heme/GU/renal Flashcards
what helps increase the absorption of iron? what can decrease absorption?
gastric acid and ascorbic acid; milk and tea–take between meals
foods with high iron
Total cereal--most! Grape-nuts cereal --most! Instant Cream of Wheat Instant plain oatmeal Wheat germ Broccoli Baked potato Raw tofu Lentils Beef chuck
recommended iron per day
200 mg of elemental iron per day in 2-3 divided doses (better tolerated) on an empty stomach
what important factor do you have to look at to determine amount of iron in iron supplements?
the elemental iron %–the amount of iron patient gets is not equal to mg of dose
AE of iron supplementation
GI – discoloration of feces (dark), abdominal pain, heartburn, constipation, N/V
if iron supplementation intolerable how do you take it?
Take iron with meals
• Decrease total daily dose to 110-120 mg elemental Fe
modest reticulocytosis after Fe therapy should occur in how many days? how much should hgb increase?
7-10; hgb should increase about 1g/dL per week
how long should Fe therapy be continued after anemia resolves to replete iron stores? what are some exceptions?
3-6 months; exceptions if acute bleed, may only have to continue for 1 month after anemia resolves, or if chronic negative values (chronic heavy menstruation or malabsorption) requires low maintenance dose qd
indications for parenteral iron therapy
Evidence of malabsorption
Intolerance of oral iron
Long-term adherence is a problem
Chronic HD or CAPD
when giving parenteral iron, you should give what first b/c of the risk of anaphylaxis?
a test dose of 25 mg IM or IV with epi, diphenhydramine and corticosteroids on hand. watch for 1 hour before giving rest of dose
RFs for VB12 deficiency anemia
vegan diet, older age, women, decreased absorption (prolonged h2ra or PPI, metformin?), inadequate utilization
PO dose of B12
1-2 mg po qday
if someone has neuro sx, whats the best way to give their B12 for anemia? what’s the dose?
Parenteral Vitamin B12 Therapy (IM or deep subcutaneous)
Cyanocobalamin 1000 mcg qd for 1 week initially to saturate B12 stores and resolve clinical
manifestations, then to 1000 mcg q week until Hgb/Hct normalizes, then 1000 mcg q month until normalization of sx and hematologic indices;
can then convert to oral (first dose on due date for next injection)
how many days until reticulocystosis in new B12 therapy for anemia?
2-5 days
AE of B12 thearpy
Hyperuricemia (caution gout)
Fluid retention (more likely in pt with compromised CV status)
Hypokalemia (check K)
Anaphylaxis with parenteral administration
sources of folic acid in diet
fresh fruits and veggies, yeast, mushrooms, animal organs
rec’d amount of folic acid in non pregnant females, pregnant, lactatign
400 mcg/day in non-pregnant females, 600 mcg/day in pg females, 500 mcg/day lactating females
dose of folic acid
1 mg po qd x 4 months (if underlying cause is identified and corrected)
dose of folic acid in pregancy
400-1000 mcg qd prior to conception and during pregnancy
4 mg/day recommended for high risk pregnancies
when is a low maintenance dose of folic acid indicated?
Low-dose folate therapy (500 mcg po qd) can be used for anticonvulsant-induced anemia to avoid
discontinuation of the AED (may PHT levels)
tx of anemia of chronic disease
Treat the underlying disorder and correct reversible causes of anemia
Red cell transfusions
Erythropoietin stimulating agents (ESA)
If endogenous EPO is high (>150), may not respond to exogenous EPO
Check Hgb q 2 wks: > 0.5 g Hgb predicts + response; no change in Hgb, ↑ EPO dose
Watch serum iron levels carefully and give Fe supplements if needed
For chemotherapy-induced anemia, ESA use restricted to anemia without a curative intent due to
mortality
names of drugs for anemia of chronic renal failure
Epoetin alpha (Epogen, procrit) Darbepoetin alpha (Aranesp)
what is the black box warning for epo agents?
