Ischemic Heart Disease Flashcards
1
Q
Nitroglycerin Contraindications?
A
Use in combination with ricoguat or PDE-5 inhibitors
2
Q
What are the 3 beta blockers used in HF?
A
- Carvedilol
- Metoprolol succinate
- Bisoprolol
3
Q
What is the ointmetn dosing?
For nitro
A
dose BID 6 hours apart
4
Q
How should effient be dispensed?
A
In the original container
5
Q
Long acting nitrates need what?
A
need a 10-12 hour nitrate free period to decrease tolerance
6
Q
Patho of Ischemic heart disease?
A
Imbalance of myocardial demand (workload) and supply (blood flow)
Supply often decreased by arethrosclerosis which is CAD reduced blood flow to the heart
7
Q
Ranexa MOA
A
inhibits late phase Na current decrease intracellular Ca
decrease myocardial oxygen demand
8
Q
Preferred agent for Prinzmetal Angina?
A
CCBs
9
Q
The ABCDE treatment for SIHD?
A
- A: antiplat and antiangina: BB, CCBs, Nitrates
- B blood pressure and beta blockers
- Cholesterol statins and cigs
- D diet and DM
- Exercise and education
10
Q
Warnings for Nitrates 3
A
Hypotension, HA, tachyphylaxis (decreased effectiveness and tolerance)
11
Q
Cardiac enzymes are positive in what types of ACS MI?
Negative?
A
NSTEMI
STEMI
Negative in UA
12
Q
Effient contraindications?
A
Hx of TIA or Stroke
13
Q
Clopidogrel is a prodrug metabolized by?
A
CYP 2C19 check genotype for best use
14
Q
Ranexa Notes
A
Had no effect on HR or BP
15
Q
SEs of aspirin? 3
A
Dyspepsia
Heartburn
Nausea
16
Q
Patients with an acute MI, STEMI or Non-STEMI should be?
A
Transported to a hospital with PCI capabilities
17
Q
What CCBs are preferred when using in combination with BBs?
A
DHPs
18
Q
What is recommended in all patients? IHD
A
nitroglycerin for immediate releif
19
Q
Patch instructions for LA nitrates?
A
on 12-14 hours off for 10-12 rotate sites
20
Q
What is the goal of antianginal treatment in IHD?
A
Decrease myocardial pxygen demand and increase supply
21
Q
Vaccine rec for IHD patietns?
A
Flu and pneumococcal Prevnar and Pneumovax
22
Q
When are long acting nitrates indicated?
A
When BBs are contraindicated or as add on
23
Q
Benefit of CCBs in IHD?
A
Non-DHPs: reduce HR
DHPs: reduce SVR afterload
All CCBs increase myocardial oxygen supply increase blood flow to the coronary arteries
24
Q
WHat 4 properties does Aspirin have?
A
- Antiplat
- Antipyretic
- analgesic
- Anti inflammatory
25
What is effient indicated for?
Pts with ACS who are managed with PCI
26
What do nitrates do?
Decrease preload and
27
If patient is going for urgent CABG what shouldnt they get?
p2y12 inhibitors
28
SEs of Nitrates?
HA, flushing, syncope
29
What are the 3 GPIIb/IIIa antagonists?
Who are these for? What should they be given with?
1. Abciximab
2. Eptibifibatide
3. Tirofiban
Option for medical management Eptibi, Tirofiban or for PCI +/- stent (all agents)
If used for PCI must be given with heparin
30
A complete or partial block is seen in what type of ACS?
Partial block in UA
Complete block in STEMI
31
What is a rare and serious SE of clopidogrel?
TTP: pale skin, fever, weakness
32
What is the benefit of BBs fo IHD
Decrease HR
Decrease contractility
Decrease left ventricular wall tension
33
Contraindications for Aspirin?
Salicylate allergy, children and teenagers due to risk of reyes
34
Indication for ACE in ACS?
Time it should be received?
Important to note?
Should be started within first 24 hours and continued indefinetly
In all pts with EF \< 40%, those with HTN, DM, or stable CKD
ORAL
35
What chronic therapy should be initiated in ACS patients?
High intensity statin
36
Drug Treatment of ACS?
1. MONA
1. Morphine
2. Oxygen
3. Nitro
4. Aspirin
2. GAP
1. GPIIb/IIIa antagonists
2. Anticoagulants
3. P2Y12 inhibtors
3. BA
1. Beta blocker
2. ACE inhibitor
37
Prinzmetal Angina
Unpredicable caused by vasopasms
38
Anticoagulant Therapy in ACS? 3
LMWH, UFH, Bivalrudin (preferred for STEMI)
39
What is Yasprala and who is it used for?
Aspirin for patients at risk of developing aspirin associated gastric ulcers
40
Bayer, Bufferin, Ecotrin
Aspirin
41
What other med should be avoided with Brillinta?
Ticagrelor
Doses of aspirine above 100 mg should be avoided
42
Ranexa warnings?
QT prolongation
43
Clopidogrel warnings?
Increase bleed risk avoid use with omeprazole (prilozec) or esomeprazole (nexium)
Increased risk of thrombosis when DC prematurely
44
What medications should not be given during ACS?
NSAIDs
Immediate release nifedipine increases risk of death
45
Who should get DAPT?
3 and how long should they be on it?
For IHD
1. Bare metal stent: at least 1 month
2. drug eluting stent: 6 months
3. Post CABG: 12 months
46
What therapy is recommended for IHD patients?
Antiplatelet with aspirin or clopidogrel if allergy or both in select patients
47
ACS?
Acute chest pain
* Not relieved by rest or nitro
* These include UA, NSTEMI, STEMI
48
Clopidogrel MOA?
Prodrug that irreversibly binds to P2Y12 ADP mediated platelet activation and aggregation
49
Ranexa
Drug interactions and dosing limits
With CYP3A4 moderate inhibitors (Dilt and verapamil) limit dose to 500 mg BID
DONT USE WITH STRONG 3A4s
If using simvastatin limit dose to 20 mg/day
50
Effient generic?
Prasugrel
51
Renexa
Ranolazine
52
Maintenance dose for Brillinta?
Administration notes
90 mg PO BID for 1 year then 60 mg BID
Tablets can be crushed or mixed
53
How to know if someone has stable ischemic heart disease?
When does pain occur?
How is it relieved?
It is predictable, happens with acitivity or stress relieved by rest or nitroglycerin
usual underlying cause of CAD
54
BBs should be avoided in?
Prizmetal ANgina
55
How is nitroglycerin given during an acute coronary sydrome?
Use one dose every 5 minutes for up to 3 doses of improvement is not seen 5 minutes after the first dose call 911
56
What drugs increase risk of bleeding for P2Y12s? 4
Warfarin, NSAIDs
SSRIs and SNRIs
57
Diagnosis of IHD
What is performed and why?
Cardiac stress test to assess the likelihood of CAD
Lexiscan or regafenoson
58
Monoket
Isosorbide mononitrate
59
Beta blockers
What is the target dose?
Trick question! Titrate slow to a target HR od 55-60
60
Clopidogrel dosing and contraindication
75 mg
COntra; serious bleeding
61
Alcohol shoul dbe limited to?
1 drink per day
62
IHD patients should do what with their lifestyle?
Heart healthy
maintain BMI of 18.5- 24.9
63
All nitroglycerin contain products patient counseling
Dont use with sildenafil, tadalafil, avanafil, riociguat
64
Nitroglycerin Spray COunseling
Dont shake
spray on or under the tongue dont inhale
65
Ideally when should a PCI be performed?
Within 120 minutes of first medical contact
66
Ranolazine
Counseling
Not for chest pain when it occurs
can cause QT prolongation
67
MOA of Aspirin?
Irreversibly binds to COX 1 and 2
Which decreases prostaglandin and thromboxane A2 production
68
Nexium and Prilozec should not be used with what?
Plavix
69
What is first line therapy for antiangina in IHD?
Beta blockers
70
Brillinta
Ticagrelor
71
3 recs for IHD patients?
BB, CCBs all, or long acting nitrates
72
What are the preferred aspirin formulations?
Non-enteric chewable formulations
If not available shew enteric coating
73
Ranexa Contraindications? 2
Liver cirrhosis
CYP3A4 inhibitors or inducers 3A4
74
What type of CCBs are effective?
