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Therapeutics IV > Exam 4 Drugs > Flashcards

Exam 4 Drugs Flashcards

1
Q

ASA treatment

A

-Sulfasalazine
-Mesalamine

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2
Q

Immunosuppressives for IBD

A

-Azathiopurine
-Mercaptopurine
-Cyclosporine
-Methotrexate

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3
Q

TNF-alpha inhibitors

A

-Etanercept
-Infliximab
-Adalimumab
-Certolizumab
-Golimumab

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4
Q

Anti-integrins

A

-Natalizumab
-Vedolizumab

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5
Q

Anti-interleukins

A

-Ustekinumab
-Risankizumab-rzaa
-Mirikizumab-mrkz

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6
Q

JAK inhibitors

A

-Tofacitinib
-Upadacitinib

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7
Q

S1P receptor modulators

A

-Ozanimod
-Estrasimod

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8
Q

TNF inhibitors class ADRs

A

-Increased risk of serious infections
-Injection site reactions and infusion related reactions
-Risk of malignancy
-Hepatosplenic T-cell lymphoma
-Risk of demyelinating disease
-May exacerbate CHF
-Hepatitis B reactivation
-No concurrent live vaccination administration
-Headaches and rash

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9
Q

TNF inhibitors class monitoring

A

-CXR, PPD every 8-12 weeks
-Signs and symptoms of infection every 8-12 weeks
-UA every 8-12 weeks
-CBC every 8-12 weeks
-SCr, lytes every 8-12 weeks
-LFTs every 8-12 weeks
-Hep B, C every 8-12 weeks

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10
Q

Infliximab indication

A

UC and CD

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11
Q

Infliximab monitoring

A

-S/S of infection
-Vitals
-Infusion reactions
-TDM

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12
Q

Adalimumab indication

A

UC and CD

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13
Q

Golimumab indication

A

UC

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14
Q

Certolizumab indication

A

CD

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15
Q

Natalizumab indication

A

CD

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16
Q

Natalizumab adverse effects

A

Associated with progressive multifocal leukoencephalopathy

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17
Q

Vedolizumab indication

A

UC and CD

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18
Q

Ustekinumab indication

A

CD and UC

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19
Q

Ustekinumab ADRs

A

-Similar to other biologics
-Hypersensitivity possible (including anaphylaxis and angioedema)
-ADAs
-Rapidly developing cutaneous cell carcinoma in patients with risk factors
-Possible neurotoxicity (RPLS and PRES)

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20
Q

Ustekinumab monitoring

A

-CXR
-Hep B, C
-Lipids 1-2 months after start then periodically
-LFTs 1-2 months after start then periodically
-Renal function periodically
-Infection - check for signs and symptoms
-Skin annually

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21
Q

Risankizumab-rzaa indication

A

CD and UC

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22
Q

Risankizumab-rzaa adverse effects

A

-Headache
-Nasopharyngitis
-Arthralgia
-Abdominal pain
-Anemia
-Nausea
-Infections/latent infections (TB)
-Hypersensitivity possible
-ADAs
-Potential hepatotoxicity
-Increase in lipids

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23
Q

Risankizumab-rzaa monitoring

A

-CXR, PPD
-Hep B, C
-Lipids 1-2 months after start then periodically
-LFTs 1-2 months after start then periodically
-Renal function periodically
-Infection - monitor signs and symptoms

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24
Q

Mirikizumab-mrkz indication

A

UC

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25
Q

Mirikizumab-mrkz adverse effects

A

-Headache
-Arthralgia
-Rash
-Injection site reaction
-Infections/latent infections (TB)
-Upper respiratory tract infections
-Hypersensitivity possible
ADAs
-Potential hepatotoxicity (increase in LFTs)

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26
Q

Mirikizumab-mrkz monitoring

A

-CXR, PPD
-Hep B, C
-Lipids 1-2 months after start then periodically
-LFTs 1-2 months after start then periodically
-Renal function periodically
-Infection - monitor for signs and symptoms

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27
Q

What does it mean when biologics have sub-therapeutic drug levels and detectable ADAs?

A

Change to alternate drug within the same class +/- immunomodulator

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28
Q

What does it mean when biologics have sub-therapeutic drug levels and undetectable ADAs?

A

Dose escalate

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29
Q

What does it mean when biologics have therapeutic drug levels and detectable ADAs?

A

False positive or mechanistic failure so repeat test. If results consistent then switch to out of class biologic agent

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30
Q

What does it mean when biologics have therapeutic drug levels and undetectable ADAs?

