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Year 1: Patho/Pharm > MSK_Pharm > Flashcards

MSK_Pharm Flashcards

1
Q

Function of calcium in the body

A
  1. bone - structure, storage
  2. contraction - VSM, heart
  3. coagulation
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2
Q

Is bone static?

A

No
Remodelling occurs with osteoclasts (reabsorption), osteoblasts (deposition), and osteocytes (homeostasis)
Takes 3-4 months
trabecular bone > cortical bone

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3
Q

Drugs that decrease calcium in body

A

Glucocorticoids
furosemide diuretics
sodium
calcitonin
SSRI
PPI
blood thinners
bisphosphonates
denosumab
SERMs (raloxifene)
estrogen
teriperatide

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4
Q

Drugs that increase calcium in the body

A

thiazide diuretics
calcium salts
PTH
vitamin D

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5
Q

Effect of PTH

A

*released from parathyroid gland when serum calcium level is too low

increase bone reabsorption - release calcium

increase GI absorption of calcium

decrease kidney excretion of calcium

increase level of calcium in the blood

decrease phosphate in blood

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6
Q

Effect of Vitamin D

A

*made by liver and kidney
1, 25 dihydroxyvitamin D

increase bone reabsorption

increase GI absorpiton calcium

decrease renal excretion calcium

increase phosphate level in blood

increase level calcium in the blood

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7
Q

Calcitonin

A

*Released from thyroid gland when serum calcium is too high

decrease bone reabsorption

increase renal excretion

decrease serum calcium

no effect on intestine

no effect on phosphate

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8
Q

Hypercalcemia

A

too much calcium in the blood

cardiovascular damage

kidney damage (kidney stones)

fatigue, lethargy, depression, muscle weakness, constipation, abdominal cramping, nausea, vomiting, anorexia

Causes:
cancer
vitamin D toxicity
sarcoidosis
thiazide diuretics

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9
Q

Hypocalcemia

A

too little calcium in the body

spasms, tetany, muscle cramping

Causes:
low PTH
low vitamin D
diet
thyroidectomy
furosemide diuretic

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10
Q

Drugs involved with calcium and bone mineralization

A

bisphosphonates
denosumab
SERMs (estrogen, raloxifene)
calcium salts, cinacalcet
Furosemide/thiazide
glucocorticoids
teriparatide, PTH
vitamin D

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11
Q

List of Calcium salts

A

calcium carbonate
calcium gluconate
calcium citrate
calcium acetate
calcium lactate

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12
Q

Indication Calcium salts

A

hypocalcemia
pre-menstrual cramps
colorectal adenoma

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13
Q

AE Calcium salts

A

hypercalcemia
cramping, constipation, anorexia
kidney stones
lethargy, fatigue, depression
dysrhythmias

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14
Q

Drug interactions Calcium salts

A

glucocorticoids - decrease GI absorption calcium, incrase bone reabsorption, increase kidney excretion calcium

PPI, SSRIs, furosemide, blood thinners, glucocorticoids decrease calcium

thiazide diuretics - hypercalcemia

chelation of other drugs - don’t take at the same time, decrease drug absorption

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15
Q

RDA of calcium

A

600-900mg/day
only use supplements to top up diet

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16
Q

Baseline data required before calcium salt prescription

A

ECG - heart, dysrhythmias

Serum calcium, phsophate, magnesium

Albumin - Kidney

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17
Q

Vitamin D
Scientific forms

A

Vitamin D2 - ergocalciferol (plants, inactive form)

Vitamin D3 - cholecalciferol (partially active, sunlight)

1,25 dihydroxyvitamin D - Calcitriol (fully active)

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17
Q

Contraindication Calcium salts

A

hypophosphatemia
hypercalcemia
kidney stones

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18
Q

Indication
Vitamin D supplements

A

Low vitamin D

Rickets
osteomalacia
hypoparathyroidis

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19
Q

MOA
Vitamin D

A
  1. Bone - increase bone reabsorption
  2. GI - increase SI absorption of calcium
  3. Renal - decrease excretion calcium and phosphate, reabsorption
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20
Q

Target level of Vitamin D for bone health

A

30-60ng/mL

Deficiency treatment

infants 2000IU
children 4000IU
adults 10,000IU

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21
Q

Baseline labs for Vitamin D

A

serum vitamin D
serum calcium, phsophate, magnesium
ALP (bone reabsorption)
24 hour urine calcium

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22
Q

Contraindication
Vitamin D

A

hypercalcemia
hypervitaminosis D
digoxin
malabsorption

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23
Q

AE
Vitamin D

A

Hypervitamin D
- fatigue, lethargy, depression
- supression growth, reabsorption bones
- constipation, nausea/vomiting, decreased appetite

deposition calcium in vasculature, heart, kidney

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24
Q

Antedote Vitamin D

A

furosemide
fluids
glucocorticoids
low calcium diet

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25
Q

Bisphosphonates
List of drugs

A

alenDRONATE (PO)
riseDRONATE (IV)
ZoleDRONic acid (IV)

