PHARM LAST JUNIOR TEST Flashcards
When does LH and FSH spike?
On day 14 of a woman’s cycle
This is peak ovulation
When does progesterone spike
During the luteal phase
From the corpus luteum
What are the lengths of the various phases of Menstration
Follicular phase last about 12 days
Menstrual uterine phase: Last 3-5 days (here estrogen and progesterone are the lowest)
Proliferation phase: once menstrual flow has stopped (under the influence of FSH, lining begins to thicken)
Ovulatory phase; lasts 4 days leading to one fully mature follicle rupturing
Luteal Phase: usually lasts 12 days Begins after ovulation occurs and continues until Day 1 of the next menstrual cycle
Secretory uterine phase: If conception does not occur, estrogen and progesterone levels decline, and the uterus (endometrial) lining begins to shed, which leads to menstruation
What are the three phases of the ovarian cycle
Follicular, ovulatory, and luteal
What are the three phases of the uterine cycle
Mensuration, proliferation, secretory
How long must sex be avoided when using the Temp, Mucus, colander methods
Most effective to combine all 3 methods
Standard Days Method
Track cycle for several months
Avoid unprotected sex on days 8-19!
How long can a diaphram BC stay in place
6-8 hours remove after 24
How long can a cervical cap remain in place
6-8 hours remove within 48
How long can a BC sponge stay in place
Remain in place for 6 hours after intercourse
Remove within 30 hours
How long can spermicides stay in place
Insert close to uterus, < 30 mins prior to intercourse
Remain in place for 6 hours
How do tubal implants work
Scar tissue forms and blocks sperm
Where is the cut in a vasectomy
Vas deferens
What is the difference between a copper and a hormonal IUD
Copper IUD
Remain in place for 12 years
Hormonal IUD
Releases progestin in uterus
Remain in place for 3-5 years
How does a vaginal ring work for BC
Delivers synthetic estrogen and a progestin analogs for 3 weeks
Remove for 4th week, insert new ring 7 days later
High estrogen content increases risk of blood clots, stroke, heart attack, or cancer
How does the BC implant work
Releases a low dose of progestin
Protects for up to 3 years
How do you instruct a pt to use a BC patch
Place on lower abdomen, buttocks, outer arm, or upper body
Apply new patch once a week for 3 weeks
No patch on 4th week
High estrogen content increases risk of blood clots, stroke, heart attack, or cancer
What should you tell a pt who is getting injectable BC
Given in arm or buttocks once every 3 months (IM vs SubQ)
Should eat diet rich in calcium and vitamin D
In adolescents can cause temporary loss of bone density
Most of the bone loss occurs during the first two years of therapy
What is the drug in injectable BC
Injection of a medroxyprogesterone
When is Estriol made
In the placenta during pregnancy
What are the 4 different types of phases for BC
Constant: assoc with less mood swings, also is the MC and is DOC for painful menses
Biphasic: 2 dose regimen, that is great for acne control
Triphasic: increase dose q 7 days, not to use more than 21 days, with 7 day placebo
Quad: best for lowest dose ADE
What is the difference of extended vs continuous BC admin
Extended is 84 days of BC with a & day placebo
Only has 1 period every 91 days
Continuous, is exactly that, no breaks, no periods with a recommend break for 1 wk q year
What is the difference between V. Low dose, low dose and high dose EE
V low dose is less than 30
Low dose is 20-30
High dose is any thing above 50
(Assoc with increase ADE/VTE)
What are the three different approaches to EE starts
Quick and Sunday appracohes
(Both require 7 day condoms)
1st day dosing, may not require condoms
What is the approach to missed EE
Miss 1 day then just start the next dose the next day
Miss 2 days then start next dose and add 7 days condoms
Miss more than 2 days
Then start new, add 7 days condoms, plus 7 days condoms for build up
What is the Best BC method for a pt that is breastfeeding
Progestin only
What pts is progestin only BC best in
Migraines Breastfeeding Smokers CV risk HTN Post Birth
If a pt in taking progestin only BC and then miss a dose, what is the window and time to use back up
Miss dose window of 3 hours
And 48 hours of back up contra
What is the advantage of using progestin only BC
No risk of VTE or ADE in CV pts
What are the approaches to starting progestin only BC
Quick or same day with a 48 hour contraception use
Or wait 3 weeks if breastfeeding with formula or 6 weeks if only on the tit
What are the ADE of progestin only BC
Increased bleeding/ spotting and wt gain
But there is no associated VTE, or HA
May have more androgen effects
What are the 4 generations of Progestin only BC and the specifics of each
1st gen: increased bleeding risk But low androgen effects Norethindrone Norethindrone acetate Ethynodiol diacetate
2nd gen: more potent with longer half life, but increased androgen
Norgestrel
Levonorgestrel
3rd gen:
Increased risk of VTE of the progestins
Norgestimate
Desogestrel
4th gen: least potent Increased VTE risk, and PE risk! Low bloating effects Drospirenone Dienogest (Spirinolactone effects)
How long after the stop of COC is a woman fertile
1-3 months
how long after injection BC is a woman fertile again
10 months
How long after an implant in removed is a woman fertile again
1 month
When should a woman use the Patch for BC
Wt less than 198 lbs
With out a risk for VTE (causes increased risk)
She can use the patch x 3 wks (not more than 21 days)
And use backl up contra for 1 week if the patch falls of for more than a day (24 hrs)
How should a woman use the nuvaring
Can use for 3weeks long
If it falls out for more than 3 hours
Use back up
Don’t use for more than 21 days straight
How can a woman use the depo shot BC
Gets an injection every 11-13 weeks
For up to 2 years
Can last as long as 18 months
Has a very low failure rate
But can cause some wt gain, bone loss, and increases risk of cancer
What pts can not get a copper IUD
Known or suspected cancer, STD within 3 months, currrently pregnant, allergy to copper, small uterus lesss than 6 or greater than 9 cm
What pts can not get an hormone IUD
Pts with a history of PID, multiple partners , post partum in the last 3 months to include abortions, or actively preg.