A

Switch to out of class biologic agent

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31
Q

Tofacitinib indication

A

UC patients who have had an inadequate response or who are intolerant to TNF blockers

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32
Q

Tofacitinib adverse drug reactions

A

-Diarrhea
-Elevated cholesterol
-Headache
-Herpes zoster
-Increased creatine phosphokinase
-Nasopharyngitis
-Rash
-URI
-Malignancy
-Serious infection
-Neutropenia
-Hypersensitivity

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33
Q

Tofacitinib black box warning

A

-Increase mortality in RA patients 50 years and older with at least one CV risk factor
-Thrombosis - increased risk in RA patients 50 years and older with at least one CV risk factor

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34
Q

JAK inhibitor monitoring

A

-CXR, PPD
-Hep B, C
-ANC every 3 months
-CBC every 1-2 months then every 3 months
-Lipids 1-2 months after start then every 3 month
-LFTs 1-2 months after start then every 3 months
-Infection - monitor for signs and symptoms
-Skin exam periodically

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35
Q

Updacitinib indication

A

UC and CD

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36
Q

Updacitinbib black box warning

A

-Increase mortality in RA patients 50 years and older with at least one CV risk factor
-Thrombosis - increased risk in RA patients 50 years and older with at least one CV risk factor

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37
Q

Updacitinib adverse effects

A

-Increased risk of serious infection
-Upper respiratory tract infection
-Acne
-Increased creatine phosphokinase
-Elevated cholesterol
-Headache
-Herpes zoster
-Malignancy
-Increase in LFTs
-Anemia
-Neutropenia
-Lymphopenia
-Hypersensitivity
-Potentially teratogenic, excreted in breast milk

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38
Q

Ozanimod indication

A

UC

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39
Q

S1P contraindications

A

-Any major cardiac event in the last 6 months
-With Mobitz type 2 second or 3rd degree AV block, sick sinus syndrome, or SA block unless patient has functioning pacemaker
-With severe untreated sleep apnea
-Taking MOA inhibitor

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40
Q

Ozanimod adverse drug reactions

A

-Potential risk of infections
-Bradycardia/AV conduction delays
-Liver injury/elevated transaminases
-Moderate increase in systolic BP
-Respiratory effects - dose dependent reductions in FEV1
-Macular edema
-RPLS/PRES

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41
Q

Ozanimod drug interactions

A

-Adrenergic and serotonergic drugs
-Combination beta blocker and calcium channel blocker
-Foods high in tyramine
-MAO inhibitors - contraindication (active metabolite inhibits MAO-B)

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42
Q

S1P monitoring

A

-CXR, PPD
-Hep B, C
-CBC periodically
-LFTs periodically
-Infection - monitor for s/s
-BP each visit
-Spirometry if clinically indicated
-ECG
-Optho - regular exams

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43
Q

Estrasimod indication

A

UC

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44
Q

Estrasimod adverse drug reactions

A

-Potential risk of infections
-Risk of progressive multifocal leukoencephalopathy
-Bradycardia/AV conduction delays
-Liver injury/elevated transaminases
-Moderate increase in systolic BP
-Macular edema
-RPLS/PRES
-Respiratory effects

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45
Q

Which dosage form is best for treating left-sided disease?

A

Enema

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46
Q

Which dosage form is best for treating proctitis?

A

Suppositories

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47
Q

Which dosage form is best for treating pancolitis?

A

Requires systemic treatment

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48
Q

How to treat distal mild-moderate UC

A

-Sulfasalazine
-Mesalamine

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49
Q

How to treat extensive mild-moderate UC

A

-Mesalamine
-Budesonide

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50
Q

How to treat moderate-severe UC

A

-Budesonide
-Prednisone
-Treatment naive: prednisone + infliximab or vedolizumab +/- azathioprine
Previous infliximab exposure: ustekinumab to tofacitinib

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51
Q

Methotrexate dosing for RA

A

-2.5mg tablets
-7.5mg per week Po or IM (up to 15-20mg - weekly dose can be taken in one day)
-Onset: 1-2 months

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52
Q

Methotrexate contraindications

A

-Pregnancy
-Chronic liver disease
-Immunodeficiency
-Pre-existing blood dyscrasias
-Chronic liver disease
-Pleural/peritoneal effusions
-Leukopenia/thrombocytopenia
-CrCl < 40ml/min

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53
Q

Leflunomide mechanism of action

A

-Inhibit de novo biosynthesis of pyrimidines
-Interferes with tyrosine kinase activity
-Inhibit cell cycle progression

