Pharm Exam 2: Ear/Eye/Health Promotion Flashcards
Blepharitis
Eyelid margin infection/inflammation
Complications: dry eyes
Symptoms: irritated red eyes, burning sensation, increases tearing, blinking, photophobia, eyelid sticking, contact lens intolerance, eyelid margins are red, greasy, crusted, eyelid dermatitis, matted scaly eyelids
More common in adults; chronic in nature
Rarely cause vision troubles
Causes: Staphylococcus aureus, eye makeup, contact lens buildup, smoke, smog, chemicals, meibomian glands, inflammation/hypersecretion of sebaceous glands
No cure
Goal of treatment: control symptoms and prevent secondary complications
Blepharitis
Treatment
Bacitracin (Baciguent-polypeptide antibiotic
Apply fingertip size amount to affected are 1-3 times daily
Side effects: itching, burning, inflammation
Erythromycin Ophthalmic Ointment 0.5% (macrolide abx)
Apply 1cm to infected eye up to 6x daily
Side effects: minor ocular irritation, redness, hypersensitivity
Pregnancy Cat B
Blepharitis
Agent selection
First line:
Erythromycin 0.5% ophthalmic ointment (cause blurry vision)
Bacitracin 500 units ointment (cause blurry vision)
Ophthalmic fluoroquinolone solution (Besifloxacin, gatifloxacin, levofloxacin, moxifloxacin
Second line: refer to ophthalmologist
Blepharitis
Education
Improve eyelid hygiene: warm massages, occasional abx use, no contact lens use during flareups
Conjunctivitis (Pink eye)
Most common cause of red, painful eye
Inflammation of bulbar conjunctiva or palpebral conjunctival.
Symptoms: consistent inflammation of conjunctiva, red eyes, swollen conjunctiva, discharge from eyes
Normal pupil exam, normal vision
All types are self-limiting and usually resolve without tx in 2-5 days. Meds can speed up process, but abx NOT necessary usually
Pts should use cold compress and lubricants (artificial tears) for comfort
Topical vasoconstrictors and antihistamines can be used for severe itching (not usually indicated)
Conjunctivitis
Bacterial
More common in children
contagious
Cause: gram-positive Staph or Strep, gram-negative Moroxella/Haemophilus, Chlamydia or Gonorrhoeae
Transmission: contact with eye by fingertip, neonates by infected mother, contaminated pool
Symptoms: rapid onset of conjunctival redness
swelling of the eyelid
usually in one eye first and spread to other eye in 2-5 days
Grittiness/irritation, stringy, opaque, grayish or yellowish mucopurulent discharge, sticky lids, lid crusts
Foreign body sensation
Conjunctivitis
Viral
contagious
Cause: upper resp tract infection, common cold, sore throat.
Symptoms: excessive watery discharge, itchiness
foreign body sensation, peripheral injection, usually starts in one eye
Treatment: no effective tx
Risk of spreading infection
Topical antihistamines, artificial tears, cool compress
Conjunctivitis
Allergic
Cause: immunoglobulin-E mediated release of mast cells in conjunctiva
Symptoms: watery discharge, itching, burning, both eyes, excessive blinking
Treatment
Minimize allergen
First line: ophthalmic antihistamines alcaftadine or emedastine
Second line: topical corticosteroid
Third line: mast cell stabilizer -> azelastine, epinastine, ketotifen, olopatadine; opthalmic ketorolac
All pts can use cool compress and artificial tears
Conjunctivitis
Bacterial
Treatment
Ointments preferred for children, poor compliance difficult admin
First Line
Erythromycin Ophthalmic Ointment 0.5% (macrolide)
1cm directly to eyes up to 6x daily
Side effects: minor ocular irritation, redness, hypersensitivity
Preg Cat B
Polymyxin B sulfate & trimethoprim Ophthalmic solution
Aeroci gram-positive and gram-negative tx
1 gtt q3h for 7-10 days
