GU Pharm Cases Flashcards
Case 1: 70 y/o man with new onset afib. You start on BB. Now he has erectile dysfunction and is apathetic and withdrawn. COPD. HTN. Afib. Lisinopril 10 mg, HCTZ 12.5 mg daily, metoprolol 100 mg daily. DOC2?
SXS come from the BB
DOC1: decrease dose of metoprolol and continue to drop so long as HTN is controlled until sxs diminish
DOC2: warfarin or dabigitran for afib to prevent clot
what happens when metoprolol is at high doses? what can this cause?
looses selectivity so it now binds with receptors in the penis and brain causing ED and depression/apathetic mood and withdrawn
what can metoprolol cause in high doses? (5)
depression fatigue loss of sex drive ED malaise
Case 2: 20 y/o woman for routine pre-natal follow. BP is 150/100 and she is 12 weeks pregnant. G1P0A0. DOC1
Need to determine if this woman has preexisting HTN or preclampsia HTN SO NEED TO CHECK FOR PROTEINURIA!!!!! this is the distinguishing factor
consider ambulatory monitoring to make sure this is not white coat syndrome because yes pregnant people can get this too and you don’t want to give them unnessacary medications
DOC1: if pre-eclamptia: tx labetalol
what is the drug class for labetalol? so who should you avoid using this in?
non-selective alpha 1, B1, and B2 receptor blocker so if a patient has asthma use with caution or consider other medication
do primary care providers usually use methyldopa in pregancy?
this is usually something OB deals with
what is the definition of preclampsia?
SBP over 140 or DBP over 90
PLUS proteinuria 0.3 gm or more in 24 hour urine
what are the two OTC prenatal vitamins?
folic acid and pyridoxine
what does folic acid prevent and what is the most common concern of this?
prevent neural tube defects
most commonly spina bifida or a baby born with a fluid filled sac in head due to failure of closure
what is the definition of a tocolytic agent?
one we give to suppress premature labor or contractions
what is the most commonly used tocolytic agent?
magnesium sulfate, given IV
Case 3: 33 y/o female wants to avoid pregnancy over the next year while starting a new job, she would want to become pregnant soon after. She is obese, 20 pack year smoking history and still smokes currently and bp 145/100. C0P0A0. DOC1? why?
Paraguard IUD (copper IUD)
hx of obesity (against POP), smoking (against COC), and new job make it difficult for her to take the pill at the same time each day
how long can the mirena IUD be used for?
5 years
how long can the paraguard IUD be used for?
10 years
what do IUDs do?
prevent implantation in the uterus
what percent do COCs decrease ovulation by?
97%
what percent do POPs decrease ovulation by?
50%
Case 4: 24 y/o patient would like to start contraception. Her PMH is significant for migraine headaches without aura that occur about once every 3 months. DOC1?
can still take COCs since no aura and migraine without aura is a relative contraindication
DOC1: Lo esterin FE
is there a difference between the 21 day and the 28 day packet?
nope! it is the womens choice as to which one she prefers
if a woman takes regular BC and they don’t want to get their period can you take the hormones straight through so you don’t get a period?
yes, but be careful because it is only the MINIMAL research that says this is ok….
…not a lot of research has been done about htis but to the best of our research it is ok
what are 9 absolute contraindications for COC?
thromboembolitic events VAD breast cancer estrogen dependent neoplasm undiagnosed uterine bleeding smoking hepatic tumor active liver disease migraine with aura
migraine with aura is absolute contra for COC because ….
increase risk of CVA 5-6%
what are two SE of progesterone?
acne and weight gain
what form of BC do you want to use in someone who gets headaches with their mestrual flow/?
use OCP when you get your period every three months
AKA
quartette
as you increase estrogen levels you increase change for…
migraines
Case 5: 17 y/o female would like to start a COC for contraception for regulating menses. Her 35 y/o sister uses triphasic COC so she would like to use this too. She is most concerned with preventing pregnancy.
monophasic OCP loestrin FE 1/20
alternatives: Mirena, Paraguard, Depo
Stay away from: triphasic or quadriphasic COC because it increases risk for breakthrough bleeding
what precent of pregnancies are unintended?