Slow release and long acting
short acting shouldnt be used: Nifedipine IR
75
What GIIb/IIIa antagonist is not recommneded for medical managment?
Abciximan Reopro
76
Integrillin?
Eptifibatide
77
COntraindications for GIIb/IIa? 5
1. Thrombocytopenia plats\<100,000
2. Severe uncontrolled HTN
3. Active bleed
4. Recent surgery or trauma 4 wks tirofiban, 6 weeks others
5. Hx of stroke within the past two years for Reopro
78
Contraindications for Abciximab? 4
1. GI bleed in past 6 wks
2. Increased prothrombin time
3. Hypersens to murine proteins
4. Intracranial neoplasm, aneurysm
79
Integrillin contra
Eptifibatide
Dependency on dialysis
80
3 SEs of GIIBs/IIas
1. Thrombocytopenia (ezpecially abcix)
2. Bleeding
3. Hypotension
81
Administration note for GIIb/IIas
Abciximab must be filtered
82
What are fibrinolytics used for?
Only used for STEMI
83
PCI timing preferred 2 time frames
1. 90 minutes door to needle
2. 120 from first medical contact
84
If it is not possible to perform PCI within 120 minutes what should be done?
Give fibrinolytic
Given within 30 minutes door to needle
85
Cathflo activase?
Used to restore function of potentially clotted central lines
86
Activase?
Alteplase
87
Activase dosing?
\>67 kgs 100 mg over 1.5 hours
88
What are the two fibrinolytics?
Activase: Alteplase
Tenecteplase: TNKase
89
SEs of fibrinolytics?
Bleeding including ICH, hypotension
90
What 3 things should be monitored with fibrinolytics?
Hgb, Hct, s/sx bleeding
91
Protease activated receptor 1 antagonist? 1
Warnings 1
SEs 2
Varapaxar
Do not use in severe liver impairment
SEs: Anemia, Bleeding
92
Vorapaxar DIs?
Substrate of 3A4 and P-gP
Dont use with strong 3A4s
93
Secondary prevention in ACS
7 drugs
1. Aspirin
2. P2Y12s
3. Nitro
4. BBs
5. ACE
6. Aldosterone antagonists
7. Statin
94
Secondary prevention after ACS:
Aspirin and P2Y12 notes
1. Aspirin 81 mg forever
2. Medical therapy pt: Ticagrelor or Clopdogrel with ASA for 1 year
3. PCI treated DAPT
95
Secondary ACS prevention
Nitro and BBs timing
1. Nitro indef with linguakl
2. BBs: 3 years indef if HF pt or if needed for HTN management
96
Secondary ACS prevention ACE
Aldosterone antagonist
1. Indef if EF \< 40%, HTN, CKD, or DM, consider for all patients
1. Aldosterone antagonist: Indef if EF\<=40% and either symptomatic HF or DM receiving target doses of ACE and BB
2. Contraindications: sig renal imparimetn SCr\>2.5 in men, 2 for women or hyperkalemia K\>5
97
Statin therapy ACS secondary prev
1. \<= 75 high intensigty
2. \> 75 mod
98
Pts with Chronic pain and ACS what is the DOC?
Naproxen lowest CV risk
99
If patient has to be on Warfarin and has ACS?
Lower warfarin INR goal if on triple therapy 2-2.5 nd for the shortest possible time
100
What is rec'd for ACS patients if they are getting triple anticoag?
PPIs if they have a hx of GI bleed while taking triple therapy
101
What is a cardioembolic stroke?
Embolus forms in the heart and travels to the nrain
102
SIgns and Symptoms of Stroke
1. Face: one sided droop
2. A Arms one drops
3. S: slurred speech
4. T: Time call 911 fast
103
What do you need to quickly indentify when lookling ar a stroke?
Ichemic versus hemorrhagic
104
What is performed to find what stroke is there?
Brain imaging CT scan
105
What is the immediate goal during a stroke?
Restore blood flow
106
Ischemic Stroke management?
What Agent is used?
What needs to be done?
1. Alteplase (tPA), only fibrinolytic agent used for acute ischemic stroke
2. Once a clot is confirmed use this
107
What criteria need to be met for alteplase use?
1. Can be given 3 hours from symptom onset FDA approval
2. Can be given within 4.5 hours in select patients
3. It can be administered 60 minutes from hospital arrival door to needle
4. BP is \< 185/110: if this is the only contraindication then BP should be safely lowered and then admin
108
Activase dosing in ACS, and Stroke
Add pulmonary embolism when there
1. ACS: If \> 67 kg 100 mg over 1.5 hours
2. Stroke 0.9 mg/kg max 90 mg
109
Absolute contraindications for Alteplase per package insert? 5
1. Active bleed
2. Recent within the past 3 months serious head injury
3. Intracranial conditions that can increase bleed
4. Intracranial or intraspinal surgery
5. Severe uncontrolled BP \> 185/110
110
Additional exclusion criteria for alteplase? 5
1. Stroke within the past 3 months
2. Previous ICH INR\>1.7, aPTT \> 40 plat \<100,000
3. Got Tx with LMWH within past 24 hours
4. Use of Direct thrombin or direct factor Xa inhibitors with elevated anticoag tests or use within 48 hours
5. BG \< 50
111
Alteplase warnings? 2
1. Major bleed ICH
2. Angioedema
112
Alteplase notes?
Keep BP \<180/105 for at least the first 24 hours after tx
113
All treatments for Stroke? 5
1. Initial Alteplase
2. Aspirin
3. HTN management
4. Hyperglycemia management
5. DVT prevention
114
What dose and when should aspirin be given in stroke?
1. 162-325 given 24-48 hours after stroke onset, dont give within 24 hours or Alteplase
115
HTN Managment in Stroke 3 rec drugs and BP target
1. IV Labetalol, nicardipine, or clevedipine
2. Lower to Bp \<185/110 when alteplase is used maintain \<180/105
3. If they dont get alteplase may only need to treat in severe HTN BP\>=220/120
116
Safe BP reduction?
15% in first 24 hours
117
Hyperglycemic managment in stroke?
keep BG in 140-180 range
118
DVT prevention is stroke? 2 things
1. Compression socks pneumatic compression device
2. If UFH or LMWH is used cannot be start until 24 hours after alteplase
119
Risk factors for stroke? 3
1. HTN: Most important
2. A. Fib
3. Age \>=55
120
Treating HTN in stroke?
2 drugs
1. ACE
2. HCTZ
3. These have most evidence BP goal less than 130/80
121
A fib treatment in stroke
1. Cardioembolic stroke due to a fib requires anticoag
122
Life style changes in Stroke? 2 bullets
1. Sodium restriction \< 2.4 grams/day or 1.5 for more BP reduction, mediterianian diet
2. Wt reduction BMI goal 18.5-24.9 , waist in women \< 35 inches, men \< 40
123
What treatment is recommended in patients with noncardioembolic stroke or TIA?
Antiplatelet not anticoag
Antiplat reduces the risk of recurrence
Aspirin or aspirin + ER dipyridamole or clopidogrel
124
When should Plavix be used alone?
If pt has ASA allergy
125
When should combination ASA and Clopidogrel be intitiated and continued in STROKE?
within 24 hours and continued for at leat 21 days
Combo should not be used long term fro stroke or TIA due to increased hemorrhage risk
126
Dipyridamole MOA?
Inhibits the uptake of adenosine increases cAMP levels which inhibits plat ag
127
Aggrenox?
Dipyridamole
128
Warnings for Dipyridamole? SE?
Hypotension
SE: HA
129
Intracerebral Hemorrhage
Prevention treatments 2
Potentially reverse anticoag
and treat seizures when they happen not prophylaxticaly
130
What is the main treatment for ICH and what does it do?
Mannitol produces an osmotic diuresis, inhibits the tubular reabsorption of water and electrolytes, increases urinary output
BOTTOM LINE: Reduces intracranial pressure by withdrawing water from the brain
131
How is mannitol given for ICH?
IV
132
Mannitol Contraindications and Notes
Severe renal disease
Notes: Maintain serum osmolality \<300-320 mOsm/kg
133
How does an acute subarachnoid hemorrhage present?
With a severe HA
Commonly cause by aneursym
134
What can occur in a subarachnoid hemmorhage and when?
Cerebral artery vasospasm
can happen 3-21 days after bleed
135
What is used to prevent cerebral vasospasms in SAH?
