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Common drugs Used In Dermatology Flashcards

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Dermatology Board Prep flashcards
1
Q

What are the oral antifungals?

3

A
  1. Griseofulvin
  2. Terbinafine (Lamisil)
  3. Itraconazole (Sporonox)
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2
Q

Oral antifungals

  1. Used for what?
  2. Scalp fungal infection Rx (first and second line?)
  3. Nail fungal infection Rx (first and second line?)
A
  1. Used for treatment of scalp and nail fungal disorders
  2. Scalp
    - First line griseofulvin
    - Second line terbinafine (Lamisil)
  3. Nails
    - First line terbinafine (Lamisil)
    - Second line itraconazole (Sporanox)
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3
Q

Griseofulvin

  1. _ weeks therapy for what?
  2. MOA? 2
  3. Administration education? 2
A
  1. 8, tinea wapitis
  2. MOA
    - Fungistatic (inhibits fungal cell division)
    - Binds to human keratin making it resistant to fungal invasion
  3. Administration
    - Taken with a fatty meal helps to increase absorption
    - Take with food in general to lessen GI upset
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4
Q

Griseofulvin – pharmacokinetics/dynamics

  1. Half life?
  2. Aborption is enhanced by what?
  3. Distribution: can be distributed where? 4
  4. Metabolism where?
A
  1. Half life 9-24 hours
  2. Absorption: enhanced by ingestion of a fatty meal
    - erratic
3. Distribution
deposited in the 
-keratin layer of skin, hair, and nails
-concentrates in liver, 
-fat, and 
-skeletal muscles
  1. Metabolism: extensive hepatic
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5
Q

2 formulations of griseofulvin
1. The smaller the particle size the greater the what?

  1. What are the two doses? 2
A
  1. The smaller the particle size the greater the bioavailability
  2. Dosing
    -Microsize
    Suspension, Grifulvin V tablets
    20 to 25 mg/kg/day

-Ultramicrosize
Gris-PEG tablets
10 to 15 mg/kg/day

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6
Q

Contraindications and precautions with the administration of griseofulvin

5

A
  1. Liver failure
  2. Porphyria
  3. Pregnancy category X
  4. Use with caution if history of penicillin allergy as potential for cross reactivity
  5. Breast feeding not recommended
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7
Q

Adverse rxns: griseofulvin?

5

A
  1. SKIN: Photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme
  2. LIVER: jaundice, elevated liver enzymes
  3. BONE MARROW: granulocytopenia
  4. NEURO: dizziness, headache, fatigue
  5. GI: nausea, vomiting
    Drug induced lupus like syndrome
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8
Q

Drug interactions

  1. Metabolized through what?
  2. Beware of what interactions? 5
  3. Monitoring? 3
A
  1. Metabolized through
    - CYP1A2, CYP2C9 and CYP 3A4
  2. Beware of
    - warfarin,
    - oral contraceptives,
    - alcohol,
    - barbiturates,
    - cyclosporine to name a few
  3. Monitoring:
    - recommend CBC,
    - renal and
    - liver functions if on long term therapy (more than 8 weeks)
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9
Q

Terbinafine (Lamisil)

  1. What class is it?
  2. MOA?
A
  1. Systemic allylamine antifungal
  2. MOA
    Creates ergesterol deficiency within the fungal cell wall leading to cell death
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10
Q

Trials comparing griseofulvin to terbinafine
1. terbinafine was superior for the treatment of infections from WHAT?

  1. griseofulvin was superior for the treatment of infections due to WHAT?
A
  1. Trichophyton species
  2. Microsporum

If you are on one drug and its not working you can switch to the other

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11
Q

Terbinafine – pharmacokinetics/dynamics

  1. Half life of what?
  2. Distribution where? 2
  3. Important drug interactions? 2
A
  1. Half life is 36 hours
  2. Distribution to the
    - sebum and
    - skin
3. Metabolized hepatically
Inhibition of CYP450 enzymes 
Multiple drug interactions including 
-metoprolol and 
-tramadol
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12
Q

Most common Terbinafine side effects
3

Monitoring tests? 3

A
  1. Headache
  2. Diarrhea
  3. Elevated liver enzymes

Monitoring tests

  1. AST/ALT prior to initiation
    - repeat if used >6 weeks
  2. CBC
  3. Assess for taste and/or smell disturbance
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13
Q

Terbinafine for tinea capitis

  1. Approved for use at what age?
  2. Formulations available? 2
A
  1. Approved for use in ≥ 4 years of age
  2. Formulations available
    - Granules (sprinkle on non-acidic foods)
    - Tablets
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14
Q

Terbinafine for onychomycosis
1. Advantages? 2

  1. Patients who need treatment? 4
A
  1. Greater efficacy and fewer side effects than others
  2. Patients who need treatment
    - Cosmetic reasons
    - Diabetes and onychomycosis
    - History of lower extremity cellulitis and ipsilateral onychomycosis
    - Pain or discomfort secondary to infection
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15
Q

Itraconazole (Sporanox) for onychomycosis

1. BBW?

A

Black box warning: Negative inotropic effects have been observed following intravenous administration. Discontinue or reassess use if signs or symptoms of heart failure (HF) occur during treatment.

