NAPLEX Flashcards
What are the five aspects of the Model of the Pharmacist Patient Care Process
- Collect
- Assess
- Plan
- Implement
- Follow-up, monitor, & evaluate
What are some differences between primary, secondary, and tertiary literature?
Primary - Original research publications usually published in peer-reviewed journals
Secondary - Interpretations and reviews of primary sources as well as abstraction and indexing services. Examples: review articles, meta-analysis, systematic reviews, practice guidelines, indexing programs like PubMed.
Tertiary - Combines 1 and 2 sources to create textbooks, encyclopedic articles, guidebooks, handbooks, and electronic information databases such as UpToDate, MicroMedex, LexiComp, etc.
List the following in descending order in terms of level of evidence.
- Cohort study
- Meta-anaylsis
- Background info and expert opinion
- Randomized controlled trial
- Case-control study
- Animal research and lab studies
- Systemic review
*
Match the following definition:
A systemic review that uses quantitative methods to summarize the results.
- Cohort study
- Meta-anaylsis
- Background info and expert opinion
- Randomized controlled trial
- Case-control study
- Animal research and lab studies
- Systemic review
- Meta-anaylsis
Match the following definition:
A systematic search, appraisal, and summary of all of the literature for a specific topic.
- Cohort study
- Meta-anaylsis
- Background info and expert opinion
- Randomized controlled trial
- Case-control study
- Animal research and lab studies
- Systemic review
- Systemic review
Match the following definition:
A study of a randomized group of specific patients in an experimental group and a control group with specific variables and outcomes of interest.
- Cohort study
- Meta-anaylsis
- Background info and expert opinion
- Randomized controlled trial
- Case-control study
- Animal research and lab studies
- Systemic review
- Randomized controlled trial
Match the following definition:
Identification of two groups of patients, one that received a treatment and one that did not, and studies of these groups going forward for the outcome.
- Cohort study
- Meta-anaylsis
- Background info and expert opinion
- Randomized controlled trial
- Case-control study
- Animal research and lab studies
- Systemic review
- Cohort study
Match the following definition:
Identification of pts who have the outcome of interest and control pt without the same outcome and studies of the outcome of an exposure or treatment of interest
- Cohort study
- Meta-anaylsis
- Background info and expert opinion
- Randomized controlled trial
- Case-control study
- Animal research and lab studies
- Systemic review
- Case-control study
Match the following definition:
Handbook, textbook, electronic info databases, editorials
- Cohort study
- Meta-anaylsis
- Background info and expert opinion
- Randomized controlled trial
- Case-control study
- Animal research and lab studies
- Systemic review
- Background info and expert opinion
Match the following definition:
Research studies at the bottom of clinical evidence but may generate ideas and/or fundamental knowledge which ultimately may lead to clinical therapy.
- Cohort study
- Meta-anaylsis
- Background info and expert opinion
- Randomized controlled trial
- Case-control study
- Animal research and lab studies
- Systemic review
- Animal research and lab studies
Can you list some differences between Physician’s Desk Reference, Orange Book, Purple Book, and Red Book?
Which is which?
Approval Drug Products w/ Therapeutic Equivalence Evaluation –> Provided bioequivalence.
Provided availability, pricing on prescription and OTC products, dosage form info, size, strength, route of administration, NDCs, AWP, in addition to sugar-free, lactose-free, and alcohol-free products.
Only contains information on FDA approved medications and indications.
List of Licensed Biological Products with Reference Products Exclusivity and Biosimilarity or Interchangeability Evaluations.
Orange
Red
Physician’s Desk Reference
Purple
AMP
WAC
AWP
*
What does REMS stand for?
Risk Evaluation and Mitigation Strategies
Where could you go to find:
- Do Not Crush List
- FDA BB Warnings
- Consumer info or medication misuse
- Error prone abbreviations
- FDA pt safety news
- High alert meds
- Go here to report medication errors & find root cause analysis workbook
- SALAD (look alike, sound alike drugs)
- Tall man lettering
ISMP (institute for safe medication practices)
- ) If a patient has an adverse drug effect or a medication error has occurred, who should you report it to?
- ) If the above resulted in a serious rxn or near miss, who else should you report it to?
- ) Pharmacist and prescriber
2. ) FDA via medwatch
What do FAERS and VAERS stand for and what are they?
FDA Adverse Event Reporting System
Vaccination Adverse Event Reporting System
They are databases that contain info on adverse events and medication errors reported to the FDA.
