pharm exam 3 Flashcards
Drugs used for treatment of GERD
H2 blocker, PPI, antacids, prokinetics
Mild GERD treatment
antacids and lifestyle modification
H2 blocker for 4-8 weeks
Moderate-severe GERD treatment
PPI for 8 weeks
-If better, then wean off PPI
if not, then refer the patient
Pediatric GER
Very common in infants up to 18 months
-medical management is reserved for those experiencing poor weight gain, feeding difficulties, persistent irritability and pain, apnea, and cyanosis.
Peptic ulcer disease origin
from use of NSAIDs, or H. pylori
- Gastric: erosion in the stomach
- Duodenal: h. pylori releases toxins, phospholipase enzymes promoting inflammation and erosion
PUD treatment
Step 1: lifestyle modification and OTC antacids or H2 blocker
Step 2: H. pylori testing, treatment with PPIs
Step 3: Treatment for H. pylori
-all regimens include a PPI plus antibiotic to treat H. pylori
PUD triple therapy
H. pylori
PPI PLUS: Clarithromycin 500mg bid or Metronidazole 500mg bid Amoxicillin 1g bid -Treat for 10-14 days
PUD Quadruple therapy
H. pylori
PPI PLUS: Metronidazole 250mg qid Tetracycline 500mg qid Bismuth subsalicylates 525mg qid -Treat for 14 days *Used as second line therapy in patients who fail first line therapy
PUD Levofloxacin-based triple therapy
H. pylori
Levofloxacin 250-500mg bid PPI bid Amoxicillin 1g bid -Treat for 10-14 days *Used as second line or rescue therapy
After treating for H. pylori…..
Continue PPI for 8-12 weeks to promote healing
- if patient is low risk, no further treatment
- if patient is high risk, consider chronic acid suppression therapy
- if symptoms do not resolve, then refer the patient
First line treatment for UTI with no complicating factors
Bactrim
(Trimethoprim sulfamethoxazole)
TMP/SMX
Alternative first line treatment of UTI
- Ciprofloxacin (in adults)
- additional alternative= cephalosporins (cephalexin, cefpodoxime, cefixime)
- Nitrofurantoin may also be used
Urinary analgesic
Phenazopyridine
Length of treatment in UTI
- 3 days
- longer (10 days) in children, fever, chills, pregnancy, history of DM or immunosuppression
UTI and infants/children
- Diagnose with catheterized specimen
- febrile UTI is treated aggressively, with IV abx (ceftriaxone) until afebrile
- treat for 10 days
- follow up culture to document successful treatment
- children under 5 with UTI- consider vesicoureteral reflux
Adults who require workup and possible referral to urologist
gross hematuria, symptoms of obstruction, persistent UTI, symptomatic pregnant patient, or patient with fever or dehydration
Antacids
have a weak base, neutralize the gastric hydrochloric acid, have cytoprotective effects
-calcium carbonate, aluminum hydroxide, magnesium hydroxide, and sodium bicarbonate
Antacids and other drugs…
have many interactions, separate antacid administration with other drugs by at least 2 hours
Acid neutralizing capacity (ANC)
The ability of antacids to neutralize gastric acid; antacids with a high ANC are usually more effective
-combination products have the highest ANC
Indications for antacid use
PUD, GERD, hyperacidity
Calcium carbonate antacids
- all calcium containing antacids require vitamin D for absorption
- contraindicated in hypercalcemia, renal calculi
- can cause constipation
Aluminum hydroxide antacids
- used for hyperacidity, gastritis, or PUD
- contraindicated in renal failure on dialysis
- can cause constipation and hypophosphatemia
Magnesium hydroxide antacids
- used for magnesium deficiencies
- contraindicated in renal failure/insufficiency
- may cause diarrhea
- monitor mag level
Sodium bicarbonate antacid
- precaution in HTN, CHF, or renal failure
- avoid sodium containing antacids in elderly because of fluid retention
Causes of diarrhea in primary care
infection, food or drug induced, inflammatory bowel disease
Opiate and opiate derivatives
antidiarrheal
act on the smooth muscles of the GI tract, slow motility and propulsion.