Oral Nimedipine
136
Nimedipine MOA?
DHP CCB: more selective for cerebral arteries
137
Boxed warning for nimodipine?
1. NOT TO BE GIVEN IV death and threatening events have occured
138
Nimodipine DI?
Hypotension when used with CYP3A4s
* Avoid CYP3A4 inhibitors: clarithromycin, PIs, azoles
* Avoid grapefruit juice
* Avoid CYP inducers: rifampin, carbamazepine, phenytoin, at johns: can decrease levels
139
Nimodipine SE?
Hypotension
140
Nimodipine notes?
If contents cannot be swallowed the capsule can be withdrawn with a parenteral syringe and then transfered to oral syringe
Label syringe for ORAL USE ONLY
141
Bleomycin Max dose
And what toxicity?
Lifetime cumulative 400 units
Pulmonary Toxicity
142
What 4 drugs have maximum dosing recommendations due to toxicities?
Bleomycin, Doxorubicin, Cisplatin, VIncristine
143
Doxorubicin Maximum dose and why?
Lifetime cumulative: 450-550 mg/m2
Cardiotoxicity
144
Cisplatin maximum dose and why?
Dose per cycle: not to exceed 100 mg/m2
Nephrotoxicity
145
Vincristine Maximum dose and why?
Single dose capped at 2 mg
Neuropathy
146
What drugs cause myelosuppression?
3
Almost all cause myelosuppression except Asparginase, bleomycin, vincristine
147
How should myelosuppression be treated in chemotherapy patients?
If neutropenic give Colony stimulating factor
Anemia: RBC transfusion
148
Chemo drugs that cause N/V 3 main
1. Cisplatin
2. Cyclophosphamide
3. ifosfamide
149
How is nausea and vomitting treated in chemo therapy patietns? 6
1. Neurokinin-1 receptor antagonists (NKI-RA)
2. Serotonin 3 receptor antagonists (5HT3-RA
3. Dexamethasone
4. Metoclopramide
5. Prochlorperazine
6. IV/PO fluid and hyfration
150
5 chemo drugs that cause Mucositis?
1. Fluorouracil
2. Capecitabine
3. Irinotecan
4. Methotrexate
5. And many TKIs including the nibs
151
How is mucositis treated in chemo therapy patients?
Symptomatic tx , local anesthtics
152
4 chemo drugs that cause diarrhea?
1. Fluorouracil
2. Capectabine
3. Irinotecan
4. and many TKIs
153
How is Diarrhea treated in chemo therapy patients?
1. IV/PO fluid hydration, antimotiliy agents (loperamide)
2. Irinotecan: atropine for early onset
154
Main drug that causes consiptation in chemo
1. Vincristine
155
How to treat constipation in chemo?
Stimulant laxatives
polyethylene glycol
156
Xerostomia?
Dry mouth
Artificial saliva substitutes caused by radiation
157
Cardiotoxicity In Chemo
Cardiomyopathy specifically 1
* Anthracyclines
158
Cardiotoxicity in chemo
QT prolongation? 2
1. Arsenic trioxide
2. TKIs, end in nib
159
How to treat cardiomyopathy in chemo patients?
Do not exceed cumulative dose of doxorubicin 450-550 mg/m2
and dexrazoxane can be given prophylactically
160
How to treat QT prolongation in cancer patient?
Maintain electrolyte balance consider holding therapy if QT interval is \> 500 msec
161
4 chemo drugs that can cause pulmonary fibrosis
1. Bleomycin
2. Busulfran
3. Carmustine
4. Lomustine
162
Chemo drugs that cause hepatotox? 1 class?
1. Antiandrogens
1. Bicalutamide
2. Flutamide
3. Nilutamide
163
2 chemo drugs that cause Nephrotoxicity
1. Cisplatin
2. MTX
164
What can be given to treat nephro toxicity in chemo patients?
1. Amifostine (ethyol) can be given prophylactically with cisplatin
2. Ensure hydration
3. DONT EXCEED MAX CISPLATIN DOSE OF 100 MG/m2/cycle
165
Two drugs in chemo that can cause hemorrhagic cystitis
Ifosfamide all doses
Cyclophosphamide higher doses \> 1 g/m2
166
What can be given for hemorrhagic cystitis in chemo?
1. Mesna (Mesnes) is ALWAYS given with ifosfamide and sometime cyclophos
167
3 classes of chemo drugs that cause peripheral sensory neuropathy
1. Vinca alkaloids: Vincristine, vinblastine, vinorelibine
2. Platinums: cisplatin, oxaloplatin
3. Taxanes: Paclitaxel, docetaxel, cabazitaxel
168
Ways to reduce peripheral sensory neuropathy with vincristine?
limiting the dose to 2mg per wk
169
What does oxaliplatin cause?
Acute cold mediated sensory neuropathy avoid cold and cold drinks
170
Bortezomib SE treatmetn
SC admin is assoiciated with less peripheral neuropathy than IV
171
Chemo drugs that have thromboembolic risk? 2 classes
Aromatase inhibitors (anastrazole, letrozole)
SERMs (Tamoxifen)
172
What is amifostine (ethyol) for?
Given with cisplatin to prevent nephrotoxicity
173
What is Dexrazoxane used for?
With doxorubicin for cardiomyopathy prophylaxis
THis is Zinecard
Totect is used for extravacation
174
What is leucovorin or levoluecovorin (Fusilev) used for?
1. Used with fluorouracil to enhance efficacy
175
What is Uridine triacetate used for? 2 things
Flourouracil and Capecitabine
As an antidote give within 96 hours
176
What is mesna used for?
Used with ifosfamide always to prevent hemmorhagic cycstis
177
What is atropine and loperamide used for\>
Atropine: early onset diarrhea for Irinotecan
Loperamide: for delayed
178
Glucarpidase and Leucovorin or levoleucovorin used for?
given after methotrexate to prevent myelosuppresion and as a mucositis antidote
179
What hydration steps can you take with these drugs to reduce renal damage?
Mesna with Ifosfamide
Amifostene for cisplatin
When it damages the bladder and kidneys get it out with hypertonic solutions, these increase urine output and incluse mannitol and hypertonic saline
180
When are WBCs the lowest during chemo?
7-14 days
181
When do WBCs recover after treatment?
3-4 wks after
182
IOf someone has a low neutrophil count what can happen?
They are at increased risk of infection
183
Nuetropenia is classifies as an ANC of?
\<1000 cells/mm3
184
What is severe neutropenia classified as?
ANC \< 500 cells/mm3
185
What is used for the prevention of febrile neutropenia?
Filgrastim and Pegfilgrastim
186
Neupagen or Zarxio?
Filstastim G-CSF
187
Granix
Tbo-filgrastim
188
How is Neupagen, zarxio dosed?
Daily
189
Neulasta?
Pegfilgrastim
190
SEs for Filgrastim, pegfilgrastim and tbo-filgrastim?
Bone pain
191
Sargramostim SEs? 5
Fever, bone pain, arthralgias, myalgias, rash
192
How is Neulasta dosed?
Pegfilgrastim
Once per cycle
Pegylated filgrastim is longer acting and dosed less frequintly
193
How are CSFs stored?
Store in fridge protect vials from light
194
When should CSF be administered?
No sooner than 24 hours after chemo
195
What should pts report if on CSF?
Signs of enlarged spleen left upper ab pain
196
What is the potential only sign for neutropenia?
Fever can sometimes be the only sign of infection
197
How is febrile neutropenia defined?
What should be done?
Single oral temp of \>38.3 or 101
ANC \< 500
Oral temp \>38 for greater than 1 hour
If the ANC is expected to drop below 500
EXTREMELY IMPORTANT TO GIVE EMPIRIC ABX
198
What infection type poses the highest sepsis risk in febrile neutropenia?
Gram negative
Inclusing Pseudomonas
199
Patients ANC is expected to drop below 500 for \<= 7 days and has no comorbidities
What 3 Abx sets should be used?
1. Anti-pseudomonal
1. Cipro + amox/clav
2. Or Cipro +/- clinda or
3. Levofloxacin
200
Patietns ANC is expected to be \< 500 for longer than 7 days and has comorbidities evidence of renal impairment CrCl\<30 or LFTs \> 5 x ULN
What 5 Abx are recommneded?
iv Antipseudomonas
1. Cefepime or
2. Ceftaz or
3. Meropenem or
4. Imepenem + cilstatin or
5. Pip/tazo
201
What is not recommended in Chemo patients when you are trying to cure them and they have anemia?
