication from other class..can also consider B blocker if still not at goal
HTN Algorithm initial drug therapy (aside from lifestyle interventions): Complicated HTN or HTN with comorbidity
1.) Diabetes (goal is 140/90!), px stroke, CKD = start with ACEi or ARBs … if stage 2 make sure to have 2 agents (can add CCB or thiazide)…if not at goal? increase doses
2.CAD: ACEi+ARBs PLUS Beta Blocker…if not at goal? Increase dose or add thiazide or DHP CCB
3.HF: ACEi + Beta Blocker +/- aldosterone antagonist … if not at goal increase dose or add thiazide or DHP CCB
HTN starting/ monitoring: ACEi and ARBs
- ACEi: Lisinopril 5-10mg QD, eval in 2-4 weeks (max dose 40mg)
- ARBs: Losartan 25-50mg QD eval in 2-4 weeks (max dose 100mg)
.
SE/monitoring: dry cough (ACEi), increased Scr/BUN, angioedema
HTN starting/ monitoring: Dihy-CCB
Amlodipine: 2.5-5mg QD eval in 2-4 weeks (max 10mg)
SE: peripheral edema, tachy, hypotension, dizziness, flushing
HTN starting/ monitoring: Thiazides
Hydrocholrotiazide: 12.5-25mg (max dose 50mg)
SE: natiuresis (increase Na+ in urine), diuresis, hypoK+, need to monitor electolytes
.
Combination product of lisino-HCTZ! Lisinopril 10 mg/hydrochlorothiazide 12.5 mg or lisinopril 20 mg/hydrochlorothiazide 12.5 mg once daily
HTN Starting/monitoring: Beta Blocker
Carvedilol: Initial: 6.25 mg twice daily (max 50mg)
Metoprolol Tart (IR): Initial: 50 mg twice daily
Metoprolol Succ (EX): Initial: 25 to 100 mg once daily - for heart failure!
.
SE: low HR, dizziness
Asthma - what to acess/ diagnosis/ etc
- Symptom control & modifiable risk factors/ Comorbidities
- Patient goals & inhaler technique/adherence (patietn may need Educate and train skills and proper use)
- Utilize non-pharmacotherapy, if possible
- dx: Spirometry with bronchodilator tests, Peak expiratory flow (PEF) tests
Asthma Treatment: TRACK 1 (GINA preferred but not as common as Track 2)
Reliever: As-needed low dose ICS-formoterol!
For controller? Use these next steps:
- start here if: Symptoms < 4-5 days/week: use step 1-2: As-needed only
low dose ICS-formoterol
- start here if: Symptoms most days or waking with asthma ≥ 1 time/week: Step 3: Low dose maintenance ICS-formoterol (MART)
- start here if: Daily symptoms or waking with asthma ≥ 1 time/week and low lung function: Medium dose maintenance ICS-formoterol (MART)
… if symtp presist from there? Add on LAMA or consider high dose ICS formoterol!
Asthma Treatment: TRACK 2 ( more commonly use in US)
Reliever: As-needed SABA or as-needed ICS-SABA
For Controller? Use these following steps:
- Start here if: Symptoms < 2 times/month: Take ICS whenever SABA is taken
- Start here if: Symptoms ≥ 2/month but < 4-5 days/week: Low dose maintenance ICS
- Start here if: Symptoms most days or waking with asthma ≥ 1 time/week: Low dose maintenance ICS-LABA
- Start here if: Daily symptoms or waking with asthma ≥ 1 time/week and low lung function: Medium/high dose maintenance ICS-LABA
…if symp presist? Add on LAMA
COPD/ Asthma
List examples of ICS
- Flovent (Fluticasone) Diskus (100 mcg/inh 1 low, 2 mod 3 high)/ HFA
- Pulmicort (Budesonide)
- QVAR RediHaler (Beclomethasone)
.
So many different types/ doses so just know one of each is enough
COPD/ ASthma
List examples of (ICS)-formoterol combination medications… What is it?
Formoterol = LABA!!!!
- Symbicort (Budesonide/Formoterol) 160/4.5mcg/inh - 1 low, 2mod
- Advair (Fluticasone prop./Salmeterol)
- Breo ellipta also
COPD/ Asthma
List examples of SABA
Albuterol (proair, Ventolin) 1 or 2 puffs of 90 mcg every 4 to 6 hours
COPD/ Asthma
List example of LABA
Salmeterol (Serevent Diskus) 50 mcg/actuation: Oral inhalation: One inhalation twice daily (~12 hours apart)
List example of LAMA
- Incruse Ellipta (Umeclidinium)
- Spiriva (Tiotropium) handiheler or respimat soft mist 1.25 mcg/actuation: Oral inhalation: 2 inhalations once daily.
Asthma: Monitor/ Nonpharm stuff/ goals
Monitoring: PFT initially, 3-6 months after start of therapy, then every year
Goals: control symp, maintian normal activity levels, minimize risk of asthma attacks/ exacerbation, and presistent airflow limitation
Nonpharm stuff: Identify and Avoid Triggers: environmental triggers such as smoke, dust mites, mold, and pollen. Ensure good indoor air quality by using air purifiers, avoiding tobacco smoke, and ventilating living spaces.
Some side effects to some of the meds : tremor, increased nervousness and insomnia in children, nausea, fever, bronchospasm, vomiting, headache, pain, dizziness, cough, allergic reaction, dry mouth.
.
Using inhaled corticosteroids can increase your risk of developing thrush, a fungal infection in the mouth!!!!!!! Rinsing the mouth with water after using an inhaler can help reduce the risk.
Treatment for Thrush
Mild-Mod: topical : Nystatin oral Suspension (swish and swallow): 400,000 to 600,000 units 4 times daily; swish in the mouth and retain for as long as possible (several minutes) before swallowing. Duration is for 7 to 14 days
.
Clortimazole lozenges: Dissolve one 10-milligram lozenge slowly and completely in your mouth; this dose should be taken five times a day for at least 14 days
.
SEVERE THRUSH
Fluconazole IV, Oral: 400 mg (or 6 mg/kg) on day 1, then 200 to 400 mg (or 3 to 6 mg/kg) once daily for 14 to 21 days
Asthma Step Up ?
COPD
Study Jade’s handout/ Pyrls Guide on COPD
