GI/GU& REPRODUCTION Flashcards
what causes prostatic enlargement?
diphydrotestosterone ( DHT)
pharmacological treatment for BPH
alpha blockers ( silodosin, alfuzosin, tamsulosin)
5- alpha reductase inhibitors (Finasteride, dutasteride)
Phosphodiesterase type ( tadalafil)
antimuscarinics and beta 3 agonist
which alpha blockers is selective vs non selective
selective: silodosin, alfuzosin, tamsulosin
non selective: doxazosin, terazosin
MOA of alpha blockers, side effects
mediates smooth muscle activity in the bladder neck, which allows for improved urinary flow rate
AE: hypotension, dizziness, somnolence, fatigue, dyspnea
Unique AE of tamsulosin
intraoperative floppy iris syndrome, cataract formation,
retrograde ejaculation
counselling points for alpha blockers
administer silodosin and alfuzosin with food, tamsulosin may be administered with or without food
does alpha blocker provide reduction of prostate
no, symptomatic relieve only
MOA of finasteride and dutasteride
blocks conversion of testosterone to DHT
Onset of 5 alpha reductase vs alpha blockers
5 alpha: 6 -12 months
alpha: immediate
AE of finasteride and dus-
impotence, sexual dysf, decreased libido, gynecomastia ( rare)
which agent to avoid when crcl< 30 ml/min
silodosin
tadalafil
AE of tadalafil
dyspepsia, headache, nasal congestion, back pain, flushing, visual disturbances, permanent vision or hearing loss ( rare)
MOA of desmopressin
synthetic analogue of the antidiuretic hormone vasopressin. useful in men with nocturnal polyuria
AE of desmopressin
Hyponatremia, xerostomia ( dry mouth), headache, dizziness, abdominal pain
** sodium levels must be taken at baseline in all men, followed by 7 days and 30 days after initiation of therapy
what combination is recommended for BPH
alpha blocker+ 5 alpha reductase inhibitor
rapid relief by alpha blocker and sustained relief by reductase inhibtior
which agent may be choosen if symptoms were predominantly storages symptoms?
antimuscarinics and beta 3 agonist (Mirabegron)
When does progesterone peak during the menstrual cycle?
During the middle of the luteal phase of the menstrual cycle.
when does estrogen peak d
before ovulation
can the Evra patch be used for women weighing >90 kg
no
which type of COC decreases acne
Estrogen dominant ( higher estrogen) progestins with higher androgenic activity may likely increase acne
early cycle bleeding is likely due to
insufficient estrogen
late cycle bleeding is likely due to
insufficient progestin
advantages and disadvantages of progestin only
ad: decreased dysmenorrhea, bleeding, risk of endometrial cancer
- lower doses of progestin
- best for patients that have a contraindication to combined hormonal use
dis: tight regular schedule ( >3 hr= missed dose)
- higher incidence of ectopic pregnancy
- irregular bleeding
what is the main disadvantage of depo provera
delayed fertility up to 1 yeaer
weight gain
black box warning of increase risk of osteoporosis
what is the main disadvantage of depo provera
delayed fertility up to 1 yeaer
weight gain
black box warning of increase risk of osteoporosis
which drug decreases efficacy of COC
phenytoin
CBZ
Phenobarbital
how effective is levonorgestrel (plan B) and Ulipristal ( Ella) after unprotected sex
plan B: 3 days (72 hrs)
ella 5 days (120hrs)
plan B AE
N/V, cramps dizziness, irregular menstrual bleeding or spotting
how long can cooper IUD effective after unprotected sex
7 days
IS plan B effective in over weight patient
Ella is recommended for women with BMI >/ 25kg/m2
Plan B have reduced efficacy
when can u start using COC after post partum
6 weeks
is lactational amenorrhea an effective birth control
2015 contraception guidelines say its effective on its own (98%) if patient is <6 months postpartum, >75% breast feeding and remains amenorrheic
which progestin have reduce androgenic activity
norgestimate and desogestrel ( better than levonorgestrel) thus helpful for acne
common AE of COC
BTB, amenorrhea, N/V, bloating, breast tenderness, mod chagnes
can overweight women use evra patch
no, not effective for women weighing >90 kg
definition of chronic constipation
ROME criteria
>/ 3 months with an onset of >/ 6 months before diagnosis
bulk forming laxatives are contraindicated in what
fecal impaction
what is methylnaltrexone use for
opioid induced constipation in palliative care patients
indication for naloxegol
opioid induced constipation in non-cancer patient not responding to other treatment
MOA of linaclotide
guanylate cyclase c agonist
increases chloride and bicarb secretion + inhibits sodium reabsorption—> increased water secretion into intestinal lumen
red flags symptoms of constipation
GI bleedin
unintentional weight loss
family history of colon cancer
symptoms onset >/ 50 years old
indiation of linaclotide
is indicated for the treatment of chronic idiopathic constipation and IBS-C in adults
drug of choice for constipation of childnre
PEG, lactulose, sorbitol
complications of constipation includes
hemorrhoids, anal fissure, fecal impaction
When is the onset of action of bisacodyl tablets
6-12 hrs
What is the onset of action of Milk of Magnesia (magnesium hydroxide)?