Side effects: local irritation, redness, burning, stinging, itching
Preg Cat C
Second line- Fluoroquinolones
Moxifloxin (Vigamox)
1 gtt in 3x daily for 7 days
Side effects: eye burning, stinging, irritation, itching, dryness, redness tearing, blurred vision
1st line for contact lens wearers due to high incidence of pseudomonas
Preg Cat C
Gonococcal (treat immediately) Ceftriaxone (Rocephin) 1g single IM dose plus azithromycinin those who weigh 45 kg < 45kg reduced dose ceftriaxone Plus saline lavage of eye
Chlamydia: tx w/ systemic abx
Neonate: erythromycin taken PO for 14 days
Adults: single PO azithromycin dose
plus topical saline lavage of eye
Dry Eye Syndrome
Keratoconjunctivitis
Common; bilateral disruption of tear film
Most affected > 40 years
More common in women
Causes: decreased tear production, excessive tear evaporation, abnormal production of mucus or lipids in tear duct
Symptoms: dryness, burning, sandy-gritty eye irritation that gets worse as day goes on, pain, redness, pulling sensation, pressure behind eye
Damage to eye surface increases discomfort and sensitivity to bright light
Both eyes affected
Tx: First line
Environmental adjustment: humidity
Artificial tears and lubricants
Second line
Cyclosporine (Restasis) - prevents T cell activation
1-2 gtt q 12hrs
Side effects: burning, stinging, redness, pain, itching, burning, blurred vision, foreign body sensation, eye discharge
Preg Cat C
Glaucoma
Intraocular pressure -> optic neuropathy
Can permanently damage vision in affected areas of eye -> blindness if untreated
Glaucoma
Closed angle
Appears suddenly, painful , visual loss can be quick
Discomfort causes pt to seek help before permanent damage occurs
Glaucoma
Open angle
Chronic
Adult onset
Progress slower at a slower pace; pts do not notice vision loss until disease has progressed significantly
Leading cause of irreversible blindness
Progressive visual loss -> central field loss
Increase aqueous and/or decreased outflow -> increased intraocular pressure
Intraocular Pressure Measurement: best test to dx glaucoma
Acceptable IOP = 10-21
Glaucoma dx = IOP > 15
IOP > 40 = emergency referral
Glaucoma
Treatment
Goal: decrease ocular pressure, pressure retinal fibers
Beta blockers: non-selective (decrease production of aqueous humor)
Tomolol (Cosopt)
Levonbunolol (Betagan)
Carteolol
1 gtt 2x daily
Side effects: transient eye irritation, burning, tearing, conjunctival hyperemia, edema
Systemic effects: HA, hypotension, bronchospasm
Preg Cat C
Beta blockers: selective
Betaxolol (Betopic)
1 gtt 2x daily
Side effects: blurred vision, itching, swelling, eye pain, dryness
Systemic effects rare: fatigue, insomnia, nausea, dizziness, lightheadedness, bradycardia, hypotension, cold extremities, SOB, wheezing, depression
Safe use NOT established during pregnancy
Prostaglandins: improve outflow of aqueous humor
Bimatoprost (Lumigan)
Latanoprost (Xalatan)
Travoprost (Travatan)
1 gtt 1x daily at BEDTIME
Side effects: blurred vision, eye redness, discomfort, itchiness, foreign body sensation, dry eyes, tearing, eyelid crusting, increase in eyelash number number/length/thickness, darkens eyelashes and lids, eyelid changes, increased light sensitivity
Preg Cat C
Carbonic Anhydrase Inhibitors: inhibit carbonic anhydrase -> decreased aqueous fluid formation
Brinzolamide (Azopt)
Dorzolamide (Trust)
1 gtt 3x daily
Side effects: ocular burning, stinging, discomfort, bitter taste in mouth
Preg Cat C
Adrenergic Agonist: decrease norepi release from alpha receptors -> decrease aqueous humor
Apraclonidine (Lopidine)
Brimonidine (Alphaga)
1 gtt Q8h
Side effects: dry eyes, red eyes, eye irritation, HA, blurred vision, foreign body sensation, drowsiness.