40%
what percentage of people are on contraceptives?
50%
as you increase the phases of COC what do you increase your risk for?
breakthrough bleeding
what are the 6 SE of COC?
migraine N/V/ bloating decreased libido weight gain depression
what are the 3 most common SE associated with COC?
headache
N/V
weight gain
Case 6: your sexually active 20 y/o patient started COC two weeks ago and calls you with nausea of 1 weeks duration and intermittent vomiting for the past 3 days. Lo Ovral. what are the 4 options for this patient?
1: have her keep taking it since these sxs usually last 1-3 months and then disappear
Options:
when looking at the name of a pill, what is the first number and what does the second number represent?
first number: progestin
second number: estrogen
technically how many options are there for estrogen used in birth control? what are they?
technically 1 option
mestranol is the prodrug of ethinyl estradiol and is converted to this in the body
ethinyl estradiol is technically the only option because of this
how long does the N/V last on estrogen COC?
1-3 months
Case 7: 16 y/o patient with cystic acne on face and thorax txed with tetracycline. She is moderately obese and would like to start low dose COC for contraceptions. she is obese. Tetracyclcine 250 mg BID. what are 2 options? what don’t you want to use?
Option #1: paraguard IUD (copper)
Option #2: monophasic (since obese) COC and switch from oral tetracycline to topical so there isn’t an interaction
DONT USE: progestin since it can make the acne worse
what 4 reasons would you not want to prescribe a OCP in an obese pt?
it takes twice as long for them to reach a steady level in the body
impairments in obese
- absorption
- volume distribution
- metabolism
- excretion
Case 8: 72 y/o female has stress urinary incontinence and dysparunia. She has tried keagles. HTN. Hyperlipidemia. Linsinopril 10 mg, atorvastatin 10 mg daily. 3 options?
option 1: premarin intravaginal estrogen cream for dysparunia
option 2: pessaries/weight loss
option 3: ospehmifene
what oral drug can be used to tx dyspareunia in a female?
ospemifene
what should you encourage the patient to do for urinary incontinence?
keep a urinary diary
what do you use to tx stress urinary incontinence?
vaginal estrogen cream permarin
what do you use to tx urge urinary incontinence?
tolterodine
what is the drug class for tolterodine used for urge urinary incontinence?
M3 antimuscarinic
Case 9: 22 y/o man who has seen testosterone adds on TV. He states that he has been fatigues the past month and has started a new job and would like to start testosterone for his fatigue. 3 things to check?
need to do:
- CBC/iron panel (anemia)
- thyroid check
- testosterone levels
since young and health need to determine the cause of fatigue and it is unlikely to be testosterone
if you give someone testosterone and they don’t have hypogonadism, what does it do?
increase risk for CVD
what must you check testosterone levels?
between 8-10 am on three difference occasions
Case 10: 72 y/o man who is requesting testerone tx to improve his libido and tadalafil [cialis] for his erectile dysfunction. Prostatic hypertrophy. HTN 180/110 despite tx, alcohol abuse. Lisinopril 20 mg, HCTZ 12.5 mg, amlopdipine 5 mg daily, tamulosin (BPH) .4 mg daily. BP 180/110 BMI 32.
why is this guy in a perdicament? what are you two main options?
This guy is in a predictament!! he wants to take tadalafil which is a CYP34A inhibitor and so is tamulosin which he is already taking. CANT TAKE BOTH BECAUSE CYP34A and Dx-DX interaction
option 1: don’t take tadafil since it can only be used for a max of 6 MONTHS and during this time would have to be taken of tamulosin and then he would be in the same predicament in 6 months when he is no longer able to take tadafil
Option 2: take of tamulosin and put on finasteride which is for BPH but isn’t a CYP34A and then start on tadalafil
what are three drugs that are CYP34A?
sildenafil
tadalfil
tamulosin
what is the difference between sildenafil and tedalafil?
tedalafil is a once a day mediation and viagra is PRN and taken 1 hour before sexual activity
Case 11: 30 y/o woman who has had unprotected sex and is worried she may be pregnant because they had sex midcycle. She is asking about emergency contraception because she doesn’t want to become pregnant at this time.
