Indications / First-Line / Contraindications Flashcards by Zachary Schulz

What are indications for estrogen use?

Contraception
Menopausal HRT
Endometriosis treatment

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Estrogen can be used to treat what bone deficiency?

Osteoporosis

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What are contraindications to estrogen use?

History of Breast CA
DVT/PE 
MI
CVA
Anaphylatic Reaction
Liver Disease

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Should estrogen be used in pregnancy?

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What are indications for progesterone use?

Secondary amenorrhea
HRT
Cervical Ripening
Endometrial Hyperplasia

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What are indications for progestin use?

Contraception
Post-Menopausal HRT
Dysfunctional Uterine Bleeding

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Can progestins be used to maintain pregnancy?

Yes

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Should progestins be used in patients with a history of severe migraines?

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Other than severe migraines, what are contraindications to progestin use?

DVT / PE
Unexplained bleeding
Breast CA
Liver Disease

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Should OCPs be used in patients with uncontrolled HTN (> 160/110)

No, it should be avoided

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A 36 y.o. female with a pack per day smoking history presents to dicuss use of OCPs….

is this a good idea?

OCPs should be avoided in patients >35 y.o with a half pack per day smoking history

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A 4 week post-partum patient who is still breast feeding wants to start back on OCPs.

Is this a good idea?

No, OCPs are contraindicated in women <6 weeks postpartum who are still breastfeeding

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T/F: Progestin only pills are commonly used post partum and are OK with breastfeeding

True

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Should Levonorgestrel (Plan B) be given to women already pregnant?

Why?

higher incidence of ectopic pregnancy

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Which emergency contraception is commonly used with missoprostol in abortions?

Mifepristone

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Estrogen is used in post-menopausal HRT to relieve what?

Vasomotor symptoms

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Which form of estrogen HRT has no-first pass effect?

Gels
Sprays
Emulsions

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Should you give unopposed estrogen to a woman who still has their uterus?

NOOOOOOOOO

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T/F: It is okay for women with a history or family history of breast cancer to use phytoestrogens?

False

They should be AVOIDED

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Why should Dong Quai be avoided?

Carcinogenic effects

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What recently approved HRT medication is indicated for pre-menopausal women with acquired generalized hypoactive sexual desire disorder (HSDD)?

Flibanserin (Addyi)

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An alcoholic women with a history of liver failure is diagnosed with HSDD. You think about prescribing Flibanserin, but remember this is a bad idea.

Why?

It is contraindicated in patients with a history of EtOH abuse and hepatic impairment

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Should you start with the lowest dose of estrogen?

Yes

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T/F: The risks of estrogen replacement outweigh the benefits in women under 60

False

The benefits outweigh the risks

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Which form of estrogen replacement best avoids first pass?

Transdermal

Which form of estrogen replacement avoids the most systemic effects?

Intravaginal

Is tamoxifen used as monotherapy for metastatic breast CA or as adjuvant?

Adjuvant Therapy

Which SERM is used best for breast CA prevention in high risk post-menopausal women?

Raloxifene

Which SERM is best used to treat dysparenuria due to vulvovaginal atrophy following menopause?

Ospemifene

Which SERM is indicated for treatment of metastatic breast cancer in postmenopausal women with estrogen-receptor positive or unknown tumors?

Toremifene

When estrogen receptors in breast CA become resistant to hormone therapies, what medication class is recommended?

Aromatase inhibitors

Do aromatase inhibitors work best in pre or post-menopausal women?

Post-menopausal

Should aromatase inhibitors be used as adjuvant or monotherapy

Adjuvant

T/F: Switching to an aromatase inhibitor after 2-3 years of Tamoxifen does NOT have adding benefit when compared to just FIVE years of Tamoxifen

False It does have added benefits

Which medication is indicated for hormone receptor positive metastatic breast CA that has failed Tamoxifen?

Fulvestrant

Which medications are first-line for ED treatment?

PDE5 Inhibitors Sildenafil Vardenafil Tadalafil

What medication is second line for ED treatment?

Synthetic PGE-1 Alprostadil

What percentage of ED patients will fail PDE5 inhibitors

30-40%

What levels should you check when treating ED with PDE5 inhibitors?

Testosterone

What medications are indicated to treat moderate to severe BPH with an AUA score > 8?

Alpha-1 Antagonists

Should non-selective or selective alpha-1 antagonist be AVOIDED in BPH and HTN?

Non-selective Terazosin (Hytrin) Doxazosin (Cardura) Prazosin (Minipres)

What anti-hypertensive medication class should be used in HTN while treating ED?

