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1
Q

First-line agent for atrial fibrillation

A

Warfarin

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2
Q

Nitrofurantoin renal function breakpoint

A

CrCl <30

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3
Q

Gabapentin and hydrocodone–acetaminophen interaction

A

increased risk of respiratory depression

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4
Q

Omeprazole Max Use

A

should be discontinued if the patient has been using it for longer than 8 weeks

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5
Q

Sulfamethoxazole–trimethoprim (TMP-SMX) and Amiodarone interaction

A

TMP-SMX may decrease the effects of amiodarone

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6
Q

Prazosin and furosemide interaction

A

Avoid in women because of increased risk of urinary incontinence. Prazosin (Minipress) is an alpha blocker. It lowers blood pressure by relaxing blood vessels.

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7
Q

Vaginal estrogens uses

A

May be appropriate for recurrent lower urinary tract infections

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8
Q

Use of Escitalopram in combination with Tramadol

A

Risk of hyponatremia. All SSRIs, including Escitalopram, Fluoxetine, can cause SIADH and could cause hyponatremia, should be used with caution in the depressive patients with regular monitoring of electrolytes, especially in the elderly. (Use SNRI Venlafaxine)

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9
Q

To treat Depression: If 12 years old vs 52 years old

A

If 12 years old use SSRI (Fluoxetine). If 52 years old use SNRI (Venlafaxine)

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10
Q

Ranitidine renal function breakpoint

A

CrCL less than 50 mL/min reduce by 50% (ex., was 150 mg reduce to 75 mg)

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11
Q

If Gabapentin dose is 900–3600 mg renal function recommendation

A

Creatinine clearance must be higher than 80 ml/min

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12
Q

Diphenhydramine/anticholinergic long term use effects

A

50% increased risk of dementia among people who used a strong anticholinergic drug daily for about three years; long-term use of Benadryl/Diphenhydramine, has been linked to an increased dementia risk/cognitive decline

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13
Q

Colace/Docusate

A

Stool softener/Surfactant

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14
Q

Milk of Magnesia, Miralax, poly glucol

A

Osmotic laxatives

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15
Q

Senna, Castor oil

A

Stimulant laxative

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16
Q

Sucralfate with food or without?

A

must be administered on an empty stomach

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17
Q

Ciprofloxacin and calcium interaction

A

Cipro binds to calcium and prevents absorption

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18
Q

Warfarin with low risk of bleeding (INR above therapeutic range but less than 5 but less than 10)

A

Omit 1-2 doses, resume warfarin at 10-20% lower than original dose. Check INR in 24 hours. Vitamin K is no longer recommended.

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19
Q

Warfarin with higher risk of bleeding (INR greater than 10 with no serious bleeding)

A

Hold Warfarin and give vitamin K 3 to 5 mg (5 to 10) ORALLY. Check INR in 24 hours. If still high, administer vitamin K1 1-2mg PO. Resume warfarin at 10-20% lower than original dose when the INR is within therapeutic range.

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20
Q

Serious bleeding (INR results are greater than 10)

A

Hold Warfarin, vitamin K should be given by slow IV INFUSION in a dose of 5 to 10 mg (10mg slow IV plus fresh plasma or prothrombin complex concentrate, depending on urgency). Check INR in 24 hours. Repeat Vitamin K1 every 12 hours as needed. Resume warfarin at 10-20% lower than original dose when the INR is within therapeutic range.

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21
Q

If the INR is too low (titration)

A

Total weekly dose is adjusted upward by 10% and the INR is rechecked in 2 weeks.

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22
Q

DECREASE DEMAND OF INSULIN: Medications That Increase Glucose Levels > (hyperglycemia > need more insulin dose/increases insulin requirement)

A

Steroids/Glucocorticoids (Prednisone, Hydrocortisone)
Phenytoin
Protease Inhibitors (HIV treatment)
Niacin (vitamin B)
Obesity (reduces # of receptors/insulin resistance > need more insulin)

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23
Q

INCREASE DEMAND OF INSULIN > INCREASE RISK FOR HYPOGLYCEMIA because they increase affinity (binding ability) of the insulin receptor > increases risk for hypoglycemia

