NSG 533 Module 3

Question 1

Before initiating treatment for ED, a physical examination and thorough medical, social, and medication histories with emphasis on cardiac disease must be taken to assess for ability to safely perform sexual activity and to assess for possible drug interactions.

Answer 1

-

Question 2

o Non-pharmacological interventions for ED

Answer 2

 Reduce fat and cholesterol in diet
 Decrease or limit alcohol consumption
 Eliminate tobacco use and substance abuse
 Weight loss if appropriate
 Regular exercise

Question 3

(Regarding ED treatment)

If a medication is removed, consider that it probably will have to be replaced with a reasonable alternative.

Answer 3

-

Question 4

SS____ (psych drug class) are a potential cause of ED. A reasonable replacement or addition (to offset the ED) might be bup_______ (psych med) (assuming no contraindications)

Answer 4

SSRIs

bupropion

Question 5

du__________ (med for BPH) is a common cause of ED. tar_________ (med) as a replacement for or in combination with a 5-alpha reductase might be reasonable (assuming no contraindications).

Answer 5

Dutasteride

Tardenafil

Question 6

Note: There are occasions where an offending medication can NOT be discontinued because of a compelling indication and / or lack of a reasonable alternative (eg Beta-blockers in heart failure or SIHD).

Answer 6

-

Question 7

One must consider if the patient is healthy enough for sexual activity (table 51-3) and if so, possible alternatives such as vacuum erection devices or medications

Answer 7

-

Question 8

PD_______ (drug class) - Often considered drug of choice for ED when pharmacotherapy is necessary. There is no convincing evidence that one agent in this class is superior to another. Choice may be based on patient preference, cost, and

Answer 8

PDE5Is

Question 9

PDE5Is:

Answer 9

Phosphodiesterase type 5 inhibitors

Question 10

Phosphodiesterase type 5 inhibitors

Answer 10

PDE5Is

Question 11

Regarding PD________ (ED drug class):

If one agent does not work it may be reasonable to try another from the same class. It is also imperative that patient is properly educated regarding onset and duration of effect, impact of high fat meals, the need for sexual stimulation and an explanation that a single trial is inadequate.

Answer 11

PDE5Is

Question 12

Regarding ___________ (ED drug class):

There is no drug effect without some type of sexual stimulation because these drugs do not cause penile erections; they only provide the ability of the penis to respond to sexual stimulation.

Answer 12

PDE5Is

Question 13

Regarding ___________ (ED drug class):

Headache and flushing most common ADRs. Serious cardiac events possible.

Answer 13

PDE5Is

Question 14

Regarding ___________ (ED drug class):

Significant DIs exist

(+) nitrates - severe hypotension

In an emergent situation, a patient who has taken sildenafil may be given a nitrate after 24 hours; for tadalafil, after 48 hours. Vardenafil does not have a suggested time interval, but blood pressure and heart rate did not change when the drug was taken 24 hours before nitrate administration. These suggested intervals are a direct correlation to half-life and duration of action

Answer 14

PDE5Is

Question 15

Regarding PD___s (ED drug class):

Prolonging of QT interval (especially vardenafil)

Answer 15

PDE5Is

Question 16

Regarding ___________ (ED drug class):

Serious cardiovascular events have been associated with these drugs; therefore, they should not be used in patients in whom sexual intercourse is inadvisable because of poor cardiac status.

Answer 16

PDE5Is

Question 17

Testosterone replacement regimens should ______ be administered to men with normal serum testosterone levels, or in patients with isolated erectile dysfunction as the only sign of hypogonadism.

Answer 17

never

Question 18

Before initiating any testosterone replacement regimen in patients ____ years and older, patients should be screened for breast cancer, benign prostatic hyperplasia, and prostate cancer. All are testosterone-dependent conditions and theoretically could be worsened by exogenous administration of testosterone

Answer 18

40

Question 19

Regarding testosterone replacement:

Several medications may contribute to decreased testosterone: _________________________________.

Answer 19

(cimetidine, spironolactone, ketoconazole, etc).

