ITE CA2 pharm 4

Question 1

Hexamethonium

Answer 1

Hexamethonium is an example of a ganglionic blocking drug which acts as an antagonist at the neuronal-type nicotinic receptors

Question 2

neuronal-type nicotinic receptor blockers

Answer 2

hexamethonium, trimethaphan, and mecamylamine

Question 3

can you dialyze off
apixaban
dabigatran
rivaroxaban

Answer 3

apixaban - no
dabigatran - partially
ravaroxaban - no

Question 4

Bivalirudin

Answer 4

Bivalirudin is a direct thrombin inhibitor with a relatively short half-life (25 minutes in patients with normal renal function; up to three hours in dialysis-dependent individuals). Its primary application is in patients undergoing percutaneous coronary intervention (PCI). As of 2018, there is no known antidote. Given its short half-life, treatment of hemorrhage is primarily supportive

Question 5

Dabigatran
mechanism
reversal

Answer 5

Idarucizumab is a monoclonal antibody fragment that binds to the active site of dabigatran, a direct thrombin inhibitor with oral bioavailability. It is used for the management of serious bleeding caused by dabigatran but does not appear to be effective against bleeding caused by other direct thrombin inhibitors (such as bivalirudin or argatroban).

Question 6

Andexanet alfa

Answer 6

Andexanet alfa is a recombinant derivative of factor Xa, and acts as a “decoy receptor”, effectively binding factor Xa inhibitors (such as rivaroxaban, apixaban, and edoxaban) with higher affinity than factor Xa itself. Its approval represents an important step forward in anticoagulation management, as direct factor Xa inhibitors (like rivaroxaban and apixaban) continue to grow in popularity. Direct factor Xa inhibitors have oral bioavailability, do not require laboratory monitoring or have special dietary requirements (unlike warfarin), and have relatively attractive side effect profiles.

Andexanet alfa is approved for the management of major bleeding resulting from treatment with direct factor Xa inhibitors such as rivaroxaban, apixaban, and edoxaban.

Question 7

Unlike most anesthetics which directly depress the RAS, ketamine exerts its effects on the ______, causing dissociation of the _____________________.

Answer 7

Unlike most anesthetics which directly depress the RAS, ketamine exerts its effects on the thalamus, causing dissociation of the reticular activating system from the cerebral and limbic cortices.

Question 8

Amiodarone
MoA
Use

Answer 8

Amiodarone is a class III antiarrhythmic agent with a primary effect of blocking potassium channels. It also blocks calcium and sodium channels to a lesser effect as well as α- and β-adrenergic receptors. The approved clinical use of amiodarone is limited to refractory ventricular arrhythmias. Recall that amiodarone is still the antiarrhythmic agent of choice in the setting of CHF or low ejection fraction.

Question 9

Amiodarone is contraindicated in

Answer 9

Amiodarone is contraindicated in the setting of heart block and preexisting bradycardia.

Question 10

side effects of amiodarone include

Answer 10

Important side effects of amiodarone include bradycardia, hypotension, hypothyroidism, life-threatening hyperthyroid storm, pulmonary toxicity (with a pulmonary fibrosis appearance), prolonged QT interval, and elevated liver function markers.
Amiodarone is known to create extensive tissue deposits which lead to skin hypersensitivity and hyperpigmentation, described as a blue-grey appearance.

Question 11

Amiodarone half life

Answer 11

Even when amiodarone is discontinued, there is still a risk of toxicity because of the drug’s long 45 day half-life.

The risk of amiodarone-induced pulmonary toxicity correlates more with the total cumulative dose than with the daily dose or plasma concentration.

Question 12

chronic dantrolene use, what lab monitor

Answer 12

Chronic dantrolene use has been associated with liver dysfunction and potentially fatal liver failure, thus liver function testing (LFT) should be routinely monitored.

Question 13

when use steroids for pain

Answer 13

Corticosteroids such as methylprednisolone are not used for management of chronic diabetic neuropathic pain, but may be beneficial during the acute phase of herpes zoster

Question 14

treatment of chronic diabetic neuropathy

Answer 14

methadone, tramadol, antiepileptics (such as gabapentin or carbamazepine), antidepressants (such as tricyclic antidepressants (TCAs), including desipramine and amitriptyline), and SNRIs.

Question 15

Drugs which can cause hyperkalemia include

Answer 15

Drugs which can cause hyperkalemia include beta blockers, nonsteroidal anti-inflammatory drugs, spironolactone, heparin, and angiotensin-converting enzyme inhibitors

Question 16

Patients who are hyperkalemic can present with

Answer 16

Patients who are hyperkalemic can present with weakness, palpitations, bradycardia, nausea, vomiting, and paralysis.

Question 17

MoA for TXA and aminocaproic acid

Answer 17

tranexamic acid (TXA) or aminocaproic acid, both of which work by binding plasminogen and plasmin, effectively preventing further breakdown of fibrin.

