Midterm Flashcards
What are the CYP450 inhibitors?
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol
Ciprofloxacin
Erythromycin
Cranberry juice/grapefruit juice
Omeprazole
Metronidazole
What are the CYP450 inducers?
Barbituates
St John’s Wort
Carbazempam
Rifampin
Alcohol
Phenytoin
Griseofluvin
Phenobarbital
Sulfonylureas
What does Beer’s Criteria include?
Potentially Inappropriate Medication (PIM) for older adults due to
• medication-disease or medication-syndrome interactions that may exacerbate the disease or syndrome
• medications to be used cautiously in older adults
• clinically significant drug interactions that should be avoided in older adults
• medications to be avoided or dosage decreased in the presence of impaired kidney function in older adults
At what age does gastric absorption and emptying reach adult values?
6-8 months
At what age does gastric acidity reach adult values?
2 years
How are IM drugs absorbed in early infancy?
During early infancy, IM absorption is slow and erratic due to early low blood flow.
How does the speed of IM absorption compare in neonates to adults?
IM drugs are absorbed more rapidly in neonates than adults
How does the speed of transdermal absorption compare in neonates to older children and adults?
Transdermal drugs are absorbed more rapidly and more completely in neonates than in older children and adults due to thin skin and increased blood flow. This increases risk for toxicity.
At what age does hepatic metabolization reach adult levels?
the capacity of the liver to metabolize many drugs increases rapidly about 1 month after birth and approaches adult levels a few months later with complete maturation of the liver by 1 year
At what age does renal drug excretion reach adult levels?
renal drug excretion is significantly reduced at birth due to renal blood flow, glomerular filtration, and active tubular secretion; adults levels of renal function are achieved by 1 year
How does the speed of hepatic drug metabolism in children compare to adults?
drugs are metabolized faster by children until 2 years old when it gradually declines until puberty when a sharp decline occurs to reach adult levels of metabolism
What act prevents discrimination based on genetic testing results?
In 2008, the Genetic Information Nondiscrimination Act was passed
To what drug class do levorphanol tapentadol belong?
Pure opioid agonists
What are examples of opioid agonist/antagonists?
pentazocine
nalbuphine
butorphanol
buprenorphine (can prolong QT)
What are examples of selective opioid antagonists?
methylnaltrexone
naloxegol
naldemedine
These selectively block opioid receptors in the GI tract to prevent opioid-induced constipation.
What controlled substance schedule does codeine belong to?
Schedule II, III, or IV depending on dosage. Dosing with > than 90mg of codeine are schedule II while doses <90mg of codeine per dosing unit are in schedule III. Cough preparations with less than 200mg of codeine or per 100ml (Robitussin AC) are in schedule V.
Other schedule II meds include midazolam, cocaine, methamphetamine, methadone, hydromorphone, oxycodone, fentanyl, meperidine, dexedrine, adderall, Ritalin
Other schedule III meds include ketamine, anabolic steroids, and testosterone.
Other schedule V meds include Lomotil, Motofen, Lyrica, Parepectolin.
What controlled substance schedule does tramadol belong to?
Schedule IV along with xanax, valium, ativan, ambien, tramadol, talwin, soma, darvon and darvocet
What controlled substance schedule does lyrics belong to?
Schedule V along with cough preparations with less than 200 mg of codeine per 100 ml, lomotil, morofen, lyrica, parepectolin
What is the black box warning for methadone?
QT prolongation
In which order should antihypertensives be ordered?
Thiazide Diuretics
ACEIs
ARBs
CCBs
What is the preferred antihypertensives for a patient with DM?
ACEIs or ARBs are renal protective in DM.
What antihypertensives is indicated in pregnancy?
Labetalol
What interaction can occur between Warfarin and Carbazepime?
Carbazepime is a CYP450 inducer which will increase the rate of metabolism of warfarin requiring larger doses to maintain a therapeutic range.
What side effect of nitroglycerin can be treated with beta-blockers?
Reflex tachycardia can result due to dilating arterioles causing sympathetic stimulation of the heart which can be treated by beta-blockers.
What adverse event can result from abrupt cessation of beta-blockers?
Long term use of beta-blockers can sensitize the heart to catecholamines so if a beta blockers are withdrawn abruptly, anginal pain or ventricular dysrhythmias may develop. This is referred to as rebound excitation. Therefore, beta blockers should be tapered over 1-2 weeks.
Which class of medications should be avoided in patients with asthma?
Nonselective beta-blockers can cause bronchospasm in patients with asthma
What is the mechanism of action for thiazide diuretics?
Thiazide diuretics block sodium and chloride reabsorption in the distal convoluted tubule increasing renal
excretion of sodium, chloride, potassium, and water; increases serum calcium level by increasing calcium reabsorption in exchange for sodium
What med class is cross-sensitive with thiazide diuretics?
Sulfas
What drug interactions can occur with thiazide diuretics (chlorthalidone, hydrochlorothiazide)
Concurrent use of lithium may result in increased serum lithium concentrations and lead to lithium toxicity which will result in weakness, tremor, excessive thirst, and confusion.
