Final Exam Flashcards
principal endogenous estrogen
estradiol
principal progestational hormone
progesterone
days 1-14 of cycle
follicular phase, dominated by estrogen
days 14-28 of cycle
luteal phase, dominated by progesterone
raloxifene effects on bone density, breast cancer, CV, & uterine cancer
raloxifene- SERM
positive effects on bone density and breast cancer risk
increases risk of CV events
does not increase risk of uterine cancer
estrogen/bazedoxifine
combined estrogen and estrogen receptor agonist/antagonist
prescribed for vasomotor symptoms, osteoporosis prevention
PROTECTS ENDOMETRIUM
effects of adding progestin to HRT
protects against endometrial cancer
stimulates breast cancer risk
depression
breast tenderness
Women who still have a uterus must have what added to their estrogen HRT therapy?
progestin
chlorphiramine
first gen antihistamine
clemastine
first gen antihistamine
fexofenadine (allegra)
second generation antihistamine
cetirizine
second generation antihistamine
budesonide
glucocorticoid drug for asthma
fluticasone
glucocorticoid drug for asthma
adverse effects of inhaled glucocorticoid therapy for asthma
dysphonia and oropharyngeal candidiasis
Montelukast
leukotriene modifier for asthma
oral administration
cromolyn
used for prophylaxis of asthma symptoms. Suppresses inflammation.
principal bronchodilators in asthma treatment
Beta 2 adrenergic agonists-
salmeterol
longer-acting beta agonist for asthma treatment. Not effective for immediate rescue therapy.
adverse effects of beta2 adrenergic agonists
tachycardia, angina, tremor— dose dependent, should not occur unless pt is overdosing on inhaler.
fluticasone/salmeterol and budesonide
glucocorticoid/LABA combinations for long-term asthma maintenance in adults and children who have failed treatment with SABA. LABA should never be taken alone- should always be taken with glucocorticoid
How long to wait between 2 puffs of beta agonist? How much to wait between SABA and glucocorticoid?
1 minute between puffs of albuterol
5 minutes between SABA and glucocorticoid
Therapy of severe asthma exacerbations
oxygen
systemic, IV glucocorticoid
nebulized high-dose SABA
nebulized ipratropium (anticholinergic med) to reduce airflow obstruction
ipratropium
anticholinergic receptor that further reduces bronchoconstriction in acute asthma exacerbations
Adverse effects: dry mouth, irritation of pharynx, increase in eye pressure in those with glaucoma, and rare possible CV events.
What drugs are used to treat H. pylori with ulcer?
Antibiotics and antisecretory agents (H2 blockers, prilosec)
Antibiotics for PUD and H. pylori
Amoxicillin Clarithromycin Bismuth compounds Tetracycline Metronidazole (flagyl)
Use a minimum of 2 antibiotics, up to 3
Cimetidine
H2-receptor antagonist for PUD
May cross BBB and cause CNS side effects
Cannot be taken within 1 hour of an antacid, best on an empty stomach.
Antiadrogenic effects.
IV bolus: can cause hypotension and dysrhythmias.
Ranitidine
H2-receptor antagonist for PUD
Newer generation— few side effects and fewer interactions
Famotidine
H2-receptor antagonist for PUD
H2-receptor antagonists
First-choice drugs for treating gastric and duodenal ulcers. Suppress secretion of gastric acid
What should not be ingested while taking Metronidazole (Flagyl)
alcohol
sucralfate (Carafate)
Sucralfate creates a protective, mucous like barrier for up to six hours. It does nothing to acid secretions and is not absorbed and thus has minimal side effects. Constipation occurs in about 2% of patients. Because it is not absorbed, systemic effects are absent.
Proton pump inhibitors
most effective drugs for suppressing secretion of gastric acid
Increase the risk of fracture, pneumonia, acid rebound, and C. diff infection.