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16
Q

Contraindications – itraconazole

4

A
  1. Ventricular dysfunction
  2. Pregnancy
  3. CHF
  4. Concomitant use of other drugs that inhibit the CYP450 system
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17
Q

Itraconazole

  1. Half life?
  2. Metabolized by what?
  3. Better absorbed with what?
    - how should you take the solution differently?
A
  1. Half life - 21 hours
  2. Metabolized by the liver
  3. Better absorbed with food (capsules) but
    - take the solution on an empty stomach
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18
Q

Itraconazole has many drug-drug interactions
Important ones?
6

A
  1. Proton pump inhibitors,
  2. anxiolytics,
  3. pain medications,
  4. antiplatelet agents,
  5. antihypertensives,
  6. statins

Drug interaction checker a MUST for this drug and other azole antifungals

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19
Q

Adverse effects of Itraconazole?

8

A
  1. Nausea, diarrhea
  2. Edema
  3. Headache
  4. Rash
  5. Abnormal LFTs
  6. Heart failure
  7. Arrhythmia
  8. Hearing loss
    Many others
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20
Q

Monitoring for Itraconazole?

3

A
  1. Baseline LFTs
  2. Monthly LFTs if long term therapy
  3. Serum concentrations
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21
Q

When should you draw serum concentrations of itraconazole?

-Last dose affects is how?

A
  1. Draw 2 weeks after starting therapy

2. Draw without regard to when last dose was taken

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22
Q

Finasteride (Propecia)

  1. First line therapy for what?
  2. MOA?
  3. Can also be used for the treatment of what?
A
  1. First line therapy for the treatment of androgenic alopecia in men
  2. 5-alpha-reductase inhibitor
    - Ultimately inhibits the conversion of testosterone to dihydrotestosterone
  3. Same as Proscar (but lower dose)
    - Used for treatment of benign prostatic hypertrophy
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23
Q

Finasteride (Propecia): Affects PSA values

  1. How?
  2. Patients treated for ≥6 months the PSA value should be _______ when comparing to normal ranges in untreated patients
  3. So when should you check levels? 2
A
  1. PSA monitoring: Reduces prostate specific antigen (PSA) by ~50%
  2. doubled
  3. Baseline PSA needed, then recheck in 6 months
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24
Q

Finasteride (Propecia): Follow PSA levels
1. If PSA increases on this medication what should we do?

  1. If PSA did not change (go down about 50%) after 6 months of therapy of this drug then may indicate what?
  2. Finasteride efficacy?
A
  1. refer to Urology
  2. an increased risk for prostate cancer
  3. After 2 years of therapy hair counts may increase by about 25%
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25
Q

Finasteride: reproductive side effects

4

A
  1. Sexual dysfunction (may continue post discontinuation of meds)
    - Decreased libido
    - Ejaculatory dysfunction
    - Erectile dysfunction
  2. Gynecomastia
  3. Testicular pain
  4. Depression
26
Q

Finasteride Hazardous how?

2

A
  1. Women should avoid contact with crushed or broken tablets

2. Teratogenic

27
Q

Finesteride Most common side effects? 4

A
  1. Orthostatic hypotension
  2. Dizziness
  3. Weakness
  4. Sexual dysfunction
28
Q

Finasteride – metabolism and dosing

  1. Metabolism?
  2. Max results when?
  3. How long do you have to stay on it?
A
  1. Hepatic metabolism – caution for drug interactions and don’t use in liver failure
  2. Maximal results at 2 years
  3. Continuous dosing for a minimum of one year before assessment of efficacy
29
Q

Common antibiotics used in Derm

4

A
  1. Cephalexin
  2. TCN
    - Doxycycline, minocycline, tetracycline
  3. Clindamycin
  4. Mupirocin (Bactroban)
30
Q

Cephalexin (Keflex)

  1. Drug class?
  2. Derm indications?
  3. Distribution?
A
  1. Drug class
    - First generation cephalosporin
    - A beta-lactam antibiotic
  2. Derm indications: skin and skin structure infections
  3. Distribution: Widely distributed to all body tissues except does not penetrate the CSF very well
31
Q

Cephalexin Bugs it covers? 2

A

Bugs it covers

Staph and Strep

32
Q

Cephalexin (Keflex)

  1. MOA?
  2. Preg cat?
  3. Decrease dose for who?
A
  1. MOA: Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis
  2. Pregnancy category: B
  3. Decrease dose for severe renal impairment CrCl
33
Q

Mupirocin (Bactroban)
1. Indications? 3
2.

