Pharm Derm Flashcards
1
Q
what are the four anti-organism classes under antibiotics?
A
- antibacterial 2. antifungal 3. antiviral 4. pediculoside/scabicide
2
Q
what are the three antibiotics?
A
- bacitracin 2. mupirocin 3. polymixin B
3
Q
what are the 4 antifungals?
A
- nystatin 2.ciclopirox olamine 3. fluconazole 4. Terbinafine
4
Q
what is the antiviral?
A
acyclovir
5
Q
what si the pediculoside/scabicide?
A
permethrin
6
Q
what are the 3 acne medications classes?
A
- retinoic acid analogue (trentinoin, isotrentinoin) 2. benzoic acid analog ( benzyl peroxide) 3. topical retinoic acid (adapaline)
7
Q
when looking at gluccocorticoids what are the TOPICAL ratings for potentcy? (4)
A
low= betamethasone intermediate= triamcinolone acetonide .025% high= triamcinolone acetonide .5% higest=clobestasole propinate
8
Q
when looking at gluccocorticoids what are the ORAL ratings for potency? (four)
A
low= hyrdocortisone intermediate=prednisone high=triamcinolone highest= dexamethasone or betamethassone
9
Q
what are the foud drug classes that are used to treat psoriasis?
A
- vitamin D -calcipotriene 2. undefined -sulfazalasine 3. antimetabolite - foloate anatagoinst (methotrexate) -other (hydroxyurea) 4. anti-TNF alpha/beta blocker (etanercept)
10
Q
explain how the absorbtion of medication varies depending on the location?
A
regional variability in drug penetration forearm=1 scrotom=42x face=6x axilla/vulva=9x
11
Q
what are four factors that you need to take into consideration about the effectiveness of different derm medications?
A
- regional variability in th drug penetration depending on the location 2. concentration gradient modify absorption 3. dosing schedule 4. vechichles of application (tinctures, wet dressings, lotions, powders, ointments, pastes…etc)
12
Q
what are the 3 topical antibiotics?
A
- bacitracin [bacitracin] 2. mupirocin [bactroban] 3. polymixin B sulfate [polymixin]
13
Q
what are the two antiparasitic agents?
A
- permethrin 5% cream [elimite] scabicide 2. permethrin 1% cream rinse [nix] pediculocide
14
Q
what are the four antifungal drugs?
A
- nystatin [mycostatin] 2. ciclopirox olamine [loprox] 3. fluconazole [diflucan] 4. terbinafine [lamasil]
15
Q
what is the nucleoside anti-viral drug?
A
acyclovir [zovirax]
16
Q
what are the four acne drugs?
A
- trentinoin [retin-a-micro] 2.isotrentinoin [accutane] 3. topical retinoic acid [adapaline] 4. benzyl peroxide [benziq]
17
Q
explain the physiology of how gluccocorticoids like cortisol are made in the body? (6 steps)
A
1.HYPOTHALAMUS 2. CRH 3. anterior PITUITARY 4. ACTH 5. ADRENAL cortex 6. glucocorticoids
18
Q
what is the abbreviation for pathway formation of glucocorticoids that are made in the body like cortisol? what are three things that increase the production? (3 things)
A
HPA (hypothalamus, puitary, adrenal cortex….explains the pathway that is activated to make the gluccocorticoids) 1. diurnal variation (AM peak) 2. negative feedback 3. stress (up to 10x increase cortisol production)
19
Q
minteralcorticosteroids and DHEA (androgen precursor) have an impact on the …..
A
immune system
20
Q
glucocorticoids (cortisol and hydrocortisone) do what?
A
regulation CHO-metabolic
21
Q
mineralcorticoids (alosterone) regulates….
A
electrolyte balance
22
Q
what are four major physiologic imapcts of corticosteroids? metabolism? maintenance? major body system? 6 other body systems?
A
- CHO, protein, lipid metabolism 2. maintenance of fluids, electrolyte balance 3. cardiovascular function 4. immune, renal, skeletal muscle, endocrine, and nervous function
23
Q
what are the receptors the respond to corticosteroids?
A
- glucorticoid R (GR) 2. minteralcorticoid R (MR)
24
Q
how do you alter cellular protein production?
A
via glucocorticoid receptors in the cell nucleus onset of impact delayed several hours, although some non-genomic impacts occure more rapidly
25
How do GLUCOCORTICOIDS EFFECT: cardiovascular skeletal muscle anti-inflammatory/immunosuppressive HPA suppression
cardiovascular: increase cardiac reactivity to other vasoactive substances skeletal muscle: atrophy anti-inflammatory/immunosupressive: inhibits humoral and cellular immunity HPA supression
26
how do GLUCOCORTICOIDS effect cellular and humoral immunity?