Less common: corneal staining, increased sensitivity to light, eyelid redness, eye pain, tearing, eyelid swelling, low BP
Pre Gat B
Cholinergic blocking agents: increase aqueous outflow
Pilocarpine (Akarpine, isopto, pilocar)
1-2 gtt 3-4x/day
Side effects: transient stinging, burning, ciliary spasm, conjunctival vascular congestion, temporal/supraorbital HA, lacrimation, induced myopia
Systemic reactions: HTN, tachycardia, bronchiolar spasm, pulmonary edema, salivation, sweating, n/v/d
Preg cat C
Glaucoma
Treatment
Agent selection
First line:
prostaglandins -> beta blocker can be substituted if pt can’t afford prostaglandins
Second line:
Substitution or addition of beta blocker (if failure to decreased IOP)
Third line:
Addition of Carbonic Anhydrase Inhibitor or Brimonidine
Corneal abrasion
Localized loss of epithelium
Most common eye injury
Symptoms: severe eye pain with photophobia with/out foreign body sensation preventing opening eye
reduced visual acuity
lacrimation
blepharospasm
Causes: direct trauma, foreign body, contact lens
Fluorescein dye uptake (give pt tissue to wipe excess)
Seidel’s sign: possible foreign body does not stain -> streaming dye after insertion
* Do penlight exam prior to fluorescein
Rx treatment:
relieve pain, reduce risk of bacterial infection, promote healing
Usually heal within 48 hrs
AVOID steroids (increase risk of infection)
Corneal abrasion
Treatment
Cycloplegic therapy: paralyze ciliary muscle
Anticholinergics (cause pupillary dilation and paralysis of accommodation)
* Rapid action, but shorter duration than atropine
Maximal cycloplegia: 25-75 min after instillation
Accommodation recovery: 6-24 hrs
Homatropine (more cost effective) Cyclopentolate 1-2 gtt before abx Side effects: burning, stinging, redness, eye irritation, temporary blurred vision C/I: narrow angle glaucoma Preg Cat B/C
*Consider if pt will have to work, drive, use heavy machinery bc blurred vision lasts several hours
Corneal Abrasion
Abx Tx
Efficacy established when relief of pain, decreased inflammation, no infection
Antipseudomonal agents: used only for contact lens wearers
Gentamicin: most inexpensive
Can cause pseudomonas resistance
Aminoglycoside: (gram negative and positive)
1-2 gtt q4h for 7-10 days
Side effects: ocular burning, irritations, conjunctivitis
Preg Cat C
Tobramycin: used in place of gentamicin secondary to resistance
1-2 gtt q4h for 7-10 days
Side effects: localized ocular toxicity and hypersensitivity, lid itching, swelling, conjunctival erythema
Preg Cat B
Sulfonamides (inhibit bacterial synthesis)
Sulfacetamide
1-2 gtt into conjunctival sac q2-3 hrs for 7-10 days
Side effects: local irritation, stinging, burning
Preg Cat C
Stye (Hordelolum)
Rx treatment not recommended
Acute infection of secretory glands of eyelid, abscess of eyelid
Cause: Staph aureus; obstructed orifices of oil glands in eyelid
- incomplete removal of eye makeup, use of outdates or infected cosmetics, poor eyelid hygiene, inflammatory diseases of eyelid, stress and hormonal changes
Resolve on their own, pt w/ underlying skin issue are more prone
Use warm compress -> stimulates drainage of gland
if still present -> drain w/ lancet
Moxfloxin (vigamox): fluorquinolone
1 gtt 3x daily for 7 days
Side effects: eye burning, stinging, irritation, itching, dryness, redness, tearing, blurred vision
Preg Cat C
Otitis Media
Eustachian tube blockage:
trapped air in middle ear is absorbed in surrounding tissues -> vacuum in middle ear
Effusion:
fluid from surrounding tissues is sucked into middle ear cavity -> middle ear effusion
Cause: Strep pna (most common), Haemophillus influenza, Moraxella, Staph aureus (resp inf)
Risk: cigarette smoke exposure, daycare, non-breast fed children, allergies
Common < 15 yo, most common <2yo
Symptoms: ear pain, trouble sleeping, cranky, pulling on ear, fever, irritability
Diagnosis:
- Acute onset of s/s
- Signs of middle ear effusion: bulging TM, limited or absent TM mobility, otorrhea, air-fluid level behind TM
- s/s of middle ear inflammation: TM erythema, pain, tugging ear
Tx: only when symptoms of infection present, bilateral presentation, or otorrhea
Observe unless: bilateral s/s, < 6 yo, otorrhea, severe/prolonged s/s, fever > 102.2F
Otitis Media
Treatment
Start w/ amoxicillin to prevent resistance to Cephalosporins
First line - unless allergy PCNs or use within 30 days
Amoxicillin/clavulanate: well tolerated, tastes like bubblegum (can change flavor to
<88 lbs: 90mg/kg divide into 2 daily doses q 12 hrs
>88 lbs: 875mg q 12 hrs
Side effects: stomach pain, n/v, vaginal itching/discharge, HA, swollen or black or hair tongue
Preg Cat B
2nd line allergy to PCN Cefuroxime (Ceftin) Ceftriaxone (Rocephin) Azithromycin (Zithromax) Clindamycin Bactrim
Otitis Externa
Swimmers ear
Cellulitis of ear canal skin and subdermis
Occurs suddenly
Risk factors: eczema, seborrhea, excessive itching, trauma from cerumen removal, chronic otorrhea, immunocompromised (DM).
