Endo-Electro-GI-Gyn-Uro Flashcards
1
Q
Long Acting Insulins (2)
A
Detemir, Glargine
2
Q
Rapid Insulin?
Intermediate Insulin?
A
Regular
NPH
3
Q
Very Rapid Insulins (3)
A
Aspart, Lispro, Glulisine
4
Q
DPP4 Inhibitors
Name?
SEs:
Nasopharyngitis
Hypersensitivity
………………?
A
Sitagliptin
Pancreatitis
5
Q
GLP1 Agonists
Name?
SEs:
Nausea/Vom/Diarrhea
……………..?
A
Exenatide, Liraglutide
Pancreatitis
6
Q
Meglitinides
Name?
2 SEs?
A
Repaglinide
Hypoglycemia
Weight gain
7
Q
SGLT2 Inhibitors
Name? 3 SEs:
- GU Infection
2,3 ?
A
Canagliflozin
Hypotension / Hypovolemia
Hyperkalemia
8
Q
TZDs (PPAR gamma inhibitors)
Example? SEs (2)
A
Pioglitazone
Water retention, edema
Wt gain, worseningn of CHF
9
Q
Alpha Glucosidase inhibitors
Example? SE? (1)
A
Acarbose
GI SEs
10
Q
SUs
1st Gen Chlorpropamide
2nd Gen Gliburide
SEs (3)
- Hypoglycemia
2,3 ?
A
- Wt gain
- Hypothyroidism
11
Q
Metformin
Cautions: If ClCr <30 , Lactic Acidosis
Class name?
A
Biguanides
12
Q
DM
Dx Criteria:
1,2 Random Glc or 2h Glc above ………
- FBS above …….
- HbA1C above ……..
A
1,2 11.1
- 7
- 6.5%
13
Q
DM T1
Total need in Insulin if Wt=70 kg, is 35 Units
Morning ?
Evening ?
A
M: 2/3 (2/3 NPH. 1/3 Regular)
E: 1/3 (1/2 NPH. 1/2 Regular)
14
Q
DM
SEs of Insulin
1.Hypoglycemia
2,3 ?
A
Localized fat hypertrophy
Allergic reactions
15
Q
DM
Tx if mild to moderate hypoglycemia: 15 Sugar PO
Tx if severe hypoglycemia
A
If alert:
20g Glucose PO (preferably tablet)
If unconcious:
Glucagon 1 mg IM or SC, then Glucose PO
(If IV access: D50W 20-50 mL in 1-3 minutes)
16
Q
DM in Pregnancy
- Insulin is preferred
- Metformin or Gliburide are ok if necessary
- Folic Acid?
A
start 3 months before pregnancy 5 mg/day
switch to 1 mg/day after 1st trimestre is finished
continue until 3 months after delivery or until the end of breastfeeding
17
Q
DKA, Tx
- NS IV (500 ml in 4h)
- Potassium algorithm ?
- Insulin (Regular) Infusion (unless K+ is <3.3) until AG is corrected (dose: 0.1 Units/kg/h)
- +/- Bicarbonate
A
Potassium:
If <3.5 then 40 meq/l
If 3.5-5.5 then 20 meq/l
If >5.5 or anuric: do not give K+
18
Q
Thyroid
DOC in Hypo: Levothyroxine
What is the indication for Liothyronine (T3)?
A
Liothyronine (T3)
Only in short term management of thyroid cancer with hypothyroidism
19
Q
Thyroid in Pregnancy:
Target in Hypo: Normalizing TSH to 2.5-3
Target in Hyper ?
A
Free T4 and Free T3 to be upper limit of NL
20
Q
Thyroid
What is the SE of Levothyroxine in elderly if high dose?
A
Risk of bone Fx
21
Q
Thyroid
A woman already diagnosed with hypothyroidism comes with a positive beta HCG test. Advice?
A
Add 2 tablets/week to levothyroxine she is already taking
22
Q
Thyroid
Taking Levothyroxine with Iron at the same time?
A
There must be a 6 h interval
23
Q
Thyroid
Myxedematous Coma, Tx
- ABCs, Hydration
2,3. ?
A
IV Levothyroxine + IV Hydrocortisone
24
Q
Thyroid
MMZ and PTU, SEs:
- Allergic reactions
- Agranulocytosis
3 ?
A
Hepatotoxicity
Nephrotoxicity (Rare)
25
Thyroid
MMZ and PTU, Monitoring:
1. Regular CBC, LFT
2. Education for ..............
Fever
Rash
Jaundice
26
Thyroid
MMZ and PTU:
MMZ is considered 1st choice because ................