What are the ADE of hormone BC
Breast pain CV risk DVT/ VTE DM increased RSK Effects clotting fxs 7 and 12 and decreased anticlotting fxs
Can have Break through bleeding
N/V
And hair growth in male pattern
(Switch from 2ng gen to 3rd or 4th gen)
What are the high risk pts for starting BC
Smokers, Hx of VTE, stroke or CV pts. DM, Cancer, migraines
Consider Copper or progestin only BC in these pts
HTN greater than 160 use a copper
What are the drug classes that decrease BC
Anticonvulsant Anti infectious (rifampin) ABX (broad spec) St Johns wart Garlic
What are the two kinds of emergency BC
Plan b ( used asap up to 72 hours) And Ulipristol (Rx)
What is Yaz and what is its major ADE
Drospiridone and it causes PE
What is the onset of menopause
At the end of a woman’s menses
Usually 51 y/o
LF and FSH run high with an unresponsive uterus
How do we decide to start a pt on Menopause Horm. Tx
Look at HPI
Look for Cancer RSK, Cv RSK , HTN, VTE risk
How long should hormones therapy be used in menopausal women
No more than 5 years
Optimal 2-3 years
What is MHT
Menopausal hormone therapy
Can decrease pain during sex
Decrease hot flashes
Decrease Bone loss
ADE: increased CV risk, VTE, and CA
What is the MHT approach to a woman with an intact uterus
EE only
What is the MHT approach to a woman with out a uterus
EE plus progestin
Example medrosyprogestrone, that can lower RSK of CA, increased the efficacy of Estrogen, but also increase wt gain
What is the F/u criteria for MHT
F/u at 3 months to 1 year, if AS/s then D/c MHT
If S/s persist then continue for 3 more months
What is the role of progesterone in the body
Conception and maintain pregnancy
What is the diff of Cyclic vs Continous MHT
Cyclic mimics a natural cycle
EE at days 1-25 with progestin add at day 14-25, with neither after day 26
Continous is just that , Continous
How do you recognize a progestin product
End in -drones, or have -gest- in them
Also remember megestrol
What is the major benefit of using Micronized progesterone
Can prevent endometrial hyperplasia in women that are post menopausal
What is bazedoxifene
SERM
Both an agonist and antagonist at the tissues
Decrease CA risk but not completely
If they have a utuerus
ADE; gall stones and CV risk
No need to use this in OA, there are better drugs
What are some non hormonal options for post menopausal women
Lube for sex
SERMS
SSRI- paroxetine to Tx hot flashes
What are some herbal tx for menopause
Red clover
SOY (no data)
Black cohosh (limit use)
What are ospenifine, tamoxifen, and raloxifine
SERMS
ADE: CV risk, Hot flashes, DVTs
Non hormonal txs for menopausal women
What can ospemifine treat
Is a SERM used to tx painful intercourse when added with progetrin
Do not use in CA pts
What is Tamoxifen used to treat
Used to treat Cervical Cancer!
Can have increased Hot flashes!
Can you used SERMS is pregnant pts, or premenopausal women
NO!