When discarding medications and medication take back programs and/or DEA authorized containers/collectors are unavailable, what can you do?
MOST meds can be disposed of in house hold trash.
- ) Mix meds w/ an unpalatable substance like dirt, coffee grounds or kitty litter.
- ) Do not crush tablets of open capsules
- ) Put the mixture in a sealable plastic bag and discard in trash
- ) B/4 discarding the bottle, scratch out all personal information.
If the medication is a controlled substance, DO NOT DISCARD IN TRASH (to protect from children, pets, and abusers) Flush these guys down the toilet. For Fish, Wildlife and Drinking Water Stewardship the FDA recommends ONLY these controlled substances be disposed of in wastewater.
Definition: Inability to properly metabolize or use glucose
Glucose intolerance
Definition: Cells become resistant to insulin and are unable to use it effectively.
Insulin resistance
What is the difference between glucose intolerance and insulin resistance?
Glucose intolerance is when your body can’t metabolize or use glucose. Your body is intolerant to it. Its there, your body just can’t do anything with it.
Insulin resistance is when your body basically ignores insulin and is unable to use it.
What is/are the mechanism(s) of action for Metformin?
- ) inhibition of hepatic glucose production
- ) increase glucose uptake in peripheral tissues
- ) decreased intestinal absorption of glucose
What is the generic name for Glucophage?
Metformin IR
What is the brand name for Metformin IR?
Glucophage
List one vitamin you might want to monitor while on metformin.
B12…long term use (> 1 yr) can decrease B12
What adverse drug event would you be MOST concerned about with metformin?
lactic acidosis. Build up of lactate leads to decreased pH in the blood = increases acid in the blood.
What is lactic acidosis? What meds might increase the risk for lactic acidosis (you might want to avoid these while on metformin)
The build up of lactate which leads to decreased pH in the blood = increases acid in the blood. Low pH is high acid.
topiramate, zonisamide, dichlorphenamide, acetazolamide
List some situations where metformin would be a concern for caution and/or contraindication.
Caution: Lactic acidosis, impaired renal f(x), CrCl < 45 –> decrease daily dose by 50%
Contraindication: CrCl < 30, female SCr >1.4, male SCr >1.5, symptomatic HF, hepatic impairment, dye-contrast, concomitant use of meds that increase risk of lactic acidosis (topiramate, zonisamide, acetazolamide, dichlorphenamide)
What is the brand name for Metformin IR Oral Solution?
Riomet
What are the brand names of Metformin ER? Which one is associated with a ghost tablet?
Fortamet, **Glumetza, Glucophage XR
What is the usual starting and max dose for metformin IR?
starting: 500mg daily - 1000mg daily. Comes in 500mg and 850mg tablets.
max: 2550mg daily divided in 2 - 3 doses.
What is the usual starting and max dose for metformin ER?
starting: 500mg to 750mg daily.
max: 2000mg daily. (with exception of Fortamet which is 2500mg daily)
List the sulfonylureas.
Glipizide, Glipizide XL, Glyburide, Glimepiride, Glyburide (micronized)
What is the brand name for glipizide?
glucotrol
What is the brand name for glipizide XL?
glucotrol XL
What is the brand name for glimepiride?
amaryl
What is the brand name for glyburide?
diabeta
What is the brand name for glyburide micronized?
micronase
Which of the 2nd gen sulfonylureas can used in pregnancy and while breast feeding?
glyburide
When should you take glimepiride?
with the first meal of the day
What are the MOAs for sulfonylureas?
they stimulate the sulfonylurea receptors that lead to increase insulin secretion and decrease hepatic glucose production. They goose the pancreas and slow down the liver. Because it works by encouraging the pancreas to secrete insulin via beta cells, then it stands to reason that their effectiveness is dependent on B-cell f(x).
Which one of the sulfonylureas should be avoided in elderly and why?
Glyburide. It has the highest risk profile for hypoglycemia
What are the meglitinides?
Repaglinide and nateglinide
Which medication is repaglinide contraindicated with? Why?
Gemfibrozil may slow down how quickly your liver metabolizes repaglinide. Repaglintide is metabolized by CYP2C8 and gemfibrozil is an inhibitor of CYP2C8.
What might happen:
The amount of repaglinide in your blood may increase and that may lower your blood sugar too much.
DEA Numbering systems…describe it.