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54
Q

Leflunomide adverse effects

A

-Diarrhea
-Rash
-Alopecia
-Increased LFTs
-Teratogenicity

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55
Q

Leflunomide monitoring

A

-CBC
-SCr
-LFT

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56
Q

sulfasalazine mechanism of action

A

Inhibits IL-1

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57
Q

Sulfasalazine adverse effects

A

-N/V/D
-Anorexia
-Rash
-Urticaria
-Photosensitivity
-Leukopenia
-Thrombocytopenia
-Rare: hemolytic and aplastic anemia
-Caution for allergy

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58
Q

Sulfasalazine monitoring

A

-CBC
-SCr
-LFT

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59
Q

Hydroxychloroquine mechanism of action

A

Modification of cytokine infiltration in joint

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60
Q

Hydroxychloroquine adverse effects

A

-Retinal toxicity
-N/V/D
-Increase skin pigment
-Rash
-Alopecia
-Deficiency in G6PD increases free radical concentration in blood

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61
Q

Hydroxychloroquine monitoring

A

-Vision exam
-CBC
-LFTs
-SCr
-EKG

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62
Q

Etanercept mechanism of action

A

-Dimeric protein with two soluble TNF receptors fused to the IgG1 molecule
-Binds to and inhibits TNF
-Binding occurs before the cytokine can interact with cell-surface TNF receptors would produce an inflammatory response

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63
Q

Adalimumab indications RA

A

-Patients who have inadequate response to one or more DMARDS
-Can be used alone OR in combo

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64
Q

Golimumab indications RA

A

-Moderate to severe RA
-Used in combo with MTX

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65
Q

Golimumab monitoring

A

-CBC with PLT
-LFTs

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66
Q

Certolizumab indications RA

A

-RA patients with moderate to severe disease
-Can be used alone or in combo with non-BRM DMARDs

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67
Q

Anakinra indication RA

A

-Moderate to severe RA in patients who have failed one or more DMARDs
-Can use alone or in combo

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68
Q

Anakinra mechanism of action

A

-Recombinant, non-glycosylated version of the human IL-1 receptor antagonist
-Selectively blocks IL-1 binding to the IL-1 receptor

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69
Q

Anakinra adverse effects

A

-Injection site reactions
-Headache
-N/V
-Flu-like symptoms
-Hypersensitivity to e. coli-derived proteins
-Increased risk of serious infections
-Decreased neutrophils

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70
Q

Anakinra monitoring

A

Neutrophil count

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71
Q

Abatacept indication RA

A

-Moderate to severe RA
-If had inadequate response to one or more DMARDs
-Monotherapy or in combination with DMARD inhibitors or IL-1 antagonists

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72
Q

Abatacept mechanism of action

A

-Selective co-stimulation modulator
-Inhibits t-cell activation

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73
Q

Abatacept adverse effects

A

-Headache
-Nausea
-Upper respiratory infection
-Nasopharyngitis
-Infusion reactions
-Serious infection
-Malignancy

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74
Q

IL-6 receptor inhibitors

A

-Tocilizumab
-Sarilumab

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75
Q

IL-6 receptor inhibitor indication RA

A

-Moderate to severe RA after inadequate response to on or more DMARDs
-Alone or in combo with methotrexate or another DMARD

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76
Q

IL-6 receptor inhibitor mechanism of action

A

Binds to soluble and membrane-bound IL-6 receptors

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77
Q

IL-6 inhibitor warnings

A

-Black box warning: serious infections
-Contraindicated in patients with liver toxicity, thrombocytopenia, and neutropenia

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78
Q

IL-6 inhibitor adverse effects

A

-Serious infection
-Liver toxicity
-Thrombocytopenia
-Neutropenia
-Lipid abnormalities
-Intestinal perforations
-Infusion reactions

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79
Q

IL-6 inhibitor monitoring

A

-Neutrophil count at 4-8 weeks then every 3 months
-Platelet count at 4-8 weeks then every 3 months
-LFTs at 4-8 weeks then every 3 months
-Lipid profile after 4-8 weeks then every 6 months

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80
Q

Rituximab indication RA

A

-For moderate to severe RA
-In those with inadequate response to TNF antagonists
-In combination with methotrexate

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81
Q

Rituximab mechanism of action

A

Binds specifically to antigen CD20

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82
Q

Rituximab adverse effects

A

-Tumor lysis syndrome
-Mucocutaneous reactions
-Viral infection
-Hypersensitivity
-Renal toxicity
-Bowel obstruction
-Hepatitis B reactivation
-Cardiac arrhythmias

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83
Q

Rituximab monitoring

A

-CBC with platelet
-Serum creatinine
-Vital signs (during infusions)

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84
Q

JAK inhibitor indication RA

A

-Moderate to severe RA after inadequate response to TNF
-Alone or in combination with MTX or another DMARD
-Not in combination with BRM, azathioprine, or cyclosporine

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85
Q

How to reverse toxic metabolites from acetaminophen overdose?