greater risks of death, serious adverse
cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target a hemoglobin level of greater than 11 g/dL.
aka use smallest dose for as little as possible
Current FDA Recommendations for Use in Patients with CKD (Pharmacist’s Letter, 8/11)
Start treatment only when Hgb is
tx for OI in HIV: candida
propylaxis
tx
primary prophylaxis not indicated
tx: fluconazole
tx for OI in HIV: PCP
propylaxis
tx
I° Prophylaxis with SMX/TMP initiated at CD4
tx for OI in HIV: toxoplasmosis
propylaxis
tx
I°: SMX/TMP- TOXO IgG seropositives with CD4+ 200 tx: Sulfadiazine 1000-1500 mg qid \+ Pyrimethamine* 200 mg x 1, then 50-75 mg qd
tx for OI in HIV:cryptococcal infection
propylaxis
tx
primary: not indicated
II°: fluconazole, d/c after ≥3, on ARVTx, and sustained CD4>100
tx: amphotericin B
tx for OI in HIV: CMV infection
propylaxis
tx
II° Prophylaxis continued until CD4 count >100 cells/mL sustained for greater than 3-6 months on ARVTx
tx: Ganciclovir or Valganciclovir
tx for OI in HIV: Mycobacterium Avium Intercellulare
propylaxis
tx
primary: I°: Azithromycin at CD4+ 3m on ARVTx, and sustained CD4>100
tx; Azithromycin
600 mg qd
+ Ethambutol
15-20 mg/kg/d
± Rifabutin 300 mg qd (different dosing with ARVT)
12m course
entry inhibitor MOAs and AEs: enfuvirtide and maraviroc
enfuvirtide blocks viral attachment to GP41; AE ISR, bacterial pneumonia
maraviroc binds to co receptor and prevents conformation change required for virus entry
AE: fever, rash, increased LFTs
both have poor tolerance and aren’t used much
NRTIs: combo pills available
Lamivudine-Abacavir (EPZICOM) and Emtricitabine-Tenofovir (TRUVADA)
HIV med with vivid dreams
Efavirenz
NNRTI that can prolong qt interval; what is CI with this drug?
rilpivirine; CI: proton pump inhibitors
Trade names of these drugs and what class are they in?
Efavirenz (sustiva) and rilpivirine (Edurant)
what drug class are these in?
Enfuvirtide
Maraviroc
entry inhibitors
what drug class are these in? Abacavir** not renal Lamavudine** Emtricitabine* Tenofovir* Zidovudine Didanosine Stavudine
NRTIs
what drug class are these in?
Raltegravir
Elvitegravir
Dolutegravir
integrase inhibitors
what drug class are these in? Atazanavir Darunavir Lopinavir/Ritonavir Fosamprenavir Ritonavir Saquinavir Nelfinavir Tipranavir Indinavir
protease inhibitors
what drug class are these in? Efavirenz Nevirapine Etravirine Rilpivirine Delavirdine
NNRTIs
Are there Major Drug Interactions with NON- Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)?
yes
Are there Major Drug Interactions with Nucleoside Reverse Transcriptase Inhibitors (NRTIs)?
no not really, all renally cleared except abacavir
which AE go with which INSTI?
• AE: well tolerated, ↑lipids, eosinophilia, increased BGs and ALT, myopathy
• AE: well tolerated, N/D
• AEs: well tolerated, HA, hyperglycemia, elevated lipase and transaminases
- AE: well tolerated, ↑lipids, eosinophilia, increased BGs and ALT, myopathy: RALTEGRAVIR
- AE: well tolerated, N/D : elvitegravir
- AEs: well tolerated, HA, hyperglycemia, elevated lipase and transaminases: dolutegravir
what PK booster is commonly added to elvitegravir and why? what are its AE?
cobicistat: enhances by inhibiting enzyme pathway that metabolizes elvitegravir
• AE: nausea, loose stools, ↑Scr, cholesterol & triglyceride elevation
booster used with PIs that is limited d/t bad AE. what are the AE?