- little to no analgesic activity, may be habit forming*
- Lamotil, motofen, and immodium.
- ADRs: anticholinergic effects, dizziness, drowsiness, sedation, HA
Antisecretory agents
antidiarrheal
Bismuth subsalicylates
- contraindicated in children with flu-like illness
- ADRs: bismuth causes black tongue and gray-black stools
Absorbents
antidiarrheal
- reduce motility, absorb fluid, and bind bacteria and toxins in the GI tract in infectious diarrhea
- Kapectolin and bismuth subsalicylate
Anticholinergics
antidiarrheal
Slows intestinal motility
are useful only in inflammatory bowel disease
Acute diarrhea
- treat the source of diarrhea
- absorbents (kapectolin and bismuth subalicylate) after each loose stool
- maintain hydration
- opioids dosed at 3-4 times/day or after each stool
Traveler’s diarrhea
- bismuth subalicylate with each meal and at bedtime to PREVENT traveler’s diarrhea
- if diarrhea occurs, bismuth (max 8 doses) for up to 48 hours & loperamide 4mg then 2mg after every stool (max 8mg/day)
Crofelemer
Approved to treat diarrhea in patients with HIV/AIDS who are taking antiretrovirals
-125mg bid without regard to food
Cytoprotective agents
- Sucralfate and misoprostol
- given for NSAID use and ulcer formation
Misoprostol
- Cytoprotective agent
- given if patient still requires NSAID therapy
- dose 4x/day
- pregnancy category X
- ADRs: diarrhea, menstrual problems
Sucralfate
- cytoprotective agent
- selectively binds to ulcer tissue, acting as a barrier
- given for duodenal ulcers for up to 8 weeks to heal ulcers
- ADRs: constipation
Antiemetics
- used to provide symptoms relief of n&v and prevention of fluid and electrolyte imbalances
- drug classes: antihistamines, phenothiazines, sedative hypnotics, cannabinoids, and 5-HT3 receptor antagonists
Antihistamines
antiemetic
- have strong anticholinergic effects as well as H2 blocking effects
- used for motion sickness
- ADRs: drowsiness, anticholinergic effects (dry mouth, blurred vision, urinary retention)
Phenothiazine
antiemetic
- block dopamine receptors in the chemoreceptor trigger zone
- can change the urine to light pink or brown
- ADRs: drowsiness, EPS symptoms
- Contraindicated in parkinson’s disease and children under 2 years old
- Phenothiazine and lithium may mask lithium toxicity
- LT monitoring: CBC for bone marrow depression and blood dyscrasia
Cannabinoids
antiemetic
- Dronabinol
- work in the CNS to prevent n&v associated with cancer chemotherapy
- use with caution in seizure disorders
5-HT3 Receptor Blocker
antiemetic
- used for n&v due to drugs or gastroenteritis
- 5-HT3 receptor blockers may mask progressive ileus s/s
- take 1-2 hours before departure to treat motion sickness
H2 Blockers
-Cimetidine, famotidine, nizatidine, and ranitidine
-highly selective, and reduce gastric acid secretion by 35-50%
-indicated for heartburn, acid indigestion, and “sour stomach”
-ADRs: antiandronergic reactions, CNS effects
H2 BLOCKERS NOT USED FOR TX OF PUD
Prokinetic (Metoclopramide)
-metoclopramide only drug in this class
-enhance gastric motility
-BB warning: increases risk of tardive dyskinesthia
-contraindicated in obstruction, recent GI surgery, hemorrhage, or perf.
indicated for diabetic gastroparesis and GERD
Proton pump inhibitor (PPI)
- omeprazole, esomeprazole, lansoprazole, and pantoprazole.
- used to treat gastric conditions characterized by hyperacidity.