Question 18

MoA tPA

Answer 18

enzymatic catalyst for conversion of plasminogen to plasmin

Question 19

MoA protamine

Answer 19

direct binding of large negatively charged heparin molecules in the serum

Question 20

MoA DDAVP

Answer 20

induction of synthesis of von willebrand factor by endothelial cells

Question 21

type of steroid dexamethasone

Answer 21

glucocorticoid

Question 22

patient on chronic steroids do they need mineralcorticoid peri-op

Answer 22

no (secondary adrenal insufficiency)
most current literature suggests that dexamethasone alone is appropriate for prophylaxis in patients with possible secondary adrenal insufficiency (e.g. due to steroid use). Mineralocorticoid prophylaxis is most appropriate for patients with primary adrenal insufficiency (unrelated to chronic steroid use).

Question 23

which drugs can cause anticholinergic syndrome

what drug to treat it

Answer 23

Atropine and scopolamine can produce a central anticholinergic syndrome, which can only be treated with physostigmine, 1-2 mg IV (neostigmine and pyridostigmine do not pass into the CNS)

Question 24

Phenelzine

Answer 24

Phenelzine is a monoamine oxidase inhibitor (MAOI) used for treatment-resistant depression. MAOI therapy results in increased serotonin in synaptic clefts. Can cause serotonin syndrome

Question 25

signs of serotonin syndrome

key difference b/t serotonin syndrome and central anticholinergic syndrome

Answer 25

Signs of serotonin syndrome include clonus, hyperreflexia, tachycardia, hyperpyrexia, diaphoresis, ataxia, and confusion. The most accurate diagnostic criteria currently are the Hunter Toxicity Criteria Decision Rules. Criteria are met when the patient has one of the following:

• Spontaneous clonus
• Inducible clonus plus agitation or diaphoresis
• Ocular clonus plus agitation or diaphoresis
• Tremor plus hyperreflexia
• Hypertonia plus temperature > 38 °C plus ocular clonus or inducible clonus

Note that diaphoresis is more common with serotonin syndrome. In contrast, xeroderma (dry skin) is more common with central anticholinergic syndrome (CAS).

Question 26

name 3 TCAs

Answer 26

amitriptyline, nortriptyline, dosulepin

Question 27

name 3 irreversible MAO-Is

Answer 27

phenelzine, tranylcypromine, and isocarboxazid

Question 28

name 1 reversible MAO-I

Answer 28

moclobemide

Question 29

2 drugs to avoid if someone on MAOI

Answer 29

meperidine and indirect-acting vasopressors (ephedrine)

Question 30

how long discontinue prior to spinal
clopidogrel
ticlopidine
fondaparinux
garlic
ginko
ginseng
warfarin

Answer 30

clopidogrel - 7 days
ticlopidine - 14 days
fondaparinux - 36 to 42 hours
garlic - don't have to stop
ginko - don't have to stop
ginseng - don't have to stop
warfarin - 4-5 days

Question 31

Droperidol

Answer 31

Droperidol is a butyrophenone which comes from a different class than ondansetron, dexamethasone, or scopolamine and can be useful in “rescue” situations.

Question 32

burn patient
how should you alter dosing of
benzos
opioids
insulin
paralytics

Answer 32

Severe burns lead to hypoalbuminemia which increases the free fraction of many anesthetic drugs including benzodiazepines and opioids. Lower doses of benzodiazepines should be considered, while higher doses of opioids are usually required due to the rapid development of tolerance. Insulin resistance is seen due to increased catecholamine and corticosteroid levels. Proliferation of extrajunctional acetylcholine receptors leads to exaggerated hyperkalemia with succinylcholine use and resistance to nondepolarizing neuromuscular blockers.

Question 33

Donepezil

Answer 33

Donepezil is a reversible, non-competitive inhibitor of acetylcholinesterase which can cause increased availability of acetylcholine at neuromuscular junctions. Patients on donepezil should be monitored for prolonged relaxation after succinylcholine.

Question 34

name 3 cholinesterase inhibitors

Answer 34

Cholinesterase inhibitors (donepezil, galantamine, rivastigmine)

Question 35

Carbamazepine toxicity is associated with

Answer 35

Carbamazepine toxicity is associated with neurologic, cardiovascular, and anticholinergic symptoms. These include mydriasis, nystagmus, QT prolongation, tachycardia, hypotension, flushing, dry mouth, and urinary retention.

Question 36

Nalbuphine vs Buprenorphine

Answer 36

Nalbuphine: kappa agonist, mu antagonist

Buprenorphine: partial mu agonist, kappa antagonist

Question 37

M6G side effects:

M3G side effects:

Answer 37

M6G side effects: drowsiness, nausea/vomiting, coma, respiratory depression
M3G side effects: agitation, myoclonus, delirium, hyperalgesia.

Question 38

1 mg of intrathecal (IT) morphine = x mg of epidural (EP) morphine
1 mg of EP morphine = x mg of IV morphine
1 mg of IV morphine = x mg of PO morphine

Answer 38

1 mg of intrathecal (IT) morphine = 10 mg of epidural (EP) morphine
1 mg of EP morphine = 10 mg of IV morphine
1 mg of IV morphine = 3 mg of PO morphine