Lecture 4 (Special Populations)-Exam 2 Flashcards
Vitamin C deficiency
* What is the active form?
* What is the MCC?
- Active form: Ascorbic acid
- MCC: decreased intake
Vitamin C deficiency
* What are the manifestations?(5)
- Periodontal disease
- Impaired immune system
- Impaired wound healing
- Depression
- Microcytic anemia
What is the treatment for vitamin C deficiency?
- Increased intake
- Ascorbic acid: 70 to 150 mg IM/IV/SC daily
Appendicitis treatment: not ruptured
* What is first line?
* What do you need to do perioperativly? Post operative?
First-line: appendectomy
* Perioperative antibiotics: Ceftriaxone plus metronidazole
* 0 to 7 days post operative antibiotics-> Less evidence
Appendicitis treatment: ruptured or sepsis
* What is first line?
First-line: supportive care plus antibiotics
* Stabilize
* Percutaneous drain
* Antibiotic therapy
Rupture / sepsis:
* What are the empiric IV antibiotics choices? (3)
* What can be added?
- Meropenem or imipenem
- Piperacillin/tazobactam
- Ciprofloxacin plus metronidazole
- ± percutaneous drain
Appendicitis treatment:
* When do you convert the antibiotics?
* When do you f/u?
- Conversion to oral antibiotics once clinically improved to complete 7 to 10 days course
- Follow-up in 6 to 8 weeks for scheduled appendectomy
What are the challenges to safe and effective drug therapy in the elderly? (5)
- Polypharmacy
- Altered pharmacokinetics / pharmacodynamics
- Physiologic reserve
- Access to medications
- Social system and support
Polypharmacy
* WHO defines this as what?
* What are the risk factors?(6)
World Health Organization (WHO) ≥ 5 drugs at any one time
* Aging population
* Complex therapies
* Multiple prescribers
* Multiple pharmacies
* Psychosocial issues
* Adverse drug reactions (prescribing cascade)
Strategies to Prevent Polypharmacy
* Maintain what?
* Encourage patients to do what?
* Review what?
* Use the fewest what?
- Maintain an accurate medication list and medical history and update whenever possible
- Encourage patients to bring all medications including prescription, OTC drugs, supplements, and herbal preparations
- Review any changes with patient and caregiver and if possible, provide all the changes in writing
- Use the fewest possible number of medications and the simplest possible dosing regimen
Strategies to Prevent Polypharmacy
* Try to link what?
* Discontinue what?
* Screen for what?
* Use for type of approach?
* Avoid what?
- Try to link each prescribed medication with its diagnosis
- Discontinue all unnecessary medications
- Screen for drug-drug and drug-disease interactions
- Use a team approach if possible involving the caregiver or family and pharmacist
- Avoid starting potentially harmful medications; use Beer’s criteria
Strategies to Prevent Polypharmacy
* Try to start medications how?
* Avoid starting medications to combat what?
* What should you be doing during transitions of care?
* Consider what when assessing emdication appropriatenees?
- Try to start a new medication at the lowest dose and then titrate slowly
- Avoid starting medications to combat the potential side effects of other medications (prescribing cascade)
- Careful medication reconciliation during transitions of care
- Consider goals of care and life-expectancy of patients when assessing medication appropriateness
Pharmacokinetic / Pharmacodynamic changes
* Increase risk of what?
* Physiologic changes alter what?
* Increased sensitivity to what? Give examples (4)
Increased risk of adverse drug reactions due to pharmacokinetic changes
Physiologic changes alter response to drug therapy
Increased sensitivity to adverse drug reactions
* Antihypertensives
* Anticoagulants
* Anticholinergic
* CNS drugs
Pharmacokinetic / Pharmacodynamic changes
Common criteria for risk determination
* What does the drug burden index incorporate?
* Increasing number of these medications lead to what? (3)
Incorporates drugs with anticholinergic and CNS adverse effects
Increasing number of these medications leads to
* Impaired mobility
* Decrease in cognitive testing
* Increased falls
Common criteria for risk determination: Drug burden index
* Total number of medications did not increase what?
Total number of medications did not increase adverse effects if these two medication classes excluded(anticholinergics and CNS)
Common criteria for risk determination: beers criteria
* What is it?
* What does look at? (5)
List of medications potentially inappropriate for older patients due to risk of adverse effects
* Potentially inappropriate in most groups
* Typically avoided based on specific conditions (ex. Liver disease)
* Used with caution
* Drug-drug interactions
* Dose adjust based on kidney function
What are the medications commonly associated with ADRs in elderly?