First letter…A, B, F, or G would be for big four…physician, podiatrist, dentist, or vet. M = mid-level provider like NP or PA. To check the number…step 1: add 1st, 3rd, and 5th step 2: add (2nd+ 4th+ 6th) x2…..add step 1 and 2, if the last number of this product matches the last number of the DEA, its legit.
DEA Numbering systems…how the hell do you figure it out?
First letter…A, B, F, or G would be for one of the big four…physician, podiatrist, dentist, or vet. M = mid-level provider like NP or PA. Second letter is the first letter of the persons last name (it might be a maiden name or the first letter of a business name). To check the number, do this –> step 1: add 1st, 3rd, and 5th numbers together; step 2: add [(2nd+ 4th+ 6th) x2]…..add step 1 and step 2, if the last number of this product matches the last number of the DEA number, its legit.
What medication fall under the class of thiazolidinediones?
They are the -glitazones. Pioglitazone (Actos) and Rosiglitazone (Avandia)
What population is Actos contraindicated?
HEART FAILURE (BBW), bladder cancer, high risk of bone fracture
What population is Avandia contraindicated?
HEART FAILURE, MI, high risk of bone fracture, hepatic impairment, ischemic heart issues
What are the two indications for TZDs?
T2DM and fatty liver disease
What is the TZDs MOA(s)?
PPARy agonist….peroxisome proliferators-activated receptor-gamma…receptor stimulation –> insulin sensitivity in peripheral muscle and adipose tissue AND suppresses hepatic glucose output.
What is the major ADE with TZDs?
peripheral edema
What add on medication would you use if a patient developed peripheral edema on a TZD?
aldosterone antagonist (spironolactone and eplerenone)
FDA approved medication guide must be dispensed with which TZD?
Rosiglitazone (Avandia)
What are the DPP4 inhibitors?
these at the -gliptins….Saxagliptin (Onglyza), Sitagliptin (Januvia), Linagliptin (Tradjenta), Alogliptin (Nesina)
What is the brand name of Rosiglitazone?
Avandia
What is the brand name of Pioglitazone?
Actos
What is the brand name of Saxagliptin?
Onglyza
What is the brand name of Sitagliptin?
Januvia
What is the brand name of Linagliptin?
Tradjenta
What is the brand name of Alogliptin?
Nesina
What is the MOA of DPP4 inhibitors?
They block the break down of endogenous GLP1. GLP1 is an endogenous “enzyme” that is released in a glucose dependent manner. When you eat, GLP1 is released. GLP1 signals for insulin to be secreted. But GLP1 is broken down quickly by endogenous DDP4. So DPP4 inhibitors (the gliptins) block the break down of endogenous GLP1 resulting in GLP1 being around longer and stimulating insulin to be secreted longer leading to lower BG. Also decreases production of glucagon which leads to decreased production of glucose in the liver.
Common adverse drug effects of DPP4 inhibitors?
- nasopharyngitis
- HEART FAILURE
- URT infection
- HA
- UTI (Saxagliptin)
- PANCREATITIS (CONTRAINDICATION!!)
What is a contraindication with DPP4 inhibitors?
history of pancreatitis
Which DPP4 inhibitor is not renally adjusted?
Linagliptin (Tradjenta)
What are the SGLT-2 inhibitors?
these are the -flozins…Sodium GLucose co-Transporter-2 inhibitor…how do you remember these are the flozins? There is a #2 in the name and flozin hosin, and remember the MOA. Canagliflozin (Invokana), Emapagliflozin (Januvia), Dapagliflozin (Farxiga)
What is the brand name of Canagliflozin?
Invokana
What is the brand name of Emapagliflozin?
Jardiance
What is the brand name of Dapagliflozin?
Farxiga
What is the MOA of the SGLT-2 inhibitors?
SGLT-2 is the transporter that allows glucose to be reabsorbed from the urine back into the body so the body can use the glucose before it is excreted. The SGLT-2 inhibitors blocks the transporter and forces the glucose to be excreted without reabsorption. You pee glucose out –> decreased plasma glucose.
Contraindications with SGLT-2 inhibitors?
renal impairment, fracture risks, bladder cancer (dapa)…with bladder cancer stay FAR away from FARxiga.
Common adverse drug effect with SGLT-2 inhibitors?
Hypotension, dehydration, weight loss, UTIs, hyperkalemia (canagliflozin), increased LDL, increased hematocrit (dapag and empag), euglycemic ketoacidosis
Positive effects of emapagliflozin?
decreased cardiovascular death, decreased hospitalization d/t heart failure and nephropathy.
