Medication pearls Flashcards
What conditions do we treat with this medication Warnings and adverse effects (Most common and most serious) Contraindications (major) F/u Labs Key points
What class(es) of drugs do we use to treat atopic dermatitis
Topical Corticosteroids, Calcineurin inhibitors, cyclosporine, dupilumab (biologic)
What class(es) of drugs do we use to treat psoriasis?
Topical corticosteroids
salicylic acid
Vit D analogs
Methotrexate, acitretin, cyclosporine, apremilast
TNFa inhibitors
IL-23 inhibitors
IL-17 inhibitors
What class(es) of drugs do we use to treat Acne Vulgaris
Topical retinoids
Oral isoretinoin
Oral ABx (doxy)
Topicals (Benzoyl peroxide, salicylic acid, clindamycin, azelaic acid)
What class(es) of drugs do we use to treat Rosacea
Azelaic acid, metronidazole gel
What class(es) of drugs do we use to treat Tinea
Butenafine, terbinafine, ketoconazole
What class(es) of drugs do we use to treat bacterial infections of the skin?
Mupirocin (bactroban)
What class(es) of drugs do we use to treat seborrheic dermatitis?
selenium sulfide
What class(es) of drugs do we use to treat oychomycosis?
oral terbinafine, topical ciclopirox
What class(es) of drugs do we use to treat pruritis?
diphenhydramine, hydroxyzine
What drugs are used to target increased follicle proliferation and abnormal desquamination in Acne Vulgaris?
Topical reinoids, isoretinoin, azelaic acid, azelaic acid
What drugs are used to target increased sebum production in Acne Vulgaris?
oral isoretinoin, OCP, spironolactone, clascoterone
What drugs are used to target cutibacterium acnes in Acne Vulgaris?
Benzoyl peroxide, topical ABx (clindamycin, minocycline), oral ABx (tetracyclines), azelaic acid
What drugs are used to target inflammation in Acne Vulgaris?
oral isoretinoin, oral ABx (tetracyclines), topical retinoids, azelaic acid, Dapsone
What is generally first line treatment in Acne vulgaris?
retinoids (+ benzoyl perozide w/ papulopustular)
What medications could you consider if first line Acne treatment doesn’t work?
OCP & Spironolactone (females only), isoretinoin, tetracyclines for 3 months (papulopustular)
What additional considerations should patients take in regards to oral hygiene with Acne vulgaris?
Use gentle cleansers/scrubbing
Noncomedogenic agents
no picking
What therapeutic targets does isoretinoin have?
Follicular proliferation, abnormal desquamination, sebum production, c. acne bacteria, inflammation
Isoretinoin contraindications
- Pregnancy
- Severe soy allergy
Isoretinoin adverse effects
Mucotaneous (dry skin/eyes), Hyperlipidemia, Psychiatric (depression/SR), IBD, Hepatotoxicity, IC HTN
What medications/treatments/procedures should a patient avoid who is on isoretinoin and why?
Tetracycline (IC HTN), Vitamin A supp, skin procedures, Excessive EtOH, nursing, blood donation
Isoretinoin screening (patient Hx)
Prior contraceptive failure
depression (uncontrolled)
hyperlipidemia or FHx of early
FHx IBD
Dry eyes
Heavy EtOH
Extreme physical activity (photosensitive?)
Isoretinoin monitoring
Need to wait 2-3 months to gauge improvement
Worsening of acne
depression sx
bowel sx
hyperlipidemia
dry eyes/vision changes
headaches (IC HTN)
What labs should you order for a patient starting isoretinoin?
Serum ALT
Triglyceride levels
urine or serum pregnancy testing
Adverse effects of high potency topical steroids
striae, irritation; d/c after 2 weeks.
Length of treatment for high and medium potency steroids
High: 2 weeks (taper)
Med: 3 months
Adverse effects/warnings of topical retinoids
Avoid in eyes
Avoid in pregnancy
Photosensitivity
No spot treatment
What topical retinoids are the most and least irritating?
Most: Tazarotene
least: Adapalene
What medications should you avoid when taking topical retinoids?
UV light & Benzoyl peroxide b/c it can deactivate it.
Adverse effects of Benzoyl peroxide
drying or peeling of the skin
Adverse effects of salicylic acid
drying or peeling of the skin
Adverse effects of azelaic acid
burning/tingling
What conditions can be treated with salicylic acid
Acne
Psoriasis
MOA for calcineurin inhibitors
suppress cellular (T Cell) immunity
Calcineurin inhibitors are indicated for what disease(s)?
Atopic dermatitis. Can apply to face and intertriginous areas.
Can also be used for vitiligo, mucosal lichen planus, graft vs host disease, allergic contact dermatitis, and rosacea
Calcineurin inhibitor adverse effects/warnings
- Transient erythema, burning, pruritis
- Rare: systemic immune-related effects (Tacro > Pimecro)
- Black Box warning: malignancy
- Avoid long-term continuous use
- Avoid in Netherton Syndrome
Which calcineurin inhibitor has fewer adverse effects?
Pimecromilus
What diseas(s) are Vitamin D analogs used to treat?
Psoriasis
Name 2 Vitamin D analogs
Calcipotriene, Calcitrol
Vitamin D analog MOAs
binds Vit D receptors and inhibits keratinocyte proliferation while enhancing keratinocyte differentiation
Vit D analogs Adverse effects
Hypercalcemia and Hypercalciuria possible if exceeding recommended weekly dosage limit (100g Calcipotriene; 100g calcitrol (2-7yrs), 200g calcitrol (7+ yrs)
Irritation
Mild photosensitive
what treatment can be used with Vit D analogs to produce synergistic effect?
