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Medicine 2 > MED 2 HEPAT RENAL > Flashcards

MED 2 HEPAT RENAL Flashcards

1
Q

Labs in live rpt?

A

Liver:
CBC w/Plts, LFTs, PT/INR, PTT
CYP Enzymes, Pgp drug Transporters

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2
Q

Portal Hypertension can cause:

A

Ascites
Esophageal Varices associated hemorrhage
Hepatic encephalopathy

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3
Q

LFTs indicative of Acute Hepatitis:

4 main

A

ALT>AST
Alk. Phos (AP): Increased
Total Bilirubin: Increased
Direct & Indirect- B: Increased

Albumin: Normal
PT/INR: Normal

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4
Q

Patient has symptomatic complications to Cirrhosis

Symptoms can relate to Hepatic insufficiency causing Jaundice or Portal hypertension

A

Decompensated Cirrhosis:

stage 3 and 4 have acites
but stage 3 have varices and stage 4 has bleeding

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5
Q

2D6 activates what Pro-drugs (4):

A

Codeine → Morphine

Hydrocodone → Hydromorphone

Tramadol → O-demethyl-tramadol;

Valacyclovir → Acyclovir

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6
Q

Stages 1 and 2 are considered ___ cirrhosis?

A

Compensated

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7
Q

Metabolic Enzymes found in liver

A

CYP3A4 (also found in intestinal epithelium )

P-gp - txsp subst (PO) out of cells in phase 2 ( efflux)

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8
Q

CYP3A4 is a subtype of?

A

CYP450

CYP3A4 accounts for majority of the sub-types (36%) & CYP2D6 is the second highest (19%)

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9
Q

Acites (+/-) AND varices =?

A

Decompensated stage 3 cirrhosis

20% death

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10
Q

_______ is a 3A4 & 1A2 substrate: It is metabolized by CYP3A4 & 1A2

A

Theophylline

Avoid with EPI, Macrolides (Mycin drugs-eryth/clariryth/azithro) All Tetras, azoles

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11
Q

Avoid combining Pro-drugs (c,h,t,v) with ______? WHy?

A

Celecoxib (Celebrex) or SSRIs

They are STRONG 2D6 inhibitors

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12
Q

Stage 1 and 2 clinical manifestations of cirrhosis

A

Compensated:
stage 1: No varices, No acites

Stage 2: Varices, but NO acites

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13
Q

CYP2C9 metabolizes CYP2C9 substrates ______ and _____

A

Phenytoin (Dilantin) and Warfarin (Coumadin)

Metronidazole is a potent CYP2C9 inhibitor: Avoid Metronidazole with Coumadin/Dilantin

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14
Q

LFTs indicative of Alcoholic Hepatitis:

A

ALT:AST ratio = AST>ALT (>2:1)
GGT : Increased

A/G ratio: Norm
Albumin/Bilirubin: Norm

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15
Q

Patient does not have symptoms related to the Cirrhosis

Patient may have asymptomatic esophageal or gastric varices

A

Compensated Cirrhosis:

stage 2 has the varices but not acites

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16
Q

LFTs indicative of Cirrhosis

A 
Total Protein: Decreased
Albumin: Decreased
A:G ratio: REVERSED
Alkaline Phosphatase (AP): Increased
Total Bilirubin: Increased
AST>ALT
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17
Q

P-gp role in liver

A

Liver: Transports the drugs to bile for elimination

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18
Q

P-gp is found in the cells of the:

A

gut, liver, kidney & Blood Brain Barrier (BBB)

Highest P-gp amounts exists in the enterocytes of the small intestine

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19
Q

_____ activates pro-drug Clopidogrel (Plavix) to the active form 2-oxo-clopidogrel

A

2C19

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20
Q

Bleeding ( +/-)

Acites

A

Decompensated Stage 4 cirrhosis

( 57% death)

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21
Q

GGT: Severely increased
Alkaline Phosphatase: Severely increased
Total Bilirubin: Severely increased
Direct B: Severely increased

Total protein/Albumin: Norm or dec
Globulin: norm or inc
A:G ratio: norm or reversed

A

LFTs indicative of Cholestatic Disease

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22
Q

Must check _______ PRIOR TO PROBING a Cirrhotic patient

A

PT/INR & CBC with platelets

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23
Q

Norm BP
Elevated BP
Stage 1 HTN
Stage 2 HTN

A

120/80
120-129/80
130-139/80-89
140+ /90+

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24
Q

What is the next action when you take pt BP and reading is SBP≥160 mmHg or DBP ≥100 mmHg:

A

PAUSE! Do prompt evaluation for symptoms, signs & treatment compliance

If no S/S: Provide quiet-time: Re-monitor in 10-15 min: Do stat Med consult if no change. Call & get PCP appointment. Write case note

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25
Q

Thrombocytopenia can occur with_______?