Omeprazole (prilosec)
Proton pump inhibitor- inhibits gastric secretion
Irreversible proton pump inhibitor- effects last several days
Short half life
Should be used short term
misoprostol
used to treat gastric ulcers caused by NSAIDs
side effect: dose-related diarrhea
pregnancy test necessary
Anatacids (calcium, magnesium, aluminum compounds)
React with gastric acid to produce neutral salts
Use with caution in pts with renal impairment
contraindications for laxative use
abdominal pain, nausea, cramps, guarding
acute surgical abdomen- rebound, etc- workup needed before laxative
fecal impaction, bowel obstruction
habitual use
Use with caution in pregnancy and lactation
psyllium (metamucil and citrucel)
bulk-forming laxative
Functions similarly to dietary fiber
preferred treatment for temporary treatment of constipation
docusate sodium (colace)
surfactant laxative—commonly used for pts on opiates
bisacodyl (dulcolax)
stimulant laxative
stimulate intestinal motility
increase quantities of water and electrolytes in the intestinal lumen
good for opioid-induced constipation
milk of magnesia and polyethylene glycol (miralax)
osmotic laxatives
poorly absorbed salts that draw water into the intestinal lumen
low doses- work in 6-12 hours
high dose- results in 2-6 hours (cathartic effect)
cause substantial water loss and dehydration, renal toxicity
may cause sodium retention and exacerbate HF, HTN, edema (sodium phosphate compounds are worst for this)
Bowel-cleansing products for colonscopy
Sodium phosphate- hypertonic
Polyethylene glycol plus electrolytes (GoLYTELY)— isotonic with body fluids, no major loss of electrolytes, but requires large volume of bad-tasting liquid.
Which laxatives are commonly used long-term use and seem safe in children?
???
Which laxative is preferred to prevent opioid-induced constipation?
Bisacodyl (dulcolax)
Penicillin
narrow-spectrum penicillin that is effective only on gram-positive bacteria. It works on strep that can’t make the enzyme penicillinase. Penicillin can produce a mild allergic reaction or even a life-threatening anaphylactic reaction.
Ampicillin
a broad-spectrum penicillin that is effective on some gram negative bacteria as well as gram positive.
Adverse effects include rash (common side effect) and diarrhea (common side effect).
2 main gram positive bacteria
strep and staph
1 drug for group A strep
penicillin
nafcillin
narrow spectrum penicillin
pencilinase-resistant- works against staph aureus drugs that make penicilinase
ticarcillin
extended-spectrum
effective against pseudomonas
still will not kill MRSA
risk of sodium overload (given as a salt)
penicillin G (benzylpenicillin)
effective against gram positive organisms
least toxic of all antibiotics
most common cause of drug allergy
nafcillin, oxacillin, and dicloxacillin- what are they useful for?
useful against most staph aureus
NOT USEFUL AGAINST MRSA
ampicillin and amoxicillin
cover gram negative and gram positive organisms
may help for an infection like an ear or urinary infection with multiple organisms
SE: rash or diarrhea- common rxn
clavulanic acid
beta-lactamase inhibitor- blocks penicillinase.
ampicillin/sulbactam and amoxicillin/clavulanic acid
extends antimicrobial spectrum when combined with penicillinase-sensitive antibiotics
how to prescribe for pt with penicillin allergy hx
if mild rxn hx: consider cephalosporin
if severe rxn hx: avoid administration of penicillin or cephalosporins
symptoms of penicillin allergy severe rxn
laryngeal edema
bronchoconstriction, wheezing
severe hypotension
urticaria
What happens when penicillins and aminoglycoside antibiotics (gentamicin, amikacin) are mixed in IV solution? How should these drugs be administered if both are ordered for your patient?
Penicillins can inactivate aminoglycosides. Therefore, penicillins and aminoglycosides should never be mixed in the same IV solution. They should be administered separately.
How do the cephalosporins work?
Bind to penicillin binding proteins thereby disrupting cell wall synthesis and activate enzymes that damage the cell wall causing it to lyse.