A

N-acetylcysteine +/- activated charcoal

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86
Q

What are toxic doses of acetaminophen?

A

8 or more grams of acetaminophen

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87
Q

N-acetylcysteine indication

A

Based on concentration of acetaminophen (4 hours or more after ingestion) and timing since ingestion

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88
Q

Non-pharmacologic management of ascites

A

-Sodium restriction (less than 2g/day)
-Assessment for liver transplant

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89
Q

First-line treatment for ascites management

A

Aldosterone antagonist (spironolactone) + loop diuretic (furosemide)

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90
Q

Second-line treatment for ascites management

A

-Paracentesis
-TIPS

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91
Q

What do you want to avoid in patients with cirrhosis?

A

NSAIDs

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92
Q

Ratio of spironolactone to furosemide

A

100:40

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93
Q

Side effects of spironolactone

A

-Acute kidney injury
-Increased potassium
-Gynecomastia

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94
Q

Side effects of loop diuretics

A

-Acute kidney injury
-Decreased potassium

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95
Q

Monitoring of diuretics for ascites

A

-Signs and symptoms of ascites
-SCr
-K+

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96
Q

When to give albumin after performing a paracentesis

A

If >5L removed

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97
Q

Albumin dosing for replacement after paracentesis

A

25% albumin 6-8g per liter removed

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98
Q

Risk factors for variceal bleeding

A

-Varices size (larger more likely to rupture)
-Cirrhosis severity (Child Pugh)
-Red color markings noted on endoscopy
-Active alcohol use

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99
Q

Primary prophylaxis of variceal bleeding

A

-Nadolol
-Propranolol
-Carvedilol
-EVL

100
Q

Side effects of beta blockers

A

-Drowsiness of insomnia
-Bradycardia
-Hypotension

101
Q

Beta blockers monitoring

A

-HR: 55-60 bpm
-BP: SBP > 90 mmHg
-Signs/symptoms of VH

102
Q

Treatment of variceal bleeding

A

-Blood transfusions
-Octreotide (somatostatin analog which is a vasoconstrictor)
-Antibiotic prophylaxis
-EVL
-PPIs not recommended

103
Q

Octreotide duration

A

-2-5 days
-In practice, frequently stopped 24 hours after successful EVL

104
Q

Octreotide side effects

A

-N/V
-HTN
-Bradycardia
-Hyperglycemia

105
Q

Octreotide monitoring

A

-Signs/symptoms
-BP
-HR
-BG

106
Q

Goal time frame to do EVL

A

12 hours upon presentation

107
Q

Primary antibiotic prophylaxis

A

Ceftriaxone max 7 days

108
Q

Ceftriaxone side effects

109
Q

Ceftriaxone monitoring

A

Signs and symptoms of infection

110
Q

Contraindicated in variceal bleeding

111
Q

Secondary prophylaxis for varices

A

-EVL every 1-4 weeks
-NSBBs indefinitely until decompensated

112
Q

SBP clinical presentation

A

-Fever
-Abdominal pain/tenderness
-Leukocytosis
-Encephalopathy

113
Q

SBP treatment

A

-Ceftriaxone for 5-7 days
-Albumin

114
Q

Albumin dosing for SBP

A

-Day 1: 1.5 g/kg x1
-Day 3: 1 g/kg x1

115
Q

SBP secondary prophylaxis

A

-Bactrim
-Ciprofloxacin
-Avoid PPIs

116
Q

Bactrim side effects

A

-Acute kidney injury
-Photosensitivity
-Hyperkalemia
-Hyponatremia
-Stevens-Johnson syndrome
-Agranulocytosis

117
Q

Bactrim monitoring

A

-SCr
-Electrolytes
-CBC

118
Q

Ciprofloxacin side effects

A

-Antibiotic resistance
-Musculoskeletal effects
-QTc prolongation
-Rash
-Altered mental status

119
Q

Ciprofloxacin monitoring

A

-Mental status
-CBC
-Renal function

120
Q

SBP secondary prophylaxis duration

A

Indefinitely

121
Q

Stroke non-modifiable risk factors

A

-Age
-Family history
-Females
-Race
-Low birth weight
-Sickle cell disease

122
Q

Stroke modifiable risk factors

A

-Cardiovascular diseases
-Diabetes
-Hyperlipidemia
-Hypertension
-Illicit drug/alcohol abuse
-Obesity/physical inactivity
-Cigarette smoking