Concurrent use of thiazides and digoxin can precipitate dig toxicity due to hypokalemia which will result in nausea, vomiting, arrhythmias, xanthopsia (yellow halos around lights)
What monitoring is needed for thiazides?
Electrolytes (sodium, potassium, calcium), urate
Thiazides can cause hyponatremia,hypokalemia, hypercalcemia, and increased serum urate.
Which drug is contraindicated while taking digoxin?
Quinidine will decrease clearance of digoxin and lead to digitalis toxicity.
What is an ASCVD Risk Score
An Atherosclerotic Cardiovascular Disease Risk is a measure of the risk of having a cardiac event. The 2018 ACC/AHA cholesterol guideline defines high ASCVD risk as 20% or greater. Patients with existing clinical ASCVD are placed in a “very-high risk” category, despite their screening percentage. For all other people, 10-year risk must be calculated. The instrument employed most often is the Framingham Risk Prediction Score, which takes five factors into account
•age
•total cholesterol
•HDL cholesterol
•smoking status
•systolic blood pressure
Which diabetic patients should be a statin according to the American College of Physicians?
The American College of Physicians recommends a statin for
(1) all patients with type 2 diabetes plus diagnosed ASCVD, even if they don’t have high cholesterol; and
(2) all adults with type 2 diabetes plus one additional risk factor (e.g., hypertension, smoking, age older than 55 years), even if they don’t have high cholesterol.
Taken together, these guidelines suggest that most patients with diabetes should receive a statin.
What elements are required for a written prescription?
-Prescriber Name, License #, Contact Information
- NPI or DEA #
- Patient Name
- Patient DOB
- Allergies
- Medication
- Dose and Frequency
- Route
- Indication
- Number of Tablets to Dispense
- Number of Refills
What is the dose, frequency and indication for hydrocodone /acetaminophen?
Hydrocodone/Acetaminophen (Lortab)
- Dose
- • 5mg/325mg, 7.5mg/325mg, 10mg/325mg
Directions
- • take every 4-6 hours
Indication
• moderate to moderately severe pain.
What is the dose, frequency and indication for lisinopril?
Dose
- • 2.5mg, 5mg, 10mg, 20mg, 30mg, 40mg
Directions
- • take once daily
Indication
• hypertension, heart failure, acute MI
What is the dose, frequency and indication for amlodipine?
Dose
- • 5mg, 10mg
Directions
- • take once daily
Indication
• hypertension
What is the dose, frequency and indication for colchicine?
Dose
- • 0.6-1.2mg
Directions
• acute flare — take 1.2mg at the first sign of gout flare, followed by 0.6mg 1 hour later
- • prophylactic — take 0.6 mg once or twice daily
Indication
• prophylaxis and treatment of acute gout flare
What medications should be avoided in neonates and pediatrics?
Tetracycline — can stain teeth
Sulfinamides — kernicterus
Aspirin — Reye’s syndrome
Glucocorticoids — growth supression
What pharmacological changes occur in geriatrics?
Decreased Absorption
-increased gastric ph
-decreased gastric acid
-delayed gastric emptying
Altered Distribution
-increased body fat
-decreased lean muscle mass
-decreased total body water
-decreased cardiac output
-decreased albumin
Decreased Metabolization
-decreased hepatic function
Decreased Excretion
-decreased renal function
What are examples of CYP450 substrates?
Amiodarone
Aliskeren
Nifedipine
Statins
Colchicine
Naloxogel
Epelranone
Ranazoline
Rivaroxoban
Warfarin
Which are some examples of teratogenic drugs?
isotretinoin (accutane) vitamin A in large doses
fluroquinolones
tetracyclines
warfarin
DOACs
DMARDs
anticonvulsants
Are opioids safe in pregnancy?
No, opioids taken in early pregnancy can increase risk for congenital heart defects, spina bifida, and gastroschisis
How should something like osteoarthritis be treated?
NSAIDs
What is tramadol approved for?
moderate to moderately severe pain
What schedule is tramadol?
Schedule 4 controlled substances are drugs with a low potential for abuse and low risk for dependence such as xanax, valium, ativan, ambien, tramadol, pentazocine (talwins), soma, darvon, darvocet
What drugs should be avoided with tramadol?
benzos
CNS depressants
SSRIs
SNRIs
triptans
tricyclic antidepressants
alcohol
MAOIs — hypertensive crises
In what condition should tramadol be avoided?
epilepsy
What are examples of pure opioid agonists?
morphine, fentanyl, methadone, hydromorphone, oxymorphone, levorphanol, codeine, oxycodone, tapentadol
What are examples of pure opioid antagonists?
naloxone, naltrexone
What are examples of agonist-antagonists?
pentazocine, nalbuphine, butorphanol, buprenorphine
What are examples of selective opioid antagonists?
methylnaltrexone, naloxegol, naldemedine
What is codeine approved for?
Treatment of mild to moderate pain
What is the black box warning for codeine?
Respiratory depression; deaths have also occurred in breastfeeding infants after being exposed to high concentrations of morphine because the mothers were ultra-rapid metabolizers.
