Hematology/acne Flashcards
1
Q
Virchow’s triad
A
Thrombophilic abnormalities, vascular endothelial injury, stasis
2
Q
Warfarin: MOA
A
Inhibits synthesis of vitamin K dependent clotting factors (e.g. factor X, IX, VII, II)
Decline of clotting factors is function of long half lives (can be as long as 3-4 days until see Warfarin effects)
3
Q
Heparin: MOA
A
Accelerates activity of antithrombin III –> inactivates thrombin and other anticoagulation factors (factor Xa)
Prevents conversion of fibrinogen to fibrin
4
Q
Warfarin: indications
A
Thrombosis, embolism, afib, prosthetic heart valves
5
Q
LMWH: MOA
A
Accelerates activity of antithrombin III and inactivates factors Xa and IIa (thrombin)
6
Q
Heparin: indications
A
Prevention of postoperative thromboembolism
7
Q
LMWH: indications
A
DVT and/or pulmonary embolism, prophylaxis
8
Q
Dabigatran (Pradaxa): indications
A
Reducing risk of stroke and systemic embolism in patients with nonvalvular afib
9
Q
Dabigatran (Pradaxa): MOA
A
Direct thrombin inhibitor
Thrombin required for the conversion of fibrinogen to fibrin in clotting cascade
10
Q
Rivaroxaban, Apixaban, Edoxaban, Betrixaban: indications
A
Treatment of DVT and/or pulmonary embolism, reduction of stroke and systemic embolism in nonvalvular afib
11
Q
Rivaroxaban, Apixaban, Edoxaban, Betrixaban: MOA
A
Direct factor Xa inhibitors
12
Q
What are the steps to platelet adhesion?
A
1) Platelet receptor binds to von Willebrand factor, bridging platelet to injury site
2) Mediators are released - serotonin and histamine–> immediate vasoconstriction
3) Reduction in blood flow and bleeding
4) Vasodilation to permit inflammatory process to occur
13
Q
Aspirin: indications
A
MI and stroke prevention, acute coronary syndrome
14
Q
Aspirin: MOA
A
Irreversibly antagonizes COX pathway which interferes with platelet aggregation
15
Q
Concurrent use with what medication is contraindicated with anticoagulant therapy?
A
NSAIDS (also act on the cyclooxyrgenase pathway like ASA)
16
Q
Clopidrogel (Plavix): indications
A
Unstable angina, recent MI, acute coronary syndrome
17
Q
Clopidrogel (Plavix): MOA
A
Reduces platelet aggregation by inhibiting the ADP pathway
Unlike ASA, has no effect on prostaglandins
18
Q
What medication can be used as a substitute if ASA is contraindicated?
A
Clopidrogel (Plavix)
19
Q
Heparin: absorption and distribution
A
Not absorbed by the GI tract –> must be given IV or SC
Distributed in plasma and highly protein bound
20
Q
LMWH: absorption and distribution
A
Not absorbed by the GI tract –> must be given IV or SC
Distributed in plasma and have limited or no protein binding
21
Q
Warfarin: absorption and distribution
A
Rapidly and completely absorbed orally
Serum levels found in 1-2 hours but anticoagulant effects dependent on depletion of clotting factors (factor II has a half-life of 72 hours) –> full effect does not occur for 3-4 days
Highly bound to plasma protein
22
Q
Aspirin: absorption and distribution
A
Rapidly and completely absorbed after oral administration
Protein binding highest with low plasma concentrations and lower with high concentrations
23
Q
Heparin: contraindications
A
Advanced hepatic/renal impairment, pregnancy
24
Q
Heparin: cautions
A
When combining with conditions that may predispose to hyperkalemia or drug regimens
Compatible with lactation
25
Heparin: adverse effects
Thrombocytopenia, anemia, hyperkalemia
26
LMWH: contraindications
Allergies to pork, sulfites, or benzyl alcohol
27
LMWH: cautions
Renal impairment, untreated hypertension, retinopathy, severe liver disease
Compatible with pregnancy and lactation
28
LMWH: adverse effects
Anemia, hemorrhage, peripheral edema
Monitor platelet levels, hematocrit, aPTT
29
Warfarin: contraindications
BLACK BOX WARNING: fetal bleeding
Avoid in pregnancy (safe in lactation)
30
Warfarin: cautions
Hepatic impairment that may enhance response
Maintain stable intake of foods high in vitamin K
31
Warfarin: adverse effects
Hemorrhagic skin necrosis and cyanotic toes, rare allergic reactions with maculopapular rash eruption
32
Dabigatran (Pradaxa): contraindications
BLACK BOX WARNING: discontinuation may cause increase in thrombotic events (antidote: idarucizumab)