- risk for significant deficiencies: iron, vitamin B12 and calcium
- LT use is associated with osteoporosis and fractures (esp hip)
Osmotics
Laxative
mag hydroxide, mag citrate, sodium phosphate, polyethylene glycol electrolyte solution and polyethylene glycol PEG
-draw water into the intestinal lumen
starting dose levothyroxine
no more than 50mcg
when to check labs after starting thyroid medications
6-8 weeks
osteopenia
T score -1 to -2.5
mild bone loss
alendronate (Fosamax)
bisphosphonate for osteoporosis and Paget’s
10 year half life
dynamics of bisphosphonates
rapid increase in BDM for 1st year, plateau after 2-3 years
ADRs of bisphosphonates
esophagitis
gastric irritation
musculoskeletal pain (rare osteonecrosis of jaw)
H2 blockers double alendronate activity
who are the only people that can take a PPI long term>
Barretts esophagus
how often to check A1C?
every 90 days
target treatments for DM
preprandial BG 70-130
2 hr postprandial BG less than 180
A1C target <7%
Colchicine
antigout
- decreases inflammatory response from acute gout, does not prevent gout from progressing
- causes significant diarrhea and vit B12 malabsorption
Probenecid
uricosuric drug
- increases renal excretion of uric acid
- started after an acute attack has resolved
- begin to taper dose after 6mo of therapy with no attacks
- reacts with pcn and cephalosporins
long acting insulin
Lantus, Levimir, Tresiba onset- 2-4 hours peak- none duration 24 hours DO NOT MIX WITH OTHER INSULIN!
Corticosteroid ADRs
atrophy of skin, purple striae, hirsutism, poor healing, truncal obesity, buffalo hump, moon face, osteoporosis (LT use), cataracts (LT use), mood swings, agitation, severe depression, hyperglycemia
where is insulin excreted
urine
at what point in treatment would a pt. need insulin?
after 3 months of failure of an oral agent
First line oral agent for adults and kids >10?
Biguanides: Metformin (Glucophage)
Metformin
- does not cause hypoglycemia or wt. gain
- inhibits platelet aggregation
- favorable impact on triglycerides
- may be used in prediabetes, insulin resistance, and PCOS
GFR contraindications with Metformin
cut dose in half if GFR 45, STOP when GFR reaches 30
2 major contraindications of Metformin
Renal disease and lactic acidosis
Metformin ADRs
- GI disturbances (diarrhea mainly)
- withhold 48 hours prior to iodine-based contrast
- decreases B12 (watch in anemia patients)
Selective sodium Glucose Co-transporter 2 (SGLT-2) inhibitors
Invokana, Farxiga, Jardiance
monotherapy or in combination
NOT for type 1 or DKA, or hx bladder cancer
works by dumping glucose in urine- increased risk for UTI
SGLT-2 inhibitor ADRs
severe renal impair (<30), ESRD, dialysis
pregnancy C
may increase LDL
works by dumping glucose in urine- increased risk for UTI and genital fungal infections
Urine volume output on SGLT-2 inhibitor
urine volume increases abuot 300cc on day 1, and stabilizes to about 135cc by day 5.
sulfonylureas: glipizide, glyburide, glimeperide
stimulates insulin release from beta cells (hypoglycemia risk)
do not use in DM 1 or DKA, uncontrolled infection, burns, trauma
cross sensitivity to TZDs and sulfonamides
older adult on sulfonylurea?
no glyburide per ADA- falls risk
give short acting glipizide
sulfonyurea ADRs
hypoglycemia weight gain sore throat rash unusual bleeding/bruising SIADH
Dipeptidyl Peptidase-4 inhibitors (DPP-4 inhibitors)
“gliptins” sitagliptin, saxaglipin, linagliptin, alogliptin
well tolerated by elderly
best used as add on therapy in combo with Metformin and 2nd line therapy
DPP-4 inhibitor precautions
RENAL dysfunction- decrease with declining GFR
pregnancy B
not for kids
potential medullary cancer concerns
Meglitinides
Starlix and Prandin
shouldnt be used in place of metformin monotherapy or if other insulin-stimulating drugs have been unsuccessful
Pregnancy C; not for kids
repaglinide (prandin) for?
postprandial hyperglycemia
administration of Meglitinides
no more than 30 min before a meal
hold if not eating
extra meals? take extra dose!