Rolaxafine has what positve effect on menopausal pts
Increased bone health
What is the role of clomiphene
Blocks the negative feedback loop of estrogen a
Which increases estrogen production and can lead to increased fertility
Tx for ovulation failure
ADE; Cyts and Triplets
What is the role of letrozole, anastrazole, and exemestone
Aromatase inhibitors
Indicated for the advanced tx of estrogen dependent breast cancer
What are the DOC for advanced stage breast cancer that is estrogen dependent
Letrozole (Femara)
Anastrozole (Arimidex)
Exemestane
What are the approved Tx that testosterone can be used for
Osteoporosis(senile) And Anemia RHT Hypopituitary And Breast Cancer Endometriosis
What is the role of mifepristone
Can TERMINATE a pregnancy or endure ABORTION at 70 days gestation
Also can treat hyperGL in a DM pt with cushings
What are the ADE of Test
Raises LDL Lowers HDL Priapism Acne Gyno Stunted growth Masculinization
Do not apply any test treatment to the scrotum
What are two drugs that can be used both as replacement test and to treat carcinoma of the breast
Fluoxymesterone and methylestosterone
What is the androgen than can promote wt gain in pts with underlying protein def. / breakdown D/o
Oxandrolone
What is the androgen than can tx anemias with underlying RBC def production
Oxymethalone
What is the MOA and C/U on Danazol
Mechanism of Action:
Androgen Derivative
Weak progestational, androgenic, and glucocorticoid activity
Synthetic androgen (weak) that suppresses the pituitary ovarian axis by inhibiting the output of pituitary gonadotropins
Clinical Use:
Used to treat endometriosis and fibrocystic breast disease
Orally active unlike most testosterone products
What is the role of antiandrogens and Androgen antagonists
Clinical Use: Prostate Cancer Endometriosis Advanced Breast Cancer Female hirsutism Alopecia Acne Precocious puberty in males (covered in previous lectures) Benign Prostatic Hypertrophy
What is the Tx approach to BPH
Using either Alpha blockers
(-zosin, sulosin)
Or 5a reductase Inh ( Finasteide)
How does finasteride work
Mechanism of Action:
Competitive inhibitor of 5α reductase
5α reductase converts testosterone into 5α dihydrotestosterone (DHT) the principal androgen responsible for prostatic growth
Halts BPH progression and reduces prostate size and symptoms over time
Can treat male pattern baldness or BPH
What is the Tx approach to male ED
Can use PDE5 drugs like viagra, (verdenafil/ sildanafil/ avanafil/ tadalifil)
What are the ADE of PDE5 drugs
Vasodilation effects Congestion Flushing HA Vision Ect
Do not combine with nitrates
Caution use if A-blockers
(Use tamsulosin)
What is aprostadil
Ed injection or urethral pellet
Can not have a Hx of priapism
Injection or pellet directly into the penis
What is the approach to Female sexual dysfunction
Lubricants for sex
Body image
Testosterone creams
Rx: Flibanserin
What is flibanserin
Female sex drug
Causes increased libido through and unknown mechanism
Tx for hypoactive sex d/o
ADE: HOTN, Syncope,
Do not combine with alcohol
What is the building block for all hormones
Cholesterol, made in your sleep
What specific steroids are made in the adrenal glands
G: Mineralcorticoids (aldosterone
F: Corticol
R: Androgens
When shoud glucocorticoids be taken
In the morning to mimic natural steroid release
What is CBG in relation to glucocorticoids
Corticosteroid binding globulin
Binds about 90% of glucocorticoids
Can be increased by pregnancy and decreased by hypothyroid or protein def,
What are the major effects of glucocorticoids in the body
Hyperglycemia can occur
Hematopoietic effect on white blood cells, and can increase HbG, platelets, and leukocytes
And Antiimflammatory by blocking arachadonic acid
What is the perferred steroid in Adrenal Insf.
Hydrocortisone
What is the Steroid OC for asthma
Prednisone/ Predisolone
What is the steroid to use for the acceleration of lung maturation
Dexamaethsone or betamethasone
What is the steroid OC for COPD
Methylprednisone and Prednisone
What is the Steroid OC for Connective tissue/ Rhematic disorders
Prednisone
What is the Steroid OC for N/V for rads and chemo Tx
Dexamethasone IV
What is the steroid OC for IVY/OAK/ sumac
Prednisone
What is the role of systemic steroids in asthma
Rapid response during an exacerbation ( IV)
Are glucocorticoids potassium reducing drugs?>
Yes
What are the common ADE of glucocorticoids
Acute: face flushing, GI irritation, HA, mood swings, Hyoperglycemia
Long term:
Osteoporosis, glaucoma, central obesity, growth suppression, HTN, edema, Hypokalemia , Immunsuppresion
How do you do a steroid taper
5-20% reduction every week over 1-2 weeks
What level of steroids is likely to cause HPA suppression
Doses greater than 20 mg for more than 3 weeks
Or taking 5mg or more at bedtime
Any Cushing S/s means to much steroid
When do you not use Topical steroids
Warts, fungal infections, ulcers, Rosacea, or Acne Vulgaris
What potency is Augmented Betamethasone Diproprionate 0.05 %
Very High Potency
What are the Three very high potency steroids
Clobetasol proprionate
Augmented Bethamethasone disproporionate OINTMENT AND GEL
Fluconinide
Which is more potent
Lotion/ Cream
Or Oint/Gel
Oint Gel is more
What are the 4 high potency steroids
Augmented Betamethasone LOTION and CREAM
betamethasone (not augmented) 0.05% OINTMENT
Triamcinolone
Flucinonide 0.05%
(Note that 0.1% is very high potency)
What potency is hydrocortisone
LOW LOW LOW
What potency is Desonide steroid?
