MED 2 PHARM Flashcards
Enzymes, LAs, Benzoz, Barbs,Nacrs
1
Q
T/F. Benzos can be used in ASA 3/4 pt
A
FAlse
DO NOT use Benzodiazepines
2
Q
Who can not receive Benzos?
A
- MG, MS, Neuro pts
- pregnant/lactating
- Obeses
- Frail elderly
- OSA
- On CNS depressing meds (incl etoh) OR H2 blockers
- severe hepatic insufficiency
3
Q
Opioid overdose treated with
A
Naloxone (Narcan): Given IV, IM, SC or Intranasal (Acts in 1-2 minutes & lasts 30-90 minutes)
4
Q
2 Phases of Metabolism:
A
PHASE 1:
Metabolism (3A4)
Deactivation or activation of drugs occur in Phase I
Phase II
Conjugation to inactive compounds
Excretion out by efflux Transporters: P-gp action
5
Q
2D6 activates the following Pro-drugs:
A
Codeine → Morphine;
Hydrocodone → Hydromorphone;
Tramadol → O-demethyl-tramadol;
Valacyclovir → Acyclovir
6
Q
You have an ASA 3/4 pt and they want the good numbing medication. So you grab the gold standard Lidocaine. What is the next action?
A
STOP and put down the lido b/c ASA III and ASA IV patients should not get Epinephrine
even with bleeding- NO EPI CORDS –> sub with ALUM
7
Q
T/f. PgP is found in the liver and gut only
A
FALSE. CYP is in the gut and liver only
Pgp = gut liver kidney bbb
8
Q
______ accounts for majority of the sub-types (36%) & ______ is the second highest (19%)
A
CYP3A4
CYP2D6
9
Q
t/f. All types of stress management is contraindicated especially with MOD-SEV-Very severe COPD
A
TRUE.
No NO2 ( dec o2 drive) ; No Benzos (dec resp drive)
Use preemptive inhalers instead
low dose Ativan or Valium cautiously in MILD COPD
10
Q
Only use________in the ASA IV patients
A
Carbocaine or Citanest plain (if not hypoxic)
11
Q
T/F.
It is ok to prescribe Metronidazole to your patient with a mechanical heart valve with bld maintenance via coumadin
A
FALSE
Metronidazole is a potent CYP2C9 inhibitor: Avoid Metronidazole with Coumadin/Dilantin
12
Q
t/f. ASA 3/4 pt can receive lidocane and or septocaine
A
false. Avoid LA with 1:100,000 epi in this ASA III & IV patients
lido = 2% xylo + 1:100k or 1:50k Epi Septo = %4 articane + 1:100k
13
Q
Which of the following is a P-gp inhibitor?
- Digoxin
- Diltiazem
- Doxazosin
- Dabigatran
- Dilantin
A
Inbitors :
- Diltiazem (Cardizem)*****
- Doxazosin (Cardura)
The rest are substrates
Diltiazem = substrate AND inhibtor
14
Q
Valium, longer acting, dose is _____ whereas, shorter acting Ativan dose is_____.
A
Valium :5-10 mg HS (the NIGHT PRIOR and 1hr prior) (max 10 mg)
(pt 150+lb or < age 50 ; Petite OR 50+ = 2-5mg )
Ativan: 1-2 mg PO HS the night prior; and 30 mins–1 h prior
15
Q
Benzodiazepines antidote:
A
Flumazenil (Romazicon):
IV Dose:
0.1-0.2 mg IV over 15 seconds
Follow-up dose:
0.2 mg
Repeat at 1 minute intervals till l mg is given
16
Q
List CYP2C9 Substrates, Inhibitors & Inducers:
A
CYP 2C9 Substrates: Acetaminophen, Benzos, Celecoxib, Coumadin (main metabolizer), Ibuprofen,Methadone, Naproxen, Dilatin
CYP2C9 Inhibitors: , Fluconazole (high dose), Metronidazole
CYP2C9 Inducers: Carbamazepine/Tegretol, Phenobarbital, Phenytoin (Dilantin), Primidone (Mysolin), Rifampin
17
Q
T/f. Codeine is not reccomended in CKD pt
A
True
18
Q
SELECT ALL THAT APPLY: Which of the Following analgesics can be used with Kidney or Liver disease:
A. Regular strength Tylenol B. ASA C. APA ES D. Oxycodone or Hydrocodone w/Tylenol (dose mod) E. (Diluadid) F.Fentanyl G. Tramadol
A
A. Reg strength APAP
D. Oxy/ Hydrocod w/ apap
E. Dilaudid
F. Fentanyl
NO NSAIDs, ASA, Tramadol, ES APAP, Demerol
19
Q
Which of the following is a P-gp Inducer?