- Anticoagulants
- CNS agents
- Antipsychotics
- Opioids
- Benzodiazepines
- Antidepressants
- Sedative hypnotics
- Antiepileptics
- Diuretics
- Antihypertensives
What is the step wise approach to reviewing medications for older adults?
Under prescribing
* What is it?
* Why does this happen? (5)
Number of medications / medication doses below guideline recommended normal
* Prescribers not aware of continued benefits in older adults->Treatment and prophylaxis (old studies vs new)
* Informed under prescribing (scared of overdoing it)
* Increase compliance
* Limit drug interactions
* Maintain QOL
Access affordability
* What are the issues? (2)
- Underinsured or uninsured – specifically medications
- Compliance decreases with lack of insurance coverage
Access affordability
* What are the ways to help? (4)
- Know your patient’s situation
- Know least expensive drugs in major classes used
- Have a person who can tap them into resources
- Watch out for the new, “fancy” medications
Antifungal example
* What is an example of expensive drug?
* What is the dosing?
* What is the problem?
Preventable causes of drug- related problems
Preventable causes of drug- related problems
Pediatric drug therapy
* How many drugs have been approved for pediatric patients?
* Majority of drugs are what?
* Rarely what occurs? (give two examples)
25 to 30% of FDA approved drugs have specific indications for pediatric patients
Majority of marketed drugs are used to some extent in this population - off label
Rarely, drugs are approved specifically for the treatment of patients 1 to 21 years
* Rasburicase (Elitek)-> Increase uric acid secretion
* Clofarabine -> AML in children
Pediatric drug therapy
* What has the FDA created?
* What are the two acts what were passed?
The FDA has created incentives for pediatric research
* 2003 pediatric research equity act: six-month extension of patent rights to the drug for pediatric research
* 2007 best pharmaceuticals for children act: drug companies need to give detail regarding why a drug is not suitable for use in the pediatric population if they decline to do ped trials and must also describe why a pediatric formulation is not possible if pediatric indications is being sought
Pediatric drug therapy: AAP off label
* Definition: Use of drug not included in what? Does not imply what? (2)
Definition
* Use of drug not included in the prescribing information
* Does NOT imply improper, illegal, contraindicated, or investigational use
* Does NOT imply therapy unsupported by evidence
Pediatric drug therapy
* What is not required?
Consent NOT required for non-experimental use
What is gestational age, postnatal and postmenstral age?
Pharmacokinetics-children
* What is the absorption difference?
* What are the different components?(4)
- No clinically significant difference
- GI motility, gastric pH, skin integrity, intramuscular volumes
Pharmacokinetics: Peds
* What is different about distribution? (3)
- Increased total body water (lose over time)
- Increased total body fat (increase over time)
- Ineffective albumin (decrease albumin and effective)
Pharmacokinetics: Peds
* What is different about metabolism?
- Preterm – decreased metabolic activity of liver
- Term to 1 year – mild decrease in metabolic activity of liver
- 1 to 10 – increased metabolism of liver (Works very well because the liver is not damage)
CYP enzymes mature @ different times
Pharmacokinetics: peds
* What is different about excretion?
Preterm – decreased GFR (creatinine clearance)-> Vs. term babies (still not as well)
Medication dosing- Peds
* Be caution about what?
* Max dose is generally what?
* Write dose in what?
* Watch out for what?
- Mg/kg dosing – use caution with mg/kg/day vs mg/kg/dose
- Maximum dose is generally max adult dose
- Write dose in mg in order to prevent errors
- Watch for accidental weight in pounds instead of kg
Medication dosing- Peds
* Get comfortable with what?
* What is not recommended?
* Never tell a child what?
* What should be use?
- Get comfortable with appropriate volumes per age
- Mixing with food generally not recommended
- Never tell a child the medication is candy
- Syringes or measuring spoons should be use (do not use home spoon)
What is the ideal pediatric drug? (5)
- Very tasty liquid, chewable, dissolvable tablet
- Low volume
- Low frequency
- Easy storage
- Easy to administer
Prescribing and administration barriers
Prescribing and administration barriers: Taste
* What should you know?
* Avoid doing what?
* Try what?
* What are some examples?
* Professional what?
* Work on what?
- Knowing medications that taste poorly
- Avoid mixing with food
- Try foods before or after
- Popsicles, chocolate sauces, peanut butter
- Professional flavoring
- Work on pill swallowing
Poison prevention
* What are the different laws passed over the years (3)
- 1953 - 1st US Poison Center
- 1970 – Poison Prevention Act
- 2002 – Introduction of toll-free Poison Help Line (800)-222-1222
Poison prevention:
* How many centers across the US?