BLACK BOX WARNING: spinal interventions (e.g. epidural) may cause spinal hematomas
Not safe in pregnancy and lactation
33
Dabigatran (Pradaxa): adverse effects
Dyspepsia, gastritis, hemorrhage (rare)
34
Rivaroxaban, Apixaban, Edoxaban, Betrixaban: contraindications
BLACK BOX WARNING: discontinuation may cause increase in thrombotic events
BLACK BOX WARNING: spinal interventions (e.g. epidural) may cause spinal hematomas
Not safe in pregnancy and lactation
35
Rivaroxaban, Apixaban, Edoxaban, Betrixaban: adverse effects
Hemorrhage common among all
36
Rivaroxaban: adverse effects
Back pain, abdominal pain, osteoarthritis, dyspepsia
37
Rivaroxaban: contraindications
Patients with moderate/severe liver impairment, creatinine clearance <30
38
Apixaban and Edoxaban: cautions
Moderate liver impairment
39
Edoxaban: contraindications
Severe liver impairment or creatinine clearance <15
40
Edoxaban antidote
Andexanet alpha (Andexxa)
41
Apixaban: cautions
Moderate liver impairment
42
Apixaban: contraindications
Severe renal impairment
43
Aspirin: cautions
Prevent preeclampsia in pregnancy, low-dose aspirin safe in lactation
44
Aspirin: contraindications
Children who have influenza or chicken pox, creatinine clearance <10, severe liver disease
45
Aspirin: adverse effects
Bleeding, GI ulcer, angioedema, Steven Johnson syndrome
46
Clopidrogel (Plavix): cautions
Use in pregnancy and lactation ONLY if indicated
47
Clopidrogel (Plavix): contraindications
Severe hepatic disease or patients with GI ulcers
48
Clopidrogel (Plavix): adverse effects
Bleeding, Steven Johnson syndrome (rare)
49
ASA may enhance the effectiveness and increase risk of bleeding with what anticoagulant?
Clopidrogel (Plavix)
50
When is the best time to check patient INR levels?
In the morning (patient should take warfarin in the evening)
51
Patient education: anticoagulants
Taken at the same time each day (even if feeling well), missed doses should be taken as soon as remembered the same day, doses should NOT be doubled, HCP should be informed of missed doses, maintain stable vitamin K diet (no increase/decrease), avoid OTC drugs (NSAIDS, ASA, cold remedies)
52
What can enhance/inhibit the absorption of iron?
Enhance: vitamin C
Inhibit: eggs and milk
53
True/False
| The body has no mechanism for excretion of iron
True - iron balance achieved through control of the amount of iron absorbed in the gut
54
Ferrous sulfate (20% elemental iron): MOA
Replaces iron found in hemoglobin, myoglobin, and other enzymes
Most easily absorbed and cost-effective
55
Ferrous sulfate is based on ___
Elemental iron
56
Ferrous sulfate: adverse effects
Constipation, dark green/black stools
57
Common causes of folic acid deficiency
Inadequate dietary intake of green vegetables or excessive boiling
58
Folic acid: MOA
Required for nucleoprotein synthesis and maintenance of normal erythropoiesis
Within three months of inadequate folate intake, megaloblastic change and anemia develop
59
Folic acid: contraindications
Administration when vitamin B12 is deficient
60
Vitamin B12: MOA
1) cofactor in metabolism of methylmalonyl-CoA --> when metabolism doesn't happen there is a buildup of fatty acids --> neurologic manifestations
2) vitamin B12 deficiency prevents the final steps of folate metabolism (causes megaloblastic anemia) --> corrected with folic acid supplementation
61
Vitamin B12: indications
Pernicious anemia (lifetime admin), vitamin B12 deficiency
62
Vitamin B12: adverse effects
Hypokalemia, diarrhea, pruritic, urticaria, anaphylactic shock
63
Pathophysiology of acne
Sebaceous glands produce too much sebum which mixes with dead skin cells --> both substances form a plug in the follicle
64
Whiteheads
If plugged follicle is close to the surface of the skin, will bulge outwards
65
Blackheads
If plugged follicle is open to the skin
66
Papules, pustules, cyst (acne)
When harmless bacteria that live on the skin contaminate and infect plugged follicles
67
Mild comedonal acne
Open blackheads and closed whiteheads
68
Mild to moderate inflammatory acne
Papules, pustules, or both
69
Moderate to severe acne
Nodules and cysts (painful)
70
What are the types of medications that are used to treat acne?