123
Q

Clinical presentation of stroke

A

-Dysphasia
-Facial droop
-Unilateral or bilateral weakness
-Ataxia
-Vision changes
-Headache

124
Q

How often to check BP in stroke

A

-Every 15 minutes for 2 hours
-Every 30 minutes for 6 hours
-Every hour for 16 hours

125
Q

BP goals for first 48 hours stroke

A

-No tPA: less than 220/110
-tPA: less than 180/105
-After 48 hours then gradually lower BP to outpatient BP goal

126
Q

Hypertension management 48 hours after stroke

A

-Resume home antihypertensives (if applicable)
-If no home therapy, select therapy based on co-morbidities

127
Q

Criteria to receive tPA

A

-Within 4.5 hours of symptom onset
-Ischemia stroke
-Do not give if BP is over 185/110 at time of administration
-Do not give if BG is less than 50
-Bleed risk

128
Q

Alteplase dosing

A

-0.9 mg/kg IV
-Max 90 mg
-10% of dose given bolus over 1 minute
-90% given basal over 60 minutes

129
Q

Tenecteplase dosing

A

-0.25 mg/kg IV
-Max 25 mg

130
Q

Side effects of tPA

A

-Bleeding
-Cerebral edema

131
Q

When to use aspirin for acute treatment of stroke

A

-First-line treatment
-All ischemic stroke patients initially unless contraindicated
-24 hours or more after tPA is administered

132
Q

Aspirin acute stroke treatment dosing

A

High dose for 2-4 weeks

133
Q

Aspirin monitoring

A

-Bleeding
-Stroke

134
Q

When to use aspirin + clopidogrel in acute stroke treatment

A

Only in minor strokes (NIHSS less than or equal to 4)

135
Q

When to use ticagrelor

A

-Data only in minor stroke (NIHSS 5 or less)
-Likely second line due to safety concerns
-Likely use for true aspirin allergy

136
Q

When to use anticoagulants in stroke

A

If cardioembolic stroke or other indication for anticoagulant, recommended to start 2-14 days after stroke

137
Q

How to reverse warfarin

A

IV vitamin K

138
Q

How to reverse heparin products

139
Q

How to reverse DOACs

A

-Andexxa
-Dabigatran - idarucizumab

140
Q

How to reverse antiplatelets

A

No antidote

141
Q

BP goals for acute hemorrhagic stroke

A

-Goal BP first 24 hours: <180/110
-Goal BP 24-48 hours: <160/90
-Goal BP after 48 hours: outpatient goal

142
Q

How to prevent cerebral vasospasm

A

Nimodipine 60mg orally q4h for 21 days after subarachnoid hemorrhage

143
Q

When to use anticonvulsants in stroke

A

Only if the patient has a documented seizure history

144
Q

First line treatment for secondary prevention of stroke

A

-Aspirin
-Aspirin + dipyridamole

145
Q

Aspirin + dipyridamole side effects

A

-Headache (dose limiting)
-GI bleeding

146
Q

Clopidogrel place in secondary stroke prevention

A

-Second line treatment in non-embolic ischemic stroke
-Aspirin intolerant patients
-Mostly used in combo with aspirin

147
Q

Clopidogrel + aspirin place in secondary stroke prevention

A

-Atherosclerotic ischemic stroke
-Minor strokes (NIHSS 3 or less): first line treaetment
-Moderate-severe strokes: second line

148
Q

Anticoagulants to use in mechanical mitral valve/LV thrombus

A

-Warfarin
-Rivaroxaban

149
Q

Long-term BP goal for all patients with a history of stroke

A

Less than 130/80

150
Q

Antihypertensives to use in patients who are black and have a history of stroke

A

-CCB
-Thiazide

151
Q

Antihypertensives to use in patients who have CKD and a history of stroke

152
Q

Antihypertensives to use in patients who have CAD and a history of stroke

A

BB + ACEi (or ARB)

153
Q

Antihypertensives to use in patients who have diabetes and a history of stroke

154
Q

Antihypertensives to use in patients who have HFrEF and a history of stroke

A

-ARNi/ARB/ACEi
-ARB + BB + aldosterone antagonist

155
Q

Antihypertensives to use in patients who have Afib and a history of stroke

A

-BB
-Non-DHP CCB

156
Q

LDL goal in stroke patients

A

Less than 70

157
Q

When to use statins in stroke patients

A

-High-intensity statin in atherosclerotic ischemic stroke
-Do not use statin if cardioembolic stroke or hemorrhagic stroke