DOC optons: Plan B or Ella
*consider more regular contraception!
of the emergency contraceptions, which one is OTC and which one is RX?
plan B-OTC but behind the counter
Ella-RX only
how long do you have to take emergency contraception?
120 hours or 5 days
what are the 3 SE of emergency contraception?
nausea, vomiting and diarrhea
want to test for pregnancy prior to emergency contraception?
potentially to make sure she wasn’t previously pregnant
does emergency contraception abort an existing implanted egg?
nope, important to have patient know this as well!
what are the two emergency contraception options?
Plan B and Ella
of the emergency contraceptions, which one is Rx?
Ella
Case 12: 53 y/o female is menopausal and having repeated hot flashes, night sweats, and mood swings. she wants to help make these better. 3 DOC options?
DOC1: Prempro (combination of conjugated equine estrogen and MPA [progesterone])
DOC2: low dose COC
DOC3: tricyclic antidepressant
what are three things you need to rule out before putting someone on COC?
breast cancer, endometrial bleeding, or ovarian cancer
Case 13: 28 y/o who is taking Depo-Provera 150 mg IM every 3 months for contraception. She has been using it for a year now and has gained 10 pounds. She is concerned about weight gain and also becoming pregnant. She smokes 5 cigarrettes a day. first DOC? 1 alternate?
DOC1: Copper IUD paraguard
DOC2: if doesn’t want to try IUD and do LOW DOSE COC since smokes less than 15 cigarettes a day and is LESS THAN 35 years old
what percent of pregnancies are unintended?
50%
Case 14: 35 y/o has had bariatric surgery her pre-surgery BMI was 42 and is now 27 and she has lost nearly 100 pounds. She does not want to become pregnant right now. Obesity, bariatric surgery, HTN, dyslipidemia. No meds. DOC1? alternatives? why?
DOC1: copper IUD paraguard
DOC2: if doesn’t want a IUD, can use any other method that isn’t oral including patch, implanon, depo-provera
**you don’t want to use a oral contraceptive here because she has an altered GI tract and you don’t know how well the medication will absorb so avoid oral methods!
what is the recommendations for bariatric surgery patients?
shouldn’t become pregnant for at least a year after surgery so want to get one BC, preferrably IUD
what is the average weight gain on depo-provera?
10 pounds
progesterone leads to increased risk of what physcial changes? 4
ncreased hair growth
acne
deepening voice
increased muscle mass
Case 15: 26 y/o male has urethral discharge and you determine he has gonnorreah. Moderate urethral discharge without ulceration, pharynx, and anus negative. 2 doc? considerations?
DOC1: 250 IM injection of ceftriaxone and 1g dose of azithromycin
reportable disease!!!
TX partner!!
Check for HIV, chlamydia, and gonnoreah!!
what tx do you use for chlamydia?
azithromycin
what tx do you use for gonnoreah?
azithromycin
IM injection ceftriaxone
Case 16: you work in a homeless clinic and see a 27 y/o female pt who is pregnant and otherwise asymptomatic but in routine urinalysis is positive for GC and Chlamydia on NAAT testing. 3 months pregnant. 3 DOC? 2 considerations?
DOC1: ceftriaxone IM
DOC2: azithromycin
DOC3: daily supplement with folic acid
Tx partner
reportable disease
what combination of two drugs do you use to tx N/V in a pregnant woman?
pyridoxine (B6) and doxylamine
what do you to tx UTI in pregnancy?
nitrofurantoin
what is the name of the vitamin that is used to tx N/V in a pregnant woman?
B6 pyridoxine combined with doxylamine
Case 17: 32 y/o woman with diffuse lower abdominal pain, chills, low grade fever and cervical motion tenderness on exam. PG neg. thin gray vaginal discharge, no bleeding. NAAT testing of urine is pos for trichomonas vaginalis.