ritonavir
AE: HA, N/V/D, taste perversion, elevated CK, hyperglycemia, elevated LFTs, HLD
Are there Major Drug Interactions with Protease Inhibitors (PIs)?
yes: CYP450
preferred PI and PK booster given with it
darunavir and ritonavir
NRTI+NRTI+INSTI examples
- Emtricitabine-Tenofovir (Truvada) + Raltegravir (isentress)
- Emtricitabine-Tenofovir (Truvada) +Dolutegravir (Tidivicay)
- If HLAB5701 negative: Abacavir-Lamivudine (Epzicom) + Dolutegravir (Tivicay) OR TRIUMEQ=all 3 in 1!
2 NRTIs + INSTI + booster examples
- Stribild QUAD PILL: Emtricitabine + Tenofovir (disoproxil fumarate (TDF) + Elvitegravir + Cobicistat
- Genvoya QUAD PILL: Emtricitabine +Tenofovir Alafenamide (TAF) + Elvitegravir +Cobicistat
2 NRTIs + PI + PK booster examples
- Emtricitabine-Tenofovir (Truvada) + Darunavir (Prezista) + Ritonavir (Norvir)
- Emtricitabine-Tenofovir (Truvada) + Darunavir-Cobicistat (Prezcobix)
- Some alternative combos replace Darunavir with Atazanavir
why do we adjust for renal function?
many drugs are cleared renally, if can’t be cleared drug concentrations and toxicity increases
how does decreased GFR affect serum creatinine?
increases serum creatinine
normal Scr
0.5 to 1.5 mg/dl
creatinine is metabolic by product of what?
creatine breakdown in muscle
what is biggest reason for increased creatine?
muscle mass
physiologic things that can affect creatinine
diet (meat), exercise, dirunal (highest in PM), age, wt, gender, drugs (deceased active tubular secretion and therefore increase SCr)
EQ for measurement of LBW in kg for males and females
LBW (male) in Kg = 50 + [2.3 x (ht – 60)]
LBW (female) in Kg = 45.5 + [2.3 x (ht – 60)]
only difference is starting weight
EQ for measurement of CrCl in males and females
CrCl Male = (140-age) x LBW (Kg)
72 x SCr
CrCl Female = estimated Male CrCl x 0.85
name of EQs used for estimating creatinine clearance in stable renal function
cockroft-gault equation
affects of renal disease on drug absorption
Decreased gastric emptying Nausea/vomiting/diarrhea
Decrease in gastric pH Gastrointestinal edema
Examples of changes in absorption
how does renal problems influence serum protein binding?
decreases it: less albumin to bind to, binding sites can’t bind drugs as well, increases endogenous inhibitors of binding
what do you need to measure to get accurate amount of acidic drug in renal failure of a drug with a narrow therapeutic range (i.e. phenytoin)
measure free concentration (unbound) because increased uric acid (nitrogen products) are bruisers
can renal failure affect CYP450 enzymes?
yes
how does renal failure affect metabolism of codeine?
active metabolite increased and you need smaller dose
what’s active metabolite of meperidine that is increased in RF and can cause toxicities?
normeperidine
when creatinine clearance sucks, how do you change the dose?
decrease it
aminoglycosides are almost solely eliminated by
kidneys
what can happen if aminoglycosides not adjusted for poor renal function
Nephrotoxic when they accumulate in proximal tubule cells (cause ATN)
If dose is not adjusted for renal function, accumulation occurs and toxicity results
what are steps to adjusting drug dosages for pts with renal insuffieincy
1) hx and labs (SCr)
2) cockroft-gault to estimate CrCl
3) review current meds to see which should be adjusted
4) adjust dose
5) monitor
6) revise if necessary
factors affecting dialyzability: do the following increase or decrease removal?