* When are the open?
* Who are the people placing the phone calls?
* who are 50% of reported calls about?
- 55 centers across the United States
- 7d/24h/365d
- 70% of calls are from caregivers in the home
- 16% of calls are healthcare providers
- Children < 6 years = 50% of poisons reported
Poison prevention
* Pattern of poisoning varies by what? Expand
Pattern of poisoning varies by age
* < 6 years = unintentional
* Adolescents and young adults = mostly intentional (62%)
Most common agents involved in poisoning in developed countries
* What are the six most common causes?
Most common agents involved in poisoning in developed countries
* What are the mc one pill kills drugs? (8)
Poison prevention: Medication
* keep what locked up?
* Do not share what?
* Do not remove what?
Keep potentially poisonous medications locked and out of reach of children
Do not share prescriptions medications with others
Do not remove medications from their original containers, keep them properly labeled and stored
* PILL BOXES are a problem
Poison prevention
* Never call medication what?
* Ensure what?
* Properly do what?
- Never call medications “candy” to encourage ingestion / compliance
- Ensure you do not prepare medication or administer medication in the dark
- Properly discard unfinished or unused medications
Poison prevention: household products
* Keep all products in what?
* Keep what locked up?
* Do not place what where?
- Keep all products in their original containers and label them properly
- Keep potentially poisonous household items locked and out of reach of children
- Do not place poisonous household items in food containers
Poison prevention
* What needs to be out of reach for children?
* What needs to be properly labeled?
* Be cautious with what?
- Cosmetics and toiletries should be kept out of reach of children
- Laundry products must be properly labeled and kept out of reach of children
- Be cautious with items such as hairspray, perfume, shoe polish, nail polish remover, and hair dyes
Pregnancy / lactation reproduction
* What was passed?
* What are the categories?
- Pregnancy and Lactation Labeling Rule (PLLR) passed by the FDA in 2015
- Elimination of the previously lettered categories A, B, C, D, and X
Pregnancy / lactation reproduction
* What does the New labeling include?
- Pregnancy Risk Summary
- Registry Information (if applicable)
- Clinical Considerations
- Females and Males of Reproduction Potential (NEW)
What are the drugs that are contraindicated in pregnancy? (7)
- Statins
- Spironolactone
- Warfarin – fetal syndrome
- Anticonvulsants – topiramate
- Guaifenesin – neural tube defects
- Isotretinoin, tretinoin
- Antibiotics
SIA SWAG
Drugs contraindicated in pregnancy
Drugs contraindicated in pregnancy
Drugs contraindicated in pregnancy
Drugs in lactation: considerations
* Need for what?
* Potential side effects on what?
* What type of drug has high excretioin in milk?
Need for drug by mom (how important does mom needs)
Potential side effects on milk production (maybe no harm bady but decreases milk production)
Amount excreted in the breast milk
* Unionized, small molecule, high lipid solubility, low Vd, low protein binding = high excretion
Drugs in lactation: Considerations
* Drug _
* Potential what?
* Age of who?
* Maternal status of what?
* What agents?
- Drug half-life (pump and dump)
- Potential adverse effects
- Age of infant
- Maternal HIV status
- Chemotherapy agents
lactation: contraindicated medications ( it is a lot, i did not know how to break it up)
- Acebutolol, atenolol– hypotension, bradycardia
- Amiodarone - hypothyroidism
- Antidepressants – some (tricyclic antidepressants)
- Antiepileptics – some (phenobarbital, phenytoin, lamotrigine)
- Aspirin – metabolic acidosis
- Benzodiazepines
- Cytotoxic agents – methotrexate
- Ergotamine – N/V/seizures
- Estradiol
- Lamotrigine
- Lithium
- Nitrofurantoin – hemolysis if G6PD deficient
- Sulfasalazine – bloody diarrhea
lactation
fill in aftered part
Immunizations
* What type of immunity?
* Creation of what?
* Repeat exposure leads to what?
- Active, adaptive immunity
- Creation of memory B and T cells after exposure to antigen of vaccine
- Repeat exposure leads to rapid response and replication of immune cells
Immunization types
* What are whole cell vaccines? Fractionated vaccine?
Whole cell vaccine:
* Live attenuated
* Inactivated
Fractionated vaccines:
* Subunit
* Toxoids
Live attenuated:
* How does is work?
* What are the examples?
