clw 8 Flashcards
HF, hepatitis, liver cirrhosis, asthma, VTE
name 3 differential causes of dyspnoea
- fluid overload secondary to hfref
- asthma
- pulmonary embolism
- pneumonia
- lung cancer
- MI
- ascites due to liver cirrhosis
main sx of fluid overload secondary to HF
Orthopnoea - cannot breathe when lying down at night
telltale sx of ascites due to liver cirrhosis causing dyspnoea
palmar erythema
jaundice, ascites
pruritis
spider angiomata
lab results to look out for when liver has issues
elevated lft
coagulation tests (PT, aPTT, INR)
asthma sx
wheezing (auscultation)
SOB
chest tightness
unable to talk in sentences
elevated pulse rate
pulmonary embolism s/sx
d-dimer
unilateral pitting edema (dvt)
ssx of pneumonia
fever
cxr lung consolidation
chest pain
s/sx of MI
chest pains
elevated heart rate
palpitations
diaphoresis (excess sweat)
elevation in cardiac troponin
ST elevation? ECG abnormalities
GOT for HF
resolve fluid overload (0.5kg weight loss/day)
optimise HF therapy to prevent complications and reduce mortality risk
improve exercise capacity
when increasing furosemide for fluid overload episode, how much to increase?
double home dose or switch to IV (of same dose)
BD dosing for diuretic should not be at night to_
prevent need for pt to wake up at night to pee
always start with IV for episodes of fluid overload requiring hospitalisation at how much dose?
at same IV dose
what do beta blockers do
decrease HR and cardiac output
if patient is hemodynamically unstable, what to do with F4 agents
continue but maintain same dose
when to hold off SGLT2i
before surgery, in acute illness. not for fluid overload
what are the agents for HF
spironolactone
sglt28
arni/acei
bb
+
diuretic
first line for ascites
spironolactone, furosemide
when to hold use of bb
HR low
non pharm of HF
lose weight
restrict Na (<2g/d) and water (800-1L)
remove K from veg
weigh daily to monitor for fluid issues
cardiac rehab program and exercise
what to monitor for diuretic use
serum k, Na, Cr
genital infections
uses of f4 agents
- relieve/reduce sx
- reduce need for admissions
- prolong survival
GOT of ascites with liver cirrhosis
- managing sx and normalising liver abnormalities
- slowing down disease progression
- preventing complications of liver cirrhosis
GOT of viral hep B
viral suppression
GOT of hep C
viral eradication
what to do before treating hep b
screen for hiv
main side effect of concern for arni/acei
hypotension
bb for HF
bisoprolol, carvedilol (but not selective), metoprolol XL
how to manage portal htn
propranolol, nadolol, carvedilol
endoscopic variceal ligation (EVL)
nonpharm of ascites/cirrhosis
- drain out ascitic fluid
- abstain from alcohol
- salt restriction
- avoid nsaid, acei
*fluid restriction not necessary unless serum Na ≤125mmol/L
non pharm hepatitis b
- prevent disease transmission (household contacts shd b vaccinated)
- do not donate blood
- weight loss
- avoid alcohol and smoking
- inform healthcare providers of the condition
spironolactone se
gynaecomastia, hyperK
how to monitor asthma control
ACT questionnaire
why can’t use saba alone
increased risk of exacerbations and hospitalisation
downregulates beta receptors in lungs, reduce responsiveness, affect long term control
administration technique for ics-laba
use everyday even if well controlled
wash mouth after using to prevent oral thrush
non pharm for asthma / copd
- avoid triggers eg tobacco, allergens
- exercise/breathing exercises
- avoid use of nsaids, bb
- update vaccinations
- remediation of dampness or mould in homes
- dealing with emotional stress
- (copd) nutritional support
what is pulmonary rehab prog for copd
patient education, exercise trng, nutritional support, psychosocial support
vaccination in copd
pneumococcal: PCV13 and PPSV23
influenza
how to monitor asthma
symptoms of exacerbation, frequency of exacerbation and use of inhaler
what to always monitor fo HTN drugs
serum creatinine
benefit for sglt2i and loops used together
natriuresis effect - kidneys excrete sodium
how does liver cirrhosis affect drug distribution
decreased albumin pdtn. affects protein binding and amt of unbound drug
how does liver cirrhosis affect cyp enzyme
cyp expression reduced, decreased metabolism of drug, longer half life /elimination of drug
what is formula of hepatic extraction ratio
E = 1-F
what happens to drug when reduced hepatic blood flow
less drug brought to liver for metabolism, decreased clearance
high extraction ratio
> 0.7
when drug has high extraction ratio, is it perfusion limited? is it sensitive to changes in perfusion or protein binding?