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26
Q

Bisphosphonate
MOA

A

structural analog of pyrophosphate
deposition into bone structure

  1. Ingested by osteoclasts; decrease activity, recruitment
  2. increase osteoblast inhibition of osteoclasts
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27
Q

bisphosphonate
AE

A

Esophagitis, ulcers, cancer
- sit up for 60 minutes
- take with full glass of water

Osteonecrosis of the jaw (IV)
- Dentist prior to Rx

Hip and long bone fractures
- decreases remodeling of bone

Musculoskeletal pain
- after first dose or months after
- requiring opioids
- D/C if pain recurrent

Occular inflammation
- uveitis, conjunctivitis, sceleritis

Hyperparathyroidism
- low serum sodium results in PTH release

Atrial fibrillation

Flu like symptoms (IV)

Renal damage (IV)

28
Q

Bisphosphonate
administration instructions

A
  • take with full glass of water
  • do not lie down for 60 minutes
  • take on an empty stomach
  • dental work prior to prescription
  • report GI, vision, hip pain
29
Q

Bisphosphonate
Monitoring

A

BASELINE:

DXA scan
every 1-2 years

Serum calcium, magnesium, phosphate, Vitamin D (25 hydroxy vitamin D)

Serum creatinine, GFR (>30mL/min)

30
Q

Contraindications
Bisphosphonates

A
  • esophagitis, ulcers, cancer
  • osteoporosis hip and fractures
  • necrosis jaw
  • severe MSK pain
  • GFR < 30mL/min, kidney damage
31
Q

Serum Estrogen Receptor Modulators (SERMs)

A

raloxifene
extrogen

32
Q

MOA
Raloxifene

A

Estrogen agonist in bone, lipid metabolism, clotting

Increase bone mineral density
Reduction spinal fractures

Estrogen increases OPG (osteoprotegrin) which binds to RANKL on osteoblast and prevents it from activating the osteoclast RANK

33
Q

AE
Raloxifene

A

DVT/PE/CVD
- must D/C if bedrest or sedentary
- D/C 72 hours in advance
(plane travel)

hot flashes

abortive agent - teratogenic

34
Q

Benefits of
Raloxifene

A

decrease risk of breast and endometrial cancer

lowers LDL and cholesterol

increase bone mineral density and decrease fractures

35
Q

Monitoring
Raloxifene

A

HCG test
Serum calcium, vitamin D
DXA scan, height, 1-2 years

36
Q

AE
Estrogen

A

increase risk of breast cancer and endometrial cancer

37
Q

Denosumab
MOA

A

monoclonal antibody
binds to RANKL
prevents interaction between RANKL-RANK and osteoclast reabsorption

increases bone mineral density and prevents fractures

38
Q

AE
Denosumab

A

hypersensitivity reactions

Flu like symptoms
serious infection

ONJ - osteonecrosis of the jaw

Hypocalcemia
hyperparathyroidism

39
Q

Monitoring
Denosumab

A

Serum calcium, vitamin D, magnesium, phsophate, creatinine

HCG

DXA, height

40
Q

Administration instructions

A

Rx. Vitamin D, Calcium
Avoid infections
Dentist prior to prescription

41
Q

Anti-Gout Drugs

A
  1. NSAIDS (First line therapy)
    - indomethacin
    - naproxen
    - diclofenac
  2. Anti-Gout Anti-inflammatory drugs
    - Colchicine
  3. Glucocorticoids
    - prednisone
  4. Xanthine Oxidase Inhibitors
    - Allopurinol
    - Febuxostat
  5. Uricosuric agent
    -probenecid
  6. Combination drugs
    - probenecid / colchicine
42
Q

NSAIDs for anti-gout
MOA

A

Ex. naproxen, indomethacin, diclofenac

Block COX1 and COX2
prevention formation prostaglandins (inflammatory cytokines)

Decrease vasodilaiton, vascular premability, WBC migration - decrease inflammation and pain

43
Q

SE
NSAIDS

A

GI: ulceration, perforation, bleeding

Kidney: AKI

Cardio: MI, stroke, HTN, hemorrhage

Tinnitus/salicylism

Reye’s syndrome children

premature closure ductus artereosus/cleft lip and palate

*shortest duration possible

44
Q

Drug therapy
< 3 gouty attacks per year

A

Drugs for symptom management (inflammation)

  1. NSAID
  2. Colchicine
  3. glucocorticoids
45
Q

Drug therapy > 3 gouty attacks per year

A

Drugs for hyperuricemia (increase secretion, decrease production)

  1. Xanthine Oxidase Inhibitors (allopurinol, febuxostat)
    - prevention uric acid formation
  2. Uricosuric agents
    Probenecid
    - uric acid secretion by kidney
  3. uric acid oxidase
    - Pegloticase
    - convert uric acid to allantoin
46
Q

Glucocorticoid for anti-gout

MOA

A

Prednisone
second line therapy (after NSAID)
NSAID intolerance/contraindication/unresponsive

Decrease WBC recruitment, migration

47
Q

SE
Glucocorticoids

A

hypokalemia
hypernatremia
water retention, FVO, edema
striation skin
poor healing wounds, wound infections
hyperglycemia
muscular weakness/atrophy
truncal deposition of fat
moon face
osteoporosis
cataracts, glaucoma
adrenal insufficiency
aggitation, depression, insomnia, hallucinations etc.