LOW potency
Where should ointments not be used
DO not use on Hairy areas
When are creams best to use
Not as potent and dry clear after application
What type of steroid is good on hairy areas
Lotions, Gels, and Foams
What is the scale that determines steroid strength
Grade 1 (high) to 7 (low)
When should a very high potency steroid be used
Do not use longer than 2-4 weeks
Other wise you get systemic effects
Do not use with occlusive dressings
DO not use on very large areas
Do no D/C abruptly ( taper down)
CAN be used on very very thick skin (callouses)
When should we use low potency steroids
On high sensitive areas like the face , armpits, folds of skin ect
When can we use Flucocinonide
It’s high potency, do not use longer than 3 months
Rank the following oral steroid strengths
Prednisone Methylprednisolone Prednisolone Hydrocortisone Triamcinolone Dexamethasone
Hydro (weakest) Pred Predisolone Methyl Tri DEXA (strongest)
What level of action is prednisone steroids
Intermediate acting
Stronger than hydro but weaker than DEXA
What is the DOC for adrnocortical insufficiency
Hydro/ Cortisone
What is Ketoconazole
Corticoide anatagoinst
Used to treat fungal
And also cortisone excess ( cushings)
Can cause gyno
What pts for we use aldosterone in
Addisons pts
What stops drugs from making it to the blood stream through the skin
Stratum Corneum
rate limiting step for skin absorption
What are things that impact topical efficacy of drugs
Skin permeability Dosage Thickness/ presence of stratum corneum (burns) Hydration status Age ( more in kids) Frequency of application Occluding ( increase absorption)
Using Ointments on hairy areas can cause..
Foliculitis and acne
Aerosols are best to use on what body part
Good for application to the scalp or hairy areas
Where should pastes not be used
Weeping lesions or hairy areas
What are the stages of dermatitis
Acute: wet lesions, blisters, oozing
Subacute: crusts/ scabs over the wet lesions
Chronic: dry and thickened, lichenified
What is the tx approach to contact dermatitis
Do not put ointments on weeping lesions,
Prevention is best strategy
Do not use local anesthetics and antihistamines
Goal is to dry out the acute and subacute phase
Mild: wet dressing, oatmeal baths, astringents (dry mucus)
Moderate: counter irratants (Camphor) (menthol)
Benadryl cream or spray
Severe: Systemic corticosteroids (prednisone)
What is seborreic dermatitis and tx>?
Eczema
Anti fungals (fluconazole) and low dose steroids
What is the tx approach to atopic dermatitis
Increase skin hydration
(Cetaphil)
Aluminium or Oatmeal bath for weeping lesions
Steroids (medium to high potency)
Topical Immunomodulars
(Can be used but would need to be serious)
Or Systemic Therapy
(Oral antihistamines)
How do Topical immuno modulators work ?
Inhibit T cell activation in inflamed skin by blocking cytokines (interlukings, Interferons)
—pimecrolimus
—tacrolimus
When treating atopic dermatitis and you dont want to use a steroid (it’s not he face, armpits, or genitals)
What is the alternative Rx that can be used
TIMS : pimecrolimus or tacrolimus
Look out for skin burning/ warmth or flu like s.s
What is the Black box warning of TIMS
Rare skin cancer or lymphoma
Limit to short term use only (6 weeks)
What is the Tx approach to impetigo
ABX : Mupirocin or systemic ABX like Dicloxacillin
What is the tx approach to acne vulgaris
- Normalize the follicular keratinization (open the pore)
- benzoyl peroxide
- Retnoids
- Azelaic acid - Decrease sebum production
- retnoids
- hormone manipulation - Suppress bacteria
- ABX
- benzoyl peroxide
- retnoids
- azelaic acid - Prevent inflammation
- ABX
- retnoids
What is the bacteria that cause acne
Proprionibacterium acnes
How long should we treat acne before seeing improvement
1-2 months
A 35 y/o female pt presents with rosy hue on the cheeks, nose, and chin, with a burning sensation on the face
States that the S/s are triggered by alcholol, sunlight, and heat
What is the condition and best Tx approach >?