What are the alpha glucosidase inhibitors?
Acarbose (Precose) and Miglitol (Glyset)
What is the MOA of alpha glucosidase inhibitors?
delayed digestion of carbohydrates
Adverse drug events with alpha glucosidase inhibitors?
flatulence, GI upset, diarrhea, abdominal pain, increased LFTs and bilirubin (acarbose)
CI with alpha glucosidase inhibitors?
inflammatory bowel disease, ulcerative colitis, Crohn’s disease, renal impairment SCr >2 and/or CrCl less than or equal to 25 mL/min…general use is not recommended 2017
What are the GLP-1 agonists?
these are the glutides and natides…Glucagon Like Peptide - 1 agonists….Albiglutide (Tanzeum), Dulaglutide (Trulicity), Liraglutide (Victoza), Lixisenatide (Adlyxin), Exenatide (Byetta), Exenatide ER (Bydureon, BCise)
What is the GLP-1 agonists MOA?
Stimulates GLP-1 receptor resulting in glucose dependent insulin secretion (it does nothing if glucose isn’t around), decrease post prandial glucagon secretion, slows gastric emptying, early satiety
Common adverse effects of GLP-1 agonists?
N/V, diarrhea, HA, weight loss
Contraindications of GLP-1s?
gastroparesis, pancreatitis, personal or familial medullary thyroid carcinoma, multiple endocrine neoplasia syndrome type 2 (BLACK BOX)
Which GLP-1s would you be worried about with renal impairment?
Byetta, Bydureon, BCise, and Adlyxin
Which GLP1’s do not require renal monitoring?
Tanzeum, Trulicity, and Victoza
Co-administration of CYP3A4/5 inhibitors would increase [ ] of which DPP4?
saxagliptin
What are the rapid acting insulins?
Glulisine (Apidra), Aspart (Novolog), Lispro (Humalog), inhaled insulin (Afrezza)
What are the short acting insulins?
Novolin R, Humulin R
What are the intermediate acting insulins?
NPH (Novolin N, Humulin N), Regular U-500 (Humulin R U-500)
What are the long acting insulins?
Glargine U-100 (Lantus), Glargine U-500 (Toujeo), Detemit (Levemir)
What are the ultra-long acting insulins?
Degludec U-100, U-200 (Tresiba)
What are the premixed insulins?
NPH + regular (Novolin 70/30, Humulin 70/30), Insulin protamine + analogs (Novolog Mix 75/25, Humolog Mix 75/25, Humalog Mix 50/50), Degludec + aspart (Ryzodec 70/30)
What 2 classes of anti diabetic medications would be avoided in a patient with pancreatitis history?
DPP4 inhibitors and GLP1 agonists
At what eGFR should the SGLT-2 inhibitors be DC’d?
Canagliflozin (Invokana) and Emapagliflozin (Jardiance) DC when eGFR < 45 and Dapagliflozin (Farxiga) when eGFR < 60.
What 3 classes of anti diabetics require LFT monitoring?
Biguanides, alpha glucosidase inhibitors, and TZDs
% error equation
absolute value of the (actual minus the desired) divided by the desired, x 100. Figure out what is the desired by the wording of the question. Then its the absolute value of the different of the two values divided by the desired value x 100…which gives you an answer in %.
What is the minimum measurable amount equation? AKA minimum weighable quantity.
MWQ = SR / % error (as a decimal)
MWQ = minimum weighable quantity SR = sensitivity requirement
2 of the 3 numbers will be given to you.
What is Clark’s rule?
Its a child’s dose estimation given an adult dosage. Its the adult dosage x (child’s weight in kg / 70 kg). For instance…the usual adult dose is 100mg and the child weighs 40kg. ==> 100mg x (40kg / 70kg) = 57mg
What is the body surface equation(s)?
the square root of ((height in inches x weight in lbs) / 3131 ) or the square root of ((height in cm x weight in kg) / 3600) = either resulting answer is in units of meters squared.
What is the average adult BSA?
1.73 meters squared
Thinking about millimolarity. 1.) What are the units of millimolarity? 2.) What are the units of molecular weight (MW)? 3.) What are the units of mEq?
- ) millimolarity is expressed in mmol/L
- ) MW is expressed in mg/mmol
- ) mEq = millimolarity = mmol/L
What are the 3 columns of alligation from left to right?
What you have, what you want, what you need.