48
Q

Colchicine
anti-gout anti-inflammatory
MOA

A

Disrupts WBC microtubules, preventing WBC infiltration/migration

anti-inflammatory

49
Q

AE
Colchicine

A

Narrow therapeutic index
Cytotoxic to cells with high proliferation index (ex. GI, bone marrow)

GI: nausea, vomitting, diarrhea, pain (D/C)

WBC: agranulosis, thrombocytopenia, infections

MSK: Rhabdomyolysis (kidney and liver damage)

Teratogenic

50
Q

Drug interactions
Colchicine

A

Statins: increase myopathy, liver damage, rhabdomyolysis

CYP3A4 inhibitors: toxicity

51
Q

Indication
Colchicine

A
  1. management symptoms short term attack
  2. prevention gout attacks
52
Q

Indication
Allopurinol

A

Chronic tophaceous gout
Chemotherapy/cancer therapy

53
Q

MOA
Allopurinol

A

Xanthine Oxidase Inhibitor
- DNA breakdown forms hypoxanthine
- XOI blocks formation of Xanthine -> uric acid

54
Q

SE
Allopurinol

A

GI: nausea, vomiting, diarrhea

WBC: bone marrow supression, infection risk

first dose can initiate gout attack
- administer with colchicine and NSAID for up to 6 months

55
Q

AE
Allopurinol

A

WBC: agranulocytosis, thrombocytopenia

Fatal hypersensitivity syndrome
- liver, kidney failure, eosinophilia

SCAR - severe cutaneous adverse reaction
- HLA B5801 testing
- Asian heritage more common

56
Q

SE
Febuxostat

A

Gout flare ups: prescribe with NSAID and colchicine for 6 months

CVE

57
Q

Probenecid
indication

A

Hyperuremia
chronic gout
pregnancy
children < 2 years

58
Q

Probenecid
MOA

A

Kidney
decrease reabsorption of uric acid
increase excretion of uric acid

results in decrease tophi

59
Q

Probenecid
SE

A

GI: nausea, vomiting

skin: hypersensitivity

first dose: gouty flare up, administer with NSAID or colchicine

Kidney: renal injury, 3L per day fluid

Blood: hemolytic anemia, pancytopenia (G6PD deficiency African, mediteranian)

60
Q

Probenecid
Drug interactions

A

Aspirin
antibiotics - penicillin, cephalosporins, sulfonamides
*reduction dosage required

61
Q

Pegloticase
MOA

A

Urate oxidase
converts uric acid into allantoin
allantoin is water soluble and excreted by kdiney

62
Q

Pegloticase
INdication

A

Last ressort therapy
Not responding to PO
IV

63
Q

Pegloticase
AE

A

anaphylaxis infusion reaction

pre-treatment with prednisone and anti-histamines; close monitoring
- 2 hours, or delayed

hemolytic anemia - G6PD deficiency (screen)

64
Q

Urate lowering drugs
Baseline data

A

Serum uric acid
LFT
CBC
Pain assessment

Allopurinol: HLA B 5801 (Korean, Thai, Chinese)

Febuxostat: LFT, CVRisk

Probenecid: G6PD deficiency

65
Q

Urate Lowering Drugs
Monitoring data

A

SErum uric acid, CBC and diff
2-5 weeks
< 6mg/dL
then monitor every 6 months

LFTs, BUN, serum creatinine

improvement signs and symptoms of gout

66
Q

Treatment pathway Gout

A
  1. establish diagnosis
  2. elimination diet, lifestyle, drugs
  3. assess gout burden and indication for urate lowering therapy (ULT)
    - tophi
    - frequency gout attacks > 2 per year
    - presence CKD
    - urolithiasis
  4. first line therapy
    - Xanthine oxidase inhibitors (febuxostat, allopurinol)
    - alternative probenecid

XOI is prescribed with acute gout prophylaxis (NSAID, colchicine, glucocorticoid)

67
Q

Long term maintenance gout

A

continue prophylaxis treatment if > 1 tophi on exam
6 month monitoring serum urate < 6mg/dL
refer out if not responsive

68
Q

Treatment pathway acute gout attack

A
  1. continue prophylaxis therapy
    - allopurinol, probenecid
  2. initiation monotherapy or combination therapy
    - NSAID
    - glucocorticoid
    - colchicine

Year 1: Patho/Pharm (39 decks)

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