Topical retinoids or antibiotics, oral antibiotics
71
Examples of topical retinoids
Tretinoin (Retin-A), Adapalene (Differin), Tazarotene
72
Tretinoin (Retin-A): MOA
Reduce cohesion between keratinized cells --> fragmentation and expulsion of the micro plug, expulsion of comedones, conversion of closed to open comedones
Prevention of new comedone formation with continued use
Act specifically on microcomedones
73
Tretinoin (Retin-A): patient education
Has NO antibacterial properties against P. acnes
Enhances penetration of other topical agents (e.g. topical antibiotics, benzoyl peroxide)
May cause hypo/hyperpigmentation
74
Adapalene: MOA
For mild/moderate acne
Binds to specific retinoic acid receptors --> normalizes the differentiation of follicular epithelial cells --> decreased microcomedone formation
Modulator of cellular differentiation, keratinization, and inflammatory process
75
Tazarotene: MOA
Normalizes epidermal differentiation and reducing influx of inflammatory cells into the skin
76
Tazarotene: patient education
DO NOT use in pregnancy
77
Examples of topical antibiotics used to treat acne
Benzoyl peroxide, erythromycin, clindamycin, azelaic acid, salicylic acid
78
First line therapy for mild acne
Benzoyl peroxide
79
Benzoyl peroxide: MOA
Release of active or free-radical oxygen capable of oxidizing bacterial proteins, removes excess sebum
80
Benzoyl peroxide: side effects
Drying effect, mild desquamation, photosensitivity
81
Benzoyl peroxide: patient education
Can bleach clothing/towels, safe in pregnancy and children >12 years old
DO NOT apply at the same time as topical retinoids
82
Erythromycin + Clindamycin: MOA
Interrupts bacterial protein synthesis at the 50S ribosomal subunit
83
What medications can be used in combination with benzoyl peroxide?
Erythromycin and clindamycin when used separately
84
True/False
| Erythromycin and clindamycin can be used together to treat acne
True - reduces bacterial resistance
85
Clindamycin: patient education
Monitor for diarrhea (sign of colitis) --> discontinuation
86
Clindamycin: contraindications
Crohn's, ulcerative colitis, antibiotic associated colitis
87
Azelaic acid: MOA
Inhibition of microbial cellular protein synthesis
Decreases inflammation associated with acne lesions by reducing the concentration of bacteria present in the skin
Normalization of keratinization --> anticomedonal effect
88
What is first line OTC therapy for mild acne?