Question 20

Absolute contraindications in testosterone replacement:

Answer 20

• documented history of prostate cancer
• hx of breast cancer
• hct 55% or more
• sensitivity to ingredients in T formulations

Question 21

______ - PgE1 analog administered by intracavernosal injection & intraurethral inserts

Answer 21

Alprostadil

Question 22

OTC / Herbals (____________, etc) - limited evidence. Not recommended

Answer 22

Yohimbine

Question 23

_____ increases urethral resistance, resulting in compensatory changes in bladder function. Obstruction-induced changes in detrusor function, including smooth muscle hypertrophy, compounded by age-related changes in the functioning of the bladder, lead to urinary frequency, urgency, and nocturia, the most bothersome _____-related complaints.

Answer 23

BPH

Question 24

Diagnosis of BPH includes components such as ________________________.

Answer 24

symptom assessment (AUA score), PE and PSA

Question 25

_____ is present in small quantities in the serum of men with healthy prostates, but is often elevated in the presence of prostate cancer or other prostate disorders. _____ is not uniquely an indicator of prostate cancer, but may also detect prostatitis or BPH. _____ correlates with prostate size and can be used as a prognostic marker

Answer 25

PSA

Question 26

Regarding ____ treatment:

Watchful waiting is the most conservative approach for patients with mild symptoms or those with moderate symptoms without bother

◦Appropriate option for patients with mild symptoms (AUA-SI score ≤ 7), and for many with moderate to severe symptoms (AUA-SI ≥ 8) if they are not bothered

◦Behavior modification includes restricting fluids close to bedtime, minimizing caffeine, sweetened drinks and alcohol intake, frequent emptying of the bladder during waking hours (to avoid overflow incontinence and urgency), and avoiding drugs that could exacerbate voiding symptoms (e.g. antihistamines, decongestants).

◦At each visit, assess the patient’s risk of developing acute urinary retention by evaluating the patient’s prostate size or using PSA as a surrogate marker of prostate enlargement

Answer 26

BPH

Question 27

Regarding _____ the level of symptom distress that individual men are able to tolerate is variable.

Answer 27

BPH

Question 28

__________ (ED/cardiac drug class) - fairly rapid onset (2-4 weeks) with relatively rapid symptom resolution , durable effect (years) with AUA symptom index (AUASI) improving 30-45%. No effect on prostate size (PSA) or disease progression.

o Relax smooth muscle in bladder neck, urethra & prostate

Answer 28

Alpha-blockers

Question 29

Regarding BPH, new second generation (a________) (med) and third generation (t___________ and s____________) (med) agents are preferred because of uroselectivity, no need for dose titration and limited orthostasis

Answer 29

alfuzosin

tamsulosin and silodosin

Question 30

_____________________

 Management of moderate to severe BPH in patients with enlarged prostate glands.
 Management of patients who desire medical therapy but cannot tolerate alpha-1-adrenergic antagonists and do not have predominately irritant symptoms or concomitant erectile dysfunction (Symptoms are non-bothersome, so the delay in onset would not interfere with Qol)

Answer 30

5 alpha reductase inhibitors (5ARIs)

finasteride/dutasteride

Question 31

Regarding BPH, this drug class:

Reduce prostate size (and PSA) and thus outlet obstruction

5A__s (BPH med)

Answer 31

5 alpha reductase inhibitors (5ARIs)

___

finasteride/dutasteride

Question 32

Regarding BPH, this drug class, 5A_____:

• Reverses/Slows disease progression
• Decreases the risk of disease complications

Note: although dutasteride blocks both the Type I and Type II iso-enzymes of 5-alpha reductase while finasteride only blocks Type II, there is not a clinically significant difference in outcomes when either is used

Answer 32

5 alpha reductase inhibitors (5ARIs)

finasteride/dutasteride

Question 33

 ADRs – (androgen insufficiency) decreased libido, impotence & ejaculatory disorder, breast tenderness & enlargement