Causes: swimming, local trauma, hearing aids, high/humid temp
* Pseudomonas aeruginosa, Staph aureus, occasionally fungus
Wax + swelling -> conductive hearing loss
Symptoms: painful outer ear, itching, fullness, tenderness of tragus or pinna (pull on upper ear -> pain, erythematous ear canal
Otitis Media
Treatment
First line Fluoroquinolone gtt Ciprofloxacin + dexamethasone (Ciprodex) tx of bacteria and inflammation Side effects: ear discomfort, itchiness, unusual taste Preg Cat C
2nd line
Neomyxin/polymixin B + Hydrocortisone gtt
Adults: 4 gtt 3-4x daily for 10 days
Infants + children: 3 gtt 3-4x daily for 10 days
Side effects: skin sensitization
Preg Cat C
Ruptured/perforated tympanic membrane
ALL DROPS CONTRAINDICATED
Tobacco products
Traditional cigarettes
Chewable tobacco
Ground tobacco (snuff)
Dissolvable tobacco
e-cigarettes: do not contain tobacco, Deliver vaporized nicotine. Nicotine is the addictive component
Cigarette smoking
Chronic, addictive condition
Causes: lung ca, coronary heart disease, COPD, cardiovascular disease, aortic aneurysm, cerebrovascular disease, peripheral arterial disease, osteoporosis, earlier onset of menopause, increased metabolism of certain medication (theophylline, Tylenol, caffeine)
Life expectancy 10 yrs shorter for smokers
Adverse health effects lessen w/ smoking cessation
Nicotine
Binds with nicotinic receptors -> relaxation, decreased stress and anxiety, improves concentration
Ganglionic cholinergic receptor agonist
Effects: Central and peripheral NS stimulation and depression Resp stimulation Skeletal muscle relaxation Epi release by adrenal medulla Peripheral vasoconstriction Increased BP, HR, CO, O2 consumption
Cessation (withdrawal)> depressed mood, irritability, difficulty concentrating, anxiety, increased appetite, insomnia, restlessness
s/s last days, weeks, or longer
Smokers weight 2.4 - 4.5 kg less than nonsmokers
Patient discussion
Process to begin drug or non drug therapy
Ask about tobacco use and record at every visit
Strongly advise every tobacco user quit
Assess willingness to attempt to quit
Assist pt willing to make attempt to quit -> offer meds/provide referral
Arrange follow-up contact within 1st week after quit date
Nicotine Replacement Therapy
Most common
Control nicotine level in bloodstream -> withdrawal does not occur
Therapy goal: maintain cessation of smoking, develop preventative strategies to avoid relapse
No exposure to carcinogens and toxins in cigarette smoke
- Establish quit date with pt and add behavioral assistance program
- nonpharmalogical tx alone: low success rate
Smoking cessation
Treatment
First line
First line
Bupropion (Wellbutrin)
SR 150mg/d for days; 150mg 2x daily for 7-12 weeks
Start while pt smoking
Taper dose not required
Side effects: dry mouth, insomnia/nervousness, difficulty concentrating, rash, constipation, sz
In addition to counseling during and after therapy
Ok in combo w/ depression
C/I: MAOI use -> wellbutrin toxicity
Nicotine gum: chew until pt feels tingling sensation; chew q15-30min
Side effects: sore throat, hiccups
C/I: dentures, jaw joint issue, dizziness
Nicotine inhaler: don’t use > 6mos
Nicotine nasal spray: no more than 5 sprays/hr; cause nasal irritation, HA, sore throat
Nicotine patch: 16-24h/d
Nicotine lozenge:dissolve for 20-30min; don’t swallow or chew lozenge
Side effects: hiccups, dry mouth, sore mouth
C/I: current use of other nicotine products
Varenicline (Chantix)
blocks nicotine binding, blocks acetylcholine receptor
0.5mg 1x daily for 1-3 days; 0.5mg 2x daily for 4-7d; 1mg 2x on day 8
Start 1 week before pt set quit date
Side effects: nausea, constipation, abnormal dreams, HA, difficulty concentrating, somnolence, visual disturbance