It is less hepatotoxic than PTU
27
Thyroid
MMZ and PTU in Pregnancy?
1st trimetre: PTU is DOC
then switch to MMZ (also ok in breastfeeding)
28
Thyroid
MMZ and PTU in Children?
PTU is CI in children
MMZ is ok
29
Thyroid Storm
Tx:
1. Hydration + Supportive Tx
2. If fever: Acetaminophen (no ASA or NSAID)
3. .............................
PTU + Propranolol + CS +/- Lugol's solution
(Lugol's is Iodine that is helpful in Tx of acute hyperthyroidism, to be prescribed 1h after PTU)
30
Thyroid
Hyperthyroidism in Pregnancy
Screening at week 22 for ?
Anti TSH Receptor Ab (TRAb)
If (+): High risk of hyperthyroidism in baby: Refer
31
Anemias
Nonpharmacological Tx for IDA:
Heme-Iron is important:
Liver, Red meat, tuna, clam, oyster, salmon, shrimp,
but not .......
Vegetables are not very effective (Non heme)
32
Anemias
Duration of Tx for IDA
3 months after correction of Hb
33
Anemias
Iron in Pregnancy
Routinely for all:
Start Iron 20 mg/day at week 20
34
Anemias
Two important SEs of Vitamin B12:
1. In first few days .........................
2. Venous Thrombosis
Hypokalemia (Shift of K+ into the cells)
Monitorin K+ is very important in first few days
35
Anemias
Folate defficiency is usually seen in:
- Alcoholics, Pregnancy
- Taking MTX or ....... or ..........
Phenytoin
TMP
36
Anemias
SEs of Epoetin Aplha or Darbepoetin Alpha
1. Cardiovascular, Venous thrombosis, HTN
2. ...............
PRCA
Pure Red Cell Aplasia (Ab induced)
37
Obesity
3 Medications in Canada:
1. ....................
2. Bupropion
3. ..................
1. Orlistat
3. Liraglutide
38
Obesity
Orlistat is an inhibitor of lipase (gastric and pancreatic)
SEs:
1,2 ?
Fecal Urgency
Oily spotting
39
Obesity
Liraglutide (GLP1 Agonist, Incretin)
SEs:
1. GI intolerance
2,3 ?
Severe Hypoglycemia
Pancreatitis
40
Obesity
Safety in Pregnancy ?
Orlistat, Bupropion, Liraglutide
Orlistat: Not recommended
B,L are OK
41
Dehydration
Severity of dehydration: Mild/Mod/Sev
Infants: 5%, 10%, 15%
Other: 3%, 7%, 10%
Capillary filling ?
Mi: \<2 sec
Mod: 2-4 sec
Sev: \>4 sec
42
Dehydration
Absolute indications for admission:
1. Shock
2. Severe N/V
3,4 ?
Sensorium change
Hyper or Hyponatremia
43
Dehydration
Relative indications for admission:
1. HCO3- below 15
2. ?
Weak response to oral hydration
44
Dehydration
Total fluids in 24h = Maintenance + Deficit
How to calculate maitenance in children?
(M is independent of severity of dehydration)
Hourly: 4-2-1 ml/kg/hour 15 kg: 50 ml/h
or
Daily: 100-50-20 ml/kg/day 15 kg: 1250 ml/day
45
Dehydration
Total fluids in 24h = Maintenance + Deficit
How to calculate deficit in children?
(based on severity of dehydration)?
Wt x Percent of dehydration
Example: 15 kg x 10% (severe) = 1,500 ml deficit
1/2: first 8 h, 1/2 next 16 h
(deficit is done in 24 h)
46
Dehydration
Total fluids in 24h = Maintenance + Deficit
Alternative way to calculate deficit in children?
(based on body wt only)
Example:
Wt=9 kg, Age=1 y
Average wt for 1 yo= (Agex3)+7=10 kg
deficit = 10-9= 1 kg = 1,000 ml
47
Dehydration
Total fluids in 24h = Maintenance + Deficit
How to calculate Na+ and K+ in maintenance?
Na+ = 3 meq/100 mL of Maintenance
K+ = 2 meq/100 mL of Maintenance
Example: If maintenance is 1,250 ml/day
Na=37.5 , K= 25
48
Dehydration
Total fluids in 24h = Maintenance + Deficit
How to calculate Na+ and K+ loss (in deficit)?