_______ (BP/BPH drug class, -sterides)

Answer 33

5 alpha reductase inhibitors (5ARIs)

finasteride/dutasteride

Question 34

 Peak effect 6-12 months, effect is only durable as long as drug is continued (prostate will return to pre-treatment size (or larger) when / if 5ARIs are stopped
 Finasteride & Dutasteride reduces, but does not stop the prostate from producing PSA
 If PSA fails to decline by 50% after 6-12 months or an increase of 0.3 ng/L or more above the baseline nadir level, patient should be evaluated for prostate cancer. May also indicate worsening condition or non-compliance with 5 a-reductase inhibitors

Answer 34

5 alpha reductase inhibitors (5ARIs)

finasteride/dutasteride

Question 35

o Treatment of the signs and symptoms of benign prostatic hyperplasia +/- ED
 Relaxes smooth muscle of urethra, prostate and bladder neck

Answer 35

PDE5Is (tadalafil) -

Question 36

tad______________ may be prescribed alone, or along with an α1-adrenergic antagonist and/or 5α-reductase inhibitor. Although other phosphodiesterase type 5 inhibitors share the same mechanism of action as tadalafil and can improve the AUA Symptom Score, tadalafil (which is the only PDE5I approved by the FDA for this indication) is preferred because of its longer plasma half-life, which is theoretically beneficial in the management of BPH, a chronic disease.

Answer 36

Tadalafil

Question 37

 Comparable efficacy to alpha-blockers for LUTS, but does not increase flow rate or reduce PVR
 Peak onset 1-4 weeks

Which med?

t__________ (PDE5I, -fil)

Answer 37

Tadalafil

Question 38

 Adverse reactions

◦Use with alpha-blockers, antihypertensives or substantial amounts of alcohol may lead to hypotension
◦headache, dizziness, flushing, back pain, myalgia, and cyanopsia

Answer 38

Tadalafil

Question 39

Precautions regarding this med, t____________ (ED drug class).

◦Unstable angina, uncontrolled or high-risk arrhythmias, persistent hypotension, poorly controlled hypertension, or New York Heart Association Classification IV congestive heart failure

Answer 39

Tadalafil

Question 40

 Contraindication

◦Current use of nitrates

Answer 40

Tadalafil

Question 41

 Alpha-blockers offer immediate relief of BPH; 5 alpha-RIs reduce prostate enlargement over time.

Alpha-blockers are the “zosins.” Doxazosin, prazosin, terazosin. α1-adrenergic antagonists are alpha-blockers.

5 alpha-RIs are the “sterides.” Finasteride, dutasteride.

Answer 41

-

Question 42

Regarding ___________ _________ for BPH:

 Alpha-blocker offer immediate relief; 5 alpha-RIs reduce prostate enlargement over time
 ◦In patients with an enlarged prostate gland and an elevated PSA ≥1.4 ng/mL, combination drug therapy with an α1-adrenergic antagonist and a 5α-reductase inhibitor is more beneficial than single drug therapy.
◦Rationale
–a-blocker offer immediate relief
–5a-RIs reduce prostate enlargement
◦Works better for those with obstructive symptoms
◦May consider stopping a-blocker after 6-12 months, but should continue in those patients with severe symptoms as long as they are responding

Answer 42

Combination therapy

Question 43

 ◦-blocker and ______________

(combination therapy BPH)

–For men with low post-void residual urine volumes and irritative symptoms (e.g., frequency, urgency) that persist during treatment with an alpha-adrenergic antagonist, combination treatment with an ______________ agent can be tried.

Improved storage voiding parameters and frequency compared with alpha-1-adrenergic antagonist therapy alone

Answer 43

anticholinergic (or β3 agonist)

Question 44

Regarding combination therapy for BPH using an alpha-blocker and an anticholinergic:

For patients who poorly tolerate anticholinergic adverse effects, an alternative is m________________ (med).

Answer 44

Mirabegron

Question 45

Combination therapy for BPH utilizing alpha-blocker and an anticholinergic.

The risk of side effects, increased post-void residual urine volume, decreased maximal urinary flow rate, or acute urinary retention is low.