Acne rosacea
Avoid: skin care products with drying agents
ABX of choice is metronidazole
If persistent use brimonidine gel
How does Benzoyl peroxide work
two mechanisms (makes it the best acne drug option )
- Antibiotic
- Irritant to inhance skin turnover
Reduced 75% of acne in 8 weeks
What can you add to Benzoyl peroxide to enhance it for acne
Topical erythromycin
What are the topical ABX that can be used in Acne Treatment
Clindamycin
Erthyromycin
+/- benzoyl
Limit use to less than 8 weeks to avoid psuendomonas colitis
What are the systemic ABX that can be used for Acne
Tetracycline and Erthromycin
Minocyline/ DOxy (used the most)
Bactria/ Setpa ( most ADE)
Try topical ABX first
Use; daily 4-6 months then taper down
Changes seen in 3-4 weeks
What is the MOA and C/u of retnoids
Vit. A analogs
C/U: usually for acne vulgaris AFTER benzoyl trail or topical ABX failure
ADE: darken the skin or peeling skin
NOT rec in pregnancy or in UV light (put on in evening)
What kind of drug is tretinoin, adapalene and Tazarotene
Topical retinoids
What is the oral retinoid for acne vulgaris ( very severe)
Isotretinoin (High ADE and PregX
What must be told to the pt taking Isotretinoin
Take two forms of birth control to prevent pregnancy, during and for one mom that after tx
Has to have a negative preg test to start the tx
What is azelaic acid used for
To treat rosacea With minimal toxicity
Can cause pruritus, stinging, and tingling , with darkening complexion!!!
WARN PTs
When would you use brimonidine in the treatment of rosacea
When you want to use a topical treatment for persistent roseca in pts 18 years and older
(Selective A2 adrenergic agonist)
Warning can decrease BP (RARE)
A pt presents with silver, scaling skin lesions
What is the Dz and Tx/>
Psoriasis
(Inflammatory mediators cause inflammation in the skin)
Tx:
Target those mediators
Topical agents, UVB, and oral agents
What are the degrees of severity of psoriasis
Mild: less than 5%
TX w topical Tx
And UV tx
Mod-severe: 5-10%
Tx with topical, UV and systemic Tx
What is the 1st line treatment to mild to mod psoriasis
Topical steroids
(Add with vit D anaolgs to decease ADE)
Limit use for 2-4 weeks with high potency agents
How do we use coal tar in psoriasis tx
Use in mild to mod
Warn pt about the weird smell
Consider in pts that can afford Rx options
MAJOR ADE: cancer in rabbits!!
What is the common words in Vit D3 agonist and what are they used for
Drugs with Calci-
- Calcitriol
- calcipotriol
- calipotriene
Used to tx psoriasis mono Txin mild -in mod- severe add combo tx
Don’t take with acidic agents!
Monitor Calcium levels!!
DO not use on the face!
What is the MOA and C/U for Tazarotene
VIt A derivative
Reduces inflammation by inhibiting neutrophils and monocyte taxis
C/U mild psoriasis ad acne vulgaris
DO NOT USE ON GENITALS
Can cause cancer
What oral retinoid is used to treat psoriasis
Acitretin
Can be used and mono or conjunctive Tx for severe, or refractive psoriasis
It is highly teragenic
Do not get pregnant for 3 years!!!
What is the role of cyclosporine in psoriasis tx
Can be used in combo with Vit D3 analog
Can caused nephrotoxic, skin cancer
What is the PDE4 inhibitor that can be used for psoriasis
Apremilast
Can be used in pts with photo Tx
Has a Low ADE profile
What is the folic acid antagonist that can be used in psoriasis
Methotrexate
Reserved for areas that can not be tx with a steroid
ADE: ulceration in the mouth and lips!
Pulm and liver toxicity
DONT GET PREGNANT WITH THIS DRUG
(BOTH MEN AND WOMEN)
What is the reversal agent for methotrexate
Folic acid (luecovorin)
How do biological agents (Humira) work against psoriasis
As TNF-a agents or bind to T cells
Adalimumab
Inflixumab
Etanercept
-mab
Reserved for mod-to severe psoriasis
Can increase risk of infections (latent TB) and cancer
What are the two vaccines to prevent HPV
Cervarix and Gardasil
What are the options to TREAT HPV
Salicylic Acid Podofilox Podophylium Imiquimod (externally only for genital warts) DUCT TAPE
Or Cryotherapy
What is the MOA and Clin use of Imiquinod Cream
Immuno modulator that can externally treat warts (HPV)
What can happen if you incorrectly apply Podofilox or Pdophyllum to a Wart (HPV)
Tissue necrosis
What are the two types of allergic rhinitis (chronic)
Intermittent or persistent
Define allergic rhinitis
IgE mediated inflamation in the nares
What are the 5 main triggers of allergic rhinitis
Molds Pollens Dust mites Animal Dander Insect allergens
When is the late phase response of allergic rhinitis
2-12 hours after exposure
What is the difference between intermittent vs persistent allergic rhinitis
Intermittent: less than 4 days a week or less than 4 weeks total
Persistent: more than 4 days or more than 4 weeks
What is the classification of mild vs mod-severe allergic rhinitis
Mild: normal sleep, no limitations
Moderate: sleep d/o, disturbing daily life, s/s at workplace or school
What is the Tx approach to allergic rhinitis
Allergen avoidance if possible
Screen the pt for asthma!