A
  1. Impetigo due to S. aureus and S. pyogenes
    - Ointment TID for 3-5 days
  2. Treatment of secondarily infected skin lesions due to
    Staph or Strep
    -Cream TID for 10 days
  3. Intranasal
    - Used to eradicate nasal colonization of MRSA
    - BID for 5 days
34
Q

What bugs does Mupirocin (Bactroban) ointment cover? 2

What bugs does cream cover? 2

What bugs does intranasal cover? 1

A
  1. S. aureus and S. pyogenes
  2. Staph or Strep
  3. MRSA
35
Q 
Mupirocin (Bactroban)
1. MOA?
2. Absorption?
(ointment and cream?)
(intranasal?)
A
  1. Mechanism of action
    - Inhibits protein synthesis by binding to bacterial isoleucyl transfer-RNA synthetase
  2. Absorption
    - Topical ointment and cream – penetrates outer layers of skin with some minimal systemic absorption
    - Intranasal – about 3% of what is applied is systemically absorbed in adults, can be significant in neonates
36
Q
  1. What are the tetrocyclines? 2
  2. MOA?
  3. Distribution?
  4. One big SE?
  5. All are preg cat what?
  6. Have direct _________ effects?
A
  1. Doxycycline, Minocycline
  2. MOA: Inhibition of protein synthesis by binding with the 30S ribosomal subunit (and possibly the 50S) of susceptible bacteria, may also cause alterations in the cytoplasmic membrane
  3. Distribution: Good distribution in the body tissue and fluids but poor CNS penetration
  4. SE: All cause photosensitivity
  5. All are pregnancy category D and not generally used in kids (esp. less than 9 years old)
  6. Have direct anti-inflammatory effects
37
Q

Doxycycline

  1. SE? 2
  2. Absorption may be delayed with what?
A
  1. SE:
    - Nausea on an empty stomach
    - Esophagitis if not taken with fluids
  2. Absorption may be delayed with achlorydia (with high pH)
38
Q

Doxycycline dermatologic indications

4

A
  1. Ticborne rickettsial infections
  2. Acne
  3. Rosacea
  4. Off label use when 1st line dermatologic therapy is unvailable
39
Q

When would we use it off label use when 1st line dermatologic therapy is unvailable? 3

A
  1. Animal and human bites
  2. Cellulitis secondary to MRSA
  3. Skin and soft tissue infections
40
Q

Minocycline (Minocin)
Dermatologic indications:
1. USed for what?

  1. Off-label? 2
  2. SE? 3
A
  1. Acne
  2. Off-label: MRSA cellulitis
    Capsule, tablet, IV
  3. SE:
    - Vertigo especially at higher doses,
    - esophagitis if not taken with water,
    - GI upset if taken on an empty stomach
41
Q

To reduce antibiotic resistance when treating acne
1. Most resistance associated with what?

  1. Before abx therapy give what?
    - alternative?
  2. Try to limit to what?
  3. What can’t you do with these? 2
A
  1. Most resistance associated with Erythromycin
  2. Before abx therapy give benzoyl peroxide for 5 days and continue during abx
    - If benzoyl peroxide is not an option, note increased efficacy if using a topical retinoid plus oral abx therapy
  3. Try to limit abx to 12-18 weeks
    • Don’t change therapy too quickly (eval after 6-8 weeks)
    • Don’t give topical plus the same oral abx
42
Q

Clindamycin

  1. Derm indications? 2
  2. Avoid oral for treatment of acne due to risk of what?
  3. Commonly used topically aline or in conjunction with?
  4. Most common in what delivery form?
A
  1. Derm indications: Acne and Rosacea
  2. Avoid oral for treatment of acne due to risk of C. difficile colitis
  3. Commonly used topically alone or in conjunction with benzoyl peroxide (combo product)
  4. Most common is gel (Clinda-gel or Cleocin-T)
43
Q

Retinoic Acid Derivative are what?

6

A
  1. Isotrentinoin (Accutane)
  2. (Absorica)
  3. (Amnesteem)
  4. (Claravis)
  5. (Myorisan)
  6. (Zenatane)
44
Q

Isotrentinoin (Accutane) indicated for what?

A

Treatment of severe, recalcitrant, nodular acne

Acne with many inflammatory nodules (greater than 5 mm) that is unresponsive to conventional therapy, including systemic antibiotics

45
Q

Isotrentionoin (Accutane)
MOA?
3

A
  1. Shrinks sebaceous glands
  2. Decreases sebum production
  3. Decreases the number of sebum dependent bacteria Propionibacterium acnes
46
Q

Isotrentinoin
Advantages?
2

A
  1. The only acne medication that can permanently alter the natural course of the disorder
  2. After treatment, better response rates to traditional topical and systemic acne therapies
47
Q

Isotrentinoin: Extremely high risk of birth defects. What is required to start this medication?