ESAs they can increase tumor progression
202
What are the 4 criteria that need to be met if you are trying to use ESA in a cancer patient?
1. Use ESA only in non myeloid malignancies where anemia is directly caused by the chemo
2. If you use ESA you must have at least 2 more months of chemo
3. Initiate ESA when Hgb is \< 10
4. Use the lowest dose needed to avoid the need for RBC infusions
Assess TBIC and TSAT to see if iron needs to be replaced because it will not work without it
203
When are platelet transfusions indicated in cancer patients or whenever?
WHen platelets are below 10,000 or 20,000 if active bleed
204
What are the 5 risk factors for chemotherapy induced Nausea and vomiting?
1. Female
2. \< 50
3. dehydrated
4. Hx of motion sickness
5. Hx of N/V with prior regimens
205
When should antiemetics be administered in CINV?
30 minutes before chemo
and provide take home meds
206
Acute N/V onset?
Within 24 hours after chemo
207
What is delayed nausea and vomiting onset?
1 to 7 days after
208
What is anticapatory N/V related to chemo therapy?
Before chemo
209
What is the treatment for acute N/V with chemo?
5HT3-RA
210
Treatment for delayed N/V associated with chemo? 3
1 to 7 days
NK1 receptor antagonists, corticosteroids, palonosetron (only 5HT-RA indicated for delayed)
211
Treatment of anticipatory N/V associated with chemo?
Benzos
212
What drug has very high chemo emetegenic risk?
Cisplatin
213
What drug is a combo NK1 /5HT3-RA?
Netupitant/palonasetron
Akynzeo
214
What NK1 is PO?
Arepitant
215
What NK1 is IV?
Fosaprepitant
216
What do NK1 end in?
Pitant
217
What do 5Ht3 RAs end in?
Setron
218
What are two other possible drugs for CINV?
Olanzapine
Dexamethasone
219
What drugs should a patient be put on if they are on a high emetic risk chemo regimen?
3 drugs
1. NK1+5HT+Dexamethasone
2. Netupitant/palonestron (Akynzeo) + dexamethasone
3. Olanzapine + palonosetron + dexamethasone
220
What drug is included in all high or moderate emetic risk chemo regimens?
Dexamethasone
221
What drugs are commonly used for breakthrough CINV?
5HT3s, dopamine antagonists, cannabinoids
222
What do NK1s do?
Substance P/ neurokinin-1 receptor antagonists block these which augments the antiemetic activity of 5-HT3RA reeptor antagonists and corticosteroids
223
Emend?
Arepitant Oral
Fosarepitant injection
224
Contraindications to the Emends?
do not use with pimozide or cisopride: these are 3A4 substrates
225
What 3 NK1s are 3A4 inhibtiors and what should be doen?
Both emends and netupitant
Doses of dexamethasone should be decreased when used together
226
When are 5HT3s given?
1 day prior to chemo
Granisetron transdermal patch should be given prior to day 1
227
Zofran or Zuplenz film
Ondansetron
228
Sancuso?
pATCH FORMULATION OF GRANISETRON
229
Anzemet
Dolasetron
230
Aloxi
Palonosetron
231
Contraindication for 5HT3 RAs
Dont use with apomorphine (Apokyn) due to severe HTN and loss of consciousness
232
2 warnings for 5HT3s?
QT prolongation: dose dep more common with IV
Serotonin syndrome when given with other serotenergic agents
233
2 main SEs of 5HT3s?
HA, and constipation
234
What 5HT3 is not indicated for CINV and why?
Anzemet: I**V Dolasetron:** increase risk of QT prolongation
235
What 5HT3s are available both IV and PO?
All
236
Decadron
Dexamethasone
237
2 SEs of Dexamethasone?
Fluid retention and insomnia
238
3 dopamine receptor antagonists that are used in CINV?
Prochloperazine
Promethazine
Meclopramide
239
Compazine
Prochloperazine
240
Reglan
Meclopramide
241
Phenergen
Promethazine
242
Boxed warnings for Pherngen? 2
Dont give to kids \< 2
Dont give intra-arterial or SC due to extravacation
243
Reglan black box?
Tardive dyskinesia that can be irreversible
244
Droperidol is what?
Dopamine antagonist
245
Droperidol Black box?
QT prolongation
246
What 4 key SEs of Dopamine receptor antagonists?
1. Sedation
2. Lethargy
3. Decrease seizure threshold
4. Actue EPS (common in children antidote is diphenhydramine or beztropine)
247
What dopamine antagonist is not used in CINV and why\>
Droperidol due to high QT risk
248
Marinol?
Dranabinol
249
How is merinal stored?
Refridgerate
250
Cesamet
Nabilone
251
SEs of cannabinoids? 3
Somnolence, euphoria, increased appetite
252
ODT ondansetron counseling?
With dry hand peal back dont push out of foil
253
Chemo Induced Diarrhea patinet counseling?
Loperamide or diphenoxylate + atropine might be given to you
254
What is the max dose of loperamide? Chemo Diarrhea
Max is usually 16 but can be increased to 24 in these patients
255
What 3 chemo drugs commonly cause diarrhea? When does it happen?
Irinotecan
Capecitabine
Fluorouracil
Usually several days after
256
Irinotecan and diarrhea
can cause early onset diarrhea due to cholnergic excess symptoms such as ab cramp, rhinitis, lacrimation and salivation
Early onset is treated with atropine
257
Oral mucositis counseling
Many drugs that cause Chemo diarrhia cause mucositis
258
What 4 drugs are used for Oral complications of Chemo?
1. Mucosal barrier gel pray
2. Lidocaine 2% topical solution
3. Artificial saliva substitute (Xerostomia)
4. Pilocarpine (Xerostomia)
259
Salagen?
Pilocarpine
260
Lido cain boxed warning?
Avoid in patients \< 3
261
Hand foot syndrome is also known as?
Palmar-plantar erythrodysethesia
262
Hand foot syndrome occurs most frequently with what 4 chemo drugs?
1. Fluorouracil
2. Capecitabine
3. Cytarabine
4. Liposomal Doxorubicin
263
What electrolyte disturbance is often seen in cancer?
Hypercalcemia of Malignancy
264
What should all cancer patients be treated with when on chemo therapy
Proper hydration is key and hypercalcemia risk is high
give fluids, mannitol, and hypertonic
265
What are the 4 treatment options for hypercalcemia of malignancy?
1. Hydration with normal saline and loop diuretics
2. Calcitonin (Miacalcin)
3. IV bisphosphanates (Zoledronic Acid (Zometa)
4. Denosumab
266
Miacalcin
Calcitonin
267
Zometa
IV zolendronic acid
dont confuse with Reclast which is dose yearly for osteoporosis
268
Xgeva
Denosumab
Dont confuse with Prolia which is for every 6 months for osteoporosis
269
What is Xgeva MOA?
Denosumab
RANKL mab that inhibits the interaction between RANKL and RANK
270
Major chemo vesicants? 2 `
Anthracyclines
Vinca alkaloids
271
How do you treat extravacation?
Cold compress (except with vinca and etoposide which you use warm)
Anthracycline antidote: Dexrazoxane (Totect) or dimethyl sulfoxide
Vinca antidote: Hyaluronidase
272
4 drugs that can be given intrathecally and one note about them
1. Cytarabine
2. Methotrexate
3. Hydrocortisone
4. Thiotepa
5. They must be preservative free
273
Intrathecal admin of what drug can be fatal and what should you do to limit that chance\>
Vincristine is fatal
Dont dispense vincristine in a syringe
274
Vaccinations in Chemo?
Should be avoided if you need to give one give two wks prior
275
What treatment regimens are used for premenopausal women? 2
Stage 1-II
1. Aromatase inhibitors for 5 years total + ovarian abalation/ suppression (LHRH analgougues
2. Or Tamoxifen for 5 years + abalation/suppression LHRH analgoues continue tamoxifen for 5 more years (10 years total) or stop endocrine therapy at 5 years if still premenopausal
276
What change in breast cancer treatment should be done if a patient becomes postmenopausal during treatment? 2 bullets
Stage 1-2
1. Switch to AI for 5 more years 10 years total
2. Or tamoxifen for 5 more years 10 years total
277
Postmenopausal women preferred tx?
