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Clinical Medicine Ortho > Lecture 18 Pharm Treatment > Flashcards

Lecture 18 Pharm Treatment Flashcards

1
Q

Decrease stimulation of pain receptors

A

NSAIDS

APAP

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2
Q

What type of drug blocks conduction of pain signals?

A

anesthetics

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3
Q

What type of drug decreases pain reaction?

A

Narcotics

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4
Q

Pain is difficult to catch up with. When should analgesics be given?

A

Before pain increases

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5
Q

Corticosteroids increase or decrease blood sugar

A

increase

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6
Q

Corticosteroids increase or decrease sympathetic response

A

increase

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7
Q

Corticosteroids increase or decrease WBC’s

A

decrease

lower immune response

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8
Q

Corticosteroids increase or decrease cell injury

A

decrease

stabilize intracellular lysosomes

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9
Q

Corticosteroids increase or decrease inflammation

A

decrease

inhibit histamine, kinkins and prostaglandins

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10
Q

What is the prototype corticosteroid?

A

prednisone

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11
Q

Name 4 uses for Prednisone

A

Immunosuppressants
Decrease cell injury
Anti-inflammatory
Inhibit collagen synthesis - decrease scar tissue formation

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12
Q

What disease is prednisone used as replacement therapy?

A

Addison’s disease

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13
Q

What else are corticosteroids used to treat?

A 
prevent organ transplant rejection
auto-immune
allergic reactions
inflammation
cerebral edema
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14
Q

Hydrocortisone is (more/less) potent than Dexamethasone and Betamethasone

A

LESS

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15
Q

What are some adverse effects of corticosteroids?

A

Hyperglycemia
Cushing’s syndrome
Decreased immune response

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16
Q

What glands will long term use will cause suppression of?

A

adrenal glands

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17
Q

What is important to remember when taking someone off long term use?

A

Taper with hydrocortisone

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18
Q

Can you administer live vaccines with corticosteroids?

A

NO bc decrease WBC’s

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19
Q

Why should you use caution when giving these to diabetics?

A

uncontrolled sugar levels

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20
Q

Name two negative effects of corticosteroids on the GI and skeletal systems

A

Peptic Ulcer Disease

Osteoporosis

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21
Q

Are corticosteroids safe for pregnant women?

A

no

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22
Q

How do NSAIDS work

A

Block production of prostaglandins via COX inhibition

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23
Q

What NSAID is the prototype and used for its cardiac benefits?

A

COX-1
ASA
irreversibly inhibits platelet aggregation

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24
Q

Name some diseases that NSAIDS are used to treat?

A

Rheumatoid arthritis
Osteoarthritis
Gout

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25
Q

Are NASIDS well absorbed?

A

yes

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26
Q

Do you need to monitor pt with renal and liver problems on NSAIDS?

A

yes
renal excretion
enterohepatic recycling

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27
Q

What is the main side effect of NSAIDS?

A

GI problems

nasuea, vomiting, GI bleeding, ulceration

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28
Q

Therapeutic dosing of NSAIDS for inflammation is (higher/lower) than over the counter dosing

A

much higher

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29
Q

What NSAIDS has opioid like effects but not addictive?

A

Ketorolac

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30
Q

Para-aminophenols

A

tylenol

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31
Q

2 uses of para-aminophenols:

A 
fever reduction (antipyretic)
pain reliever (analgesic)
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32
Q

Name 3 advantages of para-aminophenols over NSAIDS

A

no GI problems
no allergies
no bleeding

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33
Q

Name a disadvantage of para-aminophenols compared to NSAIDS and corticosteriods

A

poor anti-inflammatory action

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34
Q

What is the one major side-effect of para-aminophenols?

A

Liver toxicity

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35
Q

What is the prototype narcotic?

A

morphine

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36
Q

What type of receptors are activated in the thalamus and limbic system with narcotics?

A

mu

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37
Q

What are two major side effects of narcotics?

A

addiction

withdrawal

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38
Q

Why does someone have to keep increasing their dose to illicit the same effects of a narcotic?

A

tolerance build up

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39
Q

Why does codeine not have any affect on some people?

A

it is a pro-drug that some can’t metabolize into its active form

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40
Q

What opioid has a lot of side effects?

A

oxymorphone

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41
Q

What are the benefits of drug combinations with opioids?

A

antipyretic

less opiate given

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42
Q

What is one thing to watch out for in combination narcotic drugs?

A

APAP accumulation from multiple sorces

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43
Q

Methotrexate (MTX) falls under what category of DMARDs?

A

Non-biologics

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44
Q

What does MTX tx?

A

RA and some malignancies

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45
Q

A pt comes into your office and they leave with a dx of RA. What’s your first line of tx?

A

Methotrexate: alone or with a biologic combo

46
Q

What’s the MOA for Methotrexate?

A

↓ cell proliferation
↑ apoptosis of T cells
↑ adenosine release (potent inhibitor of inflammation)
Alters expression of CAM (cellular adhesion molecules)
Inhibits pro-inflammatory cytokines

47
Q

What are some side effects of MTX?