Answer 45

-

Question 46

alpha-blocker and PDE-5Is:

(Comination therapy for BPH and ED)

–For men with moderate symptoms of BPH and erectile dysfunction, treatment with daily tadalafil (5 mg/day) alone or in combination with tamsulosin (0.4 mg/day) can be considered

–Addition of PDE-5Is to alpha blockers may improve lower urinary tract symptoms

Answer 46

-

Question 47

PDE-5i and 5a-RIs

–Addition of PDE-5i to 5a-RIs can offset erectile dysfunction commonly seen with 5a-RIs

Answer 47

-

Question 48

Herbals: No dietary supplement, combination phytotherapeutic agent or other nonconventional therapy is recommended for the management of LUTS (lower urinary tract symptoms) secondary to BPH.

Answer 48

-

Question 49

Commonly used / teratogenic

o __________, Phenytoin, __________________, Carbamazepine, Lithium, ___________________, Thalidomide, _____________, statins

Answer 49

o Warfarin, Phenytoin, Valproic Acid, Carbamazepine, Lithium, ACE inhibitors/ARBs, Thalidomide, Ethanol, statins

Question 50

Commonly used / teratogenic

o Warfarin, _____________, Valproic Acid, _______________, Lithium, ACE inhibitors/ARBs, __________________, Ethanol, _______________

Answer 50

o Warfarin, Phenytoin, Valproic Acid, Carbamazepine, Lithium, ACE inhibitors/ARBs, Thalidomide, Ethanol, statins

Question 51

Regarding COC (combined oral contraception)

World Health Organization and the Food and Drug Administration recommend using the lowest dose pill that is effective (as noted below, efficacy can be impacted by several factors .. including other medications. Thus, the lowest dose available is not always the lowest most effective dose)

Answer 51

-

Question 52

Concomitant use of broad spectrum antibiotics and combination contraceptives may result in decreased _________________;

Answer 52

contraceptive efficacy

Question 53

If a typical failure rate of 1% to 3% is a concern for the patient, consider additional or alternative forms of _______________.

Answer 53

birth control

Question 54

o Concomitant use of ________________________________ may result in decreased contraceptive efficacy

Answer 54

P450 enzyme inducers (rifampin, phenytoin, carbamazepine, phenobarbital)

Question 55

o Concomitant use of P450 enzyme inducers (rifampin, phenytoin, carbamazepine, phenobarbital) may result in decreased contraceptive efficacy

 If use COC – use higher doses (at least 35 mcg EE) + high progestin, shorten hormone free interval to 4 days or less

 Avoid low progestin – the patch, POP

 Consider additional or alternative forms of birth control

Answer 55

-

Question 56

Concomitant use of Anti-HIV protease inhibitors can either increase or decrease serum levels of estrogens and progestins – may need backup method.

Answer 56

-

Question 57

Regarding birth control:

d________________ (med) can cause hyperkalemia, especially if used with other agents that can increase potassium (ACEIs, heparin, aldosterone antagonists, etc)

Answer 57

Drospirenone

Question 58

_______________________ - indicated in Breastfeeding (post-partum phase), older women, women who cannot take estrogen

Answer 58

Progestin Only oral contraceptives

Question 59

HTN in pregnancy:

• When SBP reaches 160 or DBP reaches 110
• Continue treatment when multiple hypertensive’s were required before pregnancy or when end organ damage is present

 methyldopa / labatolol / nifedipine ER 1st line

Answer 59

-

Question 60

• DM I / II / GDM and pregnancy

o Treatment

 ADA diet

 Insulin – drug of choice
–Regular insulin or NPH
–Insulin lispro (Humalog)
–Insulin aspart (Novolog)

◦Insulin requirements will increase beginning around 28 weeks gestation and continue to increase due to placental hormones

 Increasing data on safety of insulin glargine in pregnancy

 Oral agents (metformin / glyburide) 2nd line. Reasonable alternative for women who decline to take, or are unable to comply with, insulin therapy.