1. decrease vasoactive and chemoattracitve factors 2. decrease secretion of lipolytic and proteolytic enzymes 3. decrease leukocyte extravasation 4. decrease fibrosis
27
what 2 ways can GLUCOCORTICOIDS cause HPA suppression?
1. supraphysiologic doses for 2-4 weeks in the past week (exceptional stress also cause) 2. maximum short-term use without taper
28
what are three determinants that effect the potency of topical corticosteroids?
1. intrinsic 2. halogenation 3. drug concentration
29
how many times stronger is dexamethasone than cortisone?
25
30
how many more times stronger is triamcinolone than cortisone?
5
31
how many more times stronger is predinisone than cortisone?
4
32
Case: a 58 year old femal with sinusitis is going to be given an antibiotic but she is nervous because she always get vaginal candida. shes a smoker and wants abx no not vaginal infection. what do you give her for sinusitis and also the infection?
DOC augmentin x10 days for sinusitis since smoker DOC for yeast infection fluconazole 2 TABLETS want to give her two tablets because then she can take one when her symptoms start and she won't hold out to take them till her symptoms are wicked bad. this is what tends to happen to pt if they only have one tab. its a long half life so it will stay in her system for a while and will hopefully get her through the whole antibiotic, but if not she has the second
33
what is the halflife of fluconazole?
30H so it stays in the patients system for a while, can give ahead of time for a patient who gets candidal infections easily
34
how long do you give antibiotics for sinusitis for a smoke?
give them augmentin 10 days opposed to regular 5-7 because it is harder for them to clear it from their symptoms
35
if a patient is diabetic, what do you need to make sure they do to prevent candidal infections? how can they achieve this?
need to have really good control of their sugars because if not it can increase the risk for candidal infections also if overweight, decreasing weight will decrease A1C levels and reduce the effect of this
36
what is a negative when using fluconazole in patients?
its expensive and many insurances don't cover it....consider this when prescribing it to patients!
37
what are some easy things you can change in your lifestyle to prevent against candidal infections, specifically vaginal candida? (4)
tight sugar control increases vaginal washing and also hands cotton underware breathable products
38
case: a 50 yr old pt with mild psoriasis. this is his first time wanting treatment. 4% BSA
DOC 1st line is topical steroids but be cautious because it can cause tachyphylaxsis!
39
what is the qualification to be considered mild psoriasis? what is the DOC for this?
40
what is the order of 2 DOC for psoriasis? what do you move on to after that?
DOC 1: topical steroids (caution tachyphylaxsis) DOC 2: calcipotriene (not tachyphylaxsis but $$$) Then you progress to methotrexate, hydroxyurea, sulfasalazide, and biologic etanercept
41
what is the qualification for mod-severe psoriasis? what do you need to get them to?
\>5% BSA get them to derm because they need severe monitoring since they can develop psoriatic athritis and CARDIOVASCULAR DISESE patient won't die from psoriasis but then can die from the things that develop from this, so for anything more than mild you want to get them to derm to be monitored and so they can put them on stronger drugs like methotrexate
42
what are three things a derm can do for psoriasis?
light therapy, monoclonal antibodies, methotrexate
43
what do you worry about as a severe complication in psoriasis?
worry about psoratic arthritis and can cause CVD!!!!!! this is from the chronic inflammation
44
what do you need to do if the pt has \>5% BSA of psoriasis?
GET THEM TO DERM! this is moderate + need to be closely monitored to prevent against CVD
45
what is psoriasis?
a life long T cell inflammatory disease it can be genetic
46
if moderate + psoriasis, what should you do as a primary care?
give them hydrocortisone for their face and get them to derm asap because this is who will be following them ...you can't do everyrthing.
47
Case: a 17 year old with asthma and acne uncontrolled with antibiotic and benzyl peroxide. she wants to try isotrentoin. she has acne on her face and throax. what do you do?
UM DON'T PRESCRIBE HER THAT....you can't, only derm and specially trained people can DOC: topical trentoin \*\*\*\*but consider BC with estrogen\*\* since this patient has acne on the face and thorax topical trentoin may be difficult to apply and annoyting, so estorgen can help with acne! may want to try this first! this also benefits the pt because trentoin is a TETRAGEN and can harm the fetus so need to make sure she doesn't get pregnant KILL TWO BIRTSH WITH ONE STONE!!
48
can you prescribe isotrentoin?
no, you have to go through a ipledge program in order to be able to prescribe it and so does the pharmacist too, derm only prescription. works really well but comes with a lot of baggage!!!
