Geriatrics, Supplements, pain2 Flashcards
T or F: in palliative care, the goal is to minimize the number of medications in order to improve quality of life, and no longer “CURE” the disease
True
what can you do to your patient’s medications if they can no longer swallow their medications?
use liquids, crush tabs, injections, rectal administration
What classes of medications can be used to treat anxiety in palliative care?
Benzodiazepines
SSRI
Antipsychotics
Haloperidol
When is Haloperidol the best choice in treating anxiety associated with palliative care?
if the patient has anxiety AND delirium
When treating delirium in palliative care, which of the following medications should you avoid:
- Antipsychotics
- Haloperidol
- Benzodiazepines
- Chlorpromazine
Benzodiazepines - may worsen delirium
you are seeing a patient who is on palliative care, and she is suffering from dyspnea. After attempting to treat the cause without success, you prescribe _____
opioids
first line for dyspnea
T or F: use a high dose opioids for respiratory depression to alleviate dyspnea at end of life
FALSE - low dose is effective enough to suppress respiratory awareness
T or F: may need a high dose opioids for pain related to palliative care.
True - may need higher dose of short-acting opioid for breakthrough pain.
what must you be cautious of with opioids used for treating pain at end of life?
Respiratory depression, constipation, neurotoxicity
when do you start treatment of terminal secretions in the lungs?
At the FIRST sign of secretions - they do not help existing secretions, only prevent it
what is the standard of therapy for pulmonary secretions?
Anticholinergic Drugs (atropine, hyoscyamine, scopolamine, glycopyrrolate)
Atropine
Hyoscyamine
Scopolamine
Glycopyrrolate
are used for what?
anticholinergics, used to dry up terminal pulmonary secretions
How could you change medications with someone who has hypotension and is at the end stage of their life with heart failure?
decrease ACE Inhibitor
taper off Beta blockers
Your patient has end stage heart failure and is experiencing volume overload. You decide to carefully increase their diuretic, but you must be cautious of what?
Dehydration
what kind of urinary incontinence is characterized by an underactive urethra leading to a lack or resistance to outflow.
Stress incontinence - when intra-abdominal pressure > intra-urethral pressure
What are some risk factors to stress incontinence?
Pregnancy, vaginal delivery, menopause, obesity, increased age.
which type of urge incontinence is characterized by an overactive detrusor muscle?
urge incontinence
which medication will you reach for first when treating Stress incontinence?
Duloxetine
which 2 adverse effects do you need to watch for with Duloxetine used to treat stress incontinence?
increase in BP
increase in suicide risk
this class of medication is sometimes used to treat stress incontinence, but is not recommended due to adverse effects and many contraindications
alpha-agonists (pseudoephedrine and phenylephrine)
estrogen
this choice of treating stress incontinence might be a good option if patient has estrogen deficiency
estrogen
Darifenacin Fesoterodine Soilfenacin Trospium Oxybutynin Tolterodine
Anticholinergic/antimuscarinic drugs (treating urge incontinence)
what is the first line treatment of urge incontinence
anticholinergic/antimuscarinic drugs
you start your patient on Fesoterodine for urge incontinence, and tell her that she should wait _____ to see the full effect
4 weeks for full effect
What are the adverse effects of the anticholinergics?
dry mouth constipation blurred vision flushing orthostatic hypotension sedation
Bethanecol and alpha antagonists (silodosin, prazosin, terazosin) are sometimes used to treat what?
overflow incontinence
your patient has BPH, which is obstructing the urethra and causing overflow incontinence. What can you treat him with?
either bethenacol or alpha antagonists (silodosin, prazosin, terazosin)
which class of medications is the worst culprit of losing bone mass density?
Glucocorticoids
your patient asks you what they can do NONPHARMACOLOGICALLY to increase bone mass density and you tell them to eat foods that contain which nutrients?
foods with calcium and vitamin D
T or F: your patient should exercise doing NON-weight bearing activity to reduce tension on the bones
False - weight bearing activities are best along with muscle strengthening
Alendronate
Ibandronate
Risedronate
Zoledronic Acid
Bisphosphonates - first line therapy for osteoporosis
how long do you treat a person with bisphosphonates?
5 years
why shouldn’t you treat with bisphosphonates longer than 5 years?
risk of jaw osteonecrosis, subtrochanteric fractures
how long before eating breakfast should you take bisphosphonates?
30-60 minutes prior, and don’t lay down after
what is the most common adverse effects associated with bisphosphonates?
GI effects (n/v, diarrhea, esophagitis)
you are about to administer Zoledronic acid IV - how can you reduce the flu-like symptom AE that is common?
pre-treat with APAP
bisphosphonates ok for pregnancy?
NO
what should you prescribe your patient who has osteoporosis but cannot tolerate bisphosphonates
Denosumab
only use this medication for osteoporosis if the patient has VERY HIGH FRACTURE RISK
Teriparatide (not first line!)
most of the osteoporosis medications block osteoclast activity, but this one specifically enhances
osteoblastic activity
Teriparatide (caution if pre-existing hypercalcemia)
Black box warning for teriparatide
Osteosarcoma
what is the maximum recommended time frame for teriparatide
2 years (daily injections)
What is the medication under the class Selective Estrogen Receptor Modulator (SERM)
Raloxifine
what is the MOA of Raloxifine
estrogen-like activity
raloxifene contraindications
pregnancy, if could become pregnancy, nursing
what fraction of patients do not reveal their supplement use to providers
2/3
why do people take CoQ10
improve outcomes in heart failure and improve ejection fraction, myocardial energy
Why do people take fish oil?
reduce triglycerides
AE of fish oil
GI reflux, fishy taste, bleeding risk if > 5 mg
Why do people take Ginkgo Biloba?
improves cognition in dementia (enhancement of cerebral blood flow)
what is the risk with ginkgo biloba
increased bleeding risk due to antiplatelet and antithrombotic effects
why do people take St. John’s Wort?
mild to moderate depression
does St johns wort work with all types of depression?
not severe.