Answer 60

-

Question 61

• hypothyroidism and pregnancy

◦Levothyroxine – DOC

◦Attain normal thyrotropin concentrations

◦Women who received thyroid replacement prior to pregnancy can expect an increased dosage requirement of 25-50% during pregnancy

Answer 61

-

Question 62

• depression and depression

o Pregnant patients with severe unipolar major depression who were successfully treated with antidepressants prior to pregnancy should generally receive the same drug during pregnancy. For patients who have not been treated with antidepressants in the past, we suggest selective serotonin reuptake inhibitors (SSRIs) as initial treatment, rather than other antidepressants

o No psychotropic drugs with labeling approved by the FDA for use during pregnancy and lactation

o 1st line – psychotherapy, but not always an option

 SSRI’s

◦Avoid paroxetine (D) during first trimester
–CV malformations
◦Fluoxetine (C) citalopram (C) sertraline (C) –>–Literature is reassuring, best data for use during pregnancy
◦Risk of PPHTN after 20 weeks gestation with SSRI’s
◦Risk of neonatal withdrawal or adaptation syndrome1
–d/c 2 weeks before term
 TCA’s
◦Literature is reassuring
◦Possible withdrawal symptoms
 Atypical antidepressants
◦Limited data

Answer 62

-

Question 63

◦Fluoxetine (C) citalopram (C) sertraline (C) –>–Literature is reassuring, best data for use during pregnancy

Answer 63

-

Question 64

• Dyslipidemia and pregnancy

o Women who are on statin therapy and anticipate becoming pregnant should stop statins three months prior to attempting to conceive.
o Maternal consumption of fish and marine omega-3 fatty acid supplement is an active area of investigation because of potential favorable effects on pregnancy and offspring outcome.

Answer 64

-

Question 65

Pharmacotherapy for menopause - hormone therapy remains the most effective treatment for vasomotor symptoms and vulvovaginal atrophy, especially in women with moderate to severe symptoms, provided there is not ____________________________________________________________________.

Answer 65

CHD, significant CHD risk factors or history of breast cancer

Question 66

___________________ - FDA approved for moderate to severe vasomotor symptoms, vulvovaginal atrophy and prevention of post-menopausal osteoporosis.

Answer 66

Oral Estrogens

Question 67

Note, ______________ should NOT be used for osteoporosis prevention in the absence of vasomotor symptoms of menopause or for patients with local symptoms ONLY

Answer 67

oral estrogens

Question 68

_________________ - Used in women with an intact uterus to reduce endometrial hyperplasia and endometrial cancer with estrogen monotherapy.

Answer 68

Oral progestins

Question 69

NOT necessary s/p hysterectomy .. so check surgical history

Oral p________ (hormones)

Answer 69

Oral progestins

Question 70

 Must be taken minimum of 12-14 days/month

Oral p_________ (hormone)

Answer 70

Oral progestins

Question 71

Length of therapy - The benefit to risk ratio appears to be best if HT is started close to the time of ____________. Typically can stop 2-3 years after starting. Longer durations may be associated with CHD, stroke, VTE, various cancers etc.

Answer 71

menopause

Question 72

Strong consideration for __________ in those patients on higher doses of estrogen or long duration.

Answer 72

tapering

Question 73

Vulvovaginal complications during menopause can range from vaginal dryness to atrophy , dyspareunia (painful coitus) and lower urinary tract symptoms (urge incontinence / OAB)

Answer 73

-

Question 74

o Local or systemic estrogen therapy for symptom relief
 Estrogen can help to restore thickness, elasticity, and lubrication
 Estrogen can help reduce the risk of recurrent urinary tract infections

Answer 74

-

Question 75

o In the absence of vasomotor symptoms, local/ topical (vaginal) estrogen therapy should be used. There is minimal systemic absorption (with exceptions) and does not require the concomitant administration of a progestin

Answer 75

-

Question 76

-

Question 77

Mr. Jackson is a 55 year old male who has been diagnosed with erectile dysfunction. He is wondering what side effects he should be concerned about with his sildenafil prescription. His current diagnoses include, GERD, hypotension, osteoarthritis, and glaucoma. What would be most important to educate him about?

• Risk for exacerbating GERD
• Increasing joint pain
• Drug interaction with glaucoma medications
• Risk of lowering blood pressure

Answer 77

• Risk of lowering blood pressure

One of the risks of sildenafil is that it can lower blood pressure. If he already has issues with hypotension, sildenafil could worsen this issue. He should be educated to stand up slowly and monitor for dizziness when changing positions.