49
if a patient is on trentoin, what do you need to make sure doesn't happen?
the patient can't get pregnant! it is a tetragen!! so maybe put htem on the pill too?!
50
what can isotrentoin cause?
bronchospasm so make sure if you're a derm PA you don't give it to someone who has asthma!
51
what do you need to consider when deciding how to treat a pts acne?
the location if it is more than on the face it may be difficult to treat with a topical because it is difficult to apply and can be inconvient for the patient CONSIDER BC!
52
what is the pregnancy rating for trentoin? who should you not use this in?
C....so consider this! don't use in
53
when should topical trentoin be used?
before bed!
54
if a pt is using a oral antibiotic for acne, what should you also use?
also want to use benzyl peroixide because it helps to cut down on resistance!
55
what can help with inflammation see with acne that is a home remedy?
tea tree oil
56
what percent of topical trentoin is absorbed systemically?
10% so consider this!
57
what are three side effects of trentoin?
redness, peeling and irritation
58
case: 20 year old pt with asthma has a exacerbation requiring a burst of steroids. he wants to stay on them. albuterol PRN, fluticasone 110 mcg/inh what is the DOC?
DOC 1: spacer, this will increase the dose up to 50% for fluticasone, this might be enough to reduce the exacerbations!!! better option than increasing the dose because increasing the dose of inhalers has a decreased effect (pushes curve to the right) DOC 2: if the spacer doesn't work than increase the dose of fluticasone!! \*\*either way make sure this pt gets the flu vax!\*
59
explain the dose response curve for inhalers
the dose response curve decreases over time as the dose of the inhaler is increased this means the strength of response (proportion) is less as you have to increase the dose of the inhaler!!! want to keep patients in the steep part of the curve with the minimal dosing requirement.....to do this: 1. give spacer 2. theory of multuple drug approach, keeps them on the steep slope longer!
60
what are three negative things that fluticasone can cause?
1. increased fungal infections 2. decreased immune response (not good!) 3. affect the cortisol levels in pt
61
if a pt with psoriasis is put on steroids for something else like a asthma exacerbation, what do you warn them might happen with their psoriasis?
it may help their psoriasis but once they stop taking it for their asthma, then they should expect their psoriasis will get worse and might come back worse initially until things balance out again
62
case: 43 year old man with recurrent herpes genital lesions. wants to decrease the outbreaks. what is the DOC
acyclovir!
63
how long can you take acyclovir?
up to 10 years!!
64
how much does acyclovir reduce the risk of transmission?
reduces risk by 50%
65
how can acyclovir be used?
long term prevention of outbreak acute treatment of outbreak
66
how many subtypes of roseca? what are they?
1. erythrotelangiectatic 2. papulopustular 3. ocular 4. phymatous
67
what are the four antibiotics you want to keep in mind that can be used to treat rosesea
erythromycin, clindamycin, tetracyclin, and metronidazole
68
for each of the four stages of roesacea what are the treatment recommedations?
1. erythrotelangiectatic- metronidazole, erythromycin, or tetracylcine 2. papulopustular-metronidazole, erythromycin, tetracycline, or clindamycin 3. ocular- metronidazole, erythromycin, or tetracylcine 4. phymatous- laser removal \*\*\* all of these you want to use trigger avoidance!!\*\*\*
69
what is an alternative therapy you can use for rosecea?
light therapy since it is the small capillaries that get swollen
70
what works really good for occular roseacea?
erythromycin
71
what is the difference in dosing for acyclovir for herpes?
acute: 5x a day for 5 days chronic: 200 mg x2 times daily
72
what is valtrex?
it is the PRODRUG form of acyclovir...it is more $$ so keep in mind!!
73
what do you need to do in a patient that has CKD and is on acyclovir?
REDUCE THE DOSEEEE!!!! BECAUSE OF THE KIDNEYS!!! DUHHH!!!!
74
how much does acyclovir reduce transmission and viral load?
reduced transmission by 50% and viral load by 1-2%
75
Case: a 30 year old comes in with acute puritic dessiminated wheals when she first woke up in the AM. She just started taking penicillin yesterday for gingivitis. what do you do?
shes having a pencillin allergic reaction but NOT anaphylaxsis DOC: bendryl at night, H2 histamine during the day \*\*still need to treat the gingivitis so since this isn't anaphylaxsis the new DOC becomes... cephalosporin like ceflex or macrolide!!!
76
if someone has an allergic rxn with desseminated urticaria, can you give them the flu vaccine?
you could....but that would be stupid. if they already have hives, you can't tell if they are having an allergic reaction or not....need to wait until the hives are cleared up, then have them come back in to get it!