Third Generation Cephalosporins
Highly active against gram-negative organisms
More resistant to beta-lactamase
Able to penetrate CSF / BBB → treatment for encephalitis, meningitis
Fourth Generation
Highly resistant to beta-lactamase
Extensive gram-negative coverage
Pseudomonas coverage (found in immunocompromised hosts)
ceftaroline
Fifth generation Cephalosporin
active against MRSA!
cefotetan (what side effects?)
Cephalosporin
Do not take with alcohol,
Interferes with vitamin K- can cause bleeding. Should not be used with warfarin, aspirin, etc.
first and second generation cephalosporins
used for prophylaxis and against gram positives
rarely used for active infections
Imipenem
carbapenem
not effective against MRSA
extremely broad spectrum with low toxicity
might give to very sick pt with multiple organisms—chemo or similar situation
vancomycin
effective against MRSA
good drug if serious infection and very penicillin allergic
Good for C. diff is metronidazole was ineffective, or for severe cases.
typically given IV, but sometimes given orally through NG tube.
toxicity: ear (careful with aminoglycosides, loop diuretics). red man syndrome- infuse slowly (1 hr) to prevent, renal toxicity
food/drug/tetracycline interactions
Absorption of tetracyclines is decreased if given with Milk products Calcium supplements Iron supplements Magnesium-containing laxatives Most antacids
What is the principle limiting adverse effect of erythromycin? What is different about azithromycin?
Erythromycin’s most common adverse effect is GI pain → nausea, gastric pain, diarrhea, vomiting. Azithromycin does not produce this adverse effect.
Who should not take tetracyclines and why?
Due to the risk of discoloration of teeth in children, pregnant women and children under the age of 8 should not use tetracyclines. Specifically, tetracycline & demeclocycline are eliminated in the urine and should not be used in a patient with renal compromise. If patient needs to be on a tetracycline, doxycycline or minocycline are better choices as they are eliminated by the liver.
What happens when erythromycin is combined with an -azole antifungal?
-azole antifungal drugs can inhibit erythromycin metabolism → raising plasma erythromycin levels which can cause QT prolongation & sudden cardiac death. Also be careful with cardiac pts
Erythromycin is a P450 inhibitor and can raise the plasma levels of other drugs: theophylline (used for asthma), carbamazepine (used for seizures and BPD), and warfarin.
erythromycin
broad spectrum macrolide antibiotics
severe GI side effects
azithromycin & clarithromycin
does not cause severe GI effects.
clindamycin
broad spectrum, treats anaerobic infections outside the CNS—often GI bugs
associated with C. diff!
which -mycin is assoiated with C. diff?
clindamycin
linezolid (zyvoxx)
new class of antibiotics called oxazolidinones Active against VRE: vancomycin resistant enterococci & MRSA
Why is the drug chloramphenicol rarely used? Be familiar with a dangerous toxicity that occurs in infants.
It is rarely used due to lack of safety and is only used for life-threatening infections. It can produce “Gray Syndrome” where they infant takes on a grey pallor and has a protruding abdomen. It is also associated with: Reversible bone marrow depression Fatal aplastic anemia GI effects Peripheral neuropathy
Tetracycline and doxycycline. How do these drugs work? What is their spectrum of action?
Tetracycline & doxycycline are in the “tetracycline” family of drugs which are broad-spectrum antibiotics for systemic therapy. They suppress bacterial growth by inhibiting protein synthesis. They are bacteriostatic → preventing growth, not necessarily killing bacteria. Because they can suppress growth of healthy bacteria as well, they can cause a “superinfection” or the proliferation of fungus in the patient.
a common immunization-preventable infection for which erythromycin is the first-line drug
Bordetella pertussis → Whooping cough
aminoglycocides
gentamicin, tobramycin and amikacin
narrow spectrum bactericidal antibiotics. They are used to kill aerobic, gram-negative bacilli
Must be given IV or parenterally
Which aminoglycocide drug will be used in your hospital, or are they all the same?