A

Levothyroxine, Growth hormone (GH), ACEIs, ARBs, aspirin, beta-adrenergic blockers, bromocriptine, fibrates, fluoxetine, linezolid, MAOIs, SSRIs, Alcohol, pentoxifylline, psyllium, salicylates, selegiline, Sulfonamides, testosterone ALL increase hypoglycemic effect of insulin, including inhaled forms

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24
Q

GLUT-1

A

ALL tissue: blood/brain
red blood, pancreas, brain, liver, kidney, muscle, adipose tissue, epithelial cells of small intestine, neurons

Basal uptake
blood-brain barrier
related with insulin resistance inT2DM
primary influence in exercise

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25
GLUT-2
small intestine, kidney, liver, PANCREAS regulates homeostasis reduced insulin secretion seen in type 2 DM
26
GLUT-3
Neurons, brain, kidney, placenta
27
GLUT-4
muscle and adipose tissue related to glucose uptake in exercise resistance in type 2 DM
28
GLUT-5
small intestine, kidney intestinal absorption of fructose
29
overall poor BG control
split-mix insulin regimen
30
fasting (SLEEP) hyperglycemia
Bedtime IAI or LAI added
31
LAI is more effective than premixed insulin in
lowering fasting BG
32
Premixed insulin is more effective than LAI in
lowering BG levels after a meal
33
Hyperglycemia titration
increase insulin by 1-2 units or 10%-15% every 1-2 weeks
34
Afrezza
Inhaled insulin/Rapid acting
35
Sulfonylureas med names
Glimepiride, Glyburide, Glipizide (Hypoglycemia)
36
Sulfonylureas - Mech of Act and Side Effect
They work by closing the adenosine triphosphate (ATP)> sensitive Potassium channels. Can cause Diuresis/SIADH especially in heart failure or hepatic cirrhosis because drugs stimulate ADH release, the result is fluid overload and hyponatremia.
37
Meglitinides aka Glinides - Mech of Act and Side Effect
Ex. Noteglinide, Repaglinide; -glinide. Similar to the Sulfonylureas, they work by closing the adenosine triphosphate (ATP)–dependent potassium channels. Can cause Diuresis/SIADH especially in heart failure or hepatic cirrhosis because drugs stimulate ADH release, the result is fluid overload and hyponatremia.
38
Sulfonylureas and Meglitinides cause hypo or hyper?
AFFECT INSULIN NOT GLUCOSE > HYPOGLYCEMIA
39
Metformin renal function breakpoint
eGFR<45 ½ the dose eGFR<30 stop metformin
40
Metformin cause hypo or hyper?
DOES NOT AFFECT INSULIN > NO HYPOGLYCEMIA
41
If you have CAD, which is 1st choice SGLT or GLP?
1st choice: SGLT 2 inhibitor (Jardiance) - (needs good renal function, this drug depends on excretion through renal tubules/urine) 2nd choice: GLP-1 (Trulicity, Victoza) - (if renal dysfunction)
42
If no CAD, which is 1st choice for oral diabetes drug?
Sulfonylurea (Glipizide), TZD (Actos), or DPP-4 inhibitor (Januvia) 1st choice.
43
Setting a Glycemic Target HbA1c
< 7% Nonpregnant adults (6.5% can be suggested if can be achieved without significant hypoglycemia) <7.5% - Children above 13 and adolescents with type 1 DM < 8% - those with severe hypoglycemia; 65 years or older in whom hypoglycemic awareness may be suppressed, children younger than 13 years, those with extensive comorbid conditions, patients with limited life expectancies of 5 to 15 years
44
Affect Glucose of Insulin?