What is the equation to figure out BMI?
weight (kg) / height (meters squared)
How many kcal/g per each?
- Carbohydrate
- Protein
- Dextrose
- Glycerol/Glycerin
- Fat
- IV Fat Emulsion 10%
- IV Fat Emulsion 20%
- IV Fat Emulsion 30%
- Amino Acids
- Carbohydrate = 4 kcal/g
- Protein = 4 kcal/g
- Dextrose = 3.4 kcal/g
- Glycerol/Glycerin 4.3 kcal/g
- Fat = 9 kcal/g
- IV Fat Emulsion 10% = 1.1 kcal/mL
- IV Fat Emulsion 20% = 2 kcal/mL
- IV Fat Emulsion 30% = 3 kcal/mL
- Amino Acids = 4 kcal/g
In which category of stroke would you use Alteplase?
ischemic
What class of medication is Alteplase?
Thrombolytic, TPA = tissue plasminogen activator
What is the MOA of alteplase?
a protease that rapidly converts plasminogen (inactive plasmin) to plasmin (the clot buster) in a thrombus. It causes a thrombolysis of a thrombus. It also has limited conversion activity in the absence of bound fibrin.
What is the dose of alteplase for acute ischemic stroke?
0.9 mg/kg, max dose 90mg. Dose is divided, 10% as a bolus, the remaining 90% infused over 60 minutes.
How would you set up an equation to figure ratio strength given a % strength? Example, express 0.25% strength in a ratio strength.
- 25/100 = 1/x
1: 400
How would you set up an equation to figure % strength given a ratio strength? Example, express 1:4000 strength in a % strength.
1/4000 = x/100
0.025%
How would you get to ratio strength without being given the % strength?
You have to convert to % strength first.
What is the corrected phenytoin equation?
[measured phenytoin (mg/L)] / [0.2 x ALBUMIN (g/dL)]
+ 0.1
What is the equation for corrected calcium?
*
sig: before meals
ac
sig: after meals
pc
sig: right eye
od
sig: left eye
os
sig: both eyes
ou
sig: as directed
ud
sig: at bedtime
hs
sig: right ear
ad
sig: left ear
as
sig: both ears
au
Convert aminophylline to theophylline.
aminophylline x 0.8
Convert theophylline to aminophylline.
theophylline / 0.8
Conceptually…Ratio strength –> % strength
Do the math, then multiply x 100 and it gives you the %
e.g. 1:400 –> (1/400)x100 = 0.25%
mL per tsp
5
mL per TBSP
15
mL per fluid oz
30 approximate (29.57 actual)
1 cup = ____ oz = _____ mL
8 oz = 240 mL
1 pint = ____ mL
473 mL
1 quart = _____ pints = _____ mL
2 pints = 946 mL
1 gallon = _____ mL = _____ quarts
3785 mL = 4 quarts
1 kg = ____ lbs
2.2 lbs/kg
1 lbs = ____ grams
454 grams
grains/gram
15.432 grains per gram
1 grain = ____ grams = _____ mg
(1/15.432) = 0.0648 grams ==> x 1000 = 64.8 mg
cm to an inch
2.54 cm in 1 inch
mEq to mmol
Monovalent ions
Divalent ions
Monovalent ions is 1:1 ==> 1 mEq = 1 mmol
Divalent ions 1:0.5 ==> 1 mEq = 0.5 mmol
Many times when given a volume and concentration, what equation will you use?
Q1xC1 = Q2xC2
And many times you’ll need to do an extra step to subtract from the total or something similar. READ THE QUESTION!
Milliosmoles and osmolarity
Osmolarity is in units of milliosmoles/liter (mOsm/L)
Millimoles are just mmol
Osmolarity (mOsm/L) = [weight of substance (g/L) / molecular weight (g/mole)] x (# of particles) x 1000
Compounds and the # of dissociation particles:
Dextrose
Mannitol
Potassium chloride (KCl) Sodium chloride (NaCl) Sodium acetate (NaC2H3O2)
Calcium chloride (CaCl2)
Sodium acetate (Na3C6H5O7)
Dextrose 1
Mannitol 1
Potassium chloride (KCl) 2 Sodium chloride (NaCl) 2 Sodium acetate (NaC2H3O2) 2
Calcium chloride (CaCl2) 3
Sodium acetate (Na3C6H5O7) 4
Equations for BMI
weight in kg / height in m^2
OR
[weight in lbs / height in in^2] x 703
IBW equations for male and female
male = 50 + (2.3 x [” over 60”])
female = 45.5 + (2.3 x [” over 60”])
Adjusted body weight equation
AdjBW = IBW + [(0.4 x(Actual BW - IBW)]
Normal range of SCr?