- Captopril
- Diltiazem
- Atorvastatin
- Dilantin
- Rifampin
A
Inducers:
- Dilantin *****
- Rifampin
Dilantin = both inducer and Substrate
20
Q
IF pt on digoxin they are automatically ASA
If pt on THeodur they are automatically ASA
A
3
3
21
Q
Which med is both a 3A4 and Pgp Substrate?
A
Diltiazem ***
22
Q
- Metronidazole is a CYP3A4 Inhibitor
- Metronidazole is a CYP2C9 Inhibitor
A. The first statement is false, but the second is true
B. The first statement is true, but the second is false
C. Both are true
D. Both are false
A
C. Both are true
Metronidazole is a 3A4 inhibtor and also inhibits CYP2C9
23
Q
Antidote for Methemoglobinemia:
A
Oxygen + IV methylene blue 1% solution (10 mg/ml) 1-2 mg/kg slowly over 5 minutes
Repeat the dose in 1h if needed
24
Q
All epinephrine containing LAs contain _______, an oxidant preservative
A
metabisulfite
IE NO in Methemoglobinemia ; no in pt wiht sev hypoxiz
25
Your pt John's was born with a congenital heart defect that wasnt necc to repair as a child. He comes in with tooth pain on #3. You ordered labs returned :
- Hgb: 7
- HCt: 27
- PO2: 91 baseline
What LA's would you avoid giving John?
AVOID CITANEST (4% Priolocaine) or ARTICAINE (4% Septo) in
NO Sev COPD ( seve hypoxia)
cyanotic congenital cardiac defects
neuro-muscular dysfunction such as:
- MD, MG, MS, ALS ,
26
St. John’s Wort is metab by type of enzyme ?
P-gp Inducers
| CYP3A4 Inducers
27
T/F. Liver disease INCREASES THE HALF-LIFE of the amides
True
28
______ has the LOWEST CARDIOTOXICITY & LOWEST LIPID SOLUBALITY
Prilocaine (Citanest Forte or Plain):
29
Avoid ___(list)__ Pro-drugs with ______ b/c they are STRONG 2D6 inhibitors
Codine; Hydrocodone; Tramadol; acyclovir;
Celecoxib (Celebrex) or SSRIs
30
1. Epinephrine is contraindicated with SSRIs
2. Avoid using Lidocaine with simultaneous intake of an SSRI
A. The first statement is false, but the second is true
B. The first statement is true, but the second is false
C. Both are true
D. Both are false
A. EPI = OK with SSRIs ; No Epi + SSRi at same time
Epinephrine is not contraindicated with SSRIs but avoid using Lidocaine with simultaneous intake of an SSRI.
****No issue if a 2-hour interval is maintained between the two****
**** Since 2 hr window neede - NO lido and BENzos for stress management ( 30-1hr prior to tx)******
31
List notable CYP2D6 Substrates, Inhibitors & Inducers:
Substrates: Most anti-depressants, Codeine
Inhibitors: Celecoxib, Fluoxetine (Prozac), MAO-Is, INH
32
_________ is a potent CYP2C9 inhibitor: Avoid taking it with Coumadin/Dilantin
Metronidazole
33
Can you give Azoles with ASA 3/4 pt on digoxin?
NOooo. Azoles = P-gp substrates & inhibitors
AVOID WITH DIGOXIN:
- EPI
- ASA
- NSAIDS
- ALL Macrolides, Tetracyclines & Metronidazole & Azithromycin
- Azoles
34
1. 3A4 inducers increase metabolism of drugs dependent on 3A4 thus decreasing blood levels
2. Pgp inducers REDUCE bioavailability of susceptible drug
A. The first statement is false, but the second is true
B. The first statement is true, but the second is false
C. Both are true
D. Both are false
C. Both are true
So a 3A4 inducer and Pgp inducer like St. John's Wort will have very low bld lvls of the drug
35
AAA ok with Digoxin?