Meglitinides aka Glinides: Noteglinide, Repaglinide (Hypoglycemia) – work by ATP/Calcium – SE: SIADH/Diuresis Sulfonylureas: Glimepiride, Glyburide, Glipizide (Hypoglycemia)- work by ATP/Calcium – SE: SIADH/Diuresis Thiazolidinediones: ~ zone, Pioglitazone (Actos) and rosiglitazone (Avandia) – (Hypoglycemia) - work by DNA – SE: CHF because of fluid retention effect Biguanides: Metformin; (No Hypoglycemia) – SE: lactic acidosis SGLT-2 Inhibitors ~liflozin, Canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance) – (No Hypoglycemia) - – work through renal tubule/glucosuria; needs good renal function; SE: UTI, Vaginal infection Amylin analogs ~ tide GLP-1 injectable Trulicity, Victoza, DPP-4 oral ~liptin, Januvia, Tradjenta) (No Hypoglycemia)- work by activate GLP-1 and decrease gastric emptying; SE: PANCREATITIS, weight loss, NAUSEA; RESP INFECTION; UTI Alpha Glucosidase Inhibitor: Acarbose, Miglitol, (No Hypoglycemia) – work by decreasing intestinal absorption of glucose; SE: Flatulence and Diarrhea; NO Lactic acidosis
45
weight loss/weight gain diabetic oral meds
Meglitinides/glipizide, Su, TZD, Insulin > weight gain (hypoglycemia) DPP/GLP, SGLT, Metformin > weight loss Alpha - No effect on weight
46
Factor inhibitors
Fondaparinux - 10 Warfarin - 10 LMWH - 10 and 2 Heparin >antithrombin III Dabigatran (Pradaxa) - direct 2; ; Idarucizumab (monoclonal antibody fragment) is antidote for Dabigatran RivaroXaban (Xarelto), ApiXaban (Eliquis) – direct 10; NO ANTIDOTE (10 is fibrin inhibitor and 2 is thrombin inhibitor)
47
UFH Heparin
monitor PTT; risk of HIT; antidote Protamine sulfate
48
Warfarin
monitor INR; Antidote Vitamin K
49
COX
Aspirin, NSAIDs; Aspirin and ibuprofen have antiplatelet, analgesic, antipyretic, and anti-inflammatory actions related to their cyclooxygenase (COX) activity
50
P2Y12
(inhibit ADP pathway) Clopidogrel, Prasugrel, Ticlopidine, Ticagrelor - they have no effect on prostaglandin metabolism
51
GP2b/3a
Abciximab, Tirofiban, Eptifibatide
52
PDE3
(phosphodiesterase – inactivates converting cAMP to AMP > increase calcium) Dipyridamole, Cilostazol (Cilostazol side effect headache due to vasodialation of blood vessel
53
Increase Warfarin Response - increased risk for bleed
NSAIDS, ASA, Acetaminophen Antibiotics/Antifungals (cephalosporins); Quinolones/Fluoroquinolones (e.g., Cipro), sulfonamides, metronidazole Amiodarone Fibrates
54
Decrease Warfarin Response
Seizure meds (Phenobarbital, Carbamazepine, Phenytoin) Vitamin K rich foods/Green leafy vegetables Coenzyme Q10, St. John’s wort, echinacea, goldenseal Ginseng, Grapefruit, ginkgo, garlic, ginger, anise, arnica, chamomile, clove, feverfew
55
DVT Initial and Long-term treatment
Initial: Heparins First: Warfarin Second: Dabigatran (Pradaxa), Rivaroxaban (Xarelto), Apixaban (Eliquis), or Edoxaban
56
Surgery/Hip replacement
First: Non UFH Heparins Second: UFH Heparin Third: ASA/Dextran
57
TIA
First: ASA, or combination of ASA and Dipyridamole, or Clopidogrel
58
AFib
First: Warfarin Second: ASA Third: combination of ASA and Clopidogrel
59
Recurrent Embolism or Prosthetic Heart Valves
Warfarin
60
AMI with ST-segment elevation (STEMI)
Initial: Fibrinolytics; Tranexamic acid and ε-Amino-n-Caproic Acid are antidotes for fibrinolytic agents Long term with stent: Warfarin, ASA and Clopidogrel for a month after stent placement, then warfarin and one antiplatelet drug for months 2 and 3 after stent placement. After 3 months, warfarin can be discontinued and replaced with dual antiplatelet therapy (ticagrelor and ASA or Clopidogrel and ASA) for up to 12 months. Who do not get a stent are treated with Warfarin and ASA.
61
Rheumatic mitral valve disease but no AF
ACCP recommends no antithrombotic therapy
62
Prevention of DVT after abdominal surgery
Dalteparin (Fragmin)
63
lower initiation Warfarin/ antithrombotic therapy doses for
Older than 75 years Multiple comorbid conditions Poor nutrition (low albumin) Elevated INR when off warfarin Elevated liver function tests Changing thyroid status
64
Air travel time longer than 8 hours