Regional resistance to certain agents has occurred. For example, in Maine, patients are started first on gentamicin and in NYC, they might first be started on amikacin.
aminoglycoside adverse effects and interactions
nephrotoxicity ototoxicity neuromuscular blockade interactions: lood diuretics, vanco (ototoxic) nephrotoxic drugs skeletal muscle relaxants (succinylcholine, anesthetics)- increased risk of neuromuscular blockade
What is the treatment for aminoglycoside-induced neuromuscular blockade?
calcium glutamate
gentamicin
narrow spectrum drug for aerobic gram negative bacilli
ototoxic
nephrotoxic
sulfamethoxazole and trimethoprim
broad spectrum antibiotics
suppress bacterial growth by inhibiting tetrahydrofolic acid
inhibit the synthesis of folic acid (folate)
sulfonamides (sulfamethoxazole and trimethoprim) adverse effects
hypersensitivity rxns, including SJ syndrome- blistering, sloughing, fever
hematologic effects- anemia
kernicterus- bilirubin in the CNS, bad in newborns
renal damage from crystalluria
sulfamethoxazole and trimethoprim drug interactions
raises levels of oral hypoglycemic drugs, may cause hypoglycemia
displaces warfarin from albumin- increases bleeding risk
sulfamethoxazole and trimethoprim
bilirubin in the CNS due to sulfonamides, may cause permanent neurological damage in newborns
trimethoprim
inhibits dihydrofolate reductase for folic acid production
hematologic effects
avoid in pregnancy
sulfamethoxazole and trimethoprim
inhibits 2 different steps in bacteria folic acid synthesis- much more effective than either one alone.
use for UTI, otitis media, bronchitis, shigellosis, pneumonia
What should we consider when giving sulfonamides to African-American patients? Recall G6PD deficiency.
Sulfonamides can cause hemolytic anemia in patients with G6PD deficiency, most common among African Americans and people of Mediterranean origin.
Induction phase of TB treatment
2 months
use four drugs
continuation phase of TB treatment—what length, which drugs?
4 months
use two drugs: isoniazid and rifampin
intermittent dosing of TB treatment
easier to accomplish
higher compliance
2-3 times a week
what ppd sign is considered positive?
1 cm induration around the injection site in moderate risk pts
latent TB treatment
INH- 9 months. treatment of choice
or isoniazid with rifapentine for 3 months
first-line anti TB drugs
isoniazid and rifampin
isoniazid (INH)
only used to treat TB
adverse effects:
peripheral neuropathy- paresthesias and weakness of hands and feet, pyroxidine (B6) is given to reverse
hepatotoxicity- drug should be stopped if lfts 3x baseline
optic neuritis
rifampin
broad-spectrum antibiotic but mainly used for TB
SE:
hepatotoxicity
discoloration of body fluids
P450 inducer- do not use with oral contraceptives
lowers warfarin levels, HIV drug levels
increases hepatotoxicity of INH and other TB drugs
fluoroquinolones (-floxacin)
broad-spectrum agents with multiple applications
disrupt DNA replication
mild side effects, can cause tendon rupture- usually effects achilles tendon- discontinue med and avoid weight bearing. this occurs more often in older pts who are taking steroids
cipro
broad-spectrum- inhibits bacterial DNA gyrase and topoisomerase II
use for respiratory, UTI, GI, joints, bones, skin, soft tissue, GU
SE: GI, CNS- dizziness, confusion, headache, restlessness, confusion- especially in elderly.
interacts with calcium, zinc, magnesium, etc
metronidazole (flagyl)
bactericidal for anaerobes
drug of choice for c. diff
protozoal infections- giardia, trichomonas
helicobacter pylori
adverse effects: GI upset, neurotoxicity
drug interaction: alcohol: DISULFURAM-LIKE RXN!