A 
*Mucosal ulcers
Nausea* (common chemo side effects)
Stomatitis 
Diarrhea
Alopecia 
Anemia
48
Q

An RA pt comes in for a f/u who has been successfully tx with MTX and tells you she is pregnant. What should you do?

A

First congratulate her then CHANGE HER MEDS

49
Q

TRUE or False: MTX is okay to use during pregnancy.

A

FALSE FALSE FALSE

50
Q

Leflunomide (Arava) is what type of drug?

A

Non-biologic

51
Q

What it the MOA of Leflunomide?

A

Inhibits mitochondrial dihydroorotate dehydrogenase (DHODH) ultimately resulting in decreased DNA and RNA in rapidly dividing cells

52
Q

TRUE or FALSE: Leflunomide is okay to use during pregnancy

A

LeFALSEomide

53
Q

Sulfasalazine (Azulfidine) is what type of drug?

A

Non-biologic

54
Q

What is the MOA of Sulfasalazine?

A

Similar to MTX…
↓ cell proliferation
↑ apoptosis of T cells
↑ adenosine release (potent inhibitor of inflammation)
Alters expression of CAM (cellular adhesion molecules)
Inhibits pro-inflammatory cytokines

55
Q

Name some side effects of Sulfasalazine?

A

N/V, HA, rash, rarely anemia and methemoglobinemia and neutropenia

56
Q

True or False: Sulfasalazine is okay to to use in pregnancy.

57
Q

What is the thing to remember about fertility and using Sulfasalazine?

A

Reversible infertility in men but not women

58
Q

Hydroxycholorquine (Plaquenil) is what type of drug?

A

Non-biologic

59
Q

What is the MOA of Hydroxycholorquine?

A

Mechanism of action in RA is unclear.

NOTE: It’s an anti-malarial drug

60
Q

How long does it take Hydroxycholorquine to work?

A

3-6 m before any improvement in symptoms

61
Q

What are some side effects of Hydroxycholorquine?

A

Retinal damage if doses exceed 6 mg/kg/day (ophthalmologic exams yearly), GI issues, rash, nightmares

62
Q

What are some other benefits seen from using Hydroxycholorquine? (diabetes & high lipids)

A

Improved glucose levels in diabetic pts & lower A1C

May improve LDL, HDL, and TG

63
Q

True or False: Hydroxycholorquine is okay to use in pregnancy.

64
Q

Tolfacitinib (Xeljanz) is what type of drug?

A

Non-biologic

65
Q

What is the MOA for Tolfacitinib?

A

Suppresses immune response

66
Q

Tolfacitinib is usually given (alone or in combo)?

A

Either.

Combo with MTX or alone in moderate to severe disease where MTX failed or cannot be used

67
Q

What cytochromes dose Tolfacitinib use?

A

CYP3A4 or CYP2C9 inhibitors

68
Q

What are some side effects of Tolfactinib?

A

HA, diarrhea, URI, rarely GI perforation

69
Q

Name the 2 classes of biologics?

A

Anti-TNF & non-TNF

70
Q

Names some anti-TNF biologic agents.

A 
Etanercept (Enbrel)
Infliximab (Remicade) - IV
Adalimumab (Humira)
Certolizumab (Cimzia)
Golimumab (Simponi)
71
Q

Name some non-TNF biologic agents.

A

Abatacept (Orencia) (T cell costimulation inhibitor) - IV and SC
Rituximab (Rituxan) (B cell depleter) - IV
Tocilizumab (Actemra) (interleukin-6 inhibitor) - IV

72
Q

What are some side effects of anti-TNF biologic agents?

A

Injection site reactions
Infection
New-onset psoriasis,
Increased risk of lymphoma and leukemia

73
Q

What are some contraindications for anti-TNF biologic agents?

A

Presence of serious or recurrent infection

Pts w/ >= Class III HF & EF

74
Q

What should you check before starting a pt on anti-TNF biologic agent?

A

Checked for TB

75
Q

What are some of the side effects of Non-TNF agents B cell depleters?

A

Infusion reactions, rash (30%) with first infusion then decreases with subsequent infusions

76
Q

What are some contraindications for Non-TNF agents B cell depleters?

A

presence of serious or recurrent infection, type 1 allergic reactions to murine proteins

77
Q

What are some of the side effects of Non-TNF agents T cell costimulation inhibitors?

A

infusion reactions, increased risk of lymphoma

78
Q

What are some contraindications for Non-TNF agents T cell costimulation inhibitors?

A

presence of serious or recurrent infection

79
Q

What are some of the side effects of Non-TNF agents IL-6 inhibitors?

A

Infusion reactions, infection, increased lipids, URI, HA, HTN, elevated liver enzymes, decreased neutrophils, decreased platelets, GI perforation (esp in diverticulitis and on corticosteroids)

80
Q

What should you check before starting a pt on IL-6 inhibitors?

A

Screen patients for TB prior to beginning tx

81
Q

Dr. Lugo’s final take way points…

A
  1. Hydroxychloroquine & TNF inhibitors may decrease risk of diabetes according to some studies
  2. MTX and sulfasalazine have proven remission rates with MTX being standard of care
  3. Pregnancy is a contraindication for MTX & leflunomide
  4. Monotherapy for nonbiologics is recommended in early disease
  5. Biologics are recommended only after nonbiologic failure in patient with poor prognosis or failure of two nonbiologic regimens in patients without poor prognosis.
  6. Biologics are almost always given with MTX
82
Q

What type of drug should you give during an acute gout attack?