high Molecular weight-decreases Water solubility--increases Protein binding--decreases Volume of distribution--decreases
system used to estimate hepatic function–what does it include?
child pugh classification: ascites, encephalopathy, serum albumin, serum bilirubin, prothrombin time
how can hepatic insufficiency affect first past effect and bioavailability?
if decreased flow through liver, less blood and drug getting metabolized= decreases 1st pass effect and increases bioavailability
how can hepatic insufficiency affect protein bound state of drugs?
it will decrease it b/c unhealthy liver making less proteins= more free and gets metabolized
how does hepatic insufficiency affect metabolism/
CYP450 can’t work as well in cirrhosis (decreases metabolism)
pharmacokinetic effects of hepatic insufficiency on drugs
Increased drug sensitivity can result from
o Altered affinity of the drug to its target
o Altered binding to the target
o Alteration in the target itself
o Altered permeability of the BBB
o Increases in GABA receptors or GABA-ergic activity ( benzos)
4 systems necessary for erection
Vascular system
Nervous system
Hormonal system
psychogenic
what are some chronic medical conditions associated with ed?
Hypertension Diabetes mellitus Inflammatory conditions of the prostate Coronary & peripheral vascular disease Neurologic disorders (e.g. PD, MS) Endocrine disorders Psychiatric disorders Dyslipidemia Renal failure Liver disease Penile disease
surgical procedures that can cause ED?
Perineal surgery
Radical prostatectomy
Vascular surgery
lifestyle factors that can cause ED
Age Smoking Excessive alcohol consumption Obesity Poor overall health & physical activity
T OR F: trauma can cause erectile dysfunction
T: pelvic fractures or spinal cord injuries
drugs that can cause ED
antihypertensives, lipid meds (gemfibrozil), antidepressants, histamine antagonists (cimetidine), antipsychotics, anticonvulsants (CBZ, PHT), antiandrogens and hormones, recreational drUGS (etoh, cocaine, marijuana, opiates)
why do you have to consider partner issues with ED?
post menopausal women can have vaginal dryness
before starting someone on tx for ED, what do you have to make sure?
that they are fit to safely perform sexual activity (i.e. cardiac disease)
possible interaction of ED drugs
CYP450
shortest acting ED drugs
sildenafil (viagra) and vardenafil (levitra)
how long before sexual activity should each ED drug be taken?
avanafil 30 minutes
sildenafil 60
vardenafil 60 min
tadalafil 30 min
AE of ED drugs
Headache, facial flushing, dyspepsia, nasal congestion, dizziness, abnormal vision (S&V)
Rare reports of prolonged erections (> 4 hrs) and priapism (> 6 hrs) reported
Decrease in BP (8-10 mmHg systolic, 5-6 mmHg diastolic) 1 hr after dose, lasting 4 hrs (S&V)
who should get eye evals before taking ED drugs?
those with glaucoma, macular degeneration, diabetic retinopathy, previous eye surgery or eye trauma b/c of r/o nonarteritic anterior ischemic optic neuropathy
trade names of: avanafil sildenafil vardenafil tadalafil
avanafil (steward)
sildenafil (viagra)
vardenafil (levitra or staxyn ODT)
tadalafil (cialis)
CI of ED drugs
nitrates use(vasodilator of coronary arteries=syncope, angina), alpha blockers (vasodilators–HOTN, falls), patients with high CV risk, conditions that propose to priapism like sickle cell, multiple myeloma, leukemia
T or F: if someone has angina you shouldn’t rx ED med
not true, mild, stable angina is a low risk
with what factors is an ED drug CI for a pt?
Has unstable or symptomatic angina, despite treatment
Has uncontrolled hypertension
Has severe congestive heart failure (NYHA class III/IV)
Had a recent myocardial infarction or stroke within past 2
weeks
Has moderate or severe valvular heart disease
Has high-risk cardiac arrhythmias
Has obstructive hypertrophic cardiomyopathy
who should get a full cardio workup before taking ED meds?