- Carbocaine
- Tylenol / percocet ( tylenol 3)
- Pens ,Azithro, Ceph, Clinda
Jon with heart problems and aan infection has (PACC) his dig
36
Clopidogrel (Plavix) is activated by what enzyme?
2C19
C for Clopidogrel and 19 for the letters in
Clopidogrel /Plavix
37
PT AB has allergy to the sulpha anti-microbials or sulphur. CAn you givein Lidocaine?
YES. ALL to sulphas sulphur can be
| given epinephrine containing local anesthetics
38
What abx can you NOT give a pt on THeodur?
Avoid Erythromycin, Clarithromycin, all Tetracyclines, Azoles (inhibit 3A4)
39
Procaine (Ravocaine) is category
C
40
Causes of Methemoglobinemia/ drugs to avoid :
Oxidants such as sulfonamides (antibiotics),
| local anesthetics citanest/articaine/benzocaine can increase methemoglobin levels
41
```
Safe AAAAAs in MCP Population:
Anesthetics:
Analgesics
Antibiotics
Antiviral Drugs:
Antifungal Drugs:
```
Anesthetics: Carbocaine (Most LA with some exceptions)
Analgesics:Regular strength Tylenol AND Percocet
Antibiotics: Penicillin, Amoxicillin, Clindamycin (PAC)
Antiviral Drugs: Acyclovir
Antifungal Drugs: Nystatin, Amp B, low dose
Fluconazole
42
_______ exacerbates the cardiotoxicity of local anesthetics
Hyperkalemia
43
_________ HIGHEST CARDIOTOXICITY & HIGHEST LIPID SOLUBALITY: MORE
PROTEIN BOUND
Bupivacaine (Marcaine):
44
All types of cOCp's are affected ONLY when combined with _______
CYP3A4 Inducer drugs IE AVOID 3A4s with COCPs
Inducer Drugs: Rifampin, anti-epileptics (Dilantin), antipsychotics, azoles & St. John's wort
Pregnant patty will DIe if you give her azoles while she's having a epilyptic seizure
45
______ should not be used continuously for more than 3 days, so space out dental visits
Afrin
46
Theophylline is a _______substrate: It is metabolized by ________
3A4 & 1A2
CYP3A4 & 1A2
47
_______ is good for Mandibular nerve block. NOT for Maxillary infiltration
Has long duration of pulpal & soft tissue anesthesia thus reducing postop. pain
Ropivacaine (Naropin)
0.5% Ropivacaine (Naropin) with/without 1:200,000 epinephrine
Newest Pregnancy Category B local anesthetic but avoid during pregnancy
48
Avoid L.A. with Epinephrine in patients with:
- Pheochromocytoma
- On Anti-Psychotics
- PTU
- Cardio-Pulmonary disease: ASA III- IV patient
- CAD
- Digoxin (Lanoxin)
- Theophylline (TheoDur
49
Reduce the dose for most opioids with ______, to avoid drug accumulation
Reduce dose to______for GFR between 10-50 ml/min
Reduce dose to ________ for GFR <10 ml/min
low GFR
75% of normal dose
50% of normal dose
50
Your CKD underwent gum flap surgery and is having mild pain . THey are a candiate for which type of analgesic?
WHat is they did not have CKD?
NON-CKD: Non-opiods and adjuvents (NSAIDs; APAP)
CKD: Acetaminophen ( NO NSAIDS)
Always avoid NSAIDs in volume depletion states!
Unless otherwise indicated, the ‘first-step’ Rx for mild pain typically involves the use of nonopioids, including Acetaminophen & NSAIDs(
51
Avoid combination of _____with Celecoxib which is a moderate_____.
pro-drug opioids (Codeine-Tylenol, Vicodin, Tramadol)
2D6 inhibitor
52
LAs ok to give pregnant pt? ( what LA are category b?)
- Lidocaine ( 2% xylocaine w/ epi)
- Citanest Forte (4% Prilocaine w epi)
- Citanest Plain ( 4% Prilocaine)
* *** Check BP to decide is ok to give epi***
* ** talk to OB prior to tx***
53
Avoid all NSAIDs for pain control due in ______ patients to ↑ bleeding risk & worsening of any anemia
anemia
54
AVOID _____ use in HF patients it can exacerbate Heart Failure by: Promoting sodium & water retention
Causing higher intravascular resistance
Causing ↓ response to diuretics by reducing renal blood flow (prostaglandin inhibition)
NSAIDS
55
With past H/O CVD, ______ is the preferred NSAID for short, intermittent or long-term use
Naproxen
56
COX-2s ______Platelet aggregation
increase
57
PT who should NOT get Topical Benzocaine gel (ester)?