A

Cirrhosis + sequestration in enlarged spleen

26
Q

Coumadin is metabolized by ________ enzymes in the liver

A

CYP3A4, 2C9, 2C19 & 1A2

CYP2C9 primarily metabolizes Coumadin

Penicillin VK & Clindamycin are safe to use with Coumadin

27
Q

Abx and Anelgesics to rx for pt taking coumadin?

A

-Penicillin VK & Clindamycin are safe to use with Coumadin

-Use regular strength Tylenol or Oxycodone (Percocet)
HYDRATE

NO EXTRA STRENGTH ( inc INR)

28
Q

Opioids to reduces in CKD patients

A
  • Hydrocodone (50%)
  • Oxycodone
  • Oxymorphone (50%)
  • Hydromorphone
29
Q

Liver damage with Tylenol occurs after____ of Glutathione stores are depleted

Damage isn’t seen until Glutathione stores decrease below

A

> 70%

30%

30
Q

Drug metabolism in general occurs in the Liver via 3 mechanisms:

what are they?

A

> Phase I: Oxidation, reduction or hydrolysis involving CYP450 enzyme system

> Phase II: Conjugation to glucuronic acid/sulfate/acetate/glycine/glutathione/methyl group

> Bile: Biliary excretion & elimination

31
Q

OPIOIDS are CONTRAINDICATED with:

A
  • Respiratory dysfunction: Sev asthma, COPD, DifBre

- GI issues: obstruction or narrowing of the stomach or intestines

32
Q

Opioids to avoid in CKD patients

A

-NO Demerol (Meperidine = high neurotoxicity)
-Morphine
-Codine
-

33
Q

_______ leads to ↑ free drug levels of highly protein bound drugs . This can lead to increased adverse effects & toxicity

A

Low albumin

34
Q

Pain Management in CKD Patients

When to reduce the dose of opiods

A
  • Reduce the dose for most opioids with low GFR, to avoid drug accumulation
  • Reduce dose to 75% of normal dose for GFR between 10-50 ml/min
  • Reduce dose to 50% of normal dose for GFR <10 ml/min
35
Q

CLD/ CKD with cirrhosis PT comes in the ED currently ok 1g/d tylenol has been taking it for 2 days. Is immediate action required?

A

YES. PT has cirrhosis.

Low dose short-acting NSAIDs & opioids OK with CLD WITHOUT Cirrhosis/Renal disease

36
Q

____________ is the leading cause of Clotting Factor deficiency

A

Alcoholic cirrhosis

37
Q

___________ are minimally metabolized by CYP450, so safer in CLD

__________have less toxicity in CLD due to their short half-life & they both don’t require adjustments based on the patient’s GFR

A

Hydromorphone & Oxymorphone

Fentanyl & Hydromorphone

38
Q

CLD with cirrhosis PT comes in the ED currently ok tylenol has been taking it for 16 days. Is immediate action required?

A

No. Tylenol ≤ 2 g/d (& no alcohol) is fine, if needed long-term (>14 days) in CLD/Cirrhosis

Tylenol 2-3 g/d appears to be safe for short-term (1-2 days) or 1-time dosing in CLD

39
Q

Best to AVOID _____ in CLD pt to avert RENAL FAILURE

A

NSAIDs

Low dose short-acting NSAIDs & opioids OK with CLD WITHOUT Cirrhosis/Renal disease

40
Q

Normal PT:

Normal INR:

A

Normal PT:10-12 seconds

Normal INR: 1

41
Q

Adjuvants frequently used to treat neuropathic pain in CLD patients

A
  • Gabapentin (Neurontin)
  • Pregabalin (Lyrica)
  • Low dose TCAs

usually started at a low dose and gradually titrated up
excreted via kidneys so dose change needed in KD

42
Q

The effect of Coumadin can immediately be reversed with_______.