158
Q

How to reduce risk of future strokes

A

-Cessation of illicit drugs
-Reduction of alcohol consumption
-Diabetes control
-Physical activity
-Diet
-Weight loss
-Smoking cessation

159
Q

Antidepressants to avoid in stroke patients

A

-Paroxetine
-Tricyclic antidepressants

160
Q

Examples of Drugs that induce lupus

A

-Methimazole
-Propylthiouracil
-Methyldopa
-Minocycline
-Procainamide
-Hydralazine
-Anti-TNF agents
-Terbinafine
-Isoniazid
-Quinidine

161
Q

Signs and symptoms of lupus

A

-Fatigue
-Depression
-Photosensitivity
-Joint pain
-N/V
-Fever
-Weight loss
-Malar “butterfly” rash

162
Q

How to diagnose lupus using SLICC

A

Must meet 4 or more features with one from each group

163
Q

How to diagnose lupus using EULAR/ACR

A

Patient’s score is 10 or more AND at least 1 clinical criterion is fulfilled

164
Q

Key labs for lupus

A

-Anti-nuclear antibody (ANA)
-Anti-double-stranded DNA (Anti-dsDNA)
-Anti-Smith Antibody (Anti-SM)
-Antiphospholipid Antibody

165
Q

Pharmacologic treatments of lupus

A

-Hydroxychloroquine
-NSAIDs
-Glucocorticoids
-Immunosuppressants
-Biologics

166
Q

Hydroxychloroquine place in lupus therapy

A

Recommended for ALL patients with SLE

167
Q

Hydroxychloroquine dosing

A

200-400 mg PO daily

168
Q

NSAID place in therapy for lupus

A

Considered the first line for mild symptoms

169
Q

NSAID dosing for lupus

A

-Ibuprofen: 400-600 mg PO q6-8h
-Naproxen: 500 mg PO BID

170
Q

NSAID side effects

A

-GI bleed, gastritis, perforation
-Increased BP
-Worsened HF
-CV events
-Increased SCr, renal toxicity
-Hepatotoxicity

171
Q

NSAID monitoring parameters

A

-CBC
-LFTs
-SCr
-BP
-S/sx of fluid retention and bleeding

172
Q

Glucocorticoid place in therapy for lupus

A

Adjunctive treatment if not responsive to NSAIDs or hydroxychloroquine

173
Q

Oral glucocorticoid dosing

A

-Mild-moderate disease: 5-30 mg/day
-Severe: 1 mg/kg/day

174
Q

IV glucocorticoid dosing

A

Pulse therapy: 500-1000 mg IV daily x 3-6 days, then PO prednisone

175
Q

What topical glucocorticoids would you use on the face?

A

Low-potency: fluocinolone valerate and hydrocortisone butyrate

176
Q

What topical glucocorticoids would you use on the trunk/extremities?

A

Moderate potency: Triamcinolone and betamethasone

177
Q

What topical glucocorticoids would you use on scalp sores and palms?

A

High potency: Clobetasol

178
Q

PO/IV glucocorticoid side effects

A

-Glaucoma
-Increased BP
-Increased risk of osteoporosis
-GI bleed
-Gastritis
-Psychosis/sleep disturbances
-Weight gain
-Increased BG
-Increased risk of infection
-Cushing syndrome

179
Q

Topical glucocorticoid side effects

A

-Skin atrophy
-Rosacea
-Telangiectasis

180
Q

Glucocorticoid monitoring

A

-BP
-BMP every 6 months
-FLP every 6 months
-Bone mineral density annually

181
Q

Immunosuppressant place in lupus therapy

A

-Adjunct to steroid therapy to lower the dose
-Insufficient response to HCQ

182
Q

Immunosuppressant medications for lupus

A

-Methotrexate
-Azathioprine
-Cyclophosphamide
-Mycophenolate mofetil

183
Q

Methotrexate lupus dosing

A

5-15 mg once weekly

184
Q

Methotrexate side effects

A

-BMS
-Infection
-Renal
-GI
-Liver
-Pulmonary
-Hypersensitivity
-Dermatologic

185
Q

Mycophenolate dosing for lupus

A

1-1.5 g BID

186
Q

Mycophenolate side effects

A

-BMS
-Infection
-Malignancy
-AIS
-GI

187
Q

Cyclophosphamide dosing for lupus

A

-1-1.5 mg/kg once daily PO
-0.5/m2 BSA every month for 6 months IV

188
Q

Cyclophosphamide side effects

A

-BMS
-Infection
-Malignancy
-Cardiac hemorrhagic cystitis
-Liver
-Pulmonary

189
Q

Azathioprine dosing for lupus

A

50 mg daily

190
Q

Azathioprine side effects

A

-BMS
-Infection
-Malignancy
-N/V/D
-Liver
-Pancreatitis
-Monitor: TPMT deficiency