* wear loose clothing * avoid tight clothing around the waistline or lower extremities * achieve good hydration * perform frequent calf muscle exercises * wear compression stockings providing 15 to 30 mm Hg of pressure during air
65
superficial vein thrombosis of the lower limb of at least 5 cm in length
45 days of Fondaparinux or LMWH. Fondaparinux preferred over LMWH.
66
Prophylaxis of DVT in adult hospitalized/ limited mobility in the hospital
Betrixaban (Bevyxxa)
67
ACEIs and Amiloride/Triamterine interaction
Risk of Hyperkalemia
68
Warfarin and Amiodarone interaction
Risk for bleeding
69
Serotonin Antagonist for Nausea
Ondansetron - setron
70
Histamine blockers
Famotidine
71
Dopamine antagonist for nausea
Droperidol, Metoclopramide /risk for extrapyramidal effects)
72
Prostaglandin E1/inhibit cAMP
Misoprostol (can cause spontaneous abortion)
73
Weakly Acidic
Decreased absorption and increased excretion - Salicylates
74
Weakly basic
Increased absorption and decreased excretion - Levodopa
75
Antiadiarrheals
Bismuth causes black tongue and gray-black stool contractions in children
76
Mucosal protectant
Sucralfate binds to ulcer tissue & stimulates prostaglandin
77
Antiemetic classes
Antihistamines Phenothiazines Sedative hypnotics Cannabinoids 5-HT3 receptor antagonists
78
Classes of GI Meds
Stimulant laxative: Bisacodyl, Senna Surfactants/Stool softener: Docusate Antacids Proton Pump Inhibitors (PPIs) H2 Blockers (Famotidine) Metoclopramide (Dopamine antagonist) Misoprostol (Prostaglandin E analog) Orlistat (blocks fat) Octreotide (blocks Growth Hormone) Osmotic: milk of magnesia, miralax, polyethylene glycol Hyperosmolar laxatives: glycerin, lactulose Bulk Forming Laxatives (Psyllium, Methylcellulose) Antidiarrheals (Loperamide, Diphenoxylate-Atropine)
79
Hyper-Osmolar laxative
Lactulose, Glycerine
80
PY12 ADP PD cAmp
81
Hypoglycemia S/S
hunger, tachycardia, decreased levels of consciousness, irritability, diaphoresis, weakness, dizziness
82
Hyperglycemia S/S
(PPP) precedes DKA and give warning of its impending occurrence weight loss, polyuria, polydipsia, polyphagia, fatigue, vomiting, dehydration, ketone odor to the breath, abdominal pain
83
DKA S/S
drowsiness, dim vision, Kussmaul respiration
84
Insulin effects on Liver
storage of glucose as glycogen resets liver decreases urea decreases protein decrease cAMP promotes triglyceride synthesis increases potassium and phosphate uptake
85
Insulin effect on Muscle Cells
promotes protein synthesis by increasing amino acid transport by stimulating ribosomal activity promotes glycogen synthesis to replace glycogen stores
86
Insulin effect on Adipose Tissue
decreases free fatty acids promotes storage of triglycerides
87
Insulin lowers blood glucose levels by following mechanisms
Stimulates glucose entry into cells Storage of glucose as glycogen/Inhibits glucose production (glycogenesis and glycolysis) Promotes protein synthesis Increases/Decreases fat storage (lipogenesis and lipolysis) ~genesis > increase ~lysis > decrease
88
Diabetic Meds Mech of Action
Sulfonylureas: Glimepiride, Glyburide, Glipizide (Hypoglycemia)- work by ATP/Calcium – SE: SIADH/Diuresis Meglitinides aka Glinides: Noteglinide, Repaglinide (Hypoglycemia) – work by ATP/Calcium – SE: SIADH/Diuresis Biguanides: Metformin; (No Hypoglycemia) – SE: lactic acidosis Thiazolidinediones: ~ zone, Pioglitazone (Actos) and rosiglitazone (Avandia) – (Hypoglycemia) - work by DNA – SE: CHF because of fluid retention effect SGLT-2 Inhibitors ~liflozin, Canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance) – (No Hypoglycemia) - – work through renal tubule/glucosuria; needs good renal function; SE: UTI, Vaginal infection Amylin analogs ~ tide GLP-1 injectable Trulicity, Victoza, DPP-4 oral ~liptin, Januvia, Tradjenta) (No Hypoglycemia)- work by activate GLP-1 and decrease gastric emptying; SE: PANCREATITIS, weight loss, NAUSEA; RESP INFECTION; UTI Alpha Glucosidase Inhibitor: Acarbose, Miglitol, (No Hypoglycemia) – work by decreasing intestinal absorption of glucose; SE: Flatulence and Diarrhea; NO Lactic acidosis