ARBs

Is tamsulosin a good medication to treat BPH in the setting of HTN?

Yes Selective alpha-1 antagonists are good in combination with anti-hypertensives

Which class of BPH medications is shown to reduce the prostate size up to 25% and lower PSA levels up to 50%?

5-alpha reductase inhibitors Finasteride Dutasteride

T/F: Combination therapy of alpha-1 antagonists and a 5-alpha reductase inhibitor is recommended to treat BPH

True

Which PDE5 inhibitor is also indicated for BPH treatment?

Tadalafil

Name one 'natural product' used to treat BPH?

Saw Palmetto | African Tree Bark

What are contraindications to testosterone replacement therapy?

Breast/Prostate CA Porstate Nodule PSA >3-4 in high risk individuals Uncontrolled HF

A patient with a history of untreated sleep apnea is interested in testosterone replacement? Are they a good candidate?

No, testosterone replacement is contraindicated in patients with a history of uncontrolled sleep apnea

A patient presents to discuss possibly starting testosterone replacement therapy. Wisely you draw a CBC because you no a hematocrit above __ would contraindicate starting testosterone replacement therapy

Above 50%

T/F: You should check a baseline PSA before starting testosterone replacement therapy

True

At what testosterone levels should you consider treatment?

<300 ng/dL

After starting testosterone therapy.... you should check testosterone levels, a H&H, and PSA levels are what intervals?

3 - 6 Months

What medications are indicated for treatment of urge incontinence, urinary frequency, urinary urgency?

Anti-cholinergics ``` Oxybutynin Tolterodine Solifenacin Darifenacin Trospium (incontinence) ``` Mirabegron

What is first-line for OAB treatment? Second line? Third Line?

FIrst: Behavioral Therapy Second: Antimuscarinics, Beta-3 Agonist Third: Botox

What is the most common reason Epilepsy/Seizure treatment fails?

Non-compliance

What are indications to STOP AEDs? How long should the taper be?

2-4 years without a seizure Complete control within one year of onset Normal Neurological Examination Normal EEG Taper: Slowly for 6 months

What AEDs are first line for focal seizures?

1. Carbamazepine 2. Lamotrigine (Adjunct in >2y.o, monotherapy in > 16) 3. Valproic Acid (Depakote) 4. Levetiracetam (Adjunct >4y.o.) 5. Topiramate (> 2y.o.) 6. Phenytoin

Should Carbamazepine be used in patients with a history of bone marrow depression?

Carbamazepine should be avoided in patients with HLA-B 1502, why?

Increased risk of SJS

What AEDs are used for partial seziures?

1. Oxcarbazepine

Which AEDs are used to treat Tonic-Clonic Seizures?

1. Lamotrigine (Lamictal) 2. Valproic Acid (Depakote) 3. Levetiracetam (Adjunct >6y.o.) 4. Topiramate ( >2 y.o.) 5. Phenytoin

Which AEDs are used to treat Mixed Seizures?

1. Valproic Acid

Which AEDs are used to treat Lennox-Gastaut Syndrome?

1. Valproic Acid | 2. Topiramate (>2 y.o.)

Which AEDs are used to treat absence seizures?

1. Valproic Acid | 2. Ethosuximide

Should valproic acid be used in pregnancy?

No | It has associated neural tube defects

What AEDs are used to treat status epilepticus?

1. Fosphenytoin 2. Diazepam (Valium) 3. Lorazepam (Ativan) 4. Midazolam (Versed)

Which second-line AEDs are used to treat focal seizures?

1. Zonisamide 2. Lacosamide 3. Perampanel (> 12 y.o.) 4. Phenobarbital 5. Primidone 6. Gabapentin 7. Pregabalin (Adjunct) 8. Ezogabine (Adjunct)

Which second-line AEDs are used to treat tonic-clonic seizures?

1. Perampanel | 2. Primidone

Which second-line AEDs are used to treat Lennox-Gastaut Syndrome?

1. Phenobarbital

When would phenobarbital be indicated to treat status epilepticus?

If benzodiazepines and phenytoin fail

Which benzodiazepines are used to treat Lennox-Gastuat Syndrome?

Clonazepam (Klonopin) | Clobazam

Which benzodiazepines are first line for status epilepticus?

Diazepam (Valium) Lorazepam (Ativan) Midazolam (Versed)

Which AEDs are used to treat refractory focal seizures in adults?

Vigabatrin | Felbamate (Last-line due to ADRs)