Topical corticosteroids
Will also reduce irritation
Things to avoid with Vit D analogs
Vitamins/Calcium supplements
Occlusive dressings
sunlight/UV exposure
Indications for Clindamycin topical gel
Acne (inhibits growth of Cutibacterium acnes)
Adverse effects of Clindamycin topical gel
Erythema, burning, itching, peeling, oiliness. Can also cause D. diff associated diarrhea. Avoid eyes
When in an acne treatment should you consider clindamycin gel?
After 3 mo of mild papulopustular acne that has failed to improve with Benzoyl peroxide and topical retinoids.
Mupirocin indications
Impetigo, MRSA derm infection
Mupirocin adverse effects
Dryness, burning, erythema, stinging, tenderness.
Allergies! Angioedema, anaphylaxis, generalized rash
Metronidazole gel indications
Rosacea
Length of treatment for Mupirocin ointment
TID 3-5 days
Warnings and adverse effects of metronidazole gel
do not use vaginal prep on face. Can also cause dizziness, HA, N/V, diarrhea
When should you see improvement in rosacea with metronidazole gel?
within 3 weeks, continuing improvement through 9 weeks.
oral tetracyclines dermatological indications
Acne
Adverse effects of tetracyclines
Esophagitis (take with glass of water)
Photosensitivity/skin discoloration
idiopathic IC HTN
Gi issues
No pregnancy and children <8. retards skeletal development
Don’t take with calcium + minerals (chelation)
When in an acne treatment plan should you consider Tetracyclines?
Mod/severe papulopustular acne. Concomitant use with topical retinoids and Benzoyl peroxide.
Methotrexate indications
psoriasis, sarcoidosis, RA, oncology (high dose)
MTX MOA
Folate antagonist/antimetabolite. Targets cells during DNA synthesis and reduces hyperproliferation
MTX contraindications
Pregnancy/nursing
Liver issues (chronic disease, EtOH liver disease)
Immunodeficiency syndromes
Preexisting blood dyscrasias
Warnings/cautions for MTX
Black box: toxicity, teratogenicity
Abnormalities in renal function
Abnormalities in liver function
Active infections
Many drug interactions
MTX adverse effects (low dose)
GI issues
Hepatoxicity
CNS effects
Rash
Pancytopenia
What medication should you supplement with MTX?
Folic Acid 1mg
Baseline labs for MTX
Pregnancy
CBC with diff
BUN and serum creatinine (kidney function)
Liver tests:
LFTs
Serum albumin
Noninvasive liver fibrosis assessment
Hep B&C screening
Latent TB testing
CXR (some providers for pulm tox)
Ongoing labs for MTX monitoring
CBC
Liver tests: LFTs, serum albumin, serum creatinine (3-6 mo)
FIB-4, Fibrosure, Fibrometer, Hepascore (annual)
After 3.5-4.0 cumulative dose-> GI consult
Apremilast indication, warnings, and notes
Psoriasis, GI effects, titrate
butenafine indication
Tinea
Butenafine Hydrochloride warnings/AE
Dermatitis, burning, worsening of condition.
Considerations to make when using butenafine HCL
if not improvement in 4 weeks, reconsider Dx
Ketoconazole indications
Tinea, seborrheic derm, dandruff
Ketoconazole AEs/warnings
burning, stinging, irritation, erythema.
Allergic: angioedema
Ketoconazole considerations
Shampoo–sit for 5 mins before rinsing
Terbinafine indications
Tinea
Terbinafine considerations
Not indicated for Tinea unguium
Improvement usually in 3-4 days, but continue for 1-4 weeks
Ciclopirox indications
Onychomycosis
Ciclopirox warnings/AEs
pruritis, erythema, burning
Ciclopirox considerations
Trim nails closesly
not as effective as oral Tx
Selenium sulfide indications
Seborrheic dermatitis, tinea versicolor
Selenium sulfide warnings/AEs
dryness or oiliness of skin
Topical Antifungal medications
Butenafine HCL, Ketoconazole, Terbinafine, Ciclopirox, Selenium Sulfide
Acitretin indication
Psoriasis
Acitretin warnings
Hepatotixicity
Elevated lipid levels
No blood donation during and 3 years post Tx
Acitretin contraindications
Avoid in pregnancy (and for 3 years post-Tx)
No EtOH (and 2mo Post Tx)
Terbinafine indications
onychomycosis
Medications that treat onychomycosis
Terbinafine (oral AF), Ciclopirox (topical AF)
Terbinafine warnings/AEs
Hepatotoxicity, Steven’s Johnson Syndrome, TEN, N/V/Rash
Terbinafine C/Is
Liver Disease
Severe Renal Disease
Terbinafine baseline labs
LFTs
Nail Bx
Diphenhydramine indications
Pruritis
Hydroxyzine indications
Pruritis
oral Antihistamines indicated for pruritis
Diphenhydramine, Hydroxyzine
oral Antihistamines warnings/AEs
Anticholinergic drowsiness, sedation, dry mouth
Oral antihistamines C/Is
NA Glc, BPH, bladder obstruction
Oral antihistamine considerations
Don’t use to treat URI
Don’t use in older adults