yes. perfusion
when drug has low extraction ratio, is it perfusion limited? is it sensitive to changes in perfusion or protein binding?
no, protein binding
in cirrhosis, for drugs of high extraction ratio, do you have to reduce initial/maintenance dose?
yes both. affected greatly by extent of metabolism of liver. first past effect evident
maximal plasma concentration and F is increased, elimination is slowed.
in cirrhosis, for drugs of low extraction ratio, do you have to reduce initial/maintenance dose?
only maintenance dose. only elimination is slowed
what do drugs in bile undergo (2 ways)
1) enterohepatic cycling -reabsorption
2) excreted via feces
characteristics of drugs secreted into bile
- polar
- MW > 350g/mol
main side effect of statins
hepatic enzymes elevation, myalgia
estrogen metabolism
liver
obesity: serum albumin?
same
obesity: liver blood flow
may increase
obesity: cyp3a4? (phase 1)
decrease
obesity: gastric emptying
increase
obesity: oral F
largely the same
renal clearance in obesity
increase then decrease
obesity: adipose tissue
increased
obesity: gut permeability
increase
what protein is increased in obesity
alpha one glycoprotein
obesity: cyp2e1 (phase I)
increased
phase 2 in obesity
increased glucuronidation and sulfation
alpha 1 glycoprotein binds more to acidic or basic drugs?
basic
albumin binds more to acidic or basic drugs?
acidic. albumin is basic
obesity: cardiac output?
increase
obesity related kidney problem
obesity-related glomerulopathy
when to use adjusted BW
aminoglycosides dosing. AG is hydrophilic with low Vd
dvt wells score? confirm dvt
at least 2 pts
if wells score less than 2? conduct d dimer. what does d dimer show?
negative: no dvt
positive: maybe dvt
DOACs under crcl_ cannot use
30, switch to enox or warfarin
GOT for DVT
prevent extension of embolisation of thrombus (ie escalation to PE)
relieve symptoms
prevent recurrence
when starting sglt2i for HF, what should be stopped
IV diuretic
which sglt2is are useful in hfref
dapa and empa
uses of sglt2i in hfref
- reduces hospitalisation due to new HF
- reduce onset of new HF for ppl with high CVS events
what is used as adjunct to bb?
ivabradine
how does ivabradine help in hf?
prolong survival, relieve symptoms, prevent admissions
if switching from acei to arni, wash out period how long
36h
when adding loop diuretics, watch out for what
K/RP (hypokalemia)
maybe give potassium chloride replacement
sglt2i watch out for what
euglycemic diabetic ketoacidosis, genitourinary tract infections
EDKA symptoms
malaise, vomiting, dyspnea, nausea
why do raasi agents cause hyperk
they retain potassium
counselling points for BB in HF
- Some px could take 3-6 months before experiencing an improvement
- There could be an initial worsening before improvement
- It is important to measure body weight daily
target hr in hfref
below 70
when starting sglt2i must make sure SBP_?
> 100
treatment for chronic hep c
Anti-HCV Nucleoside Agent (NA)- Ribavirin
side effects of chronic hep c tx
Haemolytic anaemia
Fatigue
Teratogenic
what are useful markers of liver disease
ALP, AST, ALT (GGT alone not useful)
features of viral hepatitis
fever, nausea, vomiting, pale stools, jaundice
what does liver cirrhosis result in
- portal htn
- varices
- decrease in albumin levels
- impedes portal blood flow
- hepatocellular carcinoma
- encephalopathy (disturbance to brain fx)
how does decreased albumin synthesis lead to ascites
changes in intravascular oncotic pressure
how does underfilling of circulation lead to ascites
combined with reduced aldosterone metabolism, leads to activation of RAA system
GOT of portal hypertension
prevention of bleeding
how does cirrhosis affect coagulation
Decreased synthesis of most procoagulant factors as well as naturally occurring
anticoagulants, antithrombin, protein C and S
nonalcoholic fatty liver disease risk factors
obesity, diabetes
why need to check ascitic fluid
spontaneous bacterial bacterial peritonitis (infection of ascitic fluid)
primary prophylaxis for who
- child pugh c small varices
- big varices
propranolol therapy goal
resting HR 55-60/min
sbp > 90mmhg
in patients with asthma, what is the issue of BB?