DOC?
DOC1 metronidazole
what is a contraindication for metronidazole?
seizures
what SHOULDNT you use with metronidazole? why?
alcohol because it can cause a disulfram reaction which causes profuse vomiting
what drug causes a difuse like rnx?
metronidazole
what is the pregnancy rating for metronidazole?
B
Case 18: 78 year old man who has recent onset dementia. He has become violent. you discover he has neurosyphilis. HTN. COPD. Lisinopril 20 mg daily. Albuterol MDI PRN. Fundi ne. TPHA pos. 1 DOC, 2 considerations
DOC1: benzathine penicillin G and admit to hospital since combative
get psych consult!
test the wife
how can benzanthine penicillin G be dosed if in the hospital for syphilis?
1 milliion units IV every 1 hour so that they don’t always have to hang a new bag
when giving Penicillin G for syphilis, what do you need to watch out for?
acute febrile reaction
(HA, myalgia, rigors, sweating, and rash)
If you see ulcerative lesions, what do you want to do?
viral culture
chanres are ______ and make you think _________
chanres are NONTENDER and make you think SYPHILIS
is acyclovir safe during pregnancy?
yes!
Case 19: 17 y/o hs student who has ulcers on his penis. wants to know what he has to do to get rid of them for good.
HSV
DOC1: acyclovir
DOC2: continue suppresive acyclovir therapy after clearing infection
IMMUNIZE WITH GARDISIL SINCE SEXUALLY ACTIVE
how is valcyclovir administered?
IV
what is acyclovir used more than valcyclovir?
because valcyclovir is $$$`
Case 20: 29 y/o male patient has indurated ulceration that he noticed on his penis a week ago. He is sexually active with 3 females and they do not use condoms. Allergies include penicillin that cause his lips and tongue to swell. 1 DOC? 1 consideration?
primary syphilis
DOC1: doxycycline (since allergic to benzanthine penicillin G)
must tx other three partners
when do you do the urine test for gonnoreah or chlamydia?
FIRST VOID IN THE AM
Case 21: 16 y/o female who wants to start birth control pills. She is 5’ 2” and weighs 340 lbs. What do you recommend. BMI 60. doc 1?
DOC1: paraguard COPPER IUD
should avoid hormonal options because of weight, including depo-provera, patch, and low dose CPS
how long does it take for regulation of cycle when taking depo-provera?
12-18 months
what is a abx that has been shown to decrease the efficacy of OCP?
rifampin
Case 22: 38 y/o in clinic for refill of her combination contraceptive meds. She is a 1 ppd smoker for the past 20 years. Tobacco. HTN. Obesity. Migraine headaches WITH AURA. Breast Cancer. DVT. Mastectomy. Medications: Ovcon-50daily. Amlodipine 5 mg. DOC options?
STOP ESTROGEN PILL!!
DOC1: consider tubal ligation, depo-provera, IUDS
estrogen not a option because of migraines with aura, DVT, and breast cancer! and smoker!!*
Case 23: 17 y/o who started loestrin 1/20 for regulation of her meses two months ago. she comes to clinic because she is having breakthrough bleeding and whats to know what she can do. spotting is in 3rd week of her cycle. DOC1?
increase the dose of progesterone!
DOC1: Loestrin 1.5/30…increase the dose from 1/20
what is the cycle for lybrel?
120 day cylce, more time between periods!!
what is the name of the prostin-only OC?
ovrette
what does the oral contraceptive ovrette contain?
norgestrel
Case 24: 70 y/o male for tx of his erectile dysfunction of 3 years duration. 30 pack year smoking history ending in 2012, COPD, HTN, hyperlipidemia, angina. Atrovent MDI PRN. Symbicort 80/4.5 MDI 2 inh daily, TNG 0.4 mg. amlodipine 5 mg daily, atorvastatin 40 mg. why is this case hard and pose a lot of questions?