Na+ loss = K+ loss = 8 meq/100 ml of deficit
Example: If deficit = 1500 ml
then Na loss = K loss = 120 meq/day
49
Dehydration
Half Saline (0.45%) in 1 Liter, has:
4.5 g of NaCl = 1.78 g of Na = ........... meq of Na
77 meq of Na
Example: if Na loss = 120 meq
then 120/77 = 1.55 liter of half salin will compensate it.
50
Dehydration
Oral Rehydration (with Pedialyte or Gastrolyte)
If mild to moderate, then ..............
If severe, then .................
If mild to moderate:
50 ml/kg in 4 hours Or 100 ml/kg in 1st day
If severe:
100 ml/kg in 4 hours Or 150 ml/kg in 1st day
51
Hypovolemia
Best for dehydration: Half Salin + D5W
Best for hypotension: ....................
NS (0.9%)
Or Ringer Lactate
52
Hypovolemia
Ringer lactate caution?
Risk of hyperkalemia if renal function is impaired
(Ringer lactate contains K+)
53
Hypovolemia
Maintenance fluid in adults ?
(and Na+ and K+)
Maintenance fluid in adults is 2-2.5 Liters
Including Na+ =75 mmol and K+ = 50 mmol
54
Edema
Pitting or Non-pitting?
1. Cardiac, Renal, Idiopathic
2. Lumphatic, Hypothyroidism
1. Pitting
2. Non-pitting
55
Edema
Four classes of medications that cause edema
1,2 NSAIDs, CCBs
3,4 ?
CS, TZDs
56
Edema
Best Loop diuretic if allergic to sulfa?
Ethacrynic Acid
57
Edema
Tx if refractory?
Reinforce Nonpharmacologic Tx
+ Consider Doubling the dose of loops every 5 days
58
Potassium
Normal is 3.5-5
Hypokalemia: Mild/Moderate/Severe : steps of 0.5
Hyperkalemia: Mild/Moderate/Severe ?
Mild: 5-6
Mod: 6.1-6.5
Severe: \>6.5
59
Potassium
If hypokalemia is refractory, the reason might be ................
Possible hypomagnesemia
in: Diarrhea, Diuretics, PPIbbbbb
60
Potassium
Hyperkalemia Tx:
1. IV Calcium gluconate (Fast, short acting)
2. ............
Insulin (longer acting)
+/- Salbutamol (if no CI like heart disease)
+/- (Hydration+Loops)
+/- Dialysis
(Resins are last resort, not recommended)
61
Potassium
Hypokalemia Tx:
1. Best ?
2. ?
1. Oral KCl
(if Acidosis: Potassium Citrate)
2. K+ Sparing diuretics
62
Potassium
Hypokalemia Tx:
Indications for parenteral KCl?
1,2 if unable to drink or if hepatic encephalopathy
3,4 ?
Respiratory muscle weakness
Cardiac arrhythmia
63
Hypercalcemia
Ca (NL) is below 10.5 mg/dlit or ..........
Hypercalcemia Mild/Mod/Severe
below 2.7 mmol/lit
2.7-2.9 / 2.9-3.5 / \>3.5
64
Hypercalcemia
Tx of Mild hypercalcemia (2.7-2.9) is nonpharmacologic:
Avoiding the cause, avoiding sedentary lifestyle, avoiding Vit D, Callcium, .......................
Providing 1-2 g/day oral Phosphate (except for renal dysfunction)
65
Hypercalcemia
Tx of Moderate hypercalcemia (2.9-3.5)?
Nonpharmacological + Bisphosphonates
+/- CS
66
Hypercalcemia
Tx of severe hypercalcemia (\>3.5)
Calcitonin
then bisphospnonates and IV Salin + Loop diuretic
67
Hypercalcemia
Tx of hypercalcemia in Granulomatose diseases
CS + Avoiding sunlight
68
Upper GIB
If a patient loses 50% of blood volume,
then SBP, HR, Hb?
SBP, Hb \<100
HR \>100
69
Upper GIB
Old Tx: Lavage with NG Tube (not used any more)
Current Tx: .......................
Gold standard Tx: Endoscopy
Prokinetics like Erythromycin
250 mg IV single dose
70
Upper GIB
Best PPI in Non-Variceal UGIB
Pantoprazole IV or PO (for 72 hours)
71
Upper GIB
Tx of Variceal UGIB (ER):
1. Octreotide IV
2. ...............
