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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
Antedote Vitamin D
furosemide fluids glucocorticoids low calcium diet
25
Bisphosphonates List of drugs
alenDRONATE (PO) riseDRONATE (IV) ZoleDRONic acid (IV)
26
Bisphosphonate MOA
structural analog of pyrophosphate deposition into bone structure 1. Ingested by osteoclasts; decrease activity, recruitment 2. increase osteoblast inhibition of osteoclasts
27
bisphosphonate AE
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
Bisphosphonate administration instructions
- 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
Bisphosphonate Monitoring
BASELINE: DXA scan every 1-2 years Serum calcium, magnesium, phosphate, Vitamin D (25 hydroxy vitamin D) Serum creatinine, GFR (>30mL/min)
30
Contraindications Bisphosphonates
- esophagitis, ulcers, cancer - osteoporosis hip and fractures - necrosis jaw - severe MSK pain - GFR < 30mL/min, kidney damage
31
Serum Estrogen Receptor Modulators (SERMs)
raloxifene extrogen
32
MOA Raloxifene
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
AE Raloxifene
DVT/PE/CVD - must D/C if bedrest or sedentary - D/C 72 hours in advance (plane travel) hot flashes abortive agent - teratogenic
34
Benefits of Raloxifene
decrease risk of breast and endometrial cancer lowers LDL and cholesterol increase bone mineral density and decrease fractures
35
Monitoring Raloxifene
HCG test Serum calcium, vitamin D DXA scan, height, 1-2 years
36
AE Estrogen
increase risk of breast cancer and endometrial cancer
37
Denosumab MOA
monoclonal antibody binds to RANKL prevents interaction between RANKL-RANK and osteoclast reabsorption increases bone mineral density and prevents fractures
38
AE Denosumab
hypersensitivity reactions Flu like symptoms serious infection ONJ - osteonecrosis of the jaw Hypocalcemia hyperparathyroidism
39
Monitoring Denosumab
Serum calcium, vitamin D, magnesium, phsophate, creatinine HCG DXA, height
40
Administration instructions
Rx. Vitamin D, Calcium Avoid infections Dentist prior to prescription
41
Anti-Gout Drugs
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
NSAIDs for anti-gout MOA
Ex. naproxen, indomethacin, diclofenac Block COX1 and COX2 prevention formation prostaglandins (inflammatory cytokines) Decrease vasodilaiton, vascular premability, WBC migration - decrease inflammation and pain
43
SE NSAIDS
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
Drug therapy < 3 gouty attacks per year
Drugs for symptom management (inflammation) 1. NSAID 2. Colchicine 3. glucocorticoids
45
Drug therapy > 3 gouty attacks per year
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
Glucocorticoid for anti-gout MOA
Prednisone second line therapy (after NSAID) NSAID intolerance/contraindication/unresponsive Decrease WBC recruitment, migration
47
SE Glucocorticoids
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
Colchicine anti-gout anti-inflammatory MOA
Disrupts WBC microtubules, preventing WBC infiltration/migration anti-inflammatory
49
AE Colchicine
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
Drug interactions Colchicine
Statins: increase myopathy, liver damage, rhabdomyolysis CYP3A4 inhibitors: toxicity
51
Indication Colchicine
1. management symptoms short term attack 2. prevention gout attacks
52
Indication Allopurinol
Chronic tophaceous gout Chemotherapy/cancer therapy
53
MOA Allopurinol
Xanthine Oxidase Inhibitor - DNA breakdown forms hypoxanthine - XOI blocks formation of Xanthine -> uric acid
54
SE Allopurinol
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
AE Allopurinol
WBC: agranulocytosis, thrombocytopenia Fatal hypersensitivity syndrome - liver, kidney failure, eosinophilia SCAR - severe cutaneous adverse reaction - HLA B5801 testing - Asian heritage more common
56
SE Febuxostat
Gout flare ups: prescribe with NSAID and colchicine for 6 months CVE
57
Probenecid indication
Hyperuremia chronic gout pregnancy children < 2 years
58
Probenecid MOA
Kidney decrease reabsorption of uric acid increase excretion of uric acid results in decrease tophi
59
Probenecid SE
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
Probenecid Drug interactions
Aspirin antibiotics - penicillin, cephalosporins, sulfonamides *reduction dosage required
61
Pegloticase MOA
Urate oxidase converts uric acid into allantoin allantoin is water soluble and excreted by kdiney
62
Pegloticase INdication
Last ressort therapy Not responding to PO IV
63
Pegloticase AE
anaphylaxis infusion reaction pre-treatment with prednisone and anti-histamines; close monitoring - 2 hours, or delayed hemolytic anemia - G6PD deficiency (screen)
64
Urate lowering drugs Baseline data
Serum uric acid LFT CBC Pain assessment Allopurinol: HLA B 5801 (Korean, Thai, Chinese) Febuxostat: LFT, CVRisk Probenecid: G6PD deficiency
65
Urate Lowering Drugs Monitoring data
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
Treatment pathway Gout
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
Long term maintenance gout
continue prophylaxis treatment if > 1 tophi on exam 6 month monitoring serum urate < 6mg/dL refer out if not responsive
68
Treatment pathway acute gout attack
1. continue prophylaxis therapy - allopurinol, probenecid 2. initiation monotherapy or combination therapy - NSAID - glucocorticoid - colchicine

Year 1: Patho/Pharm (45 decks)

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