191
Q

Biologics used for lupus

A

-Belimumab
-Rituximab
-Anifrolumab

192
Q

Biologics place in lupus therapy

A

-Inadequate response to hydroxychloroquine and immunosuppressants
-Severe disease

193
Q

Contraindications to biologics

A

-No live vaccines 30 days before starting therapy OR during therapy
-Do not use more than 1 biologic at the same time

194
Q

Belimumab dosing for lupus

A

10 mg/kg every 2 weeks for 3 doses

195
Q

Anifrolumab dosing for lupus

A

300 mg every 4 weeks

196
Q

Rituximab dosing for lupus

A

-1 g on days 0 and 15
-375 mg/m2 once weekly for 4 doses

197
Q

Nonpharmacologic treatment of lupus

A

-Balance of rest and exercise
-Smoking cessation
-Limit sun exposure and use of sunscreen

198
Q

First line for cutaneous lupus

A

-Topical agents: GC and CNI
-HCQ
-Systemic GC

199
Q

Treatment for refractory cutaneous lupus

A

-High-dose GC
-MTX
-MMF

200
Q

How to treat mild to moderate lupus nephritis

A

GC +/- another immunosuppressant (AZA, MMF, or CNI)

201
Q

How to treat severe lupus nephritis

A

-Mycophenolate or cyclophosphamide +/- GC
-Belimumab + MMF or CYC +/- GC
-CNI + MMF +/- GC

202
Q

How to give contraception to people with lupus

A

-Avoid estrogen-containing contraception
-Screen for antiphospholipid syndrome

203
Q

Potential risks for pregnant patients with lupus

A

-Miscarriage
-Fetal growth retardation
-Maternal mortality
-Preeclampsia
-Best prognosis is when the patient achieves remission for 6 months or more before pregnancy

204
Q

Safe drugs to use in pregnant patients with lupus

A

-Hydroxychloroquine (drug of choice)
-NSAIDs
-Glucocorticoids
-AZA discuss risk vs benefit with provider

205
Q

What is antiphospholipid antibody?

A

An autoimmune disorder characterized by antiphospholipid syndrome that can cause blood clots and miscarriages

206
Q

How to treat an acute thrombotic event or patients with a history of thrombosis in lupus patients with antiphospholipid antibody

207
Q

Prophylaxis treatment for pregnant lupus patients with antiphospholipid antibody

A

-No prior fetal loss: aspirin 81 mg
-Recurrent fetal loss: aspirin 81 mg +/- LMWH

208
Q

What is gout?

A

Inflammatory process in response to crystallization of monosodium urate in articular and non-articular tissues

209
Q

What is hyperuricemia?

A

Uric acid levels over 6.8 AND symptomatic

210
Q

Risk factors for gout

A

-Male
-Post-menopausal women
-Elderly
-Obesity
-Sedentary lifestyle
-Renal impairment
-Genetics
-Dietary/alcohol intake
-Socioeconomic factors

211
Q

What can cause overproduction of uric acid?

A

-Regulatory enzyme variability
-Cytotoxic medications
-Increase dietary intake of purines
-Chronic alcohol intake

212
Q

What can cause under excretion of uric acid?

A

-Dehydration
-Insulin resistance
-Acute alcohol intake
-Medications

213
Q

Signs and symptoms of gout

A

-Fever
-Intense pain
-Erythema
-Warmth
-Edema
-Inflammation of affected joints
-Podagra - first metatarsal joint often involved

214
Q

Laboratory tests associated with gout

A

-Elevated uric acid (over 6.8)
-WBC over 11,000

215
Q

Complications associated with gout

A

-Tophi - deposits of monosodium urate
-Nephrolithiasis - kidney stones
-Gouty nephropathy - acute and chronic kidney disease

216
Q

How to diagnose gout

A

-Synovial fluid aspiration (painful and expensive)
-EULAR

217
Q

Non-pharmacologic treatment of acute gout attacks

A

-Modification of risk factors over time
-Applying ice to the affected area to reduce pain
-No supplements have shown benefit

218
Q

Pharmacologic therapy for acute gout attacks

A

-NSAIDs
-Corticosteroids
-Colchicine

219
Q

NSAIDs used for gout

A

-Indomethacin
-Naproxen
-Ibuprofen
-Sulindac

220
Q

Corticosteroid considerations for gout

A

-Taper PO courses
-Limit treatment duration
-Increased risk of GI bleed and peptic ulcer disease
-Close monitoring of diabetes
-Avoid IA injection if suspect infection