89
Metformin Mech of Act
Decreases hepatic gluconeogenesis (inhibits creation of glycogen) Decreases absorption of glucose in liver Decreases intestinal absorption of glucose Increase glycolysis (increases ATP) Increases peripheral glucose uptake
90
Rapid insulins
LAG-Lispro, Aspart, Glulisine Humalog, Novolog Administer 15 before meals (not 30 as with Regular insulins) Afrezza inhaled insulin
91
Regular/Short insulin
Humulin R Novolin R Administer 30 min before meals
92
NPH
Isophane Combined with protamine
93
Long Insulin
Detemir, Levemir, Lantus, Glargine No peak Detemir/Levemir avoid combining with other insulins
94
Ultra Long insulins
Tresiba, Toujeo, Degludec Degludec can be used in 1 yo No peak 24hr-120hr lasts
95
Switch from twice daily IAI or LAI titration
Reduce LAI by 20%
96
Switch from once daily IAI to LAI titration
Do not change initial dose
97
LAI vs PREMIXED INSULINS
Premixed higher risk for hypoglycemia Premixed less weight gain
98
Insulin titration
1-2 units or 10-15% once or twice weekly
99
lactic acidosis s/s
chills, cool hands or feet, dizziness, low blood pressure, muscle pain, sleepiness, trouble breathing, slow or irregular heart rate, stomach pains or nausea/vomiting, and weakness; to report them immediately take off Metformin 48hrs prior and after surgery d/t risk of lactic acidosis due to hypoperfusion during surgery
100
Metformin precautions
Cautious use is in older than age 80 due to the probability of decreased renal function and they may have CHF, Metformin contraindicated in CHF and Renal dysfunction eGFR<45 ½ the dose eGFR<30 stop metformin Metformin crosses placenta and insulin does not There are many drug interactions with metformin; risk for lactic acidosis increases in the presence of renal and hepatic dysfunction; drugs that are eliminated by renal secretion (e.g., amiloride, digoxin, morphine, procainamide, quinidine, ranitidine, triamterene, trimethoprim, and vancomycin) may compete with metformin for its elimination pathway. Dosage adjustments may be needed in metformin or the interacting drugs Furosemide increases metformin levels > dosage adjustment for metformin may be necessary Alcohol should be avoided when metformin is used. Potential for vitamin B12 deficiency GI upset – major side effect
101
Fondaparinux
No antidote
102
No antidote
Fondaparinux Direct 10 Eliquis
103
Drugs that increase the risk of bleeding when used with any anticoagulant
Aspirin NSAIDs Dipyridamole Quinidine Valproic acid
104
CHADS2 scores: Antiplatelet/Anticoagulant treatment for AFib or with a CHADS2 (congestive heart failure; HTN; age 75 years or older; diabetes mellitus; prior stroke, TIA, or thromboembolism)
Patients with AF, a CHADS2 score of 0: patients with low risk of stroke, the ACCP guidelines recommend no therapy. If a patient chooses therapy, then aspirin dosed at 75 mg to 325 mg daily is prescribed. Patients with AF, a CHADS2 score of 1: patients with intermediate risk of stroke, should be treated with oral anticoagulation therapy. If intermediate-risk patients refuse to take anticoagulants, a combination of aspirin (75 to 325 mg once daily) and Clopidogrel. Patients with AF, a CHADS2 score of 2 or greater: patients with high risk of stroke, require Warfarin therapy as a first line therapy. Or 150 mg of Dabigatran twice daily.

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