0.5-6 hrs
Which of the following laxatives can cause aspiration pneumonia
mineral oil
which constipation drug is NOT recommended in pregnancy
docusate linaclotide prucalopride pastor oil mineral oil
common causes of diarrhea in neonates
rotavirus
most common bacterium responsible for antibiotic-associated infectious diarrhea.
c.diff
mac dose of loperamide/day
4mg STAT, then 2mg after loose BM ( max 16/day) x 3 days
what characteristic of drug increases the chance of placental transfer
high fat solubility
low degree of ionization
low degree of protein binding
low molecular mass ( <500 kDa rapid transit
which drugs are INCOMPATIBLE with breastfeeding
alcohol anticonvulsants ( phenobar, ethosuximide, primidone) COC ergot iodine Lithium carbonate tetracyclines
1st line treatment for H.Pylori
- PAMC x 14 days
2. PBMT X 14 days ( first line in patient with pen/amoxi allergy)
what are restricted first line options
PAC, PAM, PMC
Restricted to areas with known clarithromycin resistance <15% or proven high local eradication rates >85%.
long term AE of PPI
B12, mg deficiency
Enteric infection risk ( c.diff, gastroenteritis)
bone loss, fractures
AE of H2RAs
headache, dizziness, drowsiness
gynecomastia ( <4%)
GERD options for pregnancy
Antacids ( except sodium bicarb)
PPIs
H2RAs
what tests are done to determine if H. pylori is present?:
urea breath test (UBT)
serology
patient on clopidogrel should avoid which PPI
avoiding concurrent use with omeprazole due to the possibility that combined use may result in decreased clopidogrel effectiveness. Although all the proton pump inhoibitors may lower the effectiveness of clopidogrel, pantoprazole (or rabeprazole) may be a lower-risk alternative
which NSAID is best for peptic ulcer disease
Celecoxib
what is endometriosis
endometrial glands and stroma tissue outside of uterus
symptoms of EM ( endometriosis)
dysmenorrhea, pelvic ain, dyspareunia, bowel upset, bowel pain
** INFERTILITY
pain management for EM
1: NSAID ( inhibits prostagladins)
2: COC ( continuous use preferred)
3: progestin only
goal standard of EM diagnosis
laparoscopu +/ biopsy
serum CA 125 levels include pelvic inflammatory disease, epithelial ovarian cancer and pregnancy ** not routine recommended**
list the GnRH agonist
goserelin, leuprolide, triptorelin
list GnRH Antagonist
elagolix
which GnRH do not cause flare up
GnRH antagonists ( elagolix)
what is “add back” HT
“Add-back” hormone therapy (HT) is used to mitigate the perimenopausal-type symptoms and bone density loss that occur with GnRH agonists
Ex: MPA and Norethindrone acetate 5mg
ovulation induction therapy
letrozole 2.5mg day 3-7 of cycle
what else is recommended for women taking GnRH agonist with HT
vitamin D ( 400-1000 units/ day) and clacium ( 1200 mg/day)
CI of PD1-I
nitrates
if nitrates was to be used, when to seperate it by
24 hrs after slidenafil & vardenafil
48 hrs after tadalafil
food interaction with PD5-I
slidenafil and vardenafil avoid with fatty meals
tadalafil: no effect
which PD5-I IS NOT RECOMMENDED in CrCl <30 ml/min
tadalafil
protein limit for HE
1.2-1.5g/kg/day
score use to assess prognosis of chronic liver diease
CHILD-PUGH
MOA of lactulose
converts ammonia ( NH3) into ammonium ( NH4) which is ionized and not absorbed resulting in lowering blood ammonia [c]
pathophysiology if hepatic encephalopathy
unknown, high levels of ammonia ma be the cause
management of portal hypertesion
fluid restriction
Na+ restriction of <2g/day
reduce portal pressure <12mmhg ( use BB)
drug approved for abortion
mifepristone/misoprostol in <63 days gestation
MOA of mifepristone and misoprostool
Mifepristone is a potent progesterone receptor modulator with strong antiprogestogen and antiglucocorticoid activity
Misoprostol is a prostaglandin analogue, a potent synthetic form of prostaglandin E1 that causes the cervix to soften and the uterus to contract, causing expulsion of the pregnancy
can methotrexate be used in abortion
yes, off label used
50 mg IM on day 1 followed by misoprostol
menopause
no menses for 12 months making the end of reproductive life
long term complication of menopause
osteoporosis, CVD, cancer
hormone that is responsible for weight gain, breast tenderness and uterine bleeding
excess progestogen
indication for combined estrogen and SERM modulator
-women with uterus wishing to avoid progesteogen
moderate-severe vasomotor symptoms in women <75years
is estrogen cardioprotective
maybe if initiated at onset of menopause but harmful if started >10 years or >60 years of year
hormonal decreases risk of what and increases risk of what
decrease:
endometriosis, endometrial cancer, ovarian cancer,
increases:
BREAST cancer, cervical cancer and gall bladder disease
non pharm for vasomotor symptoms
cooling techniques (e.g., dressing in layers, using fans, lowering the ambient temperature) and avoidance of triggers (e.g., spicy foods, hot drinks, caffeine, alcohol).