Stage 1-2
AI
278
5 regimens for postmenopausal women?
5 bullets
Tage 1-2
1. AI for 5 yrs: anastrazole, letrozole, exemestane, consider AI for 5 more years 10 years total
2. AI for 2-3 years followed by tamoxifen for 5 year or
3. Tamoxifen 2-3 years followed by AI 5 years total
4. AI \< 5 years or tamoxifen for 4.5-6 years followed by AI for 5 more years
5. OR COntinue tamoxifen for 5 more years 10 years total
279
If a pt is hormonal receptor negative ER-/PR- what happens?
Stage 1-2
Patients dont benefit from adjuvant hormonal therapy
280
Visceral versus non visceral metastasis?
Treatment choices?
Visceral involving vital organs: life threatening: give cytotoxic chemo therapy (trestuzumab +/- pertuzumab) Mab HER2 targeted
Non: involving the skin or bone
281
AI are effective in who only?
Postmenopausal women
282
Preferred endocrine therapy in metastatic breast cancer?
4
1. Abemaciclib + fulverstrant
2. Palbociclib + fulverstrant or AI
3. Ribociclib + + AI
4. Fulvestrant alone
283
What do AIs need to be given with if you are going to give them in premenopausal women
GnRH agonists
284
When are SERMs used?
Hormone receptor positive tumors
285
When are SERMs used?
HR posiitve tomorrow for both pre and post but AIs are more effective in post
286
What is used to treat men with Breast cancer?
Tamoxifen
287
2 SERMs to know?
Tamoxifen
Fulvestrant
288
Soltamox
Tamoxifen
289
Faslodex?
Fulvestrant
290
Tamoxifen is a substrate of what 3 CYPs?
3A4, 2C9, 2D6
291
What drug is indicated for hot flashes when taking tamoxifen?
Venlafaxine
292
What SERM is used for prophylaxis of breast cancer?
Raloxifene
293
SEs of SERMs? 10
1. DVT/PE
2. Menopausal symptoms
3. hot flashes
4. flushing
5. edema
6. wt gain
7. HTN
8. Mood changes
9. amenorrhea
10. vaginal bleeding/discharge
294
Tamoxifen increases the risk of what?
uterine/endometrial cancer
Others decrease risk
295
3 aromatase inhibitors?
Anastrazole
Letrozole
Exemestane
296
Arimidex?
Anatrazole
297
Femara
Letrozole
298
Aromasin
Exemestane
299
2 risks in aromatase inhibitors?
Higher risk of osteoporosis
Higher risk of CVD compared to SERMs
300
AIs are contraindicated in?
Pregnancy
301
SEs of AIs? 13
1. Edema
2. DVT/PE
3. bone pain
4. osteoporosis
5. menopausal symptoms
6. hot flashes
7. arthralgia/myalgia
8. lethargy/fatigue
9. N/V
10. Rash
11. hepatotoxicity
12. Hypertension
13. Dyslipidemia
302
Tamoxifen counseling risks 3
Endometrial cancer
blood clots
Cataracts
303
Evista?
Raloxifene
304
Evista counseling?
DC 72 hours prior or during immobilization (post surgery, prolonged bed rest)
305
Aromatase Inhibitor Counseling?
3
1. This med is for pts who have finished menopause
2. Common SEs, are joint pain and osteoporosis
3. This medication should not be taken with tamoxifen
306
Common SEs of ADT in prostate cancer? 5
1. Hot flashes
2. Loss of libido or impotence
3. Gynecomastia
4. Hair thinning
5. Peripheral edema
307
What can GnRH agonists cause?
Tumor flare when starting
308
What is often given with GnRHs?
Antiandrogens to prevent symptoms of tumor flare
309
Two GnRH agonists?
Leuprolide
Goserelin
310
Lupron
Leuprolide
311
Zoladex
Goserelin
312
Risk of GnRH agonists 2
Osteoporosis risk
TUmor flare
313
SE of GnRH agonist or LHRHs agonists 9
1. Hot flashes
2. Impotence
3. gynecomastia
4. peripheral edema
5. bone pain
6. injection site pain
7. QT prolongation
8. dyslipidemia
9. hyperglycemia
314
FIrmagon
Degarelix
315
GnRH antagonists 1
Degarelix
316
2 notes for GnRH antagonists
OSteoporosis
Does not cause tumore flare
317
Added SEs of GnRH antagonists
Hypersensitivity Rxns
318
Both GnRH agonists and antagonists cause what?
Have risk for osteoporosus
319
First generation antiandrogens
Bicalutamide
320
Casodex
Bicalutamide
321
When are first gen Antiandrogens used?
Only used in combo with GnRH agonists
322
Second gen antiandrogens
Enzalitamide
323
Xtandi
Enzalutamide
324
What weight is used for calculating BSA in cancer patients
Acutal body weight
325
Mosteller Equation
Sqrt(ht cm \* wt kg/3600)= BSA in M2
326
Cell cycle not specific agents? 3 classes
1. Alkylating agents
2. Platinum based
3. Anthracyclines
327
Alkylating agents 6
1. Cyclophosphamide
2. Ifosfamide
3. Carmustine
4. Bendamustine
5. Busulfran
6. Melphalon
328
What two drugs cause hemorrhagic cysitis
1. Cyclophosphamide
2. Ifosfamide
329
What alkylating chemotherapy agents cuase pulmonary toxicity? 1 bolded
Busulfran, carmustine, lomustine
330
Cyclophosphamide SE?
SIADH
331
Platinum drugs can cause what type of symptoms?
Symptoms similar to heavy metal poisoning like peripheral sensory neuropathy
332
Cisplatin is associated with what 2 big SEs?
1. Highest incidence of nephro tocixity
2. Chemo induce NV
333
3 unique things of Cisplatin?
1. Causes nephro and ototoxicity
2. Amifostine ethyol can be used to protect from nephro
3. highly emetogenic
334
Boxed warning for platinums?
Anaphylaxis like reaction occurs with repeated exposure
335
Side effects of platinums?
Peripheral neuropathy
336
Carboplatin dose calculations
Calvert formula
Total dose= Target AUC \* (GFR +25)
337
Zinecard
Dexarazone is chemo protect form
338
What is associated with anthracyclines?
Cardiotoxicity
339
When should Zinecard be considered?
Doxorubicin cumulative doses \> 300`
340
What should be monitored with doxorubicin?
LVEF
341
Unique concerns for doxorubicin? 6
1. Strong vesicant
2. Red urine discoloration
3. lifetime cum 450-550
4. Totect for extravacation
5. Zinecard for cardioprotection
6. N/V
342
Boxed warnings for doxorubicin 3
1. Myocardial tox
2. vesicant
3. myelosuppression
343
What is mitoxantrone?
What does it cause?
Anthracycline
Causes blue urine
344
Vinca alkaloids MOA?
inhibit function of microtubules during M phase
345
Labeled warning for vinca alkaloids?
For IV use only fatal if given other routes
346
What two things are common for vinca alkaloids
Peripheral and autonomic (constiplation) neuropathies
347
What vinca is more associated with what toxicity
vinCristine: CNS toxic neiropathy
Acidental intrathecal admin and caus eparalysis and death
348
2 vinca alkaloids are associated with what?
Bone marrow suppression
VinBlastine and vinorelBine
349
Max dose of vincristine?
2 mg/dose
350
How should vincristine be prepared and why?
In an IV piggy back to prevent acidentental death
351
Wha vinca in myelosuppresive what one isnt?
What drugs can be interchanged?
Vinblastine causes myelosuppression
Vincrtistine doesnt
Liposomal Vincristine is not interchangable with vincrtistine
352
Taxane MOA?
Inhibit microtubule function in M phase
353
3 main side effects of taxanes?
Peripheral sensory neuropathies, infusion related hypersens
fatal anaphylaxis
354
Taxane metabolism?
All are metabolized by the liver and require renal/hepatic dose adjustmetn
355
Drug interactions with taxanes?
Elimination is reduced when given after cisplatin or carboplatin
Give taxane before platinums
356
4 taxanes?
Paclitaxel
Docetaxel
Cabazitaxel
Paclitaxel albumin bound
357
Docetaxel specific concern?
Severe fluid retention
358
Administration note for taxanes?
Non-PVC bag and tubing
359
Boxed warning for taxanes?