0.6 - 1.2 mg/dL
What is creatinine and why do we monitor it?
Creatinine is a breakdown product from when our muscles make energy. It is typically cleared easily by normal kidneys. When our kidneys start to fail, we do not clear creatinine as well so SCr goes up and CrCl goes down. Drugs that are renally cleared may need adjusted as CrCl declines.
What might be indicated when BUN:SCr is greater than a 20:1 ration?
dehydration
What weight do you use for calculating CrCl if the person is 1.) small (ACT < IBW), use _______ 2.) normal (Act ~=IBW), use ______. 3.) ACT > IBW overweight BMI < 25, use ______4.) ACT > IBW overweight BMI>/= 25 use ______
- ) Actual
- ) IBW
- ) IBW
- ) Adjusted
What weight should you use to dose aminophylline and theophylline?
IBW (unless the problem says otherwise)
What body weight do you use to dose lovenox?
ACTUAL
What is the calcium correction calculation and why do we need it?
Ca (corrected) mg/dL = Ca (reported/serum) + [(4.0 - Albumin) x (0.8)]
We need to correct it because almost half of our calcium is bound to albumin. If our albumin is low, then our calcium may be falsely low based on lab value. If you don’t correct it, and you give calcium supplement when the pt doesn’t need it you could provoke cardiac abnormalities.
Acidosis and Alkalosis…talk about it.
What are the normal values for pCO2 and HCO3?
How do you read a blood gas?
e.g.
ABG: 6.72/40/89/12/94%
You look at pH to determine acidosis (pH<7.35) or alkalosis (pH>7.45). Then you determine if its metabolic or respiratory. Normal pCO2 = 35-45 and HCO3 = 22-26. You have to match the pH with the disorder, so to speak. If the pH is low, then the patient is in acidosis, so you would have to see which of the pCO2 or HCO3 was in acidosis to determine if it were respiratory or metabolic. For instance, if the pH was low and the HCO3 was low, then it would be metabolic acidosis. However, if the pH was low and the pCO2 was high, then it would be respiratory acidosis.
Respiratory:
Low pCO2 = alkalosis, high pCO2 = acidosis
Metabolic:
Low HCO3 = acidosis, high HCO3 = alkalosis
HINT: Metabolic and respiratory are opposite, so if you can remember that if both pH and HCO3 are high then you’ve got metabolic alkalosis and if pH and HCO3 are low you have metabolic acidosis. In other words the pH and HCO3 go in the same direction IF its metabolic. They go the opposite direction if they are respiratory.
ABG: pH/pCO2/pO2/HCO3/O2 sat
What is the equation for anion gap?
Anion gap (AG) = Na - Cl - HCO3
Anion gap normal range is 5 - 12 mEq/L. Presents of elevated anion gap suggests metabolic acidosis.
Draw a chem 7 and label the sections.
across the top: Na/Cl/BUN
across the bottom: K/HCO3/SCr
Glucose is at the fair right
Ionized vs. un-ionized
Which is soluble?
Which can cross membrane layers?
an ionized drug is soluble and cannot cross membrane (its charged, it can’t cross…think of it like a criminal…if a person was charged with a crime, they probably couldn’t cross the border)
an un-ionized drug is not soluble and can cross membranes
What is the Henderson-Hasselbalch equation?
pH = pKa + log ( [A-] / [HA] )
What’s the equation for pH?
- log [H+] = pH….so the - log of [whatever] = pWhatever
p just means - log…. pKa = - log [Ka]
Which calcium is used as a phosphate binder?
calcium acetate…and not used as a calcium supplement because of poor absorption
What is the normal range for ANC?
2200 - 8000
ANC<1000 would predispose a pt to infection
ANC<500 indicate very high risk of developing an infection
What is the clozapine REMS program there for?
To reduce the risk of severe clozapine induced neutropenia. Clozapine cannot be refilled if ANC < 1000. So what if they are neutropenic, what does that mean? It means their neutrophils are down (i.e. white blood cells) and are susceptible to infection.
How do you calculate ANC?