Intermittent: 1st step -Avoidance 2nd step -Oral antihistamine then Intransal antihistamine \+/- decongestant Or LTRA 3rd Step all the above with INS (mast cells stabilizer)
Persistent: 1st step: avoidance 2nd step: Oral antihistamine Then intra nasal \+/-decongestant Or LTRA Can also add Intranasl steroid at this point 3rd step: 1) IN steroid 2)Oral Antihistamine or LTRA Add on Ipatropium for rhinorrhea Or a Decongestant for blockage Or oral corticoide burst (steroid)
What is the treatment in order for Persistent Mod severe Allergic rhinitis
What would you add on if they had rhinorreha?
‘
What would you add on if the had blockage?
- In steroid (Flonase)
- Oral antihistamines or LTRA
Add on Ipatropium for rhinorrhea
And add on Oral decongestant or steroid burst for blockage
What is the difference between 1st and 2nd gen antihistamines
1st are sedative
2nd non sedative
What are the Major ADE of 1st vs 2nd gen antihistamines
1st: drowsiness
2nd: HA
1st gen antihistamines can cause what effect in children
Paradoxical hyperactivity
What are the high sedation 1st gen antihistamines
Diphenhydramine and Promethazine
What is the preferred antihistamine in pregnancy
Chlopheniramine
List the 1st gen Anithistamines
Bromphenirarime Chlopheniramine Diphenhydramine Promethazine Hydroxyzine Meclizine Cyproheptadine
List the 2nd gen Antihistamines
Fexofenadine Loratadine Desloratadine Cetirizine Levocertirizine
Intranasal:
Azelastine (crosses the BBB more)
Olopatadine
How long should decongestants be used
Limit use to less than 10 days to prevent round congestion
3-5 days is ideal
Can you take decongestant with MAOI
Must take 2 weeks apart
How do decongestants work
vasodilation through A1 agonist
What are the ADE of decongestant
Increased BP that can increased stroke, CNS stimulation, Urinary retention, increased gl, rhinitis medicamentosa (rebound)
Increased ocular pressure
Nasal irrational
What are the C/u of phenylephrine
Treat HOTN in 2* chock
Mydriasis procedures
Relief of red eye, hemorrhoids, or NASAL CONGESTION
Must monitor the BP!
Careful admin to avoid tissue necrosis
What is the generic name for Afrin/ visine and what do we use it for
Oxymetazoline
Can be used in the eyes or nose to vasocon and decrease congestion
(Limit use to avoid rebound)
What receptors does Pseudoephedrine act on
Direct acting A and B agonist, while also displacing NE from storage sites
What pts should not receive decongestants (psuedofed)
Heart Dz HTN Thyroid Dz DM Glaucoma BPH
What are the option for pts who need decongestant but cant take psuedofed
Coricidin !
Nasal strips
Or Intranasal saline
What are the two oral and two intranasal decongestants
Oral: phenylnephrine and Psuedoephedrine
Intranasal: Oxymetazoline(Afrin) and Phenylephrine (Neo)
How do Leukotriene antagonist work
AKa montelukast
Inhibit inflammatory mediators (cysteinyl)
IS comparteble to antihistamines
Safe in pregnant pts
How long should Intranasal steroids be used
Takes a few days to start working
Kicking in about a week or two
(Use an antihistamine to bridge tx)
Avoid blowing nose for 10 minutes after
How do we use oral burst therapy in Allergic rhinitis
Short course prednisone can be used for severe/ debilitating rhinitis
What is the perferred INS in pregnancy
Budesonide
What are the two INS that are most likely to cause growth suppression
Beclamethasone
Flunisolide
What is the role of Ipatropium?
Muscarinic blocker to dry up secretions
What is the DOC for pregnancy rhinorreha and sneezing
Cromolyn
What is the MOA of Cromolyn
Inhibits mast cell degranulation
Can you use cold compresses for conjunctivitis
Yes, they effectively reduce itching
What is the step wise managment for conjunctivitis
Allergy avoidance first
Mild: oral Anithistamines or ocular
Artificial tears
Cold compress
Mod: ocular decongestant (redness only) Ocular antihistamine/ decongestant Ocular antihistamine/ mast cell stabilizer Or ocular nsaid
Severe: Ocualr steroid or referral to opto
What are the two non selective ocular antihistamines for conjuctivitis
Azelastine or levocabastine
(H1 receptor)
May cause stinging, dry eye, HA, bitter taste
Do not use in glaucoma pts
What are the two selective ocualr antihistmines
Ketotifen and Olopatadine (Rx)
2nd gen H1 blocker
What are the three ocular decongestants for conjunctivitis
naphazoline
Oxymetazoline
Tetrahydrozoline
All end in -zoline
What is the only ocular NSAID
Ketorolac
Has a 5 day limit for use!