Norfloxacin PO for 7 days (or Ceftriaxone IV)
+/- Vasopressin (only if no IHD)
Consider TIPS (if Tx fails)
72
GERD
Tx if Mild?
Antacids
Alginates (Al Hydroxide)
H2 Blockers
73
GERD
Tx if moderate to severe?
PPIs for 8 weeks
Pantoprazole or Esmoprazole PO
once or twice a day (30-60 min before meals)
74
GERD
Rare but serious possible SEs of PPIs:
1. Osteoporosis
2. Hypo Mg
3,4 ?
Nosocomial Pneumonia
C. Difficil infection
75
GERD
Safety of PPIs in Pregnancy/ Breastfeeding
Better to avoid
(Not enough data is available)
76
GERD
Maintenance therapy:
1. Step down ?
2. Intermittent / on demand ?
3. As needed ?
1. Half of standard Tx for long term
2. stop when Ok, start another course if relapse
3. stop when Ok, take a few doses when needed
77
PUD
Dx tests for H Pylori
Best: EGD, Other:
1. Serology
2. UBT
3. ?
H Pylori stool Ag test
(High Sp, Acceptable Sen)
78
PUD
Dx tests for H Pylori
UBT is a very good and practical test.
Limitations?
1. No ABs or Bismuth within last month
2. No PPI or H2 blocker within last week
79
PUD
H Pylori Eradication:
Standard is Amoxicillin + Clarythromycin + PPI
What if betalactam allergic?
Replace Amoxi with Metronidazole
80
PUD
H Pylori Eradication:
Standard is Amoxicillin + Clarythromycin + PPI
What is the quadraple alternative Tx?
PPI + Bismuth + Metronidazole + Tetracyclin
81
PUD
H Pylori Eradication:
Standard is Amoxicillin + Clarythromycin + PPI
What is the strongest alternative?
PPI + Amoxi + Metro + Clarythro (3 ABs) 10-14 days
Or Sequential:
(PPI+Amoxi) 5-7 days,
then (Metro+Clarythro) 5-7 days
82
IBD
Nonpharmacological Tx:
receive enough calories plus:
1. Live vaccines?
2. NSAIDs?
1. CI
2. better to avoid
83
IBD
1st line Tx in UC?
Aminosalycilates
like 5ASA or Sulfasalazine
84
IBD
Sulfasalazine SEs:
1. Hemolytic Anemia
2. Hepatotoxicity
3,4 ?
Hypersensitivity
Oligospermia
Crystalluria and renal stones
85
IBD
Azathioprin SEs:
1,2 Stomatitis, Arthralgia
3,4 Opportunistic infections, blood dyscrasia
5,6 ?
Pancreatitis
Skin Cancers
86
IBD
6MP SEs:
1,2 Stomatitis, Opportunistic infections
3,4 ?
Blood dyscrasia
Pancreatitis
87
IBD
Anti TNF Alpha SEs:
1,2 Reactivation of TB, Pneumonia
3,4 ANA, Lupus like Sd
5,6 ?
Lymphoma
Skin Cancers
Cervical dysplasia
88
IBD
Caution with:
1. Anti diarrheals: Risk of toxic megacolon
2. Opioids (2)
- Toxic megacolon
- Narcotic bowel Sd (Chronic abdominal pains)
89
IBD
Ulcerative Proctosigmoiditis, Tx?
Per rectum
5ASA or CS (suppositories or enema)
90
IBD
Safety of CS during Pregnancy?
Caution in 1st trimestre
may cause cleft palate
91
IBD
1st line Tx in CD?
CS or Azathioprin or 6MP
92
Irritable Bowel Sd
Tx:
- If Diarrhea dominant ?
- If Constipation dominant ?
- D: Loperamide PRN
- C: Psyllium or Bisacodyl PRN
93
Ascites:
If SAAG \< 11 g/Lit: Cancer or Infection
If SAAG \> 11: Portal htn, Tx ?
1. Spironolactone or ..........
2. ......................
1. Amiloride
2. Furosemide or Metolazone (loop)
94
SBP
PMN count is \> 250 (Or WBC \> 500)
DOC= 3rd Gen Cephalosporin (5 days) + .............
Then, prophylaxis with ........
Albumin
Norfloxacin PO
95
Hepatic Encephalopathy
DOC= .......
Altenative: ................. +/- Lactulose
Rifaximine
Metronidazole
96
PBC and PSC
DOC=............. + Providing Vit A,D,K
For pruritis: Cholestyramine or Naltrexone
UDCA
97
Chronic Active Hepatitis (Autoimmune)
DOC ?