Has 3 risk factors for cardiovascular disease
Has moderate, stable angina
Had a recent myocardial infarction or stroke within the past
6 weeks
Has moderate congestive heart failure (NYHA class II)
ED drug that is intracavernosally injected or intraurethrally inserted
alprostadil (PGE1)
when and why would testosterone be given?
Important for general sexual function and libido; only for patients with
documented low serum testosterone levels
AE of testosterone
gynecomastia, dyslipidemia, polycythemia, acne; weight gain, HTN, edema and HF
exacerbation may occur due to sodium retention
CI of testosertone
Prostate cancer, breast cancer
Caution with BPH
which therapies should you start first for organic ED? second line/
oral phosphodiesterase inhibitor (or vacuum erection device), if PD5 inhibitor ineffective, try intracavernosal therapy, then should try intraurtheral therapy lastly, a penile prosthesis
Subjective: RZ is a 55-year-old male with a history of erectile dysfunction for the past 6 months. PMH
is significant for HTN and cigarette smoking. He takes ramipril 5 mg qd and has NKDA.
Objective: VS: BP 160/95, HR 88, ht 72 in, wt 190 lb. Prostate exam reveals a mildly enlarged
prostate. Scr 1.2, BUN 18.
assessment;
what do you need to address?
assessment: ED d/t HTN
BP: adherence? add new med? smoking cessation
peak incidence of BPH
63-65
complications of BPH
Acute, painful urinary retention ARF
Persistent gross hematuria when tissue exceeds blood supply
Overflow UI or unstable bladder
Recurrent UTI due to urinary stasis
Bladder diverticula, stones
CRF due to long-standing bladder outlet obstruction
drugs that may aggravate BPH
tesosterone, anticholinergics (antihistamines, Phenothiazines, TCAs), sympathomimetics ( pseudo ephedrine, oxymetazoline, phenylephedrine) increases bladder tone)
T or F: you should start everyone who has BPH immediately on meds
F: for mild disease just watch and wait
general tx approaches for moderate sxatic BPH, severe sxatic BPH
modeate: pharm; severe: surgery
alpha 1 blockers: MOA onset: AE pt ed dosing:
MOA: blocking alpha relaxes smooth muscle onset in 2-4 wks AE: Orthostatic hypotension (must initiate at lowest dose and titrate at 2- 7 day intervals to minimize HOTN, not necessary for tamsulosin) pt ed: get up slowly, hang on to something dosing: start low, give at bedtime to reduce r/o orthostasis
1st line for patients with moderate BPH
alpha 1 blockers
5 alpha reducaste inhibitors MOA onset: AE dosing: monitoring:
MOA: decrease conversion of testosterone
onset: 6 months! (long)
AE : libido ,ED
dosing:qd
monitoring: baseline PSA and every year (decreases PSA levels by 50%)
when are 5 alpha reeducates inhibitors indicated?
Most effective for
patients with prostate
size (> 30 g)
Inability to take alpha blockers
what drug should you give someone with ED and mild bph/
tadalafil (PDE5 inhibitor)
likely safe, likely effective herbals for BPH
beta-sitosterol, pygeum, saw palmetto
examples of alpha 1 blockers; alpha 1 a blockers
alpha 1
alfuzosin (uroxatral)
Doxazosin
(Cardura)
Terazosin
(Hytrin)
Prazosin
(Minipress)
alpha 1 a
Tamsulosin
(Flomax)
Silodosin
(Rapaflo)
example of 5 a reductase inhibitors
finasteride (proscar), dutaseride (avodart)
what is the triad of things you should ask about?