don’t use in current psych illness; cause suicidal ideation
Smoking cessation
Treatment
Second line
Not FDA Approved
Clonidine
Reduce withdrawal symptoms in people addicted to narcotics or alcohol
3-7 day before quit date
Therapy: 3-10 weeks
When stopping: taper over several days
Side effects: dry mouth, drowsiness, dizziness, sedation
C/I: DM (hypoglycemia), rebound HTN
Nortriptyline 25mg/d -> titrate to 75 - 100mg/d Duration: 12-24 weeks Side effects: sedation, dry mouth C/I: risk of arrhythmia
Smoking cessation
Pregnancy
Breast feeding
Pregnancy
Nicotine replacement therapy can harm fetus
No meds intervention proven to increase long term cessation in pregnant women
* behavioral therapy reminded; med NOT recommended
Nicotine gum + lozenge: preg cat C
Nicotine patches, nasal spray, inhaler: preg cat D
Bupropion + Varenicline: preg cat C
Breast Feeding
No Nicotine replacement therapy evaluated for breast feeding, unknown if excreted in milk
Only consider if benefit of mother outweighs benefit of infant
Varenicline + Bupropion: AVOID
Obesity
Causes: overall body energy stores and energy balance
Genetic
Environmental
Psychological
Hypothyroidism, Cushings, depression, antidepressants, steroids
Dx: BMI + waist circumference BMI < 18.5 = underweight 18.5 - <25 = normal 25 - < 30 = overweight 30 - < 35 = class 1 obese 35 - < 40 = class 2 obese > 40 = class 3 obese (morbid, extreme, severe obesity)
Waist circumference > 40 in (102 cm) in men; 35 in (88 cm) women = increased health risk in BMI 25- 34.9
No need to measure > 35
Weight loss
Treatment
Goals
Reduce body weight; maintain lower body weight long term
Medications DO NOT change underlying physiology of weight regulation
Meds only approved for short term use
* determine underlying cause of obesity and reduce caloric intake or weight loss will not occur
Reduce caloric intake by at least 500kcal/d (1200-1500 for women and 1500-1800 for men)
Increase physical activity: aerobic activity 150min/wk (30min/d)
Behavioral therapy: self monitoring food intake, physical activity, weight
Behavioral interventions:
5-10% weight reduction in 1st 6 mos
Sustained weight loss of 3-5%:
Decreased hgn A1C, risk of DM, lowers triglycerides, HTN, cholesterol, decreased BG, decreased need for meds for chronic diseases related to weight
Weight loss
Appetite Suppressants
In addition to lifestyle changes
Diethylpropion (Tenuate), Phentermine (Adipex)
Side effects: increased HR, increase BP, insomnia, tremor, HA
C/I: advanced atherosclerosis, uncontrolled HTN, pulmonary HTN, hyperthyroidism, glaucoma, < 16 yo
Schedule IV (potential for abuse)
Phendimetrazine (Bontril)
Side effects:increased HR, increase BP, insomnia, tremor, HA
C/I:advanced atherosclerosis, uncontrolled HTN, pulmonary HTN, hyperthyroidism, glaucoma, < 17 yo
Schedule III (potential for abuse)
Decrease appetite by stimulating hypothalamus to release noes
Caution in pt w/ hx of ETOH/substance abuse
Use caution < 16 yo
Adverse: urinary frequency, blurred vision, changes in libido, dry mouth, nausea
Monitor HR and BP
Weight loss
In addition to lifestyle changes
Lipase InhibitorOrlistat (Xenical)
Side effects: oily spotting, flatus with discharge, fecal urgency, fatty/oily stool
C/I: Chronic malabsorption syndrome or cholestasis, safety not clear < 12 yo
May decrease absorption of fat soluble vitamins (A, D, E, K)
Caution: pt taking Coumadin bc it inhibits Vit K -> increased INR
Decreases amiodarone, levothyroxine, cyclosporine, some anticonvulsants
Serotonin 5-HT2c-receptor agonist
Lorcaserin (Belviq)
Side effects: HA, nausea, dry mouth, dizziness, fatigue, constipation, mood changes
C/I: SSRI, SNRI, MAOI, triptans, bupropion