What medications should be avoided with opioids?
benzos
barbituates
alcohol
CNS depressants
antihistamines
thiothixene
anesthetics
sedatives
atropine-like drugs
tryciclic antidepressants
anticholinergic drugs — constipation
MAOIs — hyperexia coma
How would you know when to refer someone to a pain specialist for pain management?
when 120 MME are used
What schedule does heroin belong to?
Schedule 1 controlled substances are drugs with no accepted medical use and high potential for abuse such as heroin, LSD, ecstacy, methaqualone, peyote
What schedule does adderall being to?
Schedule 2 controlled substances are drugs with high potential for abuse, with use potentially leading to severe psychological or physical dependance.
products with less than 15 mg of hydrocodone per dosage unit, cocaine, methamphetamine, methadone, hydromorphone, oxycodone, fentanyl, meperidine, dexedrine, adderall, ritalin
What schedule do anabolic steroids belong to?
Schedule 3 controlled substances are drugs with a moderate to low potential for psychological and physical dependence such products containing less than 90 mg of codeine per dosage unit, ketamine, anabolic steroids, testosterone
What schedule does ambien belong to?
Schedule 4 controlled substances are drugs with a low potential for abuse and low risk for dependence such as xanax, valium, ativan, ambien, tramadol, talwin, soma, darvon, darvocet
What schedule does lyrica belong to?
Schedule 5 controlled substances are drugs containing limited quantities of certain narcotics, generally for antitussives, antidiarrheal, analgesic purposes, cough preparations with less than 200 mg of codeine per 100 ml, such as lomotil, morofen, lyrica, parepectolin
What are the top 5 priorities of the HHS in regard to the opioid epidemic?
improve access to treatment and recovery services
promoting the use of overdose reversing drugs
strengthening our understanding of the epidemic through better public health surveillance
providing support for cutting edge research on pain and addiction
advancing better pain management practices
What provisions were made to the guidelines for prescribing opioids to non-cancer patients?
Only using opioids after nonopioids or more conservative options failed.
Discuss the benefits and risks of long term opioids
Use only one prescriber and one pharmacy
Comprehensive follow up to ensure efficacy and to assess for side effects of treatment.
Stopping opioids after an attempt at rotation has produced inadequate benefit.
Fully documenting the entire process of the opioid prescription process.
What can methadone be used for?
Maintenance and suppression therapy for opioid use disorder.
What is the black box warning for methadone?
prolonged QT
What baseline monitoring is indicated for methadone?
ECG
Why is buprenorphine safer to use than methadone?
It has a ceiling to respiratory depression
What is the black box warning for vicodin?
vicodin (hydrocodone/acetaminophen) has a black box warning for hepatotoxicity
What drug interactions can occur with furosemide?
lithium — increased effects of lithium
digoxin — increased risk for dig toxicity in hypokalemia
aminoglycocides (gentamycin) — increased risk for ototoxicity
NSAIDS — increased risk for prerenal kidney injury, can decrease efficacy and intensify toxicity
What adverse reaction can result from furosemide?
ototoxicity, hyperglycemia, hyperuricemia, decreased HDL, increased LDL and triglycerides
What baseline monitoring is indicated for loop diuretics?
creatinine
electrolytes
Are loop diuretics safe in pregnancy?
No, animal studies have demonstrated maternal death, abortion, and fetal resorption
What are adverse effects of thiazide diuretics?
hyperglycemia, hyperuricemia, dig toxicity, lithium toxicity
What is the black box warning for spironolactone?
Has been shown to be tumorigenic in rats.
What are side effects of spironolactone?
gynecomastia, menstrual irregularities, impotence, hirsutism, deepening of the voice
What is considered normal blood pressure?
SBP <120 & DBP <80
What is considered elevated blood pressure?
SBP 120-129 & DBP <80
What is considered stage I hypertension?
SBP 130-139 & DBP 80-89
What is considered stage II hypertension?
SBP ≥140 & DBP >90
What is the role of aldosterone?
inhibits renal excretion of sodium and water in exchange for excretion of potassium and hydrogen increasing blood volume and blood pressure; promotes remodeling and cardiac fibrosis
What is an adverse effect of ACEIs?
renal insufficiency in bilateral renal artery stenosis, neutropenia
Are RAAS blockers safe in pregnancy?
No, RAAS blockers should be avoided, especially in the second and third trimester
What is the black box warning for ACEIs?
Fetal injury in pregnancy, especially in the second and third trimesters
What drug interactions can occur with ACEIs?
Lithium — ACEIs can cause lithium to accumulate to toxic levels
NSAIDs — NSAIDs can reduce the antihypertensive effects of ACEIs and intensify toxicity
What baseline data is needed for ACEIs and ARBs?
renal function (creatinine)
What monitoring is needed for ACEIs and ARBs?
renal function (creatinine) should also be checked 2-4 weeks after starting
What drug class is indicated for cardiac fibrosis?
ARBs
What are contraindications for ACEIs?
pregnancy, renal artery stenosis
What is the only approved direct renin inhibitor?
aliskiren
What should be avoided with administration of a direct renin inhibitor?
administration with a high fat meal