Your patient notes that she wants to start an antidepressant medication to help with her depression. She mentions that she is already on St. John’s Wort. What medication should you worry about
NO SSRI! risk of serotonin syndrome
this supplement is often combined with caffeine and has a high risk of hypertension, arrhythmias, MI, stroke, seizure
Ephedra Alkaloids
This supplement is found in herbal supplements and teas and can cause liver toxicity, cirrhosis, fibrosis
Pyrrolizidine Alkaloids
This supplement is used to self-treat opioid withdrawal, but has a risk of overdose, addiction, and salmonella contamination
Kratom
this supplement is a chines herb used for weight loss, but can cause nephrotoxicity
Aristolochia
which chronic conditions have the highest risk of interactions with supplements and why?
Seizures
Arrhythmias
CHF
these patients take more Rx medications with NARROW therapeutic indexes
what happens when you take St. John’s Wort with Warfarin
increased metabolism of warfarin = decreased warfarin and lower INR
Cardiovascular medications interact the most with what supplement?
St Johns Wort
What should you educate your patient on if she takes St Johns Wort with her Oral contraceptives?
It interacts, and can cause contraceptive failure
St. John’s Wort + cyclosporine can cause what?
transplant failure!
T or F: most of palliative treatment is off label
True
what are the FDA approved cannabinoids
Dronabinol
Nabilone
of the cannabinoids used, which one is best for AIDS associated wasting?
Nabilone
Which case is NOT an example of a good time to use medical marijuana
chemo-induced n/v, painful spasms not tolerated by opioids, chronic RA pain, Acute pain, AIDS wasting
acute pain
THC is highly protein bound, so caution when taking with ____
warfarin
THC has additive effects when combined with ___
sedatives, psychotropics, hypnotics, alcohol
Contraindications THC
psychotic illness schizophrenia bipolar anxiety mood disorder substance disorder
T or F: caution using medical marijuana with Rx opioid use
True
This vaccine is found in dirt, soil and part of a combination vaccine
Tetanus
Which vaccine in DTap is responsible for the vaccine against bacteria that causes membranous pharyngitis
Diphtheria
How many DTaP vaaccinations necessary
3 (with Td booster every 10 years)
which trimester do you give a pregnant woman DTaP
3rd
how many doses of hepatitis A do we give?
2 doses
How many doses of hepatitis B do we give?
3
How are Hepatitis A and B different regarding transmission?
A - fecal/oral
B - Blood/bodily fluids
How many doses of MMR do we give?
2
which specific population should we avoid giving the MMR vaccine to, and why?
Immunocompromised - risk of measles (the vaccine is live-attenuated)
HIV infected is ok if not immunocompromised
This vaccine’s common Adverse effect is a fever >1 week later (increased risk of epilepsy)
MMR
this vaccine prevents a highly contagious progressive paralytic disease, that is now eradicated
Polio (inactivated)
How many doses of the rotavirus vaccine do we give?
2-3 doses (BOTH LIVE - ATTENUATED)
what is a major adverse effect of the rotavirus (given to kids <5 yearS)
Intussusception
T or F: the rare case of seizures that happen after MMR vaccine are life-threatening
FALSE - they are rare, temperature related, and do NOT cause lasting damage
What element of vaccines causes all the hype about autism?
Thimerosal (ethyl mercury)
what type of vaccinations should you avoid in immunocompromised?
live-attenuated
which 2 vaccinations should you give pregnant women in the second half of their pregnancy
Tdap
Influenza
(avoid live vaccines)
what delayed adverse effect can happen with the varicella vaccine?
mild rash 20 days later
Which medication is best for migraine pain?
Sumatriptan
Which type of meds treat neuropathic pain
Tricyclics and Gabapentin
Duloxetine treats what type of pain?
fibromyalgia
Dexamethasone is used to treat what type of pain
post operative n/v
what do you treat the pain from gout?
prednisone
what medication treats pain from muscle spasm?
cyclobenzaprine
which 2 opioids are less effective?
codeine
Tramadol - more interactions and risk of seizure
which medication in pediatrics gives a high risk of kernicterus
sulfamethoxazole-trimethoprim
Chloramphenicol in pediatric population has a risk of what?
Gray baby syndrome
T or F: hepatic metabolism is slower at birth, allowing medications to build up and cause adverse effects
True
benzyl alcohol and benzoic acid in babies can cause _____
gasping syndrome
your patient is newly diagnosed with stress incontinence. What can you prescribe her?
Duloxetine
the major risk of Ginkgo Biloba is ____
increased bleeding risk
do you avoid Duloxetine in liver or kidney dysfunction?
Both (liver disease or CrCl < 30)
Transdermal administration is not suggested in pediatrics, EXCEPT which?
methylphenidate for ADHD
which vitamins are water soluble and excreted in urine
B and C