daptomycin (cubicin)
kills virtually all gram positive bacteria, including MRSA and VRE
no significant drug interactions
adverse effects- possible muscle injury
monitor CK for muscle damage
drugs to kill MRSA
daptomycin (cubicin), vancomycin, linzolid (zyvoxx)
amphotericin B
broad spectrum antifungal agent
binds to ergosterol in fungal cell membrane
drug of choice for most systemic mycoses
highly toxic:
-infusion rxn- occurs 1-3 hours after starting infusion
-nephrotoxicity
-hypokalemia
-must be given IV- no oral administration
treatment for amphotericin B infusion rxn
diphenhydramine, acetaminophen, meperidine
mepiridine works best for muscle jerks
nephrotoxicity of amphotericin
extent related to dose
if you reach 4g, you will have some permanent kidney damage
infuse 1 L of saline on days of treatment
avoid concurrent administration of aminoglycosides- loop diuretics, antivirals, NSAIDs.
monitor serum creatinine.
what antifungal can be given with amphotericin B to minimize toxicity?
flucytosine can be added to amphotericin b to reduce toxicity- a dose of the 2 drugs together can reduce toxicity by lowering amphotericin dose
-azoles
broad spectrum antifungals
lower toxicity than amphotericin
can be given orally
hepatotoxic- inhibit P450 drug enzymes
itraconazole
used for systemic mycoses, alternative to amphtotericin b
SE:
cardiosuppression in patients with heart failure- decrease in ventrical ejection fraction
liver damage
can inhibit drug metabolizing enzymes- levels of many drugs go up
fluconazole
often given orally
given for yeast infections
GI effects common
onychomycosis
nail infection- difficult to treat
3-6 months of oral treatment needed- terbinafine (lamisil) is preferred treatment
clotrimazole
topical antifungal
griseofulvin
oral antifungal
terbinafine (lamisil)
topical and oral- preferred treatment for nails
how long should antifungal treatment be continued
a week after symptoms have cleared
nystatin (mycostatin)
antifungal
used only for candidiasis in skin, mouth, esophagus, and vagina
can be used orally or topically
Acyclovir (zorivax)
active only against members of herpesvirus family- HSV and VZV
suppresses recurrences, shorterns duration of infection- does not eradicate virus
some resistance occurs
adverse effects:
IV: phelbitis, nephrotoxicity (administer with fluids)
oral: GI, vertigo
oseltamivir (tamiflu)
must be given within 2 days of exposure, given to pts with high risk of serious illness
neuraminidase inhibitor
What is the G0 phase of the cell cycle? Are tumors in this phase responsive to chemotherapy?
G0 phase is resting phase → tumors in this phase are not susceptible to chemo drugs, which are targeted at DNA synthesis, etc, aspects of cell proliferation.
Chemo often affects drugs in the synthesis (S) phase, the mitosis (M) phase, or the G1 or G2 phases
What lab parameters must be carefully monitored during chemotherapy?
Neutropenia - if ANC (absolute neutrophil count) drops below 500 cells/ mm3, therapy should be stopped.
Thrombocytopenia - low platelets
Anemia - low RBC count
What is the principal earliest sign of infection in a patient on chemotherapy?
fever- Be very cautious of neutropenic patients with fever, even low grade- 38°C or 100.4°F
What does filgrastim (G-CSF) do?
Stimulates neutrophil production. Can be administered.
What does erythropoietin (epoetin, Epogen) do?
It’s a hormone that stimulates RBC production. May stimulate cancer growth so generally only given in palliative care. Given as SubQ injection.
How do we treat chemotherapy-induced thrombocytopenia?
platelet therapy
What is hyperuricemia? Hyperuricemia commonly results from after chemotherapy for which cancers?
Hyperuricemia is excess uric acid in the blood → caused by the breakdown of DNA after cell death. It is most common in treatment for leukemia and lymphomas due to the massive cell death.
allopurinol
prevents hyperuricemia in cancer patients by inhibiting xanthine oxidase, an enzyme involved in converting nucleic acids to uric acid.
Vomiting/GI symptoms treatments for cancer
Glucocorticoid like dexamethasone and Zofran (Ondansetron) or other -setron drug