hormone therapy for patient with hysterctomy
ET alone
what is the role of progestogen in combo with ET
reduce the risk of endometrial hyperplasia
oral vs topical application of ET
less incidence of increase triglyceride, reduced risk of VTE in topical
Endometrial hyperplasia
lining of uterus becomes thicken and can lead to endometrial cancer
does progsterone cream as effective as oral
no, cream does not provide endometrial protection
best way to take progestrogen
can be taken either continuously every day (continuous EPT) or cyclically for 12–14 consecutive days every calendar month (cyclic EPT).
other options for vascomotor symptoms
citalopram, escitalopram, paroxetine, venlafaxine, desvenlafaxine
gabapentin
clonidine
vitaminE?
is progestin indicated for vaginal estrogen
no
neurotransmitter that is thought to be associated with motion sickness
acetylcholine and histamine thought to be most responsible neurotransmitters signaling the medulla oblongata
chemo drugs that are high emetic risk
cisplatin
cyclophosphamide (> 1500mg/m2)
mechlorethamine
chemo drugs that are high moderate risk
carboplatin
cyclophosphamide ( < 1500 mg/m2)
oxaliplatin
acute CINV time and causes
1-2 hrs after chemmo - may last up to 24 hrs
cause: serotonin, type 2 dopamine and neurokinin 1
delayed CINV timing and causes
> 24 hrs after chemo, may last up to one week
causes: sustance P plays a large part ( serotonin plays CINV)
key patient factors for CINV
<50 years of age, female, hx of motion/pregnancy sickness
key factors for PONV
female sex, non smoker, history of motion sickness, opioid use
options for motion sickness
dimenhydrinate or diphenhydramine
promethazine ( longer duration than dimenhydrinate)
scopolamine: place behind ear atleast 4 hr prior to motion exposure
most effective combo against acute and delayed emesis with moderte high emetic chemo
5-HT3RA
cortocosteriod
NK-1 RA
treatment for NVP
mild: diclectin ( pyriodoxine/doxylamine)
moderate-severe: dimenhydrinate, promethazine, diphenhydramine
AE of diclectin
sedation, diarrhea, disorientation,
MOA of domperidone and metoclopramide
dopamine antagonist
signs of dehydration
sunken eyes, decreased skin turgor, dry mouth and tongue, decreased urination
infertility
inability to conceive after 12months of regular unprotected intercourse in women < 35 years of age
when is teratogen highest in pregnancy
1st trimester
what vitamins are recommended for PMS
Ca2+, vitamin B6, Mg2+
what can calcium help with PMS
1200mg daily
improvement in mood, water retention, cravings and pain
** most evidence for use
antidepressant for PMS
1st line treatment.
Citalopram, escitalopram, fluoxetine, paroxetine or sertraline: during luteal phase ( day 14 start of menses) or continuously
COC for PMS
2nd line,
smoking and IBD
smoking: bad for crohn
protective against UC
difference between CD and UC
CD: inflammation can occur from mouth to anus. terminal iluem most affected
- transmural inflammation
UC: limited to colon, inflammation does not extend beyond mucosa
Triad of UC
diarrhea, rectal bleeding and abdominal pain
inflammation
triad symptoms of CD
abdominal pain, diarrhea, fatigue/weight loss
pharmacological options of UC and CD
aminosalicylates ( PO and PR)
sterioids
immunomodulators
biologics
efficacy of aminosalicylates
Sulfasalazine, mesalamine, olsalazine
1st line for UC ( induction and remission)
modest effect in CD ( not efffective in inducing remission in mild CD except sulfasalize
which aminosalicylates is released in SB and which in colon
Salofalk and Pentasa release 5-ASA in the small bowel, allowing it to be available in the small bowel and colon
Sulfasalazine, olsalazine, Asacol and Mezavant release 5-ASA primarily in the colon.
which mesalamine is available as once daily
mezavant
efficacy of cortiosteroid in UC and CD
1st line induction of remission in moderate-severe UC ( more effective than 5-ASA in both UC and CD) * not used for maintenance
AE of steriods
GI upset, dyspepsia, edema, hyperglycemias, hyperlipidemia, HPA suppression, impaired wound healing,
monitoring for sterioids
annual eye exam, bone mineral density, blood sugars, and monitor for infections
efficacy of azathioprine
azathioprine, 6- mercaptopurine
MD of remission for moderate-severe UC/CD ** not for induction as monotherapy**
interaction with azathioprine
allopurinol and febuxostat
role of methotrexate
maintenance of remission for moderate-severe UC/CD
anti-TNF-alpha role
adalimumab, certolizumab pegol, golimumab and infliximab.
for induction and maintenance of remission
(2/3 of patient show response, with 1/3 showing remission for both UC and CD)
know treatment algorithm for CD
see pic
know treatment algorithm with UC
see pic