May cause an asthma attach in pts with ASA
What is the ocualr steroid
Loteprednol
Can cause increased infections
Define chronic bronchitis
Excessive mucus production x 3months over 2 years
Classify GOLD 1-4 for COPD
1; FEV1 > 80%
2: Between 50 and 80%
3: less than 50 but greater than 30
4: less than 30 % or less than 50% with resp failure
What are the non pharm tx for COPD
Excercise, supplemental O2 (88)
Reduce exposure to irritants
What is the MGMT approach to stable COPD
Start with PRN Saba or sama
If needed add LABA or LAMA
For very high risk pts use IN steroids
Long terms tx with oral steroids in not recommended
In severe can use Roflumilast
What are the 4 principle bronchodilators
B2 agonists
Anticholinergics
Theophylline
Combo Tx
What is the role of Ipatropium bromide
Short acting MUSCARINIC antagonist
That leads to BronchOdialtion
Used for the maintenance of COPD
NOT USED acute bronchospasms
Anticholinergic side effects!
Dry, reduce scretions, blurred vision, urinary retention, difficult swallowing.
NOT for MONO TX for BronchO constriction
Can cause paradoxical bronchospasms
What is the role of Tiotropium Bromide
LONG acting Muscarinic agent
Not indicated to treat acute episodes of bronchospasms
Anticholinergic effects!
Dry eye, blurred vision, anti slude
C/U: ONCE daily maintenance of bronchospasm in COPD
(Bronchitis and emphysema)
What are the SAMAs and LAMAs
SAMA: Ipatropium
LAMA: Tiotropium
Glycopyrronium
Aclidinium
Umeclidinium
Do steroids modify the progressive decline of FEV1 or decrease mortality in COPD
NO!
They do increases the risk of pneumonia tho!
What is the role of theophylline
Can be used along steroids to treat an exacerbation
(NOT GENERARALLY USED DUE TO ADE)
Blocks phospodiesterase which increased concentrations of cAMP which stimulates various processes and induces the release or Epi from the adrenal medulla
C/U adjunct BA and INS
What is Roflumilast
PDE4 inhibitor
No direct bronchodialtion
Inhibits breakdown of cAMP
Can be use daily to reduce exacerbations in GOLD 3 or 4 pts
Don’t use in liver or nursing pts
When should pts with impaired lung function get the pneumococcal vaccine
At diagnosis and if older than 65 if they have had the IM in the last 5 years
What empiric ABX can be used in COPD pts
Azithromycin and Erthryomycin
Increased risk of resistance
What is the tx approach to acute COPD exacerbation
O2 (sat greater than 90)
NIPPV
Plus Bronchodilator (SABA) Burst Steroid Tx
Antibiotics x 7-10 days
What is the pathology of Asthma
Allergen activated T cells which reales cytokines with then lead to B cells and eosinophils increasing inflammation and bronchconstriction
Aka mucus and bronchcon
In pts older than 12 years of age, what medication can be used at a pre treatment to excercise or allergen exposure in asthma
Inhaled BA, montelukast, or nedocromil
Define intermittent asthma
S/s less than 2 days a week Awakenings less than 2. X mon SABA use less than 2 days a week (Matches S/s ) No interference NML FEV1 FEV1 greater than 80% FE1/FVC NML
Recommend Step 1 tx
Define Mild asthma
S/s greater than 2 days a week BUT NOT daily
3-4 night time awakenings,
SABA greater 2 days and week BUT NOT more than 1 time a day
With minor limitations
FEV1 greater than 80%
With a NML FEV1/FVC
Recommend step 2 treatment
Define Moderate persistent asthma
S/s daily
Awakenings more than 1 time a week but not nightly
SABA multiple times a day
With mod limitations
FEV1 60-80% predicted
FEV1/FVC reduced by 5 percent
Recommend Step 3 or 4 Tx and a course of Steroids
Define Persistent Severe Asthma
S/s through the day, every day
Awakenings every night
SAba use several times a day
With extremely limited activity.