NO RIGHT ANSWER ABOUT THIS JUST TRYING TO EXPLAIN HOW THIS IS A DELIEMA
this patient takes nitrates PRN for chest pain, which is contrindication to use sidenafil because when used together it can cause a MASSIVE drop in BP and death. here you need to know how often he is taking it, if taking it daily then sildenafil is not a option, but if he takes it once every month he could consider taking sildenafil
also need to know if he gets angina during sex, because if so, he would be unable to take sildenafil and would need emerency medical care, his partner would also need to know because it is likely if no one was there the EMT woudl give him nitro which would tank him out. so if chest pain, sildenafil is a no go option!
additionally, he can’t take these two medications within 48 hours of each other
no answer just a lot of questions on this one
what two conditions does tadalafil tx?
erectile dysfunction and BPH
how is sildenafil doses?
PRN
how is tadalafil dosed?
PRN 10 mg with max of 1 daily
or
2.5 mg low dose daily
Case 25: 75 y/o male brought into clinic by his daughter because her father is unsteady on his feet, apthetic, and disoriented. He has almost fallen twice today. BPH. COPD. Tamulosin 0.8mg BID. Symbicort 80/4.5 mg MDI inh BID. Atrovent MDI prn. what should you do?
the reccomended dose is 0.4 so he is taking way more than that which is causes these SE
DOC1: stop the tamulosin, wait till the lightheadedness leaves and then symptoms disappeared and then restart at the appropriate dose of 0.8 mg
what is the standard does for tamulosin used to tx BPH?
0.4 mg
what is the drug class for tamulosin?
alpha 1 adrenergic antagonist
what is the MOA of tamulosin?
relaxes the bladder neck, prostatic urethra, and prostatic sm muscle
what are 2 SE of tamulosin that become particularly apparent in elderly?
- syncope
2. orthostatic hypotension
what can tamulosin also be used for besides BPH?
kidney stones because it relaxes the bladder and urethra AND IS FAST ACTING
what is the daily dose of tamulosin? if higher, what can it cause?
0.4 mg traditionnaly, if over 0.8 can cause retrograde ejaculation
when can you expect to see results from tamulosin?
FAST ACTING but takes 1-2 weeks to see full results
how long does it take finasteride to have its effect for BPH?
6 months
what is the differnce in timing of onset between finasteride and tamulosin?
finasteride takes up to 6 months because of enzyme inhibition
tamulosin takes 1-2 weeks for full effects
what is the drug class for sildenafil?
PDE5 inhibitor
what is the MOA of sildenafil?
inhibits PDE5 to increase NO leading to corpus cavernosum relaxation and inflow of blood to cause erection
what is a possible SE of sildenafil?
vision change particularly blue
what is the drug class for tadalafil
PDE5 inhibitor
what is the MOA of tadalafil?
inhibits PDE5 to increase NO leading to corpus cavernosum relaxation and inflow of blood to cause erection
what else can tadalfil be used to tx?
pulmonary artery HTN
what drug do you use to tx tichomonas or bacterial vaginosis?
metronidazole
what is the MOA of metronidazole?
inhibits protein synthesis
what drug is used to tx gonnoreah?
ceftriazone and azithromycin
what is the MOA of ceftriaxone?
interferes with the transpeptidization of actively growing cell walls by binding to the penicillin binding protein PBP
what is the tx for chlamydia?
azithromycin
what is the MOA of azithromycin?
reversibly binds to the 50s subunit of bacterial ribosome and inhibits protein synthesis
what is the first DOC for syphilis?
bezanthing penicillin G
what is the second DOC or first DOC1 in somone who is allergic to penicillin G?
doxycycline
what is the MOA of doxycycline?
interferes with the bacterial 30 s ribosome protein production
what is the name of the drugs 2 that are used to treat HSV, VZV?
acyclovir and valcyclovir
what is the moa of acyclovir or valcyclovir?
inhibits DNA polymerase
what is the drug you use to treat candidiasis?
clotrimazole cream
what is the MOA of clotrimazole cream?
alters fungal cell wall permeabilty
what are three drugs you can use to treat related infections in pregnany women?
metronidazole azythromycin ceftriaxone tenofovir/emtricitabine valcyclovir nitofurantoin