Hypersense rxn
360
Topo I inhibitors?
block coiling and uncoiling of DNA during S phase
Ironotecan
361
Unique concerns for Topo I inhibitor
Irinotecan
Acute cholnergic symptoms: atropine
Delayed diarrhea: loperamide up to 24 mg/day
362
Topo II inhibitors
Etoposide
363
Etoposide MOA?
uncoiling and coiling during G2 phase
364
Vepsid?
Etoposide capsules
365
Vepsid storage?
Refrisgerate capsules
366
etoposide IV unique concerns 3`
1. Infusion related rxn
2. IV prep in concentrations \<=0.4 mg/mL
3. Non-PVC due to leaching of DEHP
367
2 pyrimidine analgues and MOA?
1. inhibit pyrimidine synth in S phase
2. Flourouracil 5-fu
3. Capecitabine
368
5 FU
FLuorouracil
369
Xeloda
Capecitabine
370
Uniquie concerns of Xeloda 2
Prodrug of 5-FU
Pharmacogenomics: DPD def increase risk of severe toxicity
371
5-FU unique concerns 2
Leucovorin is given to increase efficacy
DPD def increase toxicity
372
2 folate metabolites?
MTX
Pemetrexed
S phase
373
What may be required in folate antimetabolites? 2
Folic acid/analgues +/- B12
374
What should be given with high doses of MTX?
Leucovorin or levo for rescue
375
What SE is most frequently seen with what antifolate?
MTX nephro \>=1gram/m2
376
Boxed warning for antifolate?
Myelosuppression
377
2 SEs of MTX?
Nephro and hepatotoxicity
378
All trans Retinoic acid
Tretinoin
379
Black box for all trans retinoic acid?
Tretinoin
RA-APL differentiation syndrome
380
Arsenic trioxide Black box 2`
RA-APL differentiation syndrome
QT prolongation
381
Arsenic trioxide unique concerns?
QT prolongation
382
Apariginase and Pegaspargase note
Peglyated form dicreases dosing interval q 2 wks and decreases allergic rxns
383
SEs of Asparginase or Pegaspargase? 2
1. Hypersense rxn
2. Prolonged prothrombin time: PT/INR
384
Bleomycin 2 notes
Not myelosuppresive
Max lifetime is 400 units due to pulm tox
385
Bleomycin black box and SE
Pulmonary fibrpsis
Hypersense reaction
386
mTor inhibitors end in?
Limus
387
What is zortress and what is it used for?
Everolimus used for transplant
388
Temsirolimus Unique concern?
use non-PVC bag and tubing
389
mTors are substrates of what?
3A4
390
4 SEs of Everolimus?
1. Dyslipidemia
2. Rash
3. Stomatitis
4. Lung disease interstitial
391
REvlimid
Lenalidomide
Immunomodulator
392
Revlimid Unique concern and black box? Same
severe birth defect
Fetal risk/pregnancy
393
Thalomide
Thamlidomide
394
What can be used with bortizomib and why?
Acyclovir or valacylovir to prevent herpes reactivation
395
SE od bortizumib and carfilzomib
Peripheral neuropathy
396
Monoclonal Antibodies are associated with wht?
infusion related rxns premed usually required
397
Ci with mabs?
Ciculatory system
398
Bevacizumab and Ramucirumab common toxicity 3
1. Inhibits blood vessel growth leads to HTN and proteinuria
2. Hemmorhage or thrombosis may occur
3. Impaired wound healing due to decreased blood flow
399
Tu for monoclonal antibodies
Tumor
400
Cetuxumab and Panitumab common toxicities 2
1. EGFR-- epidermis---skin toxiciy (anceform rash)
2. Development of rash is correlated with reponse to therapy
401
Trastuzumab and pertuzumab common tox 2
1. Cardiotox
2. Fetal-embryo
402
Retuximab, Brentuxumab, Daratumumab, Inotuzumab common toxicities? 2
1. Bone marrow suppression
2. Intotuzumab ozogamicin and brentuxumab vedotin: antibody drug conjugates that bind to the cell and enable cytotoxic drug to enter
403
Li
Immune system
404
ipilimumab, Atezolizumab, Nivolumab
Pemrolizmab common tox 1
1. Pts immune system becomes overactive---\> potentially life threathening immune reactions
405
VEGF Inhibitors 2
Bevacizumab
Ramucurcumab
406
Avastin
Bevacizumab
407
Cyramza
Ramucirumab
408
Unique concerns for Avastin and Cyramza 1
1. Bevacizumab, Remucircumab
2. Impaired wound health dont give for 28 days before or after surgery
409
VEGF inhibitors what to do if getting surgery?
Dont admin 28 days before or after surgery
410
Boxed warning for Avastin and Cyramza? 2
Fetal embryo toxicity, GI perforation
411
HER2 inhibitors 3
Trastuzumab
Pertuzumab
Ado-trastuzumab
412
Herceptin
Trastuzumab
HER2
413
Kadcyla?
Ado- Trastuzumab
414
What should be monitored for HER2 inhibitors?
Kadyla, Herceptin
Monitor LVEF using echocardiogram or MUGA scan
415
Boxed warning for HER2s
Kadcyla and conventional herceptin are not interchangeable
416
EGFT inhibitors 2
Cetuxumab
Panitumumab
417
Erbitux
Cetuximab
418
Vectibix
Panitumumab
419
EGFR inhitors Erbitux and Vectibix Unique concern with pharmacogenomoics?
1. Cetuximab and Panituzumab
2. EGFR gene expression and KRAS mutation
3. EGFR positive correlates with better response rate
4. Must be KRAS wild type negative
420
Notes for Erbitux and Vectibix? 3
1. Rash indicates reponse to therapy
2. Avoid sunlight
3. Topical emollient inclsing steroids and abx can be used prophylaxtically to limit skin damage
421
CD antigen inhibitor?
REtuximab
422
Rituxan
Rituximab
423
2 notes for CD inhibitors
Retuxan
Retuximab
1. Premedicate with diphenhydramine APAP and steroids
2. CD20 positive to use
424
Blincyto
Blinatumab
C19 and CD3 positive to use
425
Programmed death receptor 1 inhibitors? 2
Pembrolizumab
Nivolumab
426
Keytruda
Pembrolizumab
427
Opdivo
Nivolumab
428
Cytotoxic T-lymphocyte Antigen 4 inhibitor
1
Ipilimumab
429
Yervoy
Ipilimumab
REMS program
430
How are tyrosine kinase inhibitors given?
Orally
431
What must be done in patients taking TKIs?
Pharmacogenomic testing
432
TKI oral F?
May be altered with food
433
TKI used in chronic myelogenous leukemia? (CML) 1
BCR\_ABL inhibitors
Imatinib
434
Gleevac
Imatinib
435
Gleevac genetics?
Imatinib
must be philadelphia chromoosome (BCR-ABL) positive
436
How SE of Gleevac
Imatinib
Fluid retention
437
BRAF inhitors used in melonoma 2
Trametinib and Coniteinib
BRAF V600E ot V600K mutation positive to use
Warning new malignancy
438
EGFR inhibitors pharmacogenetics
EGFR positive to use
439
SEs of EGFR inhibitors 2
Acneform rash, dry skin
440
ALK inhibitors
ALK positve to use
441
Lapatinib and Neratinib
HER2 overexpression
442
Special instructions FOr oral Cancer agents 3 drugs
Theo and Lena eat Poms
Thamidomide, pomalidomide, lenalidomide are teratogenic
443
4 anticancer meds that should be given with food or 1 hour after a meal
1. Gleevac (Imatinib)
2. Thalomid (Thalidomide)
3. Xeloda (Capecitabine)
4. Aromasin (Exemestane)
444
What anticancer drug is taken 2 hours before or 2 hours after food?
Pomalidomide
445
6 drugs that should be taken on an empty stomach 1 hour before or two hours after food
1. Nilotinib
2. Erlotinib
3. Sarofinib
4. Temozolamide
5. Abiraterone
6. Pomalidomide
446
How does the CNS control functions of the body? 2 main systems
1. Through the peripheral nervous system
1. SOmatic nervous system
2. autonomic nervous system
447
What does the somatic nervous system do?
COntrols muscle movements
448
The somatic nervous system controls muscle moves by?
1. By sending signals through neurons to release
1. Acetylcholine Ach to act on nicotinic receptors
449
What is the parasympathetic nervous system known as?