Schedule IV: potential for abuse
Glucagon-like peptide-1 receptor agonist
Liraglutide (Saxenda)
Side effects: n/v/d, constipation, pancreatitis
Weight loss
Combination drugs
Phentermine/topiramate
Side effects: increased HR, insomnia, dry mouth, constipation, paresthesia, dizziness, altered taste
C/I: MAOI, hyperthyroidism, glaucoma
Schedule IV: potential for abuse
Naltrexone/bupropion (Contrave)
Side effect: increased HR, increased BP, nausea, constipation, HA, vomiting, dizziness
C/I: MAOI, uncontrolled HTN, sz disorder, bulimia, anorexia, drug/ETOH withdrawal, pregnancy
* Boxed warning: suicidal ideation and serious neuropsychological events
Teratogenic effects
Stimulate hypothalamus to release norepi to feel full. MAOI also stimulate release of norepi -> potential for hypertensive crisis
Weight loss
Special considerations
DM: weight loss may cause hypoglycemia
Smokers: smoking cessation -> weight gain. Higher focus on lifestyle changes to ensure pt abstains from smoking
Active immunization
Administration of all or part of microorganism or modified organism to evoke immune response that mimics response of body to natural infection
Poses little to no risk to recipient
Limited protection: need booster -> Tetanus, MMR
Lifetime protection: no booster needed
Stimulate immune system to create plasma cells
Plasma cells ready to make specific antibodies
Immunity appears AFTER exposure
Can be natural or deliberate
Passive immunization
For people already exposed or have the potential to be exposed to infectious agent
Antibodies produced by other animals injected into bloodstream
Short term immunity - body eventually destroys them
Administration of preformed antibody when pt has congenitally acquired defect or immunodeficiency
Infection results in high risk complications
Time does not permit adequate protection by active immunity -> immunizations against rabies and Hep B)
Used therapeutically during active disease to suppress effects of toxin or inflammatory response
Can be natural or deliberate
Natural: mother to fetus or breastmilk
Deliberate: vaccine (tropical diseases, rabies)
Vaccines
Adverse events
C/i
Adverse Events
Common: fever, local irritation; usually mild to moderate
- serious side effect/adverse reaction does not prove causation by vaccine
Reporting adverse events
Vaccine Adverse Events Reporting System (VAERS)
Type of vaccine, lot, site, route, manufacturer
C/I
acute febrile illness, allergy to vaccine component, hx of hypersensitivity/anaphylactic reaction to vaccine constituents
Vaccine
influenza
Everyone >6 mos receive vaccine
6 mos - 8 yo: 2 doses
> 8yo: 1 dose/season
~2 weeks for protection develop after vaccination
Influenza vaccine does not cause the flu
Ok to give with other vaccines
Recommended to receive vaccine by the end of October
Vaccine
Tetanus
S/S of tetanus jaw cramping sudden, involuntary muscle tightening (spasms) painful muscle stiffness all over body trouble swallowing jerking/staring (seizures) HA fever, sweating changes in BP and HR
Vaccine: tetanus toxoid (TT)
inactive vaccine used to prevent tetanus
during childhood: 5 doses
adolescence: 6th dose
after 3 doses, almost everyone mostly immune
additional doses q 10 yrs to maintain immunity
booster w/in 48hrs of injury
high risk injuries and not fully immunized: tetanus antitoxin
vaccine: safe for pregnancy & HIV
DTap: given to babies and young children.
Protects against diphtheria, tetanus, pertussis
DT: for babies and young children with allergy to pertussis
Tdap: booster given to older children and adults. Protects against diphtheria, tetanus, pertussis
Td: booster for older children and adults that protects against diphtheria and pertussis