CS (Prednisone)
+/- Azathioprin or Mycophenolate
98
PBC and PSC
If Ascending Chollangitis, DOC:
1- Mild to moderate ?
2- Severe?
1. Ciprofloxacine PO
2. Ampicillin + Gentamycin + Metronidazole
or Piperacillin/Tazobactam + Metronidazole
99
Acoholic Hepatitis
Tx: Abstension from alcohol + .............
CS +/- Pentoxifylline
100
Wilson disease:
Tx: Penicillamine or .................
If intolerant: ...............
Trientine
Zinc + avoid foods containing Copper:
Peanuts, chocolate, liver, mushroom, shellfish
101
GI
Safety in Pregnancy / Breastfeeding
1. UDCA
2. Penicillamine
Both:
P: safe
B: avoid!
102
GI
Major possibe SE with UDCA ?
Leukopenia
103
GI
Major poosibe SEs with Deferoxamine ? (2)
Hearing or visual toxicity
Seizures
104
GI
Major poosibe SEs with Penicillamine ? (2)
Nephrotoxicity, Pr Uria
Tasting sensory deficit
105
GI
Major possibe SE with Trientine ?
Anemia
106
Nausea in Adults
In ER, 1st choice is .......... or ...........
Metoclopramide IV
or Prochlorperazine IV
107
Nausea in Adults
DOC in mild to moderate Nausea in Pregnancy (3)
1. B6 (Pyridoxine)
2. Ginger
3. Accupressure P6
108
Nausea in Adults
DOC severe Nausea in Pregnancy (Approved in Canada)
Diclectin (Doxylamine+Pyridoxine)
109
Nausea in Adults
DOC in Uremia ?
DOC in vestibular nausea?
U: Chlorpromazine
V: Dimenhyrinate or Scopolamine
110
Nausea in Adults
PONV (Post op) how to decrease it?
1. Hydration
2. Decreasing use of Opioids, ....... , ........
Volatiles, N2O
111
Diarrhea
DOC in Pregnancy / Breastfeeding
Loperamide
112
Diarrhea
DOC for CDI:
If mild : Metronidazole PO
If moderate : Vancomycin PO
If severe?
Vancomycin PO + Metronidazole IV
113
Diarrhea
Octreotide Vs Ondansetron
Oct: Antidiarreal, for VIPoma or Carcinoid Sd
Ond: Antiemetic (5HT) for severe Nausea
114
Diarrhea
Cholestyramin: Indication, SE (2)
Diarrea caused by biliary salts
Vit A,D,K deficiency
Bleeding
115
Diarrhea
Metronidazole SEs
1,2,3 Disulfiram reaction, Metalic taste, Anorexia
4 ?
Neurotoxic in long term use
116
Diarrhea
Vancomycin SEs
1,2,3. Red man Sd, Eosinophilia, Fever
4 ?
Stomatitis
117
Diarrhea
Bismuth SEs:
1,2. Encephalopathy, Salicilate toxicity
3,4 ?
black tongue
dark stools
118
Diarrhea
Probiotics:
................. in prophlaxis and Tx of CDI
S. Boulardii
119
Constipation Vs Diarrhea
Which one(s) cause C, which one(s) D?
Al, Mg, Ca Antacids
Bismuth, Iron, Cholestyramine, Psyllium, Sucralfate
Cause diarrea:
Mg, Psyllium
Cause Constipation:
Al, Ca, Bismuth, Iron, Chlestyramine, Sucralfate
120
Constipation
- Example of bulk formings: Psyllium
- Example of Osmotics ...........
- Example of Lubricants ................
- Example of Softeners ..............
Os: Lactulose, PEG
Lub: Glycerin, Mineral Oil, Caster Oil
Sof: Decusate
121
Constipation
In Pregnancy: Nonpharmacological plus:
1st line?
2nd line?
1. Bulk formings
2. Mg hydroxide or Bisacodyl (short term)
3. Osmotics (last choice)
Note: Caster oil, mineral oil ARE CI in Pregnancy
122
Constipation
DOC for opioid induced constipation?
DOC for constipation in palliative care?
Op: Naloxegol
Pal: Methylnaltrexone
123
Viral Hepatitis
In which one(s) vaccination for Hep A or Hep B is recommended?