beta 2 found in lungs, blocking receptors can increase risk of bronchospasms
antibiotic prophylaxis for acute variceal bleed
ceftriaxone, norfloxacine
vasoactive agents in portal htn for ?
inhibit splanchnic vasodilation
eg. octreotide, vasopressin, SMT, telipressin
secondary prophylaxis of portal htn?
nsbb and chronic evl
GOT for hepatic encephalopathy
reduce ammonia blood concentration
non pharm for hepatic encephalopathy
diet: protein restriction
supplement with elemental zinc
pharm for hepatic enceph
lactulose: lower colonic pH, promotes conversion of ammonia to ammonium for excretion
rifaximin: targets anaerobic bacteria that produce urease which hydrolyzes urea to ammonia in gut
non-alcoholic fatty liver (NAFL) vs non-alcoholic steatohepatitis (NASH)
NAFL: no evidence of hepatocellular injury, minimal risk of progression to cirrhosis
NASH: inflammation and hepatocellular injury, may progress to cirrhosis and liver failure
GOT of asthma
- reduce need for reliever medication
- avoid troublesome symptoms esp at night
- avoid serious asthma flare-ups
- to achieve good control of
symptoms and maintain normal activity levels
benefits of addition of laba to ics
decreases nocturnal asthma, use of rapid-acting b2 agonist and number of exacerbations
diagnosing asthma
fev1/fvc is <0.7
what is fev1
volume of air exhaled forcefully in first second of maximal expiration
fvc
Maximum amount of air
that can be exhaled when
blowing out as fast as
possible, after full
inspiration
increase of fev1 after saba to show asthma?
≥12%
tcu of asthma
3-6 months after treatment changes; every 1-2 years if stable
host risk factors for asthma
Genetic predisposition
* Atopy
* Gender
* Obesity
environmental factors for asthma
Indoor allergens
* Outdoor allergens
* Occupational
sensitizers
* Tobacco smoke
* Air Pollution
* Respiratory Infections
* Socioeconomic
factors
* Diet
risk factor for exacerbation
- History of ≥1
exacerbations
in the previous
year - Poor
adherence - Incorrect
inhaler
technique - high saba use
benefits of low dose ics (in asthma)
– Markedly reduces asthma deaths
– Reduces hospitalizations
and readmissions
– Prevents exacerbations
– Protects against long-term decline in lung function
benefit of ics in copd
improve lung fx and oxygenation
shorten length of hospital stay
decrease relapse and treatment failure rates
IC steroids monitor for what
osteoporosis, oral thrust, cough, adrenal suppression, HTN, diabetes
after an exacerbation, review within
1w
consider step down after good control maintained for
3 months
MOA of montelukast
- Interfere in the release of leukotriene mediators from mast cells,
eosinophils and basophils - Reduce symptoms associated with the inflammatory allergic
component of asthma, including swelling of the airway and smooth
muscle constriction
adr of montelukast
Headache, nausea
Neuropsychiatric events
theophylline
induces SM relaxation via inhibition of phosphodiesterase 3, leading to bronchodilation
adr of theophylline
GI: nausea, vomiting
CNS: insomnia, headache, seizures
Cardiac: tachycardia, cardiac flutter
emphysema in copd
- Abnormal permanent
enlargement of the airspaces
distal to terminal bronchioles - Accompanied by destruction
of their walls ± obvious
fibrosis
copd primarily due to
exposure to noxious particles or gases
risk factors of copd
tobacco smoking
air pollution
occupational exposures
female
age
copd clinical presentation
dyspnea, chronic cough, sputum production
wheezing, chest tightness, fatigue, weight loss, anorexia
age>40
copd symptoms use what scoring
mMRC or CAT
mMRC scale 0-4
0 - least sx; 4 - too breathless to leave house
CAT
scale of 0 to 40, >30 is high impact on life
GOT for COPD
relieve symptoms, improve exercise tolerance
prevent disease progression and mortality
uses of LABA and LAMA in copd
improve lung fx, dyspnea, health status, reduce exacerbation rates
long term steroid use can be associated with
risk of pneumonia and mortality
over use of abx in copd can lead to
spread of resistant organisms