77
what is a hint that someone is having anaphylaxsis?
swelling of the eyelids
78
Case: a 10 year old with generalized itching for 5 days after a camping trip comes to your office. he hasn't been able to sleep for the last 5 days and he has red lines between the webs of his fingers. DOC? when must you retreat?
he has SCABIES...that god hes a boy and too young to know what it really means. DOC: topical permethrin 5% cream, must apply head to toe overnight and wash it off in the AM. REPEAT IN 7 days!!! can use oral ivermectin
79
what are two DOC for scabies?
1: 5% topical permethrin 2. oral ivermectin
80
what do you need to tell the patient about the tx of scabies?
itching continues for a couple weeks after treatment because of the dead bug carcesses and poop in the burros in the skin. gross. now im itching.
81
what can happen to the scabies lesions? where does the spread occur?
form crusts on top from itching linear!!!! run along the axis of the body
82
who must you treat in a scabies infestation?
EVERYONE IN THE FAMILY!! OTHERWISE YOURE TREATMENT WILL DO NOTHING!
83
Case: child sent home from school with scratches on the scalp. Nurse said she had lice. DOC?
DOC permethrin 1% permethrin rinse=OTC 5% permethrin rinse=RX
84
can children go back to school if they have lice?
YES!!!! they can. I don't really understand why but white stressed this. I think that it has to do with the lice surviving off the head and thats why you don't see very many of them. so theyre around anyway. if pt has been treated then they can go back only spread through intimate contact
85
Case: Case: 75 year old man with T2DM has deformed thick opaque nails bilaterally. DOC?
ORAL TERBINAFINE FOR 12 weeks for onychomycosis Need to culture and make sure it is a fungus because since the pt has to be one this drug for so long and it has hepatic and renal consquences, want to make sure it NESSACARY don't want them taking these drugs if thats not what they have
86
what is the reccurence rate for onychomycosis with terbinafine tx?
50% so it is likely it will come back even after 12 weeks of tx
87
if you have a elderly pt with onychomycosis what might you want to do?
tx and get a pediatrist involved. good foot care can help!
88
when is the use of terbinafine contraindicated?
in renal and hepatic failure/issues want to check these before starting the drug since they are on it for a total of 12 weeks
89
what are two conditions that can give you funky looking nails and want to differentiate from onychomycosis?
melanoma and psoriasis
90
when is a taper for prednisone required?
\>7.5 mg used or for 2-3 weeks
91
case: 55 year old pt with mild psoriatic plaques on trunks and extremities and arthritis of the knee. takes NSAIDS. hx GI bleed. diminished pulses peripherally. DOC
DOC: methotrexate with folic acid until arthritis and psoriasis are under control THEN TAPER BACK TO SMALLEST EFFECTIVE DOSE!!! this person has diminished peripheral pulses so may already have heart involvement which is of real concern with psoriasis. DONT USE NSAIDS since GI bleed for pain. use GET THEM TO DERM.
92
what happens if a patient has mild psoriasis by BSA but gets arthritis?
upgrades them to the severe category because you worry about CARDIOVASCULAE COMPLICATIONS if arthritis or increased BSA, then greater risk for developing this!!!
93
what is the only on label drug to treat psoriasis? what are the two off label?
on label: methotrexate off label: sulfazalazine and hydroxyurea
94
what should you consider in a pt with psoriasis when methotrexate, sulfazalazine, and hydroxyurea don't work?
CONSIDER BIOLOGIC ETANCERCEPT!!!
95
what is the MOA of etanercept?
binds to TNF alpha receptor and blocks TH1 activity
96
what is the biologic TNF alpha/beta blocker drug used to treat refractory psoriasis unresponsive to other drugs or psoriatic arthtritis?
etanercept
97
case: a 45 year old female with peeling detached skin ~25% BSA. Trimethoprim-sulfamethoxazole (BACTRIM) BID for UTI yesterday.
SHE HAS SJS/TEN \*\*\*ADMIT HER\*\*\*\*\* DOC: cipro she is inbetween the requirements for SJS and TEN, so since the bactrim is still in her system she could go either way. need to admit her to monitor her through it. stop the med and switch her to another one that will help the UTI.
98
what are the percentages of BSA associated with SJS and TEN?
30%=TEN!!! LIFE THREATENING
99
why do you want to admit any patients with SJS/TEN?
because you want to look for SUPER INFECTIONS (not super apples) since they are susceptible from sloughing skin
100
what is a common cause of SJS/TEN?
bactrim
101
what percent of SJS patients will have conjunctivitis?
30%
102
case: pt with poison ivy for hiking trip. he spends a lot of time studying and takes antihistamine but it makes him tired. DOC?