Children (routine), HIV positives, Hep C patients,
High risk sexual behavior, chronic liver diseases,
IV drug abusers, Coagulopathies
Hep A vaccine: ONLY for 3:
1.Hep C patients, 2.chronic liver diseases, 3.Coagulopathies
Hep B vaccine: ALL are recommended
124
Viral Hepatitis
Injection of Hep B vaccine and Ig at the same time?
It is ok as long as we use two separate sites of injection
125
Viral Hepatitis
DOC for chronic Hepatitis B (2)
Tenofovir Or Entecavir
126
Viral Hepatitis
DOC for chronic Hepatitis B if it is the wild form that is not able to produce HBeAg?
Adefovir
127
Viral Hepatitis
Index used for starting the Tx?
Index used for Tx follow up: HBV DNA
AST
128
Viral Hepatitis
DOC for Tx of chronic Hepatitis C:
1. If genotype 1,4 ?
2. If genotype 2,3 ?
1,4 Sofosbuvir + Peg interferon + Ribavirin
2,3 Sofosbuvir + Ribavirin
129
Viral Hepatitis
Tx for Hepatitis B in Pregnancy?
and breastfeeding?
During: Only supportive
After: Vaccine + Ig to the baby
Br: is OK unless bleeding from nipple
130
Viral Hepatitis
Tx for Hepatitis C in Pregnancy?
and breastfeeding?
During: Only supportive
After: Start antivirals for mother
Br: is OK unless bleeding from nipple
131
Viral Hepatitis
Important SEs of Peginterferon alpha 2a?
Neutropenia
Thrombocytopenia
(managed by dose reductions)
CIs: Severe Hepatic/renal/cardiac disease, pregnancy
132
Viral Hepatitis
Important SEs of Entecavir?
Increased aminotransferase levels
133
Viral Hepatitis
Important SE of Lamivudin?
Increased aminotransferase levels
134
Viral Hepatitis
Important SEs of Ribavirin?
Hemolytic anemia
may cause MI
Neutropenia
Thrombocytopenia
135
Viral Hepatitis
Important SEs of Adefovir?
Increased aminotransferase levels
Nephrotoxicity
Severe hepatomegaly with steatosis
136
Viral Hepatitis
Important SEs of Tenofovir?
Renal Toxicity
Monitor renal function and serum P
Severe hepatomegaly with steatosis
137
Viral Hepatitis
Important SEs of Sofosbuvir?
Neutropenia
(usually when combined with Ribavirin and Peginterferon)
138
Contraception
Absolute CIs for COCs (Combined Oral Contraceptives)
Total=11
1-7 DM, MI, HTN (160/100), CVA, Valvular HD, .......... , ..........
8-11 Br CA, Migrain with aura, \<6w Post partum, ...........
Hypercoagulation, Cirrhosis or hepatic tumor
Smoker \>35 yo
139
Contraception
Yaz, Yasmin: include Drospirenone
1 Pro ? 1 Con ?
Pro: antiandrogenic, good for PMDD
Con: increased VTE risk
140
Contraception
Progestin-only: recommended if ?
CI to COCs, like smoker\>35 yo or migrain or breastfeeding
141
Contraception
DMPA SE?
Decreased bone density:
Take Vit D + Ca regularly
142
Contraception
LNG= Levororgestrel Vs Mifepristone = RU 486
LNG is progestin-only, uses:
1. LNG-IUS as a contraceptive wich decreases bleeding
2. LNG Tab PO as a post-coital contraceptive
Mifepristone is anti-progestin, use:
1. in abortion
2. in post-coital (planB) (not 1st line)
143
Contraception
Postcoital (Emergency) contraception
DOC (2)
1. Tab LNG Single Dose 1.5 mg PO (upto 5d after)
2. Copper IUD insertion (upto 7d after)
144
Contraception
Breakthrough bleeding (more common with progestin-only) Tx?
Up to 3 months: No Tx
If more: Increase dosage of Estrogens to 35 ug
145
Contraception
During Breastfeeding, DOC (2)
1. Progestin-only (best)
2. ...............
LNG-IUS (2nd choice)
Note: No Estrogens up to 6 weeks post partum
146
Contraception
COCs Pros and Cons:
CVD ? VTE ? Br CA?
VTE: increased risk
CVD, Br CA: probably increased risk
147
Contraception
COCs Pros and Cons:
Fibroids, Pain in endometriosis, Br benign dis,
Ovarian cysts, Dysmenorrhea, EP, PID, Pre-menopausal
ALL are decreased
148
Contraception
Three methods for adolescents:
1. COC + Male Condom
2,3 ?