FEV1 less than 60%
And FEV1/FVC ratio reduced more than 5%
What is STEP one NON Gina asthma Tx
used for pts with intermittent asthma
No long term controller needed
SABA PRN
What is Step 2 non Gina Tx for asthma
Used for mild Asthma
Low dose ICS
With Saba PRN
What is step 3 Non Gina Asthma Tx
Low dose ICS plus LABA
Or (medium ICS alone)
With PRN SABA
For persistent mod asthma pts
What is step 4 non GINA asthma Tx
For Persistent Mod Asthma
Medium Dose ICS plus LABA
Can Add LAMA if uncontrolled
Step 5 Non Gina Asthma Tx
For persistent Severe asthma
High Dose ICS plus LABA
Consider omalizumab
Add on LAMA if still uncontrolled
Step 6 Non Gina Asthma Tx
For persistent severe asthma
High Dose ICS plus LABA
Plus steroid burst
And consider omalizumab for allergic asthma
LAMA if still uncontrolled
Pts with persistent mod and beyond asthma should receive what inhaler
A smart inhaler, ICS + formoterol
Persistent Mod: S/S daily Awakening greater than once a week or nightly SABA use daily FEV1 60-80% And 5% reduced FEV1/FVC ratio
Define well controlled asthma
S?S less than 2 days a week
Awakenings less than 2 x a month
With no limitations
Rescue Saba use less than 2 days a week
With a FEV1 greater than 80% personal best
With 0-1 exacerbations a year
Recommend: maintain Tx follow up in 1-6 months, consider step down if controlled for 3 months
Define Not well controlled asthma
S/s greater than 2x wk Awakening 1-3 times a week Interference with Some limitation SABA use more than 2x week FEV1 60-80% predicted Exacerbations more than 2 times a year
Recommended step up 1 step
F/u 2-6 weeks
Define VERY POORLY controlled asthma
S./s Daily thoughout the day
Awakenings more than 4 times a week
Extreme limitations
SABA rescue several times a day
FEV1 less than 60%
Exacerbations more than 2 times a year
Recommended step up 1-2 steps
F/u in 2 weeks
What is the approach to asthma tx
First determine severity, then determine control and need for what step vs step up step down
What is the major GINA Asthma change
Rescue inhalers are ICS and formoterol instead of SABA
What is the approach to tx EIB
SABa 15 minutes prior
Or LABA 30-60 min prior
Leukotrine modifiers can be used daily but not for prior workout use
Regardless all pts should have a SABA for breakthrough S/s
What is the DOC for acute bronchospasm
SABA
Albuterol and Leavlbulteroll
What is the black box warning for LABAs
Increased risk of death in Asthma, take to long to onset
What are the 1st line anti- imflammatory drugs in asthma
Steroids (inhaled)
What is the role of Cromolyn in asthma tx ?m
mast cell stabilizer
Anti Inflamation
Alternative medication for MIld persistent asthma instead of increasing steroids
What is the role of omalizumab in asthma
Anti IgE monoclonal antibody
Add on tx for mod- severe asthma that is not already controlled with an ICS
What is the role of Montelukast/ zafirlukast in asthma
Inhibit cyteninyl leukotriene
In mild persist at or combo in moderate asthma ass on tx
What is the major ADE of montelukast
Liver problems, so D/c med if jaundice
What is the role of zileuton PO in asthma
Leukotrine modulator
(5-Lipoxygenase)
For long term control of S.s in mild persistant asthma
Can help reduce the dose of ICS in asthma
DONT GIVE TO LIVER PTs or ETOH pts
When would you use Anitcholinergics in asthma
in pts that cant use beta agonist in asthma
Never as monotherapy
(Ipa/ Tiotropium)
How do you treat a mild asthma exacerbation
SABA at home, not an emergency
How do you treat a moderate exacerbation of asthma
If FEV1 50-69% then start O2
And use a SABA
Start short course OCS
What is the tx for a severe asthma exacerbation
FEV1 less than 50 then
ADMIT!
Start a Saba
And failure to respond to tx within 2 hrs start steroids
IN a pts with an FEV1 less than 25 percent what do we do
ADMIT immediately
Give IV steroids!
If a pt is on an ICS and has an exacerbation what should we add on to their tx
Short course pred. (Burst steroid)
What is the major ADE of bupropion
Homicidal ideation
How does varencline work
Partial agonist at the nicotinic receptor
What is the tx approach to osteoporosis
Lifestyle changes/ start working out
Smoking cessation
And drugs that end -Dronate
Careful use in pts with CrCl less than 30
ADE: esophageal d/o form pills
So dont take these then lie down within an hour
Also take on an empty stomach to avoid reduced efficacy
Assoc with an increased risk of Necorosis of the jaw, after dental surgery
Fxs and esophageal cancers
What is the MOA of -dronate drugs
Block Osteoclasts
What is the osteoporosis drug specific to women
Ibandronate
What is the use of Denosumab
Inhibit RANKL and block osteoclasts from becoming mature
Is a 1st line agent for pts with an increase risk fx for fractures
ADE: ONJ and Skin infections
What is the role of calcitonin in Osteoporosis
Antagonist of PTH which prevents bone resorption
Not a 1st line agent
C/U is for pre surgery in post menopausal women
ADE; increase cancer risk
What is the role of teriparatide in osteoporosis
Increased Osteoblast activity
By intermittent stimulation of PTH
Used in pts with a T score less than -3.5
Do not use for longer than 2 years
If a pt has osteoporosis and cant take bisphenophosphate rx
What is the alternative
Raloxifene
For post menopausal women aged 50-60
What is the cycle of osteoclasts to osteoblasts
PTH works with vit D to increase Calcitriol with increases osteoclast which break down bone and raise calcium levels
Raised calcium levels increase and stimualte calitonin and osteoblast to build up bone.