Question 78

As you review Mr. Stevens medication list, you realize that he has many PRN medications. Which one would be of highest concern with regard to drug interactions with tadalafil?

• Calcium carbonate (Tums) for GERD
• Nitroglycerin for chest pain
• Ibuprofen for pain
• Diphenhydramine for sleep

Answer 78

Nitroglycerin for chest pain

There is a drug interaction with systemic nitrate/nitroglycerin products; advise patients about the potential interaction and the risk of low blood pressure/hypotension.

Question 79

Ms. Jones has asked about the risks with regard to her birth control. She informs you that she is taking Loestrin which is a combination of estrogen and progestin. You inform her that it can increase the risk of blood clots. Which part of her history would increase the risk of a blood clot?

• 1-2 glasses of wine per week
• She runs marathons a few times per year
• She is currently taking rifampin
• She is a smoker

Answer 79

She is a smoker

Smoking and older age are two major risk factors that will increase the risk for blood clots associated with oral contraceptives. Rifampin may interact with estrogen and progestin combination products, but it would be more likely to reduce drug concentrations and not increase clot risk.

Question 80

Ms. Linn has recent had the dose of the estrogen component of her birth increased by her provider. What is the likely explanation for this?

• Reduce breakthrough bleeding/spotting
• Reduce blood clot risk
• Improve the nausea adverse effect
• Reduce breast tenderness

Answer 80

Reduce breakthrough bleeding/spotting

In general, increasing the estrogen dose in oral contraceptives will help reduce the frequency and amount of breakthrough bleeding/spotting. Increasing estrogen may increase nausea, breast tenderness, and the risk of blood clots.

Question 81

Ms. Nelson is a 34-year-old female with a complex medical history. She was asking about drug interactions in relation to her combination birth control of estrogen and progestin. Which of her medications would be most likely to reduce the effectiveness of her birth control and leave her at risk for unintended pregnancy?

• Ibuprofen for rheumatoid arthritis
• Carbamazepine for bipolar disorder
• Quetiapine for bipolar disorder
• Clonazepam for anxiety

Answer 81

Carbamazepine for bipolar disorder

Carbamazepine is an enzyme inducer that would reduce the concentrations of oral contraceptives, leaving the patient at greater risk for unintended pregnancy and birth control failure.

Question 82

A patient taking oral contraceptives read on the package that it is “monophasic”. What should you tell the patient this means?

• She has to take it at the same time everyday and cannot vary
• She is getting the same amount of hormone in every pill
• She has a lower risk of blood clots with this formulation
• She will not have periods with this type of birth control

Answer 82

She is getting the same amount of hormone in every pill

With monophasic oral contraceptives, the patient will receive the same amount of hormone in each active tablet. With triphasic, the amount of hormone will vary and try to more closely mimic physiologic hormone cycles.

Question 83

A patient presents to your clinic for their Depo-Provera injection. They receive this injection every three months. Which of the following education should be provided to this patient?

Avoid all alcohol when on this injection and for at least 3 months after stopping
Encourage taking her blood pressure on a weekly basis
Ensure that the patient is taking adequate calcium and vitamin D
Avoid use of acetaminophen while taking this medication

Answer 83

Ensure that the patient is taking adequate calcium and vitamin D

Medroxyprogesterone (Depo-Provera) carries a boxed warning for reduced bone mineral density. Educating about this risk and ensuring adequate calcium and vitamin D intake would be the most important thing to do for this patient given the options listed.

Question 84

You’re meeting your patient in the clinic for the first time and she reports that she just took an at-home pregnancy test and it was positive. She reports that she is taking Tums, sertraline, lisinopril, and insulin (type 1 diabetes). Which medication should you have the provider address immediately?

• Tums
• Sertraline
• Lisinopril
• Insulin

Answer 84

Lisinopril

ACE inhibitors (lisinopril), ARBs, and aldosterone antagonists for hypertension should absolutely be avoided in pregnancy. They have a high risk of causing birth defects.