2. Copper IUD
3. LNG IUS
149
Contraception
COCs: Alarm signs to educate your patients
ACHES
A. Abdominal pain
C. Chest pain
H. Headache
E. Eyes
S. Severe leg pain
150
Contraception
CIs for Progestin-only:
Absolute (2) Pregnancy, ..............
Relative (2) Viral active Hepatitis, .................
A: Current Br CA
B: Hepatic Tumor
151
Contraception
Copper IUD, CIs:
Infections, Pregnancy, bleeding, Cancer, inability to insert, ............
1st month post partum (relative CI)
(best at this time: Progestin-only or LNG-IUS)
152
Menopause
Pros and Cons of HRT:
Br CA, Endometrial CA, VTE, MI, CVA ?
ALL: increased risk
153
Menopause
Hot FLASHES: if a patient does not like to take Estrogens or it is CI for her, there are 3 alternatives:
1. Nonpharma Tx
2,3 ?
Progestin-only
SSRI
154
Menopause
HRT: Indications
1. Estrogen-only
2. E+P combined
If hysterectomy AND short term AND low dose:
Estrogen-only is OK
Otherwise: choose E+P combined
155
Menopause
HRT including Estrogen. Absolute CIs (5)
1. Vaginal bleeding of unknown origin
2. Br or Endometrial CA
3. Pregnancy
4,5 ?
VTE, Active liver disease
156
Menopause
HRT including Progesterones. Absolute CIs (3)
1. Vaginal bleeding of unknown origin
2,3 ?
Br or Endometrial CA
Pregnancy
157
Menopause
Possible indication for LNG-IUS
If a woman is around menopause, with some times heavy bleeding and desire for contraception
158
Menopause
Tx of vaginal atrophy or dryness is topical.
Type of cream?
If \< 1y, Estrogen only is OK (Premarin vaginal cream)
Otherwise: E+P topical is recommended.
159
Endometriosis
DOC if mild? how to use it?
NSAIDs
Start as soon as pain starts, continue untill the end of cycle and then stop
160
Endometriosis
There are four hormone therapies available:
1. COCs (effective in 75% of cases)
2. ...............
3. ...............
4. ..............
2. Progestin-only: DMPA or LNG-IUS
3. Androgen Agonists: Danazol
4. GnRH analogues: Leuprolide
161
Endometriosis
SEs of therapies:
Danazol (3)
1. Acne
2,3 ?
Hirsutism, Voice change, Vaginal dryness
Dyslipidemia
(Danazol is an androgen agonist)
162
Endometriosis
Last line Tx is Leuprolide (GnRH). SEs and cautions:
1. It needs add-back hormone therapies (E+P)
2. Hot FLASHES, Insomnia, Mood changes
3. ........... , ..................
Vaginal Atrophy
Decreased bone density (needs Vit D + Ca)
163
Endometriosis
Tx in pregnancy and breastfeeding
No need to Tx (it is usually suppressed)
164
Menorrhagia
MeNorrhagia Vs. MeTROrrhagia
Meno: Bleeding is heavy (80 ml) or long (7d)
Metro: Bleeding is irregular and frequent
165
Menorrhagia
The most important question when you choose a Tx is that.............
Is a contraception desired or not?
166
Menorrhagia
If a contraception is desired, DOC:
1st choice = COC
2nd choice = ?
3rd choice = ?
2= LNG-IUS
3= DMPA
167
Menorrhagia
If a contraception is NOT desired, DOC:
1st choice = ?
2,3 =
1= MPA PO for 21 days
2. NSAIDs during the menses
3. Tranexamic Acid
168
Menorrhagia
If a contraception is desired, but a Tx with COCs or 2nd or 3rd choices fails, then Tx=?
Either Leuprolide (with add-back hormone Tx)
Or Danazol (androgen agonist)
169
Menorrhagia
If a contraception is NOT desired, but a Tx with MPA or 2nd or 3rd choices fails, then Tx=?
We have to use COCs
170
Menorrhagia
Acute Menorrhagia in ER:
1. ..................
2. ................or ...............
1. High dose Conjugated Estrogens (25 mg IV)
2. High dose Progesterone Or Tranexamic Acid
171
Menorrhagia
CIs for Tranexamic Acid (3)
1. Thrombotic disease
2,3 ..................
SAH
Hematuria
172
Dysmenorrhea
1st line Tx? how to use it?