Salicylic acid
89
Salicylic acid: MOA
Exfoliant used to clear comedones, has mild anti-inflammatory effects
90
General topical retinoid precautions and contraindications
Avoided in patients with eczema, sunburn, skin abrasions at site of application, lactating women
Should NOT be used at the same time as topical antibiotics (can cause skin irritation)
91
Topical retinoid adverse effects
Burning/pruritus after application common
Scaling, erythema, xerosis, peeling
92
Topical antibiotic adverse effects
Dryness, erythema, burning, peeling, itching
93
General patient education (topical retinoids/antibiotics)
Acne may be worse in the beginning, may take 6-8 weeks before effects are seen, wear sunscreen
94
True/False
| Topical retinoids should not be applied to the same area as topical antibiotics and/or benzoyl peroxide
True
95
Example of a systemic retinoid to treat acne
Isotretinoin (Accutane)
96
Isotretinoin (Accutane): MOA
Reduces sebum production by reducing sebaceous gland size, normalizing follicular keratinization and indirectly reducing P. acnes and its inflammatory sequela
97
Isotretinoin (Accutane): adverse effects
Chelitis, dry skin and fragility, hypertriglyceridemia, elevation of glucose levels, HA, lethargy, fatigue, arthralgia/myalgia, visual disturbances, GI reactions
98
What medications would you prescribe to treat: noninflammatory comedonal acne?
Topical retinoid OR benzoyl peroxide
99
What medications would you prescribe to treat: inflammatory papulopustular acne?
Topical combination therapy of topical antibiotic OR retinoid + benzoyl peroxide
100
What medications would you prescribe to treat: severe inflammatory acne?
Oral antibiotic + topical combination therapy of topical antibiotic/retinoid + benzoyl peroxide (OR all three agents at once)
Oral isotretinoin (prescribed by dermatologist)
101
Why are topical corticosteroids prescribed?
Utilized for their anti-inflammatory, antimitotic (for psoriasis), immunosuppressive, and vasoconstrictive properties
102
Topical corticosteroids: indications
Dermatitis, psoriasis
103
What is the least potent topical corticosteroid?
Hydrocortisone 2.5%
104
Which topical corticosteroid formulation has the greatest amount of absorption: cream, gel, ointment, solution?
Ointments - provide the most occlusive barrier
Most potent
105
Ways to enhance absorption of topical corticosteroids
Increase skin temperature, hydration, and application to denuded areas, intertriginous areas, or skin surfaces with a thin stratum corner
106
Topical corticosteroids: MOA
Inhibit formation, release, and activity of endogenous mediators of inflammation (e.g. prostaglandins, histamines)
Inhibit migration of macrophages and leukocytes into the skin area by reversing vascular dilation and permeability --> decreased edema, erythema, pruritus
107
Parts of the body with a thin stratum corneum
Face, scrotum, axilla, skin folds (use low potency formulations like lotions)
108
True/False
| Occlusions (with a dressing) decrease skin penetration
False - increase skin penetration 10 to 100 fold, but can lead to more adverse effects
109
Which topical corticosteroid formulation is least potent?
Lotions
110
Topical corticosteroid: caution and contraindications
Caution with pregnant patients (only use if benefits outweigh the risks)
Children more susceptible to effects and require lowest effective strength to be used
111
Topical corticosteroids: adverse effects
May cause local skin irritation and increase risk of secondary infections
Tolerance may occur with prolonged use
Adrenal function/growth should be monitored in children who require moderate to high potency steroids (growth can be stunted)
112
Examples of topical calcineurin inhibitors
Pimecrolimus (Elidel) and Tacrolimus (Protopic)
113
Topical calcineurin inhibitors: indications
Atopic dermatitis (short or intermittent long-term treatment)
In patients with resistance to steroids, application to sensitive areas (e.g. face, skin folds), steroid induced atrophy, long-term or uninterrupted topical steroid use
114
Topical calcineurin inhibitors: MOA
Suppresses cellular immunity through inhibiting T-cell activation by binding to intracellular proteins (e.g. calcineurin dependent proteins) --> inhibition of inflammatory cytokines and mediators of mast cells
115
Which topical calcineurin inhibitor would be prescribed for mild/moderate atopic dermatitis?
Pimecrolimus (Elidel)
116
Which topical calcineurin inhibitor would be prescribed for moderate/severe atopic dermatitis?