DOC if localized: triamcinolone DOC if systemic: prednisone with taper stop his antihistamine since likely H1, and put him on H2 instead since these have less sedating effects
103
what can help poision ivy, poison oak, and atopic dermatitis?
colloidal oatmeal bath with cool water, helps with the itching!! soothes the skin!!
104
what is the order of strength of the steroid creams? (4 options)
1. betamethasone: low 2. triamcinolone acetonide .025%: intermediate 3. triamcinolone .5%: high 4. clobetasol proprionate: highest
105
what do you need to be careful of when treating diaper rash?
don't want to give hormones to a kid since it is systemically absorbed so need to limit potency and duration
106
bacitracin kills what type of bacteria?
gram +
107
why isn't there a bacitracin pill?
BECAUSE IT IS HIGHLY NEPHROTOXIC you would literally die
108
mupirocin kills which bacteria?
G+ INCLUDING MRSA thats a big one...so know it!!! also, selective gram -
109
what bacteria does polymyxin B sulfate kill?
superficial G- PSEUDOMONAS, E.COLI, KLEBSIELLA, ENTEROBACTER!!!!
110
what doesn't polymyxin B sulfate kill?
proteus and neisseria because of resistance!!!
111
what happens after 10 years of acyclovir?
renal issues
112
what happens if you stop steroids early with poison ivy? how long do you treat for and what must the last tape not exceed?
it can come back!!! NEED TO TREAT POISON IVY FOR 3 WEEKS!!!!!! and must taper prednisone!!! Last taper MUST NOT BE ABOVE 10 mg
113
if you are worried about moisture, what should you use?
ointment
114
case: 2 year old with wet crusty golden lesions. You think that it is impetigo. can't take oral med. DOC? what do you need to warn the parents about this medication?
DOC 1: mupirocin DOC 2: dicloxacillin cephalexin if not clearing but these are oral so just keep that in mind \*\*\*\*\*\*NEED TO TELL PARENTS MUPIROCIN CAUSES STINGING OR BURNING DURING APPLICATION\*\*\*\*\*
115
what is it in mupirocin that causes the burning or itiching on the skin when using it for impetigo?
POLYETHYLENE GLYCOL...SO WARN PATIENTS
116
CASE: a 75 year old lady with T2DM and recurrent oral candida infection. She now has GSA. DOC for GCA and candidia?
GSA DOC: prednisone prednisone causes a persons sugar to go up if they have T2DM, so that is why she might be getting the oral candidiasis, same thing with vaginal because of change in pH caused by increased sugar. DOC oral candidisis: nystatin oral suspension, swish and spit DOC vaginal candidiasis: fluconazole give her these ahead of time in case she starts to get symptoms
117
why do you treat GSA?
prevent blindness
118
what do you use for oral and vaginal candidiasis?
oral=nystatin vaginal=fluconazole
119
what are the two topical antifungals?
nystatin and ciclopirox olamine
120
what arteries does GSA effect?
small-medium
121
what percent of GSA patients have eye issues/blurring?
1/3, increases risk for future occular issues
122
Case: 75 year old man with erythmatous dermatomal rash with CKD stage 4. DOC?
Doc in normal person: acyclovir 800 mg 5x daily Doc in renal failure
123
Case: a 45 year old lady with RA, refractory asthma takes oral corticosteroids. Presents to you with issues breathing. DOC?
she is on oral corticosteroids which is NOT GOOD for long term health. INCREASES HER RISK FOR T2DM. wand to transfer her over to INHALED CORTICOSTEROIDS!!! DOC: INHALED CORTICOSTEROIDS, 3-4 MONTH TAPER OFF PRENISONE
124
if someone is one corticosteroids chronically, how long does it take to taper them off?
normal patient: 3-4 months elderly: 6 months
125
if someone is on chronic glucocorticoids how often and by how much should you decrease the dose?
taper by 20% every 3 weeks or so
126
why is prednisone bad for pts with osteoporosis?
reduces systemic calcium absorption so may make osteoporosis worse
127
what crazy thing does permethrin contain?
formedalhyde isn't that what you preserve cats/fetal pigs in?
128
at what percent BSA for psoriasis would you start consider calcipotriene instead of topical corticosteroids?
10%..........once it reaches this much BSA need to upgrade to calcipotriene
129
with acne, if a pt is using both trentoin and benzyl peroxide, how should they use them?
ONE IN THE AM ONE AT NIGHT split up when you use them
130
what is a negative to calcipotriene?
its extensive 300-750$ keep this in mind when a patient needs to be upgraded because of \>10% coverage because the topical corticosteroids are only ~6-188$