A

Fresh Frozen Plasma (FFP)

Also Vit. K but a very large dose is needed for quick (high dose neg impact on the future doses)

43
Q

INR checked every ______

A

4-6 weeks

INR 2.0-3.0:
Therapeutic Range is for non-high risk for thrombosis patients
MD will OK temporary Coumadin interruption for major surgery
INR <2.0 is associated with minimal bleeding

Minor Procedures can be done without stopping Coumadin

44
Q

INR 2.5-3.5 or GREATER:

A

Above Therapeutic Range level is reserved for high-risk for thrombosis patients

45
Q

CLD/Cirrhosis pt has MOD Visceral or Musculoskeletal pain

what would to rx for pain?

A

Start with Tylenol ≤ 2g/day
MOD-SEV : Tramadol 25mg q8h
Very SEV: Hydromorphone 1mg PO q4h or Fentanyl 12.5 µgm topically q72h

DO NOT COMBINE THESE AGENTS WITH TRAMADOL

46
Q

INR 2.0-3.0:

A
  • Therapeutic Range is for non-high risk for thrombosis patients
  • MD will OK temporary Coumadin interruption for major surgery
47
Q

Avoid combination of pro-drug opioids (Codeine-Tylenol, Vicodin, Tramadol) with
______ which is a moderate 2D6 inhibitor

A

Celecoxib

48
Q

Partial Thromboplastin Time (PTT): Normal PTT:

A

25-38 seconds

Coumadin ( PTT 1.5-2 x norm)

LMWH/Lovenox does not affect PTT

49
Q

CLD/Cirrhosis pt has Neuropathic pain

what would to rx for pain?

A

Gabapentin 300mg orally daily AND

Acetaminophen ≤ 2g/da

50
Q

Best to avoid _______ with cirrhosis/dialysis

A

Tramadol (Ultram)

Reduced Tramadol dose can be used with pre-failure liver/kidney disease

51
Q

Vitamin K deficiency occurs commonly in end stage liver disease (ESLD) because of:

A
  • Poor nutrition
  • Malabsorption of fat soluble vitamins
  • Biliary tract obstruction, bile salt deficiency or bile salt secretory failure
  • broad spectrum antibiotics
  • acquired unresponsiveness to Vitamin K; –> INC levels of hypo-carboxylated vitamin K-dependent clotting factors
    2. 5-5.0 mg Vit K, IV x 3 days is adequate to correct deficiency in compensated Cirrhosis
52
Q

Common cause for thrombosis in young adults:

A

Factor V Leiden mutation

More Venous than arterial thrombosis

53
Q

Analgesic to prescribe in the presence of Kidney or Liver disease:

A

-Regular strength Tylenol
-Dose modified Oxycodone or Hydrocodone with Tylenol
-Hydromorphone (Diluadid): Safe with liver/kidney failure
Fentanyl: Safe with liver/kidney failure

54
Q

It takes______for Coumadin to be effective

It takes_____ for therapeutic levels to occur

A

9-16 hours = effective

36-48 hours = theraputic

55
Q

Delay dentistry by ______ with a recent thromboembolic event history

A

6 months

56
Q

Coumadin is metabolized by ________ enzymes in the liver

A

CYP3A4, 2C9, 2C19 & 1A2

CYP2C9 primarily metabolizes Coumadin

57
Q

Antihypertensive drug treatment should be initiated
at a BP of _____ or higher
with a treatment goal of

A

130/80 mmHg

< 130/80 mmHg

All first-line antihypertensive drugs that are useful & effective are:
Diuretics, ACE-I, ARBs & CCBs

58
Q

Chronic kidney disease occurs when GFR is ____ for _______.

A

< 60 mL/min/1.73 m2

3 months

59
Q

normal s. creatinine in most labs is:

A

0.4-1.2mg/dL

60
Q

GFR is used to determine the severity of kidney disease

The 5 levels of severity or Stages of severity are:

A 
Stage 1: GFR ≥ 90mL/min/1.73m2 
Stage 2 (Mild): GFR 60-89mL/min/1.73m2 
Stage 3 (Moderate): GFR 30-59mL/min/1.73m2 
Stage 4 (Severe): GFR 15-29mL/min/1.73m2 
Stage 5 (Kidney Failure): GFR <15mL/min/1.73m2

Medicine 2 (3 decks)

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