A
  1. 2 forms of birth control required to have started at least 1 month prior to rx
  2. 2 negative pregnancy tests prior to initial prescription
  3. Pregnancy test and counseling once monthly
  4. Need to be a registered prescriber in the iPledge program and document expertise in prescribing isotrentinoin per FDA regs
48
Q

Mucocutaneous side effects
Isotrentinoin
10

A
  1. Cheilitis
  2. Dry skin and mucous membranes
  3. Epistaxis
  4. Desquamation
  5. Photosensitivity
  6. Pruritus
  7. Ocular symptoms related to dysfunction of meibomian glands within the conjunctiva
    - Corneal abrasion
  8. Cutaneous staphylococcal infections
    - Paronychia, pyogenic granulomas
  9. Temporary diffuse alopecia, or nail brittleness
49
Q

More side effects of Isotrentinoin?
3

Permanent?

A
  1. Depression
  2. Hypertriglyceridemia
    (Up to 45% of patients, ETOH may potentiate this reaction)
  3. Elevated total and LDL cholesterol
    -Up to 30%

Usually resolves after discontinuation of the drug

50
Q

Monitoring of Isotrentinoin? 3

Repeat after how long of therapy?

When can we stop monitoring?

A
  1. CBC,
  2. fasting lipid profile, and
  3. liver function tests at baseline

and repeat them after 4 and 8 weeks of therapy

If these test results are normal and the dose of isotretinoin remains stable, can discontinue laboratory monitoring other than…pregnancy tests if applicable

51
Q

When do we need to pregnancy tests for Isotrentinoin?

2

A
  1. Monthly pregnancy test during administration of drug and

2. one month after discontinuation of therapy

52
Q

Isotrentinoin: Discontinue therapy for abnormal labs?

2

A
  1. TG > 800

2. LFTs 3X upper limit of normal

53
Q

What drugs are the Topical calcineurin inhibitors? 2

A
  1. Tacrolimus (Protopic)

2. Pimecrolimus (Elidel)

54
Q

Topical calcineurin inhibitors

Indications? 4

A
  1. Atopic dermatitis
  2. Lichen planus
  3. Vitiligo
  4. Psoriasis
55
Q

BBW for Topical calcineurin inhibitors?

A

Topical calcineurin inhibitors have been associated with rare cases of malignancy (including skin and lymphoma); therefore, it should be limited to short-term and intermittent treatment using the minimum amount necessary for the control of symptoms and only on involved areas.

56
Q

Topical calcineurin inhibitors

  1. Not reccommended for who?
  2. Do not administer with what?
  3. Do not administer in who?
A
  1. Not recommended for use under the age of 2 years
  2. Do not administer with systemic immune suppressants (cyclosporine)
  3. Do not use in immunocompromised patients
57
Q

Topical calcineurin inhibitors MOA?

A

Suppresses cellular immunity (inhibits T-lymphocyte activation)
-binds to an intracellular protein, FKBP-12 and complexes with calcineurin dependent proteins to inhibit calcineurin phosphatase activity

58
Q

Topical calcineurin inhibitors

  1. Concomitant ______ ingestion can cause redness and flushing
  2. Do not use under an what?
  3. _____________ is recommended with use?
A
  1. alcohol
  2. occlusive dressing
  3. Sun protection
59
Q

SE of Tacroliumus (Protopic)?

4

A
  1. Headache 20%
  2. Skin burning at application site 58%
  3. Pruritus 46%
  4. Erythema 28%
60
Q

Pimecrolimus (Elidel)

1. Advantage?

A
  1. Less burning than Protopic

Cream

61
Q

Drug induced lupus like syndrome

3 History findings?

A
  1. Patients present with some combination of arthralgia, myalgia, malaise, fever, rash, and/or serositis (inflammation of serous lining around organs)
  2. Usually are on the drug for a month or more
  3. Multiple drugs can be responsible for this
    - In Alex’s case it was secondary to grisefulvin
62
Q

Drug induced lupus

  1. How is this resolved?
  2. ____________ if symptoms do not resolve within 4-8 weeks
  3. ________________ for severe symptoms or if quick relief is needed (think pleurisy or pericarditis)
  4. Mainstay of therapy is what? 2
A
  1. Usually spontaneous resolution of the clinical manifestations of the disease, typically within several weeks to months after the offending drug has been discontinued
  2. Hydroxychloroquine
  3. Systemic corticosteroids
  4. discontinuation of drug and symptomatic treatment with NSAIDs

Dermatology (12 decks)

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