- congenital methemoglobinemia
- (G6PD) deficiency
- Pregnant & breast-feeding patient
58
How do you treat the following patients in a LA OD?
- Conscious pt Tx:
- Unconscious pt tx :
- Seizing pt tx
-Conscious pt Tx: Semi–sitting ; Reassure ; HYPERVENTILATE
-Unconscious pt tx : Horizontal position; Assess ABCs;
Activate EMS
-Seizing pt tx: Midazolam 0.5-1 mg IV over 2 minutes (max. 2.5 mg/dose)
Wait 2-3 minutes before repeating 2nd Midazolam dose, when needed
59
Can pt with asthma* on theodur get Septo/Lido?
NO. AVOID: L.A with Epinephrine in pt on THeodur
*Bisulfite sensitivity is seen more frequently in asthmatics than in non-asthmatics
60
Lidocaine is a _______ substrate and should be avoided in ________.
CYP1A2 & CYP3A4
Avoid Lidocaine use with other 3A4 substrates like SSRIs & Benzodiazepines (drugs compete )
61
Max. # of carpules of Xylocaine for a Healthy 140 lb. Adult:
11.5 carpules
62
Carbocaine is the go to LA for MCPs. Can you give in Pregnant pt?
NOO. Category C
OK to give: 4% prilocaines ( w/wo epit) AND lido
Avoid epi. with mild to moderate Hypertension
Use 4% Prilocaine HCL without epinephrine (Citanest Plain) after OBGYN clearance
63
Analgesics for G6PD:
Use meds that prevent hemolytic crises, such as Benzodiazepines, Codeine, Codeine derivatives,
Propofol, Fentanyl, and Ketamine
Use Codeine Phosphate or OxyContin (without Tylenol) or Tramadol
Use Codeine Phosphate: 15–60 mg/dose q4–6 h: Typically 30mg q4-6h
Oxycodone (OxyContin) is dosed at 20mg oral, q8-12h: Only given if already in use
Tramadol (Ultram), 25-50 mg q6h PRN can be prescribed SHORT-TERM if a non-
narcotic analgesic is needed: Tramadol is now a Schedule IV drug
64
NSAIDs decrease elimination of ______; potentially leading to toxicity
Methotrexate
65
T/F. Also avoid NSAIDs with NOACs
TRUE
66
Ibuprofen, Naproxen, Celecoxib and Coumadin are _____ substrates:
CYP2C9
When any one of these NSAIDs are taken PO at the same time with Coumadin, the NSAID can compete with Coumadin for CYP2C9, thus affecting Coumadin response
67
Your CKD underwent gum flap surgery and is having MOD pain . They are a candidate for which type of analgesic?
What is they did not have CKD?
CKD: Tramadol
NON-CKD: Nonopioids ± adjuvants ± weak opioids (Codeine, Dihydrocodeine, Hydrocodone, Oxycodone, Tramadol)
68
Your CKD underwent gum flap surgery and is having SEV pain . They are a candidate for which type of analgesic?
What is they did not have CKD?
CKD: Methadone or Fentanyl may be acceptable; reduce dose & frequency
NON-CKD: Nonopioids ± adjuvants ± moderate to strong opioids (Fentanyl, Morphine, Hydromorphone, Methadone, and Oxycodone)
69
No 4% meds with which condition
Asthma
Asthma pt on theodur = NO EPI, Azoles, macrolides
70
Daily cough and sputum productionfor at least 3 months out of the year for ay least TWO CONSECTUTIVE years
Chronic bronchitis
* no lung dz definitions *
71
Antidote for NOACs
Izabrab?