Explanation:
* Live virus particles that have been weakened to keep them from causing disease
* Strong immune response; like natural response
* May not be appropriate for some individuals (immunocomp and preg)
Examples:
* Measles, mumps, rubella
* Varicella vaccine
* Intranasal influenza
* Rotavirus
VIRM
Immunization types: inactivated
* How does it work?
* What are the examples?
Explanation
* Virus that has been weakened by heat or chemicals; virus is dead
* Immunity mostly mediated by plasma cells without T-cell involvement
* Requires multiple boosters
Examples
* Hepatitis A
* Polio
* Influenza
* Rabies
RHIP
Imunization types: Subunit
* How does it work?
* What are the examples?
Explanation:
* Most immunogenic portion of vaccines that immune system responds to; polysaccharides or proteins
* Multiple subtypes conjugated together
Examples:
* Streptococcus pneumonia
* Bordetella pertussis
* Hemophilus influenza type b
* Hepatitis B
* Varicella zoster
* Human papillomavirus
* Neisseria meningitidis
Immunization types: Toxoids
* how does it work?
* What are the examples?
Explanation:
* Fixed or inactivated pathogen toxins; targets the toxins that are the main cause of illness
Examples:
* Tetanus
* Diphtheria
Newer vaccine technology
* What are vector vaccines? What are the examples?
Low pathogenic viruses altered into viral vectors that produce same proteins as disease-causing viruses
* Veterinary medicine, Ebola
Newer vaccine technology
* What are RNA vaccine? What are the samples?
Piece of mRNA that will produce some antigenic proteins of the disease-causing virus
* Covid 19 spike protein
* Pfizer, Moderna vaccines
Routes of administration
* What are the routes?
- Intramuscular
- Subcutaneous
- Subdermal
- Intranasal
- Oral
CDC – the vaccine resource
* What are the two type of schedules?
* _ schedules
* What are the resources for healthcare professionals?
Immunization schedules
* Adult
* Child
Catch up schedules
Resources for healthcare professionals
* VIS
* VAERS
* VFC
* APPs
Fill in when
adult and catch-up vaccines
* Catch up schedules available for who?
* Recommendation vary by what?
- Catch up schedules available for unvaccinated or under vaccinated
- Recommendations vary by age, concomitant disease states, and contraindications
Vaccine information sheets (VIS)
* When does this need to be given?
Required by law to be given to patient or adult caregiver prior to vaccine administration
* All vaccines
* Documented in medical record; including date given
Vaccine information sheets (VIS)
* Other medical record documention?
Other medical record documentation
Lot
* Expiration date
* Vaccination site
Contraindications and precautions
* When should any vaccine not be given
* When should pertussis not be given?
* What should rotavirus not be given
Risk serious of adverse drug reaction
* Vaccine should NOT be administered
Pertussis
* Encephalopathy within 7 days after previous pertussis-containing vaccine
Rotavirus
* Patient with severe combined immunodeficiency (SCID)
* History of intussusception
Contraindications and precautions
* Who should not get live attenuated vaccine?
- Pregnancy
- Immunocompromised
Precautions for vaccines
* Might have increased risk of what?
* _ Confusion
* Compromised what? (4)
Administration guidelines
* Live attenuated and inactive vaccines can generally be given when?
* If 2 or more inactive vaccines cannot be given when?
* If live attenuated vaccines cannot be given simulataneously, they must be separated who?
- Live attenuated and inactive vaccines can generally be given on the same day at different sites
- If 2 or more inactive vaccines cannot be given on the same day, they may be given without regard to spacing between doses
- If live attenuated vaccines cannot be given simultaneously, the must be separated by 4 weeks
Administration guidelines
* Tb skin test must be administered when?
* What may interfere with the host immune response?
* Inactive vaccines may be given when?
- Tuberculin skin test must be administered 4 to 6 weeks after live attenuated vaccines
- Simultaneous administration of live attenuated vaccines and immune globulin may interfere with the host immune response
- Inactive vaccines may be given simultaneously with immune globulin
Administration guidelines
* What is considered immunosuppressive? Live vaccines should be held for a minimum for how long?
* Who should not receive live attenuated vaccines?
- Prednisone 20mg/day (2mg/kg/day) for ≥ 2 weeks considered immunosuppressive; live vaccines should be held for a minimum of 4 weeks after last steroid dose
- Severely immunocompromised patients and pregnant patients should not receive live attenuated vaccines
Vaccine Adverse Event reporting System (VAERS)
* National vaccine safety surveillance program run by who?
* What can occur after vaccination?
* Anyone can do what?