NSAIDs (not ASA)
2-3 days/cycle regularly, for a trial of 3-6 months and then reevaluate
173
Dysmenorrhea
1. Indication for COCs?
If contraception is also desired or if not responding to NSAIDs trial of 3-6 months
2. Alternative Tx?
2. LNG-IUS (if heavy bleeder) or DMPA (if Estrogens are CI, like smoker above 35 yo)
(Note: for DMPA: add vit D + Ca, and avoid in \<18 yo)
174
Female Sx dysfunction
Tx for arousal/desire dysfunction?
Ask for Medications she uses
+ No drug is recommended +/- CBT
175
Female Sx dysfunction
Tx for orgamsic dysfunction? (2)
Ask for Medications she uses
+/- Sildenafil or DHEA
+/- Coital alignement
176
Female Sx dysfunction
Genito-pelvic pain/penetration Sd
(Dysparonia + Vaginismus),
Tx? (3)
Reverse Kegel exercises
Vaginal cones
Estrogen creams +/- lubricants
177
Male Sx dysfunction
VEDs (Vacuum Erectile devices), CIs:
1. Hx of periapism or high risk of that (hematological)
2. .........................
Taking Warfarin or high INR for any cause
178
Male Sx dysfunction
Sildenafil and Vardenafil: SE with PDE6: ..............
Tadalafil (Cialis) : SE with PDE11: ..............
Eye problems
Myalgia
179
Male Sx dysfunction
PG analogues for ED, example, use
Alprostadil
1. Intracovernosal injection
2. Urethral instillation (Pellet)
180
Male Sx dysfunction
Premature ejaculation Nonpharma Tx (4)
1,2. Start-stop (1 min), Quiet vagina
3,4 ?
Adaptation (2nd erection)
Squeeze technic
181
BPH
1st line: Alpha blockers (SEs)
1. Doxazocin, Terazocin
2. Tamsulosin
1. first dose syncope, hypotension with Viagra
2. No.
182
BPH
A SE of Alpha blockers in Cataract surgery?
IFIS (Intraoperative Floppy Iris Sd)
183
BPH
2nd line Tx: Finasteride (5 alpha red inhibitor)
Caution?
Decreased PSA may result in late dx of cancer
184
BPH
Daily usage of PDE inhibitor is approved in combination with alpha blockers
Tadalafil (Cialis)
185
Urinary Incontinence
In Stress UI:
1st line is Nonpharmacological ?
2nd: Adding Pessary or vaginal cones
3rd: Surgery
Nonpharmacological:
Pelvic floor muscle training (Kegel)
+ Bladder Training (=Timed Voiding)
Note: Kegel : 3-6 times a day for 6-8 weeks
186
Urinary Incontinence
In Urge UI:
1st line is Nonpharmacological: (PFMT + Bladder Tr.)
2nd: Medications ?
Oxybutinin (PO or gel or patch)
or Darifenacin (new)
or Mirabegron (beta 3 agonist)
187
Urinary Incontinence
In Overflow UI:
1st line is ?
Intermittent Catheterization
(No meds, No behavioral, no surgical)
188
UI in Children
1st line Tx= Nonpharmacologic
2nd line Tx .......... , ...........
Last line Tx= Imipramine
Desmopressin (DDAVP)
Oxybutinin
189
UI in Children
Nonpharmacological Tx:
1,2 Reduce fluid intake, Do not punish
3,4 ?
Reward the child
Use alarms
190
UI in Children
Alarms Vs Desmopressin
fast response? relapse?
A: slow response, low relapse
D: fast response, high relapse
191
Chronic Renal disease
Monitoring for ACEIs?
K+ and GFR should be measured:
before ACEI And 1-2 w after ACEI
If GFR decrease is \> 15% then repeat GFR in two weeks
192
Chronic Renal disease
in DM: Insulin dosage should be reduced
Best antidiabetic drug in renal disease is?
Gliclazide
193
Chronic Renal disease
Two Tx for metabolic acidosis in renal disease:
1. NaHCO3
2. ?
Shohl's solution
194
Chronic Renal disease
Calcium: Supplementation is recommended
Phosphate: Low P diet +/- ..........
Vit D ?
Sevelamer (P binder) if hyperphosphatemia
If only PTH\>53 then Calcitriol (Vit D analogue)
195
Chronic Renal disease
High Phosphate foods to avoid (5)
Cheese
Fish
Pork
Beef
Seeds
196
Leflunomide vs Leuprolide vs Teriflunomide
Leflunomide: used in RA, Hepatotoxic, Teratogenic
Leuprolide: GnRH Analogue
Teriflunmide: in MS