Target TSH
0.3-3
Measure 6-8 weeks after starting therapy
treatment for hyperthyroid induced tachycardia and palpitations?
Beta blocker!
Bulk producing laxatives
- psyllium, methylcellulose, and polycarbiphil
- natural and alternatives polysaccharides and cellulose that mixes with water in the intestine
- have slower response and are indicated for LT use
- safest to use in pregnancy
Lubricants
laxative
- mineral oil
- softens stool and lubricates intestine
Surfactants
laxative
- docusate compounds
- reduces surface tension of the oil-water interface on the stool and facilitate admixture of fat and water into the stool
Hyperosmolar laxatives
- glycerin, lactulose
- draws water into the intestine
Stimulants
laxative
- cascara, senna, bisacodyl, and castor oil
- drug of choice for constipation*
- direct action on intestinal mucosa by stimulating the myenteric plexus
Laxative ADRs
excessive bowel activity, cramping, flatulence, and bloating
Phases of gout
asymptomatic hyperuricemia, acute gouty arthritis, intercritical gout, and chronic tophaceous gout
Acute gout s/s
acute onset of pain, erythema, decreased ROM, and swelling of involved joints.
Allopurinol
antigout
- reduces production of uric acid (levels fall in 2-3 days)
- works best in patients with renal dysfunction
- ADRs: rash, drowsiness, dizziness
Febuxostat
antigout
- may take 2 weeks to see effect
- used in chronic gout (maintenance drug)
- may cause acute gouty flare- NSAIDs or colchicine are given for first 6 mo. of therapy
Probenecid
uricosuric drug
- increases renal excretion of uric acid
- started after an acute attack has resolved
- begin to taper dose after 6mo of therapy with no attacks
Sulfinpyrazone
uricosuric drug
- inhibits renal reabsorption of uric acid (increases secretion through urine)
- may cause platelet dysfunction
Clinical usage of corticosteroids
adrenal insufficiency, inflammation, immune suppression, and rheumatoid arthritis
Education regarding corticosteroids
take exactly as prescribed, do not abruptly stop treatment, wear medic alert bracelet, need diet high in potassium and calcium and low in sodium and carbohydrates
NSAID mechanism of action
inhibit cox-1 and cox-2 activity, thus inhibiting prostaglandin synthesis
-primarily used for their anti-inflammatory activity
NSAID ADRs
GI disturbances- most common
BB warning: increased risk of MI or CVA
NSAID monitoring
renal function with LT therapy, CBC prior to therapy and annually thereafter
Acetaminophen indications
- mild to moderate pain in pregnancy, history of GI bleed, blood coagulation disorders, upper GI disease
- fever in children younger than 6mo old, especially children with fever during flu-like illness
Acetaminophen toxicity
- acute hepatic necrosis occurs with doses of 10-15mg (doses above 25 usually fatal)
- refer to poison center, get acetaminophen level, oral N-acetylcysteine is specific antidote
Aspirin clinical usages
Fever (not in kids or pregnancy) Mild to moderate pain RA Osteoarthritis acute rheumatic fever MI & CVA prophylaxis
Aspirin ADRs
GI irritation, ulcers, bleeding, iron deficiency anemia, ototoxic at high levels, aspirin in kids associates with reye’s syndrome, avoid after surgery due to bleeding risk, pregnancy category D
Aspirin poisoning
lethal doses in adults is 10-30g
- respiratory alkalosis
- tx includes emesis, gastric lavage (within 2 hours of ingestion), hemodialysis
Aspirin monitoring
- random salicylate level should be drawn 7-10 days after initiation of therapy
- renal function
- CBC at baseline and annually
- fecal blood testing
Aspirin education
- take with plenty of water and remain upright for 15-30 minutes
- do not crush or chew enteric-coated tablets
- tablets with a vinegar-like odor should be discarded