221
Q

How to dose colchicine

A

-Day 1: 1.2 mg PO once, then 0.6 mg one hour later
-Day 2+: 0.6 mg BID until attack resolves
-CrCl less than 30: 1.2 mg at onset, 0.6 mg 1 hour later
-Dialysis: single 0.6 mg dose; treatment course should be repeated no more than once every 2 weeks
-Severe hepatic impairment: do not repeat more than once every 2 weeks
-Administer within 24 hours of acute attack

222
Q

Colchicine adverse effects

A

-Nausea
-Vomiting
-Diarrhea
-Neutropenia
-Axonal neuromyopathy

223
Q

Colchicine drug interactions

A

-CYP3A4 inhibitors
-PGP inhibitors

224
Q

What to do if inadequate initial response to colchicine

A

-Switch agents
-Add a second recommended agent (avoid NSAIDs with PO corticosteroids)
-Corticotropin, anakinra, canakinumab

225
Q

Non-pharmacologic treatment for chronic gout

A

-Weight loss if overweight or obese
-Dietary approaches to stop hypertension
-Alcohol restriction
-Limit purine rich foods (high fructose corn syrup, organ meats and some seafood)

226
Q

Indications to start ULT

A

-2 or more gout flares per year
-1 or more tophus
-Radiographic evidence of damage attributable to gout
-More than 1 flare, but infrequent
-Patients experiencing first flare in the presence of CKD stage 3-5, uric acid over 9, urolithiasis

227
Q

Who is not a candidate for ULT?

A

-Asymptomatic hyperuricemia with no prior gout flares or tophi
-First gout attack without risk factors

228
Q

When to initiate ULT?

A

During an acute gout attack

229
Q

How long should ULT be given?

A

Indefinitely

230
Q

Pharmacologic therapy for chronic gout

A

-Allopurinol (first line)
-Probenacid (second line)
-Pegloticase (third line)

231
Q

Allopurinol dosing

A

-Initial dose: 100 mg PO daily
-Titrate every 2-4 weeks in 100 mg or less increments to achieve a uric acid level of less than 6
-Max dose of 800 mg/day
-eGFR less than 60: initial dose 50 mg daily

232
Q

Allopurinol drug interactions

A

-Loop and thiazide diuretics
-Warfarin
-Azathioprine, fluorouracil products, mercaptopurine, didanosine

233
Q

Allopurinol ADRs

A

-Skin rash
-Headache
-Urticaria
-Hepatotoxicity
-Hypersensitivity reaction (Stevens-Johnson syndrome) (toxic epidermal necrolysis)

234
Q

Risk factors for allopurinol hypersensitivity syndrome

A

-Female
-Age over 60
-High initial doses
-CKD
-CV disease
-HLA-B*5801 allele + (non whites)

235
Q

Allopurinol monitoring

A

-Uric acid every 2-5 weeks while titrating, every 6 months when stable
-Renal function
-LFTs

236
Q

Counseling for allopurinol

A

-Drink plenty of fluids
-Take this medication even when you do not have gout symptoms

237
Q

Febuxostat BBW

A

Increased cardiovascular mortality

238
Q

Probenecid ADRs

A

-GI irritation
-Rash
-Urolithiasis - CI in patients with history

239
Q

Probenecid cautions

A

-G6PD deficiency
-Not recommended in eGFR less than 60

240
Q

Probenecid drug interactions

A

-Penicillins
-Cephalosporins
-Sulfonamides
-Indomethacin

241
Q

When to use pegloticase

A

-Severe gout and hyperuricemia
-3 or more gout flares within 18 months
-1 or more tophi
-Joint damage due to gout
-IV infusion

242
Q

Pegloticase BBW

A

-Anaphylaxis and infusion-related reactions
-G6PD deficiency-associated hemolysis and methemoglobinemia

243
Q

Pegloticase ADRs

A

-Constipation
-Nausea
-Vomiting
-Chest pain
-Nasopharyngitis

244
Q

Pegloticase pearls

A

-Immunogenicity - patients may develop antibodies that result in lack of efficacy
-Screen patients at risk for G6PD deficiency (non-whites)

245
Q

Pharmacologic therapy for gout flare prophylaxis

A

-NSAIDs at the lowest effective dose
-Prednisone
-Colchicine

246
Q

Colchicine prophylactic dosing

A

-CrCl 30 or more: 0.6 mg once or twice daily
-CrCl less than 30: 0.3 mg daily (consider alternate therapy)
-Dialysis: 0.3 mg twice weekly (consider alternate therapy)

Therapeutics IV (4 decks)

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