Question 85

What is a potential risk when using estrogen to treat menopausal symptoms like hot flashes?

• Osteoporosis
• Breast cancer
• Bleeding
• Vaginal atrophy

Answer 85

Breast cancer

Hormone replacement therapy (HRT) can increase the risk of breast cancer, blood clots, cardiovascular disease, and stroke. It would be likely to improve bone mineral density and vaginal atrophy.

Question 86

A 42-year-old patient who presents to the clinic is taking clomiphene 5 days out of the month. What is this likely being used for?

Improve chances of pregnancy
Reduce hot flashes in a patient with early menopause
Reduce spotting and breakthrough bleeding between cycles
Prevention of multiple births (i.e. twins, triplets, etc.)

Answer 86

Improve chances of pregnancy

Clomiphene binds estrogen receptors, which interrupts the normal estrogen negative feedback mechanism that prevents ovulation. It helps to stimulate ovulation and may help improve the chances of the patient becoming pregnant.

Question 87

Topical _________ products (not transdermal systemic) with limited systemic absorption may be useful for women experiencing vulvovaginal atrophy.

Answer 87

estrogen

Question 88

For older women, long-term use of _____ for menopause is associated with more overall risk than benefit and should not be used.

Answer 88

HRT

Question 89

Short-term ___________ therapy can be useful for patients with bothersome vasomotor symptoms, although they should be prescribed at the lowest possible dose and for the shortest possible duration.

Answer 89

hormonal

Question 90

__________ should not be continued for any other purpose besides bothersome vasomotor symptoms (e.g., prevention of osteoporosis)

Answer 90

HRT

Question 91

Per the WHI trial: _____ not protective against CHD and increased risks. Increased risk of breast cancer after woman on combo estrogen/progestin for 3 years.

Answer 91

HRT

Question 92

Women who have an _______ _______ should be prescribed a progestin in addition to estrogen to decrease the risk of endometrial hyperplasia and endometrial cancer.

Answer 92

intact uterus

Question 93

Women who have had a hysterectomy can do _____.

Answer 93

HRT

Question 94

Risks of HRT include: _____, _____, _____

Answer 94

CVD, breast cancer, VTE

Question 95

Benefits of HRT include: _______, ______, ________. _______________

Answer 95

vasomotor symptoms, vulvovaginal atrophy, secondary osteoporosis prevention, and improvement of well-being and mood.

Question 96

Contraindications of HRT: ________, ________, _____________, ____________, ________, _________, __________

Answer 96

History of thromboembolic disease, CHD, breast cancer, estrogen-dependent neoplasm, pregnancy, liver disease, or undiagnosed vaginal bleeding.

Question 97

_______ _________ therapy is not to be used for the prevention or treatment of CVD, cerebrovascular disease, or dementia.

Answer 97

hormone replacement

Question 98

__________ is the only ABT to date that has been reported to reduce plasma estrogen concentrations. Oral contraceptives cannot be relied upon for birth control while taking __________. This ABT makes it easier to get pregnant.

Answer 98

Rifampin

Question 99

________ is a CHD risk factor.

Answer 99

Diabetes

Question 100

What signs and symptoms are associated with menopause?

Answer 100

Vasomotor symptoms, sleep disturbances, mood swings, vaginal dryness, depression.

Less common: fatigue, irritability, migraine, arthralgia, myalgia, and decreaed libido.

Question 101

Risks of contraceptive use:

Answer 101

STIs, CV events, HTN, VTE, gallbladder disease exacerbation, benign hepatic tumors, cervical cancer (especially in women who test positive for HPV).

Question 102

_________ is only indicated in patients who also have documented low serum testosterone levels.

ED is an off-label use.

Answer 102

Testosterone

Question 103

All PDE51s have comparable efficacy for ____.

Answer 103

ED

Question 104

Non-pharm for ED include:

Answer 104

lifestyle modifications
psychotherapy
vacuum erection devices
prostheses

Question 105

The four category “X” anticonvulsants:

• P__________
• V__________
• C__________
• P__________

Answer 105

Phenytoin, valproic acid, carbamazepine, phenobarbitol.