The rest and digest system
450
The sympathetic nervous system is also known as?
What three things does it result in?
Also known as fight or flight
1. Increase in
1. Blood pressure
2. HR
3. and glucose production
451
The sympathetic nervous system works by?
releasing epinephrine and nerepinephrine
to act on the adrenergic receptors (aplha 1, beta 1 and beta 2)
452
Alpha 1 agonism causes what two things?
increased Vasoconstriction and BP
453
Antagonism of the alpha 1 receptor causes what?
Vasodilation through smooth muscle relaxation and decrease BP
454
Beta 1 agonism causes what two things?
Increased CO and HR
455
One alpha 1 agonist?
Phenylephrine
456
Example of beta 1 agonist?
Dobutamine
457
Examples of two vasopressors?
Epinephrine and NE
458
What do Epi and NE do? Leads to what 3 things?
Stimulate multiple receptors including alpha 1 and beta 1, b2
WHich leads to increased vaso constriction HR and BP
459
What is clonidine?
Central acting alpha 2 adrenergic agonist
460
What happens when alpha 2 receptors in the brain on stimulated?
Decrease in overall sympathetic output
461
Dopamine dosing? 3 bullets
1. Dopamine stimulates different receptors depending on dose
2. Low renal dosing: 1-4 mcg/kg/min: Dope 1 agonist
3. Medium: 5-10 mcg/kg/min Beta 1 agonist
4. High: 10-20 mch/kg/min: Alpha 1 agonist
462
What 3 things do vasopresssors cause
1. Vasoconstriction
2. Increased SVR
1. which increases BP
463
4 vasopressors
1. Dopamine
2. Epinephrine
3. NE
4. Vasopressin
464
Adrenalin and Epipen?
MOA?
Epinephrine
A1,B1,B2 agonist
465
Levophed?
MOA?
NE
Alpha 1\> B1 agonist
466
Boxed warning for vasopressors?
Dopamine and NE have Black boxes for extravacation
But all are vesicants
It should be treated with phentolamine
467
How is vesication with vasopressors treated?
Phentoloamine
468
5 SEs of vasopressors
1. Arrythmias
2. Tachcardia
3. necrosis gangrene
4. Bradycardia with phenylephrine
5. Hyperglycemia with epinephrine
469
What should be monitored all the time with vasopressos?
Continuos BP monitoring
470
When should vasopressor solutions not be used?
If they are discolored or contain a precipitate
471
How are vasopressors given?
Through IV central line
472
Epinephrine concentration used for IV push
0.1 mg/ml 1:10,000 ration strength
473
Ration strenght for IM or compounded epinephrine?
1:1000
474
How does phentolamine work?
Alpha 1 antagonist
475
Vasodilators 2
Nitroglycerin
Nitroprusside
476
Nitroprusside, Nipride
Nitroprusside
477
Doses of nitroglycerin pertaining to its effects 2
1. Low: venous vsaodilation
2. High: arterial vasodilation
478
Nitroglycerin contraindications? 3
1. SBP\<90
2. Use with PDe-5
3. Ricoguat
479
3 SEs of nitroglycerin?
1. HA
2. tachycardia
3. tachyphylaxis
480
Nitroglycerin notes?
Need non PVC container glass, polyolefin
481
Nitropress, Nipride MOA?
Equal venous and arterial vasodilation
482
Boxed warning for Nitropress, Nipride? 3
1. Metabolism leads to cyanide
2. Excessive hypotension
3. Not for direct injection must be further diluted with D5W
483
Warning for Nitroprusside?
Increase Inctracranial pressure
484
3 SEs of Nitroprusside?
1. HA
2. Tachycardia
3. Thiocyanate/cyanide toxicity (Increase risk in renal and hepatic impairment
485
Nitroprusside: Thiocyanate/cyanide roxicity risk is increased when what?
PAtients have renal or hepatic impairment
486
Administrations notes for Nitroprusside?
1. Protect from light during admin
2. Use clear solutions only a blue color indicated cyanide formation
487
If nitroprusside is hat color?
Blue indicated cyanide formation dont use
488
Nitroglycerin or NTG uses?
During MI or uncontrolled hypertension but efficacy is limited to 24-48 hours due to tachyphylaxis (tolerance)
489
What is used to prevent cyanide toxicity with nitroprusside?
Hydroxocobalamin
Sodium thiosulfate is used for cyanide toxicity
490
What does nesiritide do?
Recombinant B-type natriuttic peptide
Binds to vasuclar smooth muscle and increases cGMP
491
What do inotropes do?
Increase contractility of the heart
492
Two inotropes to know?
Dobutamine
Milrinone
493
How does dobutamine work?
B1 agonist
Increases HR and force of contraction
Which increases cardiac output
494
How does milrinone work?
PDE-3 inhibitor
Produces inotropic effects with significant vasodilation
495
Special note for dobutmaine?
Way turn pink due to oxidation but potency is not lost
496
Crystalloids versus Colloids
Which one is less costly and generally has fewer adverse effects?
Crystalloids
497
What are colloids?
large molecule typically proteins or startch
Remain in the intravascular space and increase oncotic pressue
498
When is dextrose used pertaining to fluids
when water is needed intracellularly
These products contain free water
499
Most common fluids used when volume rescusitation is needed in shock state?
Lactate ringers and NS
500
What is the most common colloid?
Albumin
501
When is albumin particularly useful?
WHen there is significant edema (cirrhosis)
502
Hydroxyethyl startch boxed watning?
Limited by box warning for use in critically ill including sepsis due to increase mortalitiy
503
Crystalloids 3
Dextrose
NS
LActate ringers
504
Colloids 3
Albumin
Dextran
Hydoxyethyl startch
505
Albuminar, Albutein, Alburx
Albumin 5% and 25%
506
General principles for treating shock 3
# 1. Fill the tank
1. Optimize preload with IV crystalloids bolus as needed
2. Squeeze the pipes
1. Peripheral vasocontrictors (a1agonists) to increase systemic vascular resistance
3. Kick the pump
1. B1 agonist to increase myocardial contractility and cardiac output
507
How is shock usually caused and defined?
Hypoperfusion
Hypotension: SBP \<90
MAP \<70
508
What are the 4 types of shocK?
1. Hypovolemic (hemorrhage)
2. Distributive (eptic, anaphylactic)
3. Cardiogenic (post MI)
4. Obstructive
509
What is first line for hypovolemic shock?
IV crystalloids
In pts with hypovolemic chock that is not caused by hemorrhage
510
When are vasopressors not effective?
If intravascular volume is not adequate
511
How is sepsis defined?
Life-threatening organ dysfunction due to dysregulated host response to infection
512
Common ICU infections
2 ones
Mechanical ventilations
foley catheter
513
Increased time on ventilator increases risk of infection what is a common pathogen?
Pseudomonas they like moist air
514
Increasd time with foley catheter does one?
Increase chance of bladder infection
515
treatment for sepsis and septic shock?
Broad spectrum abx and IV fluid resucitation with IV crystalloids
516
What is the vasopressor of choice in septic shock?
NE
517
Acute decompensated HF and cardiogenic shock
What is it?
Acute decompensated heart failure
rapid decline in health, wt gain, worseing of symptoms
518
What has to be present to characterize acute decompensated heart failure to cardiogenic shock?
Hypoperfusion and hypotension
519
When is a ADHF patient considered volume overloaded?
Edema, ascites, jugular venous distention
520
Treatment options for volume overloaded ADHF patients? 2
Loop diuretics
vasodilators can be added
521
How is hypoperfusion characterized? 3 things
1. Decreased renal function
2. ALtered mental status
3. or cold extremities
522
2 treatment options for ADHF patient experiencing hypopurfusion?
1. Intoropes : dobutamine, milrinone
2. If pt become hypotensiove consider adding vasopressor, NE, dopamine, or phenylephrine
3. Avoid vasodilators become they can decrease BP and worsen
523
What should pts be treated with if they have both volume overload and hypoperfusion
Both sets of agents
Loops, but avoid vasodilators
524
When should BBs be stopped in patients with ADHF?
If hypotension or hypoperfusion is present
525
What can be used for invasive monioring?
What does it do?
Catheter called Swan Ganz
1. Measures congeestion pulmonary cap wedge pressure
526
Treating volume overload?
Loops and IV vasodilators
527
What 2 drugs are uniquely suited for hypoperfusion?