ANC (cells/mm^3) = WBC x [(%segs + %bands) / 100], but you don’t calculate by the %, just the number. For example:
WBC: 14.8 (assumed 10^3)
segs: 10%
bands: 11%
ANC = 14,800 x [(10 + 11) / 100] ==> 3108
Describe the HLB number and when to use.
The HLB number is the Hydrophilic-Lipophilic Balance of a surfactant. Its a range from 0 - 20.
HLB < 10 are more oil soluble and are used for water-in-oil emulsions.
HLB > 10 are more water soluble and are used for oil-in-water emulsions.
**If you know the preparation is a water-in-oil emulsion, you would want to pick a surfactant with an HLB number less than 10. Visa versa for oil-in-water.
What is Vd? What does it tell us? What is the equation? What units is Vd? Why do we need it?
Vd is volume of distribution and is an “apparent”or theoretical number. It tells us how large of an area in the patient’s body the drug has distributed into. The larger the Vd the more it will disperse to tissue. The smaller the Vd, the more it is contained in the body fluid. The equation is:
Vd = Amt of drug in the body (mg) / [Drug] in the plasma (mg/L)…..final units of L
We need it because it helps us convert between amounts and concentrations. A dose is given in mg, a concentration is taken sometime later reported in mcg/mL. The dose divided by the concentration = Vd.
What is the corrected phenytoin equation? Why do we need it? What is the normal range for Albumin?
Phen (cor) = Total Phen measured / (0.2 x Alb) + 0.1
Only unbound drug is active. Phen is highly protein bound. If we have a patient on Phen with low albumin, then there will be a higher % of unbound drug (i.e. active drug) than suspected in that patient, that could lead to toxicity. The corrected phenytoin equation only the unbound drug.
Normal range for albumin = same a K+ normal range = 3.5 - 5
What are some factors contributing to greater drug distribution?
high lipophilicity
low molecular weight
unionized status
low protein binding
What is the difference in terms of elimination between first order, zero order, and Michaelis-Menten kinetics?
Zero order kinetics removes the same AMOUNT of drug per unit time. First order kinetics removes the same PERCENTAGE of drug per unit time. Michaelis-Menten is mixed kinetics where given enough time, enzymes are saturated and even a small increase in dose can cause large increases in concentration (like phenytoin, theophylline, and voriconazole)
________ calculation are inappropriate for phenytoin. Why?
Proportion. When [phenytoin] > 7mg/L only small adjustments in dose are allowed (30 - 50mg) due to Michaelis-Menten kinetics.
Kinetics equations:
Vd =
Cl =
t1/2 =
Ke =
Loading dose =
Vd (L) = Amt of drug in body / [drug] in plasma
Cl = Rate of elimination / concentration (mass/time)/(mass/volume) = volume/time
Cl = F x dose / AUC (extravascular)
Cl = dose / AUC (intravascular)
t1/2 = 0.693 / Ke
Ke = Cl / Vd
Loading dose = (desired [ ] x Vd) / F
When would we need to give a loading dose?
When the t1/2 of the drug is long relative to the dosing frequency, it will take several ( 4-5 ) t1/2 to reach steady state. Patients on these medication may require a loading dose.
Acronym for cyp inducers? And what are they?
PPORCSS
Phenobarbital
Phenytoin
Oxcarbazapine
Rifampin (and rifabutin and rifapentine)
Carbazapine
Smoking
St. John’s Wart
Acronym for cyp inhibitors? And what are they?
G-PACMAN
Grapefruit juice
Protease inhibitors (the -avirs…like ritonavir)
Azoles - fluconazole, itraconazole, ketoconazole, posaconazole, voriconazole, and isavuconazole)
Cyclosporine, cimetidine, cobicistat
Macrolides (clari- and erythromycin, BUT NOT AZITHROMYCIN)
Amiodarone (and dronedarone)
Non-DHP CCBs (Diltiazem and verapamil)
What 4 drugs are common ones to look out for with cyp rxns with Amiodarone?
Warfarin (decrease dose by 30 - 50%)
Digoxin (decrease dose by 50%)
Simvastatin
Lovastatin
Which enzyme does grape fruit/juice effect and how?
Grapefruit/juice is an inhibitor of 3A4. In general, avoid grapefruit/juice with 3A4 substrates.