A

Fast-acting NSAIDs: indomethacin, naproxen, sulindac

NOTE: Begin within first 24 hours

83
Q

How long do you continue the therapy for an acute gout attack?

A

High dose for 2-3 days then step down over 2 weeks and continue for 2 days after resolution

84
Q

What other meds can you prescribe for an acute gout attack?

A

COX-2 inhibitor, Corticosteroids (injections), Colchicine (Colcrys)

85
Q

What is the standard of care medication for chronic management of gout?

A

Allopurinol

Give w/ NSAID or colchicine initially until uric acid levels are

86
Q

What are some side effects of allopurinol?

A

GI disturbance, HA, rash, rarely cataracts, aplastic anemia, peripheral neuritis

87
Q

Febuxostat (Uloric) is a xanthine oxidase inhibitor. It is used for what type of gout tx?

A

Chronic management

88
Q

What side effects are there with Febuxostat?

A

elevated LFTs (liver fxn tests), diarrhea, HA, nausea

89
Q

Pegloticase (Krystexxa) is a urate oxidase enzyme. It is used for what type of gout tx?

A

Chronic management

NOTE: After 6 months of treatment 45% of patients experienced complete resolution of tophi

90
Q

What is a major contraindication of Pegloticase?

A

G6PD deficiency; screening of patients of African and Mediterranean decent recommended

91
Q

What are some side effects of Pegloticase?

A

Infusion reactions (premed with antihistamine and corticosteroid), gout flares, nausea, bruising

92
Q

How should you choose an agent for chronic tx?

A

Remove any offending drugs (i.e. thiazides…)
Decrease or eliminate alcohol intake
Renal vs hepatic
Cost

93
Q

What are the two classes of local anesthetics?

A

Esters and Amides

94
Q

Name some ester based local anesthetics

A

Cocaine
Procaine
Tetracaine
Benzocaine

95
Q

Name some amide based local anesthetics.

A 
Lidocaine
Mepivacaine
Bupivacaine (Marcaine)
Ropivacaine
Articaine
96
Q

What is the MOA for local anesthetics?

A

Work on afferent nerve fibers; LA given in unionized form, enters neuron, ionizes and cannot leave cell, binds to NA channel , stops Na from entering neuron and prevents generation and conduction of action potential

97
Q

What are some common additives found in many local anesthetics?

A

Epi, bases, opioids, Alpha-2 adrenergic agonists (i.e. clonidine)

98
Q

What is one benefit and one disadvantage of Epi’s ability to vasoconstriction?

A

Benefit: Keeps the drug in the specific location
Disadvantage: Can cause skin necrosis

99
Q

How are esters metabolized?

A

Hydrolyzed by pseudocholinesterases to PABA (allergy risk)

100
Q

How are amides metabolized?

A

In liver by cytochromes

101
Q

What are some issues we see with local anesthetics?

A

HA, dizziness, confusion, CNS depression

102
Q

Lidocaine is ___________ & Bupivicaine is ___________, in terms of onset.

A

fast, slow

NOTE: Both are affect the heart in some way

103
Q

What is Methemoglobinemia?

A

Ferric hemoglobin present instead of ferrous hemoglobin; poor O2 delivery

104
Q

In what cases do we see methemoglobinemia in?

A

Chloraseptic throat sprays & teething babies

105
Q

There is a risk of toxicity with some local anesthetics, one of which is Transient neurological symptoms (TNS). What is this?

A

Pain in lower extremities (gluteus and moving down)
Resolves within a week
Lidocaine more likely culprit

106
Q

What 2 drugs cause arrhythmias?

A

Bupivacaine & ropivacaine

107
Q

What do you do if a pt seizes after you administer a local anesthetic?

A
  1. Benzos
  2. ACLS but no big doses of epi; amiodarone for arrhythmias
  3. IV lipid is used to manage cardiovascular collapse

NOTE: Don’t use anesthetic type antiarrhythmics to treat arrhythmias from anesthesia

108
Q

What is the MOA of Intra-articular Hyaluronic Acid?

A

Replaces OA synovial fluid with higher HA concentration improves viscosity

109
Q

What are the side effects of Intra-articular Hyaluronic Acid?

A

Allergy, pain, swelling, heat, redness, and/or fluid build-up around the knee.

110
Q

What are the contraindications for intra-articular hyaluronic acid?

A

Pts with known allergy

Pts w/ joint infections or skin diseases or infections in the area of the injection site.

111
Q

What do you need to know about Taylor’s natural medicines?

A

These products are regulated as food, not drugs.
Best advice to a pt, stick with the food (med) that was studied in the study.
Purchase high quality

112
Q

Glucosamine is legit. How does it work?

A

Tx OA pain; increases production of synovial fluid, repair of damaged tissue, new (knee) cartilage synthesis

Clinical Medicine Ortho (42 decks)

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