Question 106

M_____________ (GI med for ulcer prohylaxis) is category “X” and causes uterine contractines.

Answer 106

Misoprostol

Question 107

Don’t use _________ in the 3rd trimester. Safe in 1st and 2nd trimester.

Answer 107

NSAIDs

Question 108

What medications can contribute to the development and/or worsening of BPH/ED and could be reasonably stopped or substituted?

Answer 108

Anticholinergics and caffeine could be more easily stopped. Replacement depends on what the patient is being treated for. BZDs could be switched out for the shortest-acting one. Thiazide diuretics’ increased urination stabilizes after 2 weeks., whereas loop diuretic never do. TCAs could be switched to SSRIs or SNRIs or others depending on what the disease is.

Question 109

SSRIs are a potential cause of ED. A reasonable replacement or addition (to offset the ED) might be ____________ (assuming no contraindications).

Answer 109

Bupropion.

Question 110

d_____steride (for BPH) is a common cause of ED. Tardenafil as a replacement for or in combination with a 5-alpha reductase inhibitor might be reasonable (assuming no contraindications)

Answer 110

Dutasteride

Question 111

PDE51s + nitrates =

Answer 111

severe hypotension

Question 112

In an emergent situation, a patient who has taken s_____________ (ED med) may be given a nitrate after 24 hours; for t___________ (ED med), after 48 hours. Vardenafil does not have a suggested time interval, but blood pressure and heart rate did not change when the drug was taken 24 hours before nitrate administration. These suggested intervals are a direct correlation to half-life and duration of action

Answer 112

sildenafil, tadalafil

Question 113

Behavior modification for BPH:

Answer 113

Behavior modification includes restricting fluids close to bedtime, minimizing caffeine, sweetened drinks and alcohol intake, frequent emptying of the bladder during waking hours (to avoid overflow incontinence and urgency), and avoiding drugs that could exacerbate voiding symptoms (e.g. antihistamines, decongestants).

Question 114

Reduce prostate size (and PSA) and thus outlet obstruction

5a________ / 5A__s (DM drug class)

Answer 114

5 alpha reductase inhibitors

Question 115

fairly rapid onset (2-4 weeks) with relatively rapid symptom resolution , durable effect (years) with AUA symptom index (AUASI) improving 30-45%. No effect on prostate size (PSA) or disease progression.

(a_______ b________s)

Answer 115

Alpha blockers

Question 116

One significant DI regarding PDE5Is is prolongation of QT interval, especially v__________ (ED med)

Answer 116

Vardenafil

Question 117

_________ (ED drug class) can cause severe CV events, and so should not be used in patients with poor cardiac status.

Answer 117

PDE5Is

Question 118

5ARIs

Answer 118

5 alpha reductase inhibitors

finasteride
dutasteride

Question 119

• Management of moderate to severe BPH in patients with enlarged prostate glands.
• Management of patients who desire medical therapy but cannot tolerate alpha-1-adrenergic antagonists and do not have predominately irritant symptoms or concomitant erectile dysfunction (Symptoms are non-bothersome, so the delay in onset would not interfere with Qol)
• Reduce prostate size (and PSA) and thus outlet obstruction

Answer 119

5ARIs (5 alpha reductase inhibitors)

finasteride
dutasteride

Question 120

o Concomitant use of P450 enzyme inducers (rifampin, phenytoin, carbamazepine, phenobarbital) may result in decreased ________________ ____________.

Answer 120

contraceptive efficacy

Question 121

Regarding VTE / Thromboembolism:

___________ (hormone) - increase hepatic production of factor VII, factor X, and fibrinogen in the coagulation cascade, therefore increasing the risk of thromboembolic events

Answer 121

Estrogens

Question 122

__________ Only oral contraceptives - indicated in Breastfeeding (post-partum phase), older women, and women who cannot take estrogen

Answer 122

Progestin

Question 123

Alpha blocker drugs (“-zosin”):

D____________
P____________
T____________

Answer 123

Doxazosin (Cardura)
Prazosin (Minipress)
Terazosin.