72
Mild
Mod
Sev
COPD
Mild
Mod
SeV. PO2 <50
73
Nystatin Rx
Nystatin Oral Susp for Candidiasis: CAT B
Rx: Nystatin Oral Suspension 100,000 units/ml
Disp: 473 mL (1 pint) bottle (14 day supply)
Sig: Use 1 teaspoonful or 5 ml, qid
Rinse and hold in the mouth as long as possible before swallowing
There should be no eating or drinking for 30 minutes after use
Note: Nystatin suspension is also dispensed as a 60 mL bottle
Add 5mL-10 mL of 1:100,000 units Nystatin to half cup of water
Soak the dentures overnight daily, for 14 days. Rinse the dentures before use
74
Anti-Virals Acyclovir and Valtrex are drugs are minimally metabolized by the _____ & excreted mainly by the ____ . This means that you need to_____.
liver ; kidneys; Lower the dose with renal compromise/dysfxn ; Dose repeated after hemodialysis
75
Avoid combining Acyclovir with following drugs which can compete for TUBULAR SECRETION:
Aspirin, Amphotericin B, NSAIDs
***Zovirax ointment is most effective when used in conjunction with Zovirax capsules ie no ointment by itself**
76
Fluconazole Rx:
Fluconazole (Diflucan) Prescription for refractory oral or systemic Candidiasis:
Rx: Fluconazole (Diflucan) 50 mg or 100 mg/capsule
Disp: 15 capsules
Sig: Day 1: Take 2 capsules. Days 2-14: Take 1 capsule daily
Fluconazole (Diflucan) Treatment for esophageal Candidiasis:
Rx: Fluconazole (Diflucan) 50 mg or 100 mg/capsule
Disp: Variable
Sig: 100 mg qd (maximum 400 mg qd) for 14-21 days
77
There are 2 classes of Azole antifungal drugs: ____
Imidazole & Triazole
78
Amph B Rx:
3% Topical Amphotericin B: CATEGORY B
Disp: 20 g tube
Sig: Apply to the affected area 3-4 times/day for 2-4 weeks
Oral Amphotericin B: CATEGORY B
Poorly absorbed & dispensed in capsule or suspension form
Rx: Amphotericin B, 500 mg/capsule or Amphotericin B suspension: 500 mg/mL
Disp: 56 capsules or 56 mL suspension
Sig: 500 mg PO qid x 2 weeks or 1 mL, swish and swallow qid for 2 weeks
79
VALTREX IS A ______. Avoid WITH ____.
PRO-DRUG; Celebrex or SSRIs
*Celebrex or SSRIs INHIBIT THE 2D6 ENZYME NEEDED TO ACTIVATE VALTREX*
80
Polyenes (topical/oral) are commonly used for:
HIV/AIDS patients with a low CD4 count
Patients undergoing chemotherapy
Patients in whom Azole antifungals are contraindicated
81
2 Polyenes Classification:
Nystatin (Mycostatin): Topical & oral Nystatin
Amphotericin B (Fungizone): Oral/ IV Amp B
82
T/F. Newer azoles ( Triazole ie Diflucan ) have fewer SE and are more potent.
TRUE.
give in MCP vs ketoconazole
83
Avoid Fluconazole with______ , 3A4 drugs, to prevent impaired cardiac conduction
Amiodarone & Quinidine
84
1. Fluconazole is a category C drug that can be taken with meals
2. Fluconazole shows very high concentrations in breast milk
A. The first statement is false, but the second is true
B. The first statement is true, but the second is false
C. Both are true
D. Both are false
C. Both are true
85
What is the least amount of time to be prescribe anti-fungal therapy?
14 days
14d in oral
21d in esophageal (or s/s persist)
86
______ analgesic is contraindicated in CKD pts (and dialysis pts ) ; high neurotoxicity; metabolites accumulate
Meperidine
87
Drugs affecting Platelet Function
```
ADP inhibitors
Aspirin (and asa + Dipyridamole (Aggrenox)
Clopidogrel (Plavix)
NSAIDS**
Ticlopidine (Ticlid)
```
**All except NSAIDS, irreversibly & permanently affect entire life-span of platelets ****
88
1. NSAIDS affect on PLT is temporary
2. The Platelet count is affected by anti-platelet drugs like ASA, NSAIDS, Plavix, Ticlid
A. The first statement is false, but the second is true
B. The first statement is true, but the second is false
C. Both are true
D. Both are false
B.
NSAIDS affect is temporary - lasts till the drug clears the system, ( 24 hours )
*****The Platelet count is NOT affected by any one of these drugs ONLY FXN ie INC bleeding time*****
*NORM BT is 2.4-8 minutes*
IV heparin will affect count
89
Platelet transfusion when needed is given ______.
| 1 platelet concentrate transfusion increases the platelet count by______.
20 minutes prior to planned procedure
10,000