ED, BPH (urinary problems) and urinary incontinence
4 mechanisms of urinary incontinence
Urge Incontinence (bladder overactivity): Detrusor hyperactivity
Stress Incontinence (urethral underactivity): Sphincter incompetence
Overflow Incontinence (urethral overactivity and/or bladder underactivity): Detrusor hypoactivity,
urethral sphincter obstruction
Functional Incontinence: Not caused by bladder- or urethra-specific factors
pneumonic for causes/RFs of urinary incontinence
DIAPPERS:
delirium, infection, atrophic urethritis or vaginiitis, pharmaceuticals, psychological, excessive urine output, restricted mobility, stool impaction
non pharm management methods for urinary incontinence
Make toilets more accessible Higher toilets Well lit floors Change bedroom to be close to bathroom Consider bedside commode Wear clothes that are removed easily Use moderation in fluid intake Lose weight (if obese) Smoking Cessation Avoid Diuretics Avoid alcohol Avoid caffeine
best tx of urinary incontinence
*non pharm stuff is best! bladder training, bladder control strategies, floor muscle training, fluid management
anticholinergic drugs that can treat urge incontinence
oxybutynin (well established, inexpensive), tolterodine (more expensive but less doses per day)
first line therapy for urge incontience
anticholinergics/antispasmodics
rec’d tx for urge incontinence + depression or neuropathic pain
TCAS
indications for topical estrogen in urge incontinence
women with urethritis or vaginitis
duloxextine
indications
MOA
AE
indications: not technically indicated for stress incontinence but used first line
MOA: inhibits reuptake of HT/NE in spinal cord
AE: Nausea most common adverse effect;
may also cause dry mouth, constipation,
↓ appetite, fatigue, somnolence,
sweating, sexual dysfunction, ↑ BP
alternative firs line therapy for stress incontinence
pseudo ephedrine only in those with no HTN, DM, CHD
tx of functional incontinence
scheduled bathroom breaks
tx of overflow incontinence, what are CIs?
cholinomimetics (bethanechol)
CI: asthma, heart disease
T or F: only try pharm tx if non pharm fails for urinary incontinence
T
most likely pathogen in chronic and acute prostatitis
e. coli
abx capable of reaching therapeutic concentrations in prostatic fluid
FQS, trimethoprim
T or F: in acute prostatitis, More antibiotics penetrate due to inflammation
T
tx of acute prostatitis with r/o STD
Ceftriaxone 250 mg IM x 1 then
Doxycycline 100 mg po bid x 10
days
options for txing prostatitis (acute) with low risk of STD
FQs or TMP-SMX Levofloxacin 500-750 mg IV/po qd or Ciprofloxacin 500 mg po bid or 400 mg IV bid or TMP/SMX 1 DS po bid x 10-14 days (minimum)
pharm tx of chronic prostatitis
Cipro 500 mg po bid x 4-6 weeks or Levofloxacin 750 mg po qd x 4 wk Alt: TMP/SMX 1 DS bid x 1-3 mo long duration--may need longer
most common pathogens of epididymitis in men
gonorrhea, chlamydia
non pharm epidydimitis tx
Analgesics prn
Rest in bed with legs slightly apart
Elevate testes on a towel roll
Scrotal support when sitting, standing or walking
when is expedited partner tx for prostatitis or epididymitis ok?
CDC recommends for heterosexual partners of patients diagnosed with chlamydia or gonorrhea
when it is unlikely the partners will seek timely evaluation and treatment
why is expedited partner tx not rec’d for MSM in prostatitis/epidydmitis?
Not routinely recommended for MSM because of a high risk for coexisting infections, especially
undiagnosed HIV infection, in their partners and because data are limited regarding the
effectiveness of this approach in reducing persistent or recurrent chlamydia among MSM
what needs to be included with rx of expedited partner tx?
Treatment instructions
Appropriate warnings about taking medications (if the partner is pg or has med allergies)
General STI health education and counseling
Statement advising that partners seek personal medical evaluation, particularlywith PID sx
F/U for prostatitis and epididymitis
Abstain from intercourse for 7 days after both have completed treatment, (to prevent
reinfection)
Seek retesting for infection about 3 months after finishing treatment, due to the high risk of
reinfection