Symptoms of serotonin syndrome.
agitation, hallucinations, rapid heart rate, fever, excessive sweating, shivering, shaking, muscle twitching, muscle stiffness, trouble with coordination, nausea, vomiting, diarrhea
Serotonergic drugs
SSRIs SNRIs Tricyclic antidepressants MOAI Lineazolid Methylene blue Buspirone Dextromethorphan Fentanyl Lithium Methadone Mirtazipine St. John's Wart Tramadol Trazadone OTHERS: Cyclobenzaprine Lorcaserin Meperidine 5HT3-RA Some triptans
Which class(es) of ABx do you avoid with antacids or any multivalent cations due to chelating.
Quinolones and tertracyclines
A QT interval exceeding _________ ms are higher risk for developing arrhythmias, including TdP. What is a normal QT interval?
500
normal is < 440
Which drug is associated with HLA-B-5701? Are concerned if its positive or negative result? What might it cause? What population(s) should it be tested on?
Abacavir (and any combination medication that includes abacavir…Epzicom, Triumeq). Positive (do not use). Fatal hypersensitivity reaction. All patients prior to starting.
Which drug is associated with HLA-B-5801? Are concerned if its positive or negative result? What might it cause? What population(s) should it be tested on?
Allopurinol. Positive (do not use). SJS. DC at first sign of allergic reaction including a rash. Might consider in high risk individuals (Korean patients with renal impairment)
Which drug is associated with HLA-B-1502? Are concerned if its positive or negative result? What might it cause? What population(s) should it be tested on?
Carbamazepine, phenytoin, fosphenytoin. Positive (do not use unless benefits outweigh risk). Skin reaction (SJS and toxic epidermal necrolysis [TEN]). All Asians before starting carbamazepine.
Which enzyme metabolizes clopidogrel? What do you know about it?
Clopidogrel is a prodrug converted to the active metabolite by CYP2C19. *1 is the normal allele but *2 and *3 allele are reduce metabolism which results in less active metabolite. In other words *2 and *3 are poor metabolizers, consider an alternative treatment.
Which enzyme metabolizes codeine? What do you know about it?
Codeine is a prodrug converted to morphine through 2D6. Ultra rapid metabolizers may have exaggerated response du to extensive metabolism to morphine. Ultra rapid metabolizers (get too much morphine too quickly) should not use. Poor metabolizers should not use do to lack of efficacy.
Which enzyme metabolizes warfarin? What do you know about it?
2C9 and VKORC1. Alleles CYP2C9*2 and *3 and VKORC1 G > A variants should start on a lower dose.
What do you know about HER2?
Herceptin, Kadcyla, Perjeta are HER2 inhibitors, i.e., require HER2 gene over-expression for efficacy. It tumor is HER2 NEGATIVE, do not use.
What do you know about the KRAS mutation?
Erbitux and Vectibix. Only patients with KRAS mutation NEGATIVE should receive these medications.
What do you know about Thiopurine methyltransferase (TPMT)?
Azathioprine. Low or absent TPMT activity could lead to myelosuppression (decreased WBC, RBC, platelets). If low or absent TPMT, start on low dose or consider alternative treatment.
If you are DPD (dihydropyridime dehydrogenase deficiency) what drug(s) should you avoid?
Capecitabine and fluorouracil
HLB number.
HLB >10 is water soluble and is used in oil-in-water emulsions
HLB < 10 is oil soluble and is used in water-in-oil emulsions
MOA breaks down
norepi, epi, and serotonin…
Concurrent use of MOAi and serotonergic drugs lead to increased levels of serotonin –> serotonin syndrome
Select serotonin drugs that could lead to serotonin syndrome when used in combo
SSRI SNRI TCA MOAi Buspirone DM Fentanyl Lithium Methadone Mirtazapine St. John's Wort Tramadol Trazodone
Which enzyme metabolizes codeine? What can happen in ultra-rapid metabolizers?
2D6 (also the enzyme that activates Tramadol, fyi)
Poor or those on 2D6 inhibitors will have diminished effect with Tramadol.
Ultra-fast metabolizers, however, can convert codeine to morphine very quickly and could be fatal to patient or baby if mom is an rapid metabolizer and breastfeeding.
What enzyme metabolizes fentanyl, hydrocodone, oxycodone, and methadone?
3A4
Which enzyme converts Clopidogrel?
2C19
2C19*2 or *3 are poor metabolizers and should consider alternative txt
Which enzyme converts warfarin?
2C9*2 or *3 = increased bleeding risk.
Trastuzumab…
If tumor is HER2 (-), do not use.
Tumor must be HER2 + to use
Cetuximab…
If + for KRAS mutation, do not use