Dobutamine and milrinone
528
Common ICU conditions
Pain?
IV pioids
morphine and fentanyl first line
529
Strategy when pain in ICU?
Analgesosedation: sedation strat that used analgesics first
530
What is preferred for sedation in ICU patients?
Non-BZDs are preferred propofol and dexmedomadine
531
How is agitation managed in the ICU?
WIth BZDs: lorazepam or midazolam
532
What is the only sedative approved for intubated and nonintubated patients?
Dexmetomadine
533
Benzos role in sedation two times?
Seizure patients
and
Alcohol withdrawal patients
534
What type of sedation is preferred?
Light sedation
535
What is used to assess someones readiness to get off of sedatives?
Sedation vacaiton baby!`
`
536
What can decrease the risk of delerium in ICU patients?
Using non BZDs and or shorten the suration
537
What drug can be useful for delirium in ICU patients?
Quitiapine
538
Dilaudid?
Hydromorphone
539
Precedex?
Dexmedetomidine
540
How does precedex work?
A2 adrenergic agonist
541
SEs of precedex 3?
1. Hypotension
2. HYpertension
3. bradycardia
542
How long should the infusion for precedex be?
Duration should not be longer than 24 hours
543
Used of precedex?
Sedation in intubated and not intubated patients
544
Diprivan?
Propofol
545
Contraindications to propofol?
hypersesitivity to eggs or soy
546
SEs of Diprivan
Hypotension, apnea, hypertg, green urine/hair/nail beds, propofol related infusion syndrome (PRIS) can be fatal
547
What should be monitored for propofol?
Triglycerides with given for more than 2 days
548
Notes for propofol?
bacterial growth discard vial and tubing within 12 hours
549
What does propofol give you?
Oil in water emulsion give 1.1 kcal/mL
550
Ativan
Lorazepam
551
Note about Ativan injection?
formulated in propylene glycol prop glycol toxicity: can ccause acute renal failure and metabolic acidosis
552
Versed?
Midazolam
553
Contraindication to Versed?
Strong CYP3A4 inhibitors
554
Note about midazolam?
Can accumulate in obese patients and renal impariment (active metabolite)
555
Monitoring for Etomidate?
Adrenal insufficiency
556
Ketamine Warnings?
Emergence reactions vivid dreams hallucinations delerium
557
Haldol
Haloperidol
558
Seroquel?
Quetiapine
559
What is recommended for stress ulcers in ICU patients?
H2RAs and PPIs
560
What 3 things have PPIs been associated with?
Bone fracture, C Diff, Nosocomial Pneumonia
561
What anesthetic can be fatal IV?
Bupivicaine
Commonly used in epiderals
562
Local anesthetic?
Lidocaine
563
Xylocaine?
Lidocaine
564
Inhaled anesthetics? 2
Desflurane, sevoflurane
565
Suprane
Defsflurane
566
Injectable anesthetics? 2
Bupivacaine, ropivicaine
567
What combo is sometimes used for local procedures, anesthetic
Lidocaine/Epi
568
What does epinenephrine do in the lidocaine/Epi combo?
Vasoconstriction and keeps the lido locals
pretty neat!
569
Risk factors to develop Stress ulcers? 2
Mechanical ventilation and coagulopathy
570
When are neuromuscular blockers used? 4
1. During surgery
2. To help with mechanical ventilation
3. TO manage increase ICP
4. Treat muscle spasms
571
What do you need to make sure before giving someone NMBA? 2
1. Ensure adequate sedation and analgesia
2. Must be mechanically ventilated
572
Label for NMBA?
Warning paralyzing agent
573
What is the only available depolarizing NMBA?
Succinylcholine
574
What is succinylcholine typically reserved for?
Intubation
575
What special care needs to be taken with NMBA?? 3
1. Ensure eye lubrication
2. Airway suction
3. Protect the skin
576
What can be used to reduce airway secretions when using NMBA?
What does it do?
Glycopyrolate
Anticholinergic
577
Quelicin?
Depolarizing NMBA
Succinylcholine
578
4 SEs for all non-depolarizing NMBA?
Bradycardia, flushing, hypotension, tachyphylaxis
579
Nimbex?
Cisatracurium
580
Nimbex Notes
Hofmann elimination: independent of renal and hepatic impairment
581
Pancuronium?
Long acting agent
582
How do systemic hemostatic agents work?
By inhibiting fibrinolysis and enhancing coagulation
583
2 topical hemostatic agents?
Recothrom, Thrombin JMI
584
Cyklokapron?
Tranexamic acid
Hemostatic
585
Lysteda?
Tanexamic acid: tablet
586
What is lysteda used for?
Heavy menstrual bleeding: mennorhagic
587
Novoseven RT?
Recombinant factor VIIa
Hemostatic
588
IVIG uses? 4
1. Used to only be indicated for immunodef conditions
2. Now has many uses, MS, myathenia gravis, guilliane barr
589
Treating with IVIG can do what?
impair response to vaccines
590
Carimune NF, Flebogamma DIF, Gammagard, Gamunex-C, Octagam, Privigen
IVIG
591
How is Carimune NF, Flebogamma DIF, Gammagard, Gamunex-C, Octagam, Privigen, dosed?
Using IBW
592
Administration note for IVIG?
Use slower infusions rate for renal and CV disease
593
Boxed warnings for Carimune NF, Flebogamma DIF, Gammagard, Gamunex-C, Octagam, Privigen
2
1. Acute renal dysfunction, usually within 7 days, more likley with products stabalized by sucrose
2. THrombosis
594
SEs of Carimune NF, Flebogamma DIF, Gammagard, Gamunex-C, Octagam, Privigen
10
1. HA
2. Nausea
3. diarrhea
4. injection site rxn
5. infusion rxn, facial flushing, chest pain, tightness, fever, chills, hypotension- slow/stop infusion
595
How is hyponatremia defined?
Na \<135 meq/L
596
How is hypovolemic hyponatremia caused? 5
1. Diuresis
2. salt wasting syndromes
3. blood loss
4. vomitting and diarrhea
597
How is hypovolemic hyponatremia treated?
Sodium chloride containing products IV
598
How is hypervolemic hyponatremia caused?
fluid overload, cirhosis, HF, renal failure
599
How is hypervolemic hyponatremia treated?
Duiretics and fluid
600
How is isovolemic hyponatremia caused?
COmmonly caused by Syndrome of Inappropriate antidiuretic hormone
SIADH
601
What can be used to treat SIADH and hypervolemic hyponatremia?
arginine vasopressin receptor antagonists (AVP)
602
What is the safe way to correct sodium?
12 meq/L over 24 hours
More rapidly can cause osmotic demethylation syndrome (ODS)
or central pontine myelonolysis
can cause paralysis, seizure and death
603
Samsca?
Talvaptan
Arginine vasopressin receptor antagonist
604
How long should a pt be treated with Samsca?
Talvaptan AVP
limited to less than \<=30 days due to hepatotoxicity
605
2 boxed warnings for Samsca?
Talvaptan
1. Intiated and re-initiated in hospital
2. Overly rapid correction of hyponatremia \>12 meq/L/24 is associated with ODS
606
SEs of Samsca? 4
Thirst, nausea, dry mouth, polyuria
607
Warning for Samsca?
Hepatotoxicity
608
What to monitor for samca?
Rate of Na increase
609
How is hypernatremia defined?
What is it associated with?
Na\>145 meq/L
Water deficiency and hypertonicity
610
How is hypokalemia defined?
K\<3.5 mEq/L
611
Common causes of Hypokalemia?
Underlying causes usually, meds, amphotericin and insulin
612
K deficiency related to total body
1. 1mEq drop in serum below 3.5
1. Indicated a total def of 100-400meq
613
Max infusion rate and max concentration of IV potassium chloride?
\>=10mEq/hr
max concentration of 10 mEq/100 mL
614
How can potassium chloride kill you?
IF it is not diluted or given via IV push
615
What is needed for potassium?
Mg must be corrected
616
When is IV mg recommended?
When Mg \<1mEq/L with life threatening symptoms (seizure or arrythmias)
617
What is used for IV mg replacement?
Mg sulfate
618
Common oral mg agent?
Mg oxide
619
When is hypophosphetemia life threatening?
\<1mg/dL
620
When is IV phos used?
PO4 is \< 1mg/dL