- National vaccine safety surveillance program run by CDC and FDA
- Volunteer reporting of adverse events (possible side effects or health problems) that occur after vaccination
- Anyone can submit – healthcare professionals or patients
Vaccine Facts vs myths
Vaccine Facts vs myths
Vaccine Facts vs myths
Pneumococcal vaccines: 23-valent pneumococcal polysaccharide vaccine
* First major vaccine against what?
* What type of immune response?
* T-cells cannot mount a response to what?
* What is not produced? ( not effective in what? Immune system not as effective without what)
* B-cells need what?
- First major vaccine against S. pneumonia
- T-cell independent immune response
- T-cells cannot mount a response to polysaccharides, only proteins
- Memory B cells not produced
* Not effective in children < 2 years
* Immune system not as effective without t-cell help - B-cells need cytokine help to produce strong antibody response
Pneumococcal vaccines: Pneumococcal conjugate vaccine
* Polysaccharides are attached to what?
* Protein can be recognized by what?
* Effective in who?
- Polysaccharides are attached (conjugated) to a carrier protein
- Protein can be recognized by T-cells to mount immune response
- Effective in pediatric immune systems
Pneumococcal recommendations
* Who do you give it to? What is the series?
Patients birth to 18 years
* 15 or 20-valent conjugate vaccine (PVC15 or 20)
* 4 dose series: 2, 4, 6, 12-15 months
Pneumococcal recommendations
* What are the risk conditions?
Pneumococcal recommendations: Patients with risk conditions
* For 2 to 18 years previously fully vaccinated before age 6, when do you give vaccines?
2 to 18 years previously fully vaccinated before age 6
* If used ≥ 1 dose PCV20 – no additional doses
* If used no doses of PCV20 – one additional dose with PCV20 or PPSV23
Pneumococcal recommendations
* 6-18 years not previously vaccinated with risk conditions: What is the dosing?
6-18 years not previously vaccinated
* 1 dose of PCV15 or PCV20
* If PCV15 used; 1 dose of PPSV23 at least 8 weeks later
Separate PCV and PPSV23 vaccines by what?
at least 8-weeks
Pneumococcal recommendations
* Who is this recommended in?
Adults aged ≥65 years / aged 19–64 years with certain underlying medical conditions or other risk conditions
Pneumococcal recommendations: adults
* What is the vaccine recommendation for No previous PCV or unknown?
- One dose of PCV (either PCV20 or PCV15)
- If PCV 15 used, it should be followed by a dose of PPSV23 at ≥ 1 year
Pneumococcal recommendations
* What is the recommendations if previous PPSV23 only or PCV13 only
Previous PPSV23 only
* One PCV (either PCV20 or PCV15) ≥1 year after their last PPSV23 dose
Previous PCV 13 only
* One dose of either PCV20 or PPSV23
Pneumococcal recommendations
* What is the recommendations if Previous PCV13 and PPSV23?
One dose of PCV20 or PPSV23 at ≥ 5 years after last pneumococcal dose (see table)
Pertussis
* Since 1997, what has been recommended for all five childhood doses?
Since 1997, acellular pertussis vaccine (DTaP) has been recommended for all five childhood doses.
Pertussis
Pertussis prevention: DTaP
* Full strength of what?
* Used for what? What is the dosages?
* Tetanus prophylaxis if what?
Pertussis prevention: Tdap
* Full strength what? Reduced dose of what?
* Used for who?
* When do people get booster doses?
* Tetanus _
rabies:
* What is the mortality rate?
* Three reports of what?
* MC where?
Mortality almost 100%
* Three reports of young people surviving rabies; none received immunoprophylaxis
* MC in the US following bat contact (no bites)
rabies
* What is the post exposure prophylaxis?
- Wound cleaning and
- Vaccination and
- Human rabies immune globulin (HRIG)
rabies
* What is HRIG?
20 IU/kg once on day 0
* The dose should be infiltrated in and around the wound(s)
* Can be administered via IM injection (gluteal area)
rabies
* What is the rabies vaccine?
4 doses IM (deltoid) on days 0, 3, 7, and 14 (Day 28 dose added if immunocompromised)
Covid – most recent recommendations
* Recommended for who?
* What is currently available?
* Sepcific dosing depends on what?
- Recommended for all patients ≥ 6 months
- 2024-2025 vaccines formulations currently available
- Specific dosing depends on previous vaccinations
Covid – most recent recommendations
* What are the two types of caccines currently available? What is the strain coverage and what is the age groups?
Covid – most recent recommendations for 12 years old or older
