EENT: Mouth/throat- Viral-Herpes simplex, oral candidiasis

Question 1

Primary outbreak of oral herpes

Answer 1

Herpetic gingivostomatitis

Primarily on gingiva

Question 2

What lesion is described as “gray base with red halo”

Answer 2

Aphthous ulcers (Canker sores)

Question 3

Graph showing comparison b/w recurrent intraoral herpes (RIH) and Recurrent Aphthous stomatits (RAS)—> which side is which?

Answer 3

Question 4

–Prodrome of burning, pain, tingling

–Burning erythematous papules–>vesicles that rupture–>superficial ulcers that form scabs

Answer 4

Mouth/throat: Viral-Herpes Simplex

–>HSV 1 or 2

Question 5

***Acyclovir*** within 3 days of onset (cheap option, take TID)

***Valacyclovir (prodrug of acyclovir)*** (expensive option, but BID instead of TID)

Famciclovir (No RCTs, so not standard)

Answer 5

Treatment options for oral HSV 1 or 2

Question 6

–For comfort care, consider suggesting patients use

• ice, popsicles,
• or rinse and expectorate every two hours with diphenhydramine 12.5/5 cc mixed with magnesia-aluminum 1:1
• Topical lidocaine
• Fluids as tolerated given after pain management

Answer 6

Supportive care/ pain and fluid management for oral HSV

Question 7

Side effects:

1.***malaise***

2. ***headache***

3. nausea, vomiting, diarrhea

Answer 7

Adverse events/Side effects of antiherpetic

Question 8

Efficacy/Monitoring:

–Urinalysis, BUN, serum creatinine, liver enzymes, CBC

-note: Adjust dose in renal impairments

Answer 8

Efficacy and monitoring for the use of antiherpetics

Question 9

Drug interactions:

****_____, ____, and ___may diminish the therapeutic effect of Zoster Vaccine

•*****discontinue antiviral agents with anti-zoster activity ( i.e. _____)for at least 24 hours prior to and 14 days after receiving a live attenuated zoster vaccine

–may enhance the CNS depressant effect of Zidovudine (HIV tx)

Answer 9

Acyclovir-Valacyclovir, Famciclovir

Question 10

What is the main tx for Aphthous ulcers?

Answer 10

***Pain management****

Question 11

***Pain management****

–For comfort care, consider suggesting patients use:

• ice, popsicles,
• or rinse and expectorate every two hours with diphenhydramine 12.5/5 cc mixed with magnesia-aluminum 1:1
• Topical lidocaine

Answer 11

Treatment for Aphthous ulcers

Question 12

Which condition has the following clinical presentation:

•Painful creamy-white curd-like patches overlying erythematous mucosa

–Easily rubbed off –only the underlying irregular erythema may be seen

Answer 12

Fungal-oral candidiasis

Question 13

Diagram of Antifungal MOA

Answer 13

Antifungals disrupt the membrane

Question 14

–***Nystatin Suspension 1:100,000***

–Clotrimazole troches

–Itraconazole Suspension (Second line to fluconazole)

Answer 14

***First line topicals to treat Fungal-oral Candidiasis***

These have less adverse events and drug interactions

Question 15

***Fluconazole***

Answer 15

Fungal-oral candidiasis: treatment with “azole” antifungal

***oral prototype: Fluconazole***

Question 16

What medication has the following mechanism?

•Mechanism: Binds to sterols in fungal cell membrane, changing the cell wall permeability allowing for leakage of cellular contents

Answer 16

Oral prototype: Fluconazole (medication that can be used to treat fungal-oral candidiasis)

Question 17

Which medication has the following adverse effects/side effects:

–Anaphylactic reactions

–Angioedema (rare)

–Headache, dizziness

–Rash

–Nausea, abdominal pain, vomiting, diarrhea, dysgeusia, dyspepsia

–***Increased Alkaline phosphatase, ALT, AST, hepatic failure (rare), hepatitis, jaundice***

Answer 17

“azole” antifungal: fluconazole (treatment for oral candidiasis)

Question 18

Which medication has the following Efficacy/Monitory?

–***Periodic liver function tests (AST, ALT, alkaline phosphatase)

–***Renal function tests: baseline SrCr

• Potassium levels

–***QT prolongation

Answer 18

“azole” antifungal: fluconazole (treatment for oral candidiasis)

Question 19

Which medication has the following interactions? (Note, all of the following was red in the powerpoint)

•Interactions:

–Inhibits CYP1A2 (weak), CYP2C19 (strong), CYP2C9 (strong), CYP3A4 (moderate)

• Increase the serum concentration of Atorvastatin, simvastatin, Citalopram, Phenytoin, Proton Pump Inhibitors, Sulfonylureas, Vitamin K Antagonists
• May decrease the metabolism of Benzodiazepines, Carbamazepine, Losartan
• May enhance the adverse/toxic effect of Calcium Channel Blockers

–etc, etc, etc

****Main idea: -azoles have a lot of interactiosn so look them up!

Answer 19

“azole” antifungals: Fluconazole (a treatment for fungal-oral candidiasis)

Question 20

What is the pregnancy category for “azole” antifungals like Fluconazole

Answer 20

Pregnancy category C (single does for vaginal candidiasis)

Category D for all other indications

Question 21

True or false, dosage adjustment in renal impairment is requried for “azole” antifungals (Fluconazole)

Answer 21

True

Question 22

What is unique about Ketaconazole?

Answer 22

This is another “azole” that is unique because you have to take with breakfast because it requires acidic gastric environment