Tacrolimus (Protopic)
117
Topical calcineurin inhibitors: caution and contraindications
BLACK BOX WARNING: rare cases of malignancy
DO NOT apply to site of active cutaneous viral infection, lactation, pregnancy
Avoided in children younger than 2 years and immunosuppressed
118
Topical calcineurin inhibitors: adverse effects
Local reaction at site of application: burning, pruritus, tingling
HA, fever, flu-like symptoms, acne, folliculitis
119
Example of topical antihistamine
Diphenhydramine (Benadryl)
120
Example of topical antipruritic
Doxepin (Zonalon)
121
Diphenhydramine (Benadryl): MOA
Provides local relief from pruritus and edema b/c local effect on H1 receptors suppresses formation of edema, flare, and pruritus
Provide local anesthetic activity be decreasing permeability of nerve cell membrane to sodium ions --> block transmission of nerve impulses
122
Doxepin (Zonalon): MOA
Histamine-blocking action of H1 and H2 receptors, inhibiting the activation of histamine receptors
123
Diphenhydramine (Benadryl): cautions and contraindications
Not used to treat chicken pox, measles, poison ivy, sunburn, blistering/oozing skin
Applying to large surface areas increases potential for toxic psychosis, especially in children
Can be used in children 2+ years
Avoid use >7 days
124
Doxepin (Zonalon): cautions and contraindications
Drowsiness
Anticholinergic effect --> caution in elderly, untreated narrow angle glaucoma, urinary retention
NOT for children or lactating women
125
Diphenhydramine (Benadryl): indications
Local reactions to insect bites, stings, minor cuts, burns or rashes (poison ivy, oak, sumac)
Mild symptoms
126
Doxepin (Zonalon): indications
Short term management of moderate to severe pruritus
127
Pyrethrins (RID): indications
Head, body, and pubic lice
128
Pyrethrins (RID): MOA
Absorbed through the exoskeletal of arthropods, causing paralysis and death
129
Pyrethrins (RID): caution and contraindications
Avoid in chrysanthemum or ragweed allergy, children younger than 2 years
Compatible with pregnancy and lactation
130
Pyrethrins (RID): adverse effects
Localized burning, pruritus, skin irritation
131
Pyrethrins (RID): patient education
- No residual activity after rinsing
| - Works best on dry hair
132
Permethrin: indications
Head lice
133
Permethrin: MOA
Absorbed through the exoskeleton of arthropods, causing paralysis and death
134
How long is permethrin effective for in treating head lice?
Has residual activity against lice for up to 10 days
135
What is first line treatment for head lice?
Permethrin
136
What is first line treatment for scabies?
Permethrin
137
Permethrin: caution and contraindications
Should not be used in infants younger than 2 months
Compatible with pregnancy and lactation
138
Permethrin: patient education
Avoid use near the eyes
139
Would you prophylactically treat patients with head lice or scabies?
Scabies
140
Permethrin: adverse effects
Localized burning, pruritus, skin irritation
141
Malathione (Ovide): indications
Head lice
142
Malathione (Ovide): MOA
Acts as a pediculicide by inhibiting cholinesterase activity in vivo
Both pediculicidal and ovicidal
143
How long is malathione effective for in the treatment of head lice?
Some residual activity for up to seven days
144
Malathione (Ovide): caution and contraindications
Flammable --> do not use hair dryers
Avoid in children younger than 6 years, pregnancy, and lactating women
145
Malathione (Ovide): adverse effects
Organophosphate poisoning and severe respiratory distress if ingested
Localized burning, skin irritation
146
Benzyl alcohol (Ulesifa): indications
Head lice
147
Benzyl alcohol (Ulesifa): MOA
Stuns the lice, leading to the ability to penetrate their respiratory mechanism which leads to asphyxiation
Effective against LIVE lice
148
Benzyl alcohol (Ulesifa): caution and contraindications
Avoid in infants younger than 6 months
Compatible with pregnancy and lactation
149
Benzyl alcohol (Ulesifa): adverse effects
Pruritus, erythema
150
Ivermectin (Sklice): indications
Head lice
151
Ivermectin (Sklice): MOA
Interferes with the function of the nerve and muscle cells, resulting in parasite paralysis and death
Single application is effective for eradication of head lice
152
Ivermectin (Sklice): caution and contraindication
Avoid in pregnancy and/or lactation
Approved for infants older than 6 months
153
Ivermectin (Sklice): adverse effects
Dry skin, burning